Factors affecting medical students´ hidden and null experiences Hidden and Null Curriculums

Document Type: Original Article

Authors

1 Education Development center, Mashhad University of Medical Sciences, Mashhad, IRAN

2 Islamic Azad University, Roudehen Branch, Roudehen , Iran

3 Department of curriculum, Islamic Azad University, Roudehen Branch, Roudehen, Iran

4 Department of Medical Education, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran

10.22038/fmej.2020.42764.1292

Abstract

Background: Living in a university just through attending the academic environment has always been full of different experiences that play a significant and unseen role in the formation of a formal and predetermined curriculum. The purpose of this study is to narrate the seven-year lived experiences of medical students in Mashhad University of medical Sciences about the factors constituting the hidden and null forms of their curriculum.
Methods: This research was conducted with the qualitative method of content analysis through 1- Semi-structured personal interview with students of different basic and clinical levels of medicine, 2- Performing two-group interviews(Focus Group) 3- Reviewing and analyzing the content of all medical students’ logbooks, the section which is about the expression of experiences, criticisms and suggestions from attending different wards of the hospital and clinical training by using Graneheim and Lundman method in data analysis.
Results: After analyzing individual and group interviews as well as analyzing students' logbooks, 942 initial codes were obtained. The codes were classified in 11 main classes with the following titles: Existence of specific educational plan, content materials and educational resources, master's pattern model, student role, teaching method, assessment method, teaching and learning strategies in the environment, the role of area, location, equipment and infrastructures, teaching time, gender composition and mixing, and the atmosphere governing relationships and the environment.
Conclusion: In this study the factors that formed the hidden and null experiences of medical students were examined. The students expressed their experiences and their role in learning 11 dimensions. This demonstrated that attention by politicians, policy makers, and managers can create an environment full of dynamism and education.

Keywords


Introduction

There are three types of curricula usually considered in the process of designing, producing, and performing formal curricula: Intended, Implemented, and Learned (1). The intended curriculum refers to the goals, desires, policies, content, and methods of teaching-learning and assessment methods which is announced by regulations, guidelines and approved curricula (2) and higher education system and its subset universities are required to implement it. However, the implemented curriculum contains students' experiences and various learning activities in order to achieve the curriculum (3). The learned curriculum is a set of learning process that takes place through implementing the curriculum (4). With a little care the present researchers noted that there is a difference between what is intended and what is eventually learned from one university to another one, one field to another field, and even sometimes from one entry to another entry. Unique differences arising from students' lived experiences become more important when we realize that a set of learning experiences students acquire in the university educational system is not limited to the obvious curriculum, so other important factors such as the hidden and null curriculum play an important role in the formation of their educational and professional experiences too.

The hidden curriculum in the medical educational system has become more and more complicated due to the type of education (basic and clinical), the duration of study, staying in the educational system (7 years), different educational places (classroom, hospital, clinic, and dormitory), the need to attend different environments and experience multiple interpersonal relationships (college, class, hospital, standbys, shifts, communication with professors, classmates, communication with higher students as their supervisors at the beginning of clinical work, and communication with medical staff including nurses communication with patients.

The importance of a null curriculum is that it draws the attention of curriculum's decision makers to reflect on what has been removed from an obvious curriculum. In this regard, the dynamics of the curriculum will be maintained and the curriculum is saved from falling into the trap of tradition and habit. On the other hand, with the help of identifying a null curriculum, it is possible to decide on a new curriculum or analyze the current one (5). As a result, it is especially important to pay attention to the lived experiences of medical students as hidden and null factors that shape the curriculum.

Most of the students' learning process and their experiences are the result of their dynamic interaction with culture or a set of communications, relationships, rules and regulations, as well as the prevailing atmosphere in the learning environment which is one of the undeliberate, unintended, and mostly valuable, normative, and attitude-based types of learning and is considered as a part of the hidden curriculum (6).

