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Infusing Curricula with Humanity

The curriculum is so much necessary raw material, but warmth is the vital element for the growing plant and for the soul.

—Carl Jung, 2014, p. 17

Curricula refer to different educational and instructional practices. A curriculum, the singular form of curricula, is a formal plan of study that provides the philosophical underpinnings, goals, and guidelines for delivery and evaluation methods that a specific educational program will implement (Keating, 2015).

In his seminal article “What Is Curriculum?” Egan (1978, 2003) explained that the word derives from the Latin currere, which carried directly over into English, and means “running a race [or a] course,” with a secondary meaning of running around a racetrack (1978, p. 10). The metaphor of running a race suggests that curricula, like racetracks, have predetermined structures clearly in place. Curricular structures include explicit plans for learners to interact with instructional content and processes and for evaluating the attainment of educational goals.

In higher-education settings, the academic content of a curriculum is a foundational element of most learning experiences. Additionally, an informal curriculum—the activities that students, faculty, administrators, staff, and consumers experience outside the academic curriculum—is part of the overarching curricula in higher education. Examples of an informal curriculum include interpersonal relationships, athletic/recreational activities, study groups, organizational activities, special events, and academic or personal counselling (Keating, 2015). It is important to note that about one of every two undergraduate students at Canadian universities is taught by contract staff not generally involved in planning either the academic or the informal curricula at their institutions (Ellis-Hale, 2017).

In the health professions, curricula are profoundly influenced by the requirements of professional associations, regulatory bodies, and approval boards. Curricula must address discipline-specific competencies (Melrose, Park, & Perry, 2015). To achieve these competencies, partnerships with health-care agencies are usually required. In turn, agency structures exert influences on curricula. Furthermore, the “hidden” curricula (the customs, rituals, and taken-for-granted aspects of education in the health professions, particularly those that learners experience during interactions with faculty and clinicians in practice settings) also affect educational experiences (Hafferty, 1998; Hafferty & Franks, 1994; Hafferty & O’Donnell, 2014; Mahood, 2011).

Infusing the varied influences of academic, informal, and hidden curricula with humanity can make a substantial positive difference to pre-service and in-service learners in the health professions. For many learners, the memory of how a teacher brought a course outline or learning activity to life outlasts what the course required. In health professional education, many elements of the curriculum are mandated by professional associations and other governing bodies. At times, this required content can seem to be mundane and even uninspiring. The challenge for educators is to help learners see that knowledge of these elements becomes part of who they are as caring and competent practitioners. Students who acquire this required knowledge and come to know the governance and historical backdrops to their areas of practice are more fully prepared to provide comprehensive care experienced as humane. Educators skilled at infusing even the most tedious educational content with a sense of the human provide students with both knowledge (the what) and a positive sense of being taught by a humanizing educator (the how).

In this chapter, we begin by presenting a historical backdrop to illustrate how curricula in health professions education has evolved. We focus on the critical role that professional associations played in this transformation. Next, we discuss the influence of governance structures on curricula, introduce the Tyler (1949) academic curriculum model, and provide a snapshot of aspects of informal and hidden curricula that can influence learners’ experiences.

HISTORICAL BACKDROP

The philosophical underpinnings that guide curricula in specific health profession programs often evolved because of historical shifts and legacies that shaped higher education in general. These legacies can still be seen in academic curricula. Understanding connections with the past can help to clarify and evaluate present-day practices. In this section, we describe a select group of Canadian postsecondary educational and instructional practices at different times.

Service for Training

Health professionals were not always educated in universities. Many acquired their skills by providing services or unpaid work to organizations in return for an education. Known as “service for training,” this historical curricular approach was common. In Canada, in the early 1900s, higher education consisted of only a small number of provincially funded universities and private denominational institutions. Many of these institutions relied on financial donations from patrons. Postsecondary educational institutions were not-for-profit organizations, served an elite fraction of the population, received only modest levels of provincial government funding, and operated with considerable autonomy (Jones, 2014). Each university had a unique University Act approved by the provincial legislature.

Physicians. University faculties included science, arts, theology, and only later medicine. Historically, education for physicians and other health professionals, including nurses, was provided by hospitals. Curricula were grounded in an apprenticeship model in which training was provided in return for service (Canadian Association of Schools of Nursing, 2012; Wytenbroek & Vandenberg, 2017).

In 1910, a landmark examination of medical schools in Canada and the United States, known as the Flexner Report, resulted in the closing of all hospital schools of medicine, and universities became responsible for the education of physicians (Flexner, 1910). Once physician education became integrated into university settings, schools of medicine shifted away from service for training approaches and embraced the scientific knowledge inherent in a biomedical curricular model (Duffy, 2011).

Nurses. Shifts away from service for training curricula did not come as readily for registered nurses (RNs) and other health professionals. Schools of nursing were housed in hospitals, which relied heavily on student nurses to provide care for patients. Curricula often revolved around staffing needs, and the educational needs of students inevitably took second place to hospital workforce requirements.