Due to the role of the hidden curriculum in the field of values and ethics, it is very important to study and pay attention to the hidden curriculum, because in the process of training a physician, in addition to the knowledge and skills being necessary to be engaged in this profession, attention should be paid to the development of values, attitudes, moral norms, social skills, and other characteristics that shape the human behaviors or professional skills.

The values and principles that students have at the time of entering the university will normally change during their studies at the university. Some research also suggests that unprofessional and unethical behaviors, especially in clinical education, indicate a complex dimension of negative hidden education in the medical curriculum. The multiplicity and complexity of the medicine students require a sense of responsibility, accuracy, and consciousness, since any shortcomings in the training of medical groups will certainly affect the quality and quantity of health services and eventually the health of a society.

According to the mentioned points, it seems that the hidden curriculum is the most powerful way to transfer the values of professionalism in medicine learners; therefore, it is necessary to examine the role of the hidden curriculum and its positive and negative effects through which the hidden components of the curriculum will be recognized, and the null layers of the obvious curriculum will be achieved.

One of the issues compromising the effectiveness of a curriculum is the existence of a gap or lack of an alignment between the intended curriculum as well as the knowledge and skills gained by students and graduates.

Considering the results of other research conducted in the country, it is noted that not only in the pre-diploma courses but in the university courses the mismatch between the intended, implemented, and the learned curriculums is clearly seen (7-9). Since the curriculum development system in our country, even in universities, has a centralized method and at the same time this centralized curriculum design system does not use the optimal and targeted combination of curriculum experts in curriculum development, the curriculum planning and educational evaluation specialists are either null or very insignificant. It is because the key role in designing the curriculum of the fields as well as the contribution of the education are played by the content of the field and the educational orientation specialists. As a result, this approach ignores the factors that shape the curriculum and creates a deep gap between planning and the way of its implementation. Of course, this gap will never be completely filled, but by identifying the factors that shape it, we can take a step in the direction of an educational positive guideline in the field of communication policies.

The inconsistency in the results of these three programs (intended, implemented, and learned) draws the attention of each planning expert to hidden and null programs in the learning environment, programs that result from the lived experiences of students, professors, and those involved in the education system as the previous research has examined and confirmed these points from different dimensions:

In a research, Safarnavadeh and Fathi Vajargah (1387) tried to answer why educational centers do not teach some topics with considering the application aspects of the null curriculum concept through adapting it to specific resources and texts of curriculum and resources related to the medical education (10).

Yamani (1388) suggested the seven areas of professionalism including: Implicit professionalism training, obvious education, professionalism teaching methods, modeling of professors, monitoring, evaluation and systematic monitoring of students and professors in order to improve the situation (11).

Some researchers have also focused on the role of hidden curriculum components (Architecture and quality of the faculty or university building, social and official structure of the faculty or university, the interaction of science committee and students, and the interpersonal relationships of students with staff and with each other) in strengthening students' scientific identity (12).

In a qualitative study, the qualifications needed to train general medicine students for lifelong learning were described: Awareness and attitude towards the dynamics of science and medical knowledge, flexibility against the changes in knowledge and science, being up to date and mastering basic and specialized knowledge, having a positive attitude towards learning, self-learning skills, study skills, creativity and innovation, time management skills, reflection skills on performance, evidence-based medicine skills, communication skills to participate their scientific findings, skills to participate in social networks of medical experts and fluency in English, combined and interprofessional learning skills, basic and clinical science knowledge skills, interprofessional learning skills in the workplace (13).

In a research, Fathi Vajargah and Bozorg demonstrated that the discussion of higher education and the hidden curriculum regardless of the culture series would be an incomplete effort due to the different characteristics that each group of students has due to their presence in that field and internalizing its special features. On the other hand, discussing about the physical environment, space, understanding it, and its impact on humans regardless of norms, values, interests, or in other words, cultural or social emphases including community series will have fewer results. Therefore, since higher education is the basis of the various community series in which everyone has its own culture; it is necessary to interpret the lived experiences of students in identifying the hidden messages derived from this culture (14).

However, the development of professional ethical values of medical students can be influenced by the quality of role models and the experiences they meet during their studies (15), and perhaps nonprofessional performance can be managed by controlling emotions (16).

Therefore, considering the content provided, it should be admitted that several research have been done on the hidden and null curriculum separately. However, a closer look at this issue reveals that attention to research on these issues in different schools of our country has a longer history, and in recent years, more attention has been paid to academic environments. At the same time, these studies are very few in Iran’s medical universities and specifically have not been studied at Mashhad University of Medical Sciences in the field of medicine. More important point in conducting this research is a special attention to the hidden and null curriculum as a comprehensive study by understanding the necessity of conducting such research. In fact, this study aims to answer the question of what the hidden and null factors that shape the curriculum based on the lived experiences of medical students at Mashhad University of Medical Sciences are.

Methods:

This research has been done with qualitative content analysis method and using several sources. The interviewees were randomly selected by snowball method. In addition to being a student or a medical graduate of Mashhad Medical Faculty, the criterion for entering the interview and selecting people was the willingness to participate in the interview along with completing a conscious consent form and cooperation in expressing their lived experiences. The criteria for leaving the interview was being as guest or transfer students and those who do not intend to change their fields.

The tools for achieving the components were open questions in the form of a researcher's framework, semi-structured interviews about the hidden and null curriculum, and the reported text from the students' logbook system. Due to the fact that the research is qualitative, the variable studied in this study was not known from the beginning and it was derived from the text of individual and group interviews as well as the text reported from the content of students' logbooks. The interviews continued until the saturation level was reached. After implementing the concepts in the interviews and reports based on the connection with similar topics, they were classified and categorized and then continued with central and selective coding. If, at any of the coding and analysis stages, the researchers discovered new aspects (variables) which needed to be re-studied, they would return to the data collection stage and continue the interviews and checking reports to reach saturation point. Details of the studied sample are given in detail:

1- Semi-structured individual interview with students of different basic and clinical levels of medicine: 8 participants

2- Performing two focus group interviews: A group of 9 students from different basic, externship and internship students, a group of seven medical graduates

3- Reviewing and analyzing the content of the writings of 984 medical students in the field of expressing their experiences, criticisms and suggestions from attending different wards of the hospital and clinical trainings in the academic year of 1396-97. There were over 1600 reports in the field of experiences.

The analysis of the data in the present study was done according to the type of research based on three stages as follows:

In the first stage, which was related to the qualitative part of the research, all the conversations were typed completely after each interview session and a focused group discussion. Then the typed texts were entered into the Max QDA software and the data were managed and coded using this software. In order to interpret and analyze the data entered into the software, qualitative content analysis method was used. In this way, the codes and contents were identified through the systematic classification of data. In data analysis, Grenheim and Landman methods were used, which its steps are given in table 1.

Table 1. Stages of research data analysis based on the Grenheim and Landman model

Stages

Activity

Starting Point

Implementing conversations and extracting log reports

Stage 1

Reviewing the prepared texts several times

Stage 2

Extracting semantic units from texts

Stage 3

Creating codes based on summarizing semantic codes

Stage 4

Reviewing the codes once more, comparing them with each other, and creating exclusive contents

Stage 5

Comparing sub contents with each other and with the main text in order to create exclusive contents

Stage 6

Independent analysis of texts by two researchers and discussion of content and achieving consensus on contents

 

Based on this, the obvious and hidden concepts were defined, coded, summarized and classified according to the participants' descriptions, and then the main contents were extracted. The codes were based on semantic units adapted from the participants' descriptions and they were categorized based on similarities and differences. To increase the accuracy and ensure the correctness and strength of the data collected at this stage of the study, four criteria proposed by Lincoln and Goba were used, including acceptability, generalizability, reliability and verifiability. To this end, the researcher tried to provide real data by spending enough time to collect data through proper communication with participants. Participants' review methods were also used to confirm the accuracy of the results and their agreement with the findings. In addition, to ensure the acceptability of the data, the implemented conversations, codes, and results were provided to three other researchers who were experts in the field of subject and methodology in order to obtain additional opinions which had a similar understanding. In order to investigate the similarity that is similar to stability in quantitative research and in fact indicate the stability of data in the same time and situation, the text of individual and group interviews and log reports were given to two persons randomly who were as foreign observers and had no connection with the research. Similar results were obtained. Of course, it should be noted that in qualitative methods, the emphasis is on the exclusivity of experiences and views, and even when all the same conditions are created, we should not expect the similar results completely. In order to ensure the generalizability of this study, efforts were made to select participants with maximum variety in terms of characteristics such as gender, age, year of entry, etc.