Hospital control over educational practices made it difficult to establish national standards for schools and their graduates (Pringle, Green, & Johnson, 2004). RN leaders began to look for opportunities to affiliate schools of nursing with Canadian universities as early as 1905, with the first baccalaureate degree program opening in 1919 (Canadian Association of Schools of Nursing, 2012).

However, hospital diploma programs were viewed as a fiscally prudent solution to ongoing nursing shortages and government funding deficits, and enrolments in hospital-based programs surged. In 1962, despite repeated efforts by professional organizations to integrate schools of nursing into universities, only 148 students graduated from baccalaureate degree programs, whereas 6,000 RNs graduated from hospital diploma programs (Canadian Association of Schools of Nursing, 2012).

A university education was not seen as a typical path for all nurses. Rather, the small group of nurses who attended university usually practised upon graduation in leadership roles, such as teaching or supervising, or worked in public health (Kirkwood, 2005). Teachers in hospital programs were referred to as instructors and generally held a baccalaureate degree. They were expected to be expert clinicians capable of sharing their hands-on knowledge and skills with learners.

Teachers in university programs were referred to as faculty and held a master’s or doctoral degree. They were expected to engage in research. Although nursing students who attended universities were “educated,” those in hospital programs were “trained.” University communities often viewed nursing faculties as more suited to technical institutes, and in the 1970s there were too few faculty members to meet university standards for appointment (Pringle et al., 2004).

In 1965, a Royal Commission on Health Services report recommended that all nursing education come under the control of the educational institutions (Mussallem, 1965). This milestone report was instrumental in moving nursing education away from a service for training approach and toward university education as a requirement for entry to practice. The report recommended two categories of practitioner: professional nurses educated at universities and technical nurses educated in two-year college programs (Mussallem, 1965). Over the next three decades, hospital schools gradually moved into community college and university settings, with the last hospital-based programs closing in the 1990s (Dick & Cragg, 2003).

Professional nurses. To address the professional nurse category, universities offered basic and post-diploma programs so that both new and practising RNs from diploma programs could earn a baccalaureate degree in nursing (BN). By 2000, Canadian RNs were expected to hold a BN (Pringle et al., 2004). However, practice placements at hospitals and other clinical sites remained a critical element of university curricula. Therefore, though service for training had been eliminated, control over practicum placements remained with clinical agencies.

Technical nurses. To address the technical nurse category, programs for licensed practical nurses (LPNs)/registered practical nurses (RPNs) were created in vocational training sectors such as high schools, technical institutes, and hospitals. The title LPN is used mainly in western Canada, whereas the title RPN is used in eastern Canada. In other jurisdictions around the world, the title of vocational nurse (VN) or enrolled nurse (EN) is also used.

Programs for technical nurses were subject to top-down control from RN professional organizations or provincial/territorial ministries of health (Pringle et al., 2004). Early programs prepared graduates who would be “assistants” to RNs, and curricula were determined by RNs rather than LPNs/RPNs. Employing LPNs/RPNs rather than RNs was a cost-saving measure for health-care agencies, and in some instances they were viewed as replacements for hospital-trained RNs (Pringle et al., 2004).

By the 1990s, the Canadian Council for Practical Nurse Regulators, formerly the Canadian Practical Nurses Association, established an increased scope of practice, expanded curricula, and standardized examinations. Yet the legacy of “assisting” RNs rather than feeling as though they were “real nurses” persisted for LPNs/RPNs (Janzen, Melrose, Gordon, & Miller, 2013). Overlapping scopes of practice between LPNs/RPNs and RNs created ambiguity and role confusion.

Limited collaboration. Limited collaboration existed among programs educating the two groups of nurses (RNs and LPNs/RPNs). Curricula in LPN/RPN programs were viewed as content driven, skills based, and geared to preparing job-ready nurses, whereas curricula in university programs were grounded in theories from nursing literature (Butcher, MacKinnon, & Bruce, 2018). Although universities such as Athabasca University, Canada’s Open University, awarded transfer credits to LPNs/RPNs earning a BN (Athabasca University, n.d.), most universities required LPNs/RPNs to complete all BN program courses to earn a degree.

Organizational models attempted to ameliorate some of the tensions by differentiating among the responsibilities that nurses are expected to assume in the workplace. For example, one model, the Care Delivery Model Redesign, identified RN responsibilities as coordinating and providing care for the most acutely ill and unstable patients and LPN/RPN responsibilities as recognizing when patient outcomes are unpredictable and then transferring care to an RN (MacKinnon, Butcher, & Bruce, 2018). Even with these efforts, some role confusion remains in most workplaces.

Professional Associations

Historical shifts have contributed to influences on curricula for other health professionals as well as the physicians and nurses discussed above. Professional associations exerted significant influence on health professions curricula. Understanding how the professional associations evolved is an important aspect of learners’ socialization into their professions. When educators share examples of how this evolution affected required knowledge, they can help learners to view that knowledge as stemming from real people who made a difference to their professions.

Social workers. As Jennissen and Lundy (2011) note, the education of Canadian social workers evolved over the past 80 years from brief periods of instruction supported by colleges