Results:

 The findings of the present study are based on the content analysis of eight semi structured individual interviews with first to seventh year medical students, two group interviews (a group of 9 students from different grades of basic, externship and internship, a seven-member group of medical graduates) and the study and analysis of the content of the transcripts of 984 medical students in the field of expression of experiences, criticisms and suggestions amounted to 1600 statements of experience and comments from attending different wards of the hospital and clinical training which were obtained in the 97-96 academic year.

Table 2. Number of sample groups

Target Group

How to Collect Information

Number

Graduates

Focus Group

7

Basic, Externship and Internship Students

Focus Group

9

Individual Interview

8

Medical Students Transcripts (Logbook)

Review and Analyze the Content of the Transcript

984

 

In data analysis, out of 942 codes, 11 main classes were extracted, each of which has several sub codes in its subset. The following is a description of some participants’ experiences in each area:

1) Existence of a specific educational program and its correct implementation:

One of the main issues in the formation of the curriculum from the students' point of view was the existence of a specific curriculum and its proper implementation, which mostly included the null aspect of the curriculum. The experiences of students were as follows:

 2) Curriculum's Materials, Content and Reference Resources:

Materials, content and reference resources of the curriculum have always been one of the most important factors in the formation of the curriculum, which is null in various aspects, and ignoring its importance will be toward the detriment of graduates of a university and eventually the society. The students' statements were divided into several subcategories:

2-1. Deleting or not teaching the essential content

2-2. Using up to date materials, content and resources

2-3. Using reference resources and references

2-4. Paying attention to the needs of society

For example, students stated:

 3) The Role of Professors:

The importance of the role and position of teachers in teaching and learning is not hidden from anyone point of view; however, what adds to its importance is the extent of the hidden influence of teachers in the education system.

Students acknowledged the hidden impact of the professor's performance on themselves in two dimensions: 1- Guidance and modeling and 2- Professionalism on bedside and clinic education, each of which covered different dimensions. They are listed in table 3.

Table 3. The Role of the Professor as a Factor in Shaping the Curriculum

Group

Main Codes

Sub codes

The Role of the Professor

Guidance and Modelling

psychological, moral, social and religion personality

Type of discipline and coating

Counseling and modeling

Observance of cultural and social issues

Performance-based Guidance and learning

Training in the field

Guide your future career

Scientific identity and learning academic behavior

Ability to make clinical arguments and make the right diagnosis and take timely action

Professionalism on Bedside and Clinic Education

Contact the health care staff

Communication with the patient and companions

Communication with the community and social responsibility

 

 "In the university, if you are only going to pay attention to the lessons, you will grow one-dimensional. It's not a matter of not having time. We were high school students and we thought we wouldn't have much time; however, we entered the university and faced lots of books. So, it is not correct to say we don't have time. If we study for even 24 hours, the books may not finish, but the way you study is more important. No one teaches you the right way to study. For example, one of the professors told us that you have to change the way you study for the purpose you have. This means that the study model is also important.>

 5) Teaching method:

The professor's teaching style, attention to students’ learning, the importance of time management in the classroom, scientific mastery of the content of the lesson, the power of transferring concepts, the ability to correlation between basic and clinical lessons, managing interactions and behavior in the classroom were the most important concepts mentioned by students. The followings are some examples:

 <It's very important that the teacher gives you a general view of a lesson, so he can use different methods like writing something on the board or using a film, or asking questions from students.>

 <In a class at 2 o’clock in the afternoon everyone is sleepy and doesn’t understand anything. It seems that they only want to harass if they hold a class at that time.>

 < At noon, some professors, instead of coming and teaching, prefer to have tea and do not attend the classes on time, but if the student arrives a few seconds late for class because of having lunch or using the self-service, they won’t allow him to enter the class or they consider it as a delay, so they cut some points of his final score.>

 10) The role of gender mixing:

In our country's education system, gender segregation is applied during 12 years of general education, and the only point of confrontation between the two sexes while studying is entering the university environment. This can lead to negative conflicts and thoughts about any kind of scientific, correct, and logical relationship between a girl and a boy. What most students experience when they enter university for the first time is answering internally to their WHY questions as well as their BUTs and IFs about this relationship. This becomes even more apparent when the city of study, according to students, has a religious environment. However, the passing time and being together for seven years as well as the content of the lessons have caused this issue to be faded gradually. Also some students have pointed to more free and easy behavior of their classmates over time:

  

11) The atmosphere of relationships, classroom, university, hospital, and clinic:

The atmosphere dominated in universities has relatively a stable quality of the educational environment. This is resulted from the efforts, relationships and interactions between the internal groups of the university, officials, professors, staff and students. The final consequence of these interactions is the formation of values, beliefs and social norms of the university system. The interaction between learners and the social environment is also important (17).

Treating the students as worthy people is very important. If learners are treated like robots, it is feared that all their emotions, interests, and attitudes toward education, academia, or any kind of educational environment will be negative and this will create a condition for intellectual stagnation, so the learning won’t take place in the true sense of the words (18).

In this study, students have repeatedly mentioned the hidden role of the present atmosphere in attitudes, motivations, their perception of future careers and decisions, competitive learning, discriminatory view, lack of meritocracy, and lack of justice. 

Discussion:

In this study, we discussed the factors that form the hidden and null experiences of students in the field of medicine in 11 different topics about their experiences and the role of these 11 topics in what they have learnt. “Existence of a specific educational program and its correct implementation, curriculum's materials, content and reference resources, the role of the professor, inclusive role – student, teaching method, method of measurement and evaluation, strategies and methods of Teaching-Learning, space, location, bedding of equipment, resources, and infrastructure and procedures, training time, the role of gender mixing, and the atmosphere of relationships, classroom, university, hospital and clinic”

For example, students shared their experiences with the null role of having a specific curriculum and its proper implementation. From Myla’s (2010) perspective the curriculum is an open question. According to her, curricula are a set of theoretical and specialized components of knowledge for human progress which should be according to reality (19) (practical components), so the interpretation of materials, content, and reference resources of the curriculum become particularly important because it considers the university as a precious and at the same time vulnerable and fragile commodity that is committed to transferring the best accumulated human knowledge to students (20). The students also spoke about the important and vital role of resources and content in the curriculum and the consequences of neglecting it in the future of community health. On the other hand, the students mentioned the effective role of the teacher as a hidden curriculum. The role of pivotal and professionalism of the professors in numerous researches is seen, Harris and Sass (2011), Bergen Henegouwen (2009), Marzooghi and Amini (2015), Seyed Majidi, Maryam and coworkers (2016), Mosallanejad (2014), Ahmadian (2014), Yamani, Nikoo (2009) (21-27).

The learners have a null role in the formation of the curriculum because the curriculum is always known by its content, resources, and teacher. Paying attention to the students and their individual needs is something that, at best, is vaguely and indefinitely assigned to professors. Students pointed to different learning styles, motivations, their abilities, and their role in self-efficacy in form of experiences. This has been approved in some research such as Parejas (2001), Rahnama and coworkers (2017), Dibaj nia (2005), Amin khandaghi and Rajaie (2013) (28-31).

Teaching methods, learning strategies, and training time on one hand can create a spirit of passivity, frustration, superficiality, and struggle to memorize like parrots and even cheat, and on the other hand, they can cause enthusiasm for learning and creativity and innovation. All these depend on the teachers’ teaching style and behavior in the classroom, their scientific mastery of the content of the lesson, the power of conveying concepts, and managing interactions and classroom behavior (32) .In this study, students paid special attention to different aspects of teachers’ teaching, as previous researchers such as Alizadeh Nayyeri and Adib (2013), Amini and Coworkers (2012), Sobhani Nejad and coworkers (2014), Taghvaie, Yazdli and coworkers (2013) (Safavi, 1994) (Vogt & Rogakka, 2009) also got the same result (33-38).

Measurement and evaluation method:According to the findings of this study, students pointed to the lack of skill assessment and the use of new assessment methods (39). The results of most studies confirm the role of measurement and evaluation in the hidden curriculum, such as Sobhani nejad and coworkers (2014), Taghvaie, Yazdli and coworkers (2013) (40,41).

Certainly, standardization of educational space, attention to the equipment and infrastructure needed for education, monitoring of the education cycle and patient-physician relationship in clinical settings, and students' welfare facilities play an important role in perceiving and building students’ positive or negative mentalities and as a result the formation of a hidden academic curriculum that isn’t hidden from students’ point of view. The following studies also confirm this: Fathi Vajargah & Bozorg (1391), Strack, Fritz & Deutsch (2004), Noorzadeh & Fathi (2009) (42,43,14).

About the role of gender mixing: Universities and higher education centers of every society represent and reflect the highest thinking and knowledge of that society, and manifest the principles of worldview as well as belief and value system of the society; however, studies show that in universities, especially with different cultural contexts and unfamiliar environment, students face social problems but they constantly adapt to these differences. One of these problems is the relationship between boys and girls at universities. The students also implicitly referred to the harms of these relationships and cited the freer relationships between the sexes as a hidden harm.

It should also be mentioned as the last discussion raised in this research:Most of the students involved in the research focused on the relationships between different educational, clinic settings, and the mentalities that each of these relationships and educational spaces create in them. For a student, it seems that the most tangible experience in a university is the atmosphere in educational and therapeutic spaces, because as a medical student, they spend most of their lives in the heart of these relations and spaces. They closely monitor intra-group and interpersonal relationships between the classmates, professors, and staff. They respond to that to the extent that the poor quality of these relationships makes students bored with the learning process, so it will lead to disruption of their abilities and will create an unfavorable attitude towards the educational processes of the university. Their judgment in this matter shapes their attitudes toward educational justice, discrimination, meritocracy, competition, or even the cultivation of critical thinking or teamwork.

Considering that critical thinkers are pioneers of change in society because they never see the future of their society, it is to be hoped that efforts to improve or correct the present relations, the atmosphere and the judgments that result from them, play a key role in reducing negative attitudes and creating better experiences in the academic environment.

Research strengths were:

1. The present study has dealt with the hidden and null dimensions of the curriculum at the same time, while the previous research examined only one dimension.

2. No research has been done on this issue in Mashhad University of Medical Sciences.

3. The content analysis approach and the Granheim and Landman’s method are powerful methods in collecting and analyzing data.

4. Since the present research is a subset of a more comprehensive research called " Analysis of the hidden and null curriculum in medical sciences in order to design a practical model according to the packs of evaluation and innovation plan " In which the final goal is designing patterns based on transformation and innovation plan, it is one of the main strengths of this research.

The limitations of the research were:

1. Sampling of the research was performed based on the snowball model which is non-random. However, in selecting the prototype, the researcher tried to cover the diversity of students in terms of year and level of students (basic sciences, internships and graduates).

2. The scope of research does not include all fields of study in Mashhad University of Medical Sciences.

Ethical considerations 

Ethical issues (Including plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc.) have been completely observed by the authors.

Acknowledgments

We would like to thank all the respectable participants who helped us advance this research by providing their valuable experiences.

Financial Support

This article is the first in a series of a PhD thesis at the Islamic Azad University of Roudehen which has been implemented with the ethics code of IR.MUMS.REC.1398.032 at Mashhad University of Medical Sciences.

Conflict of interest:

The authors reported there is no conflict of interest in connection with this article.

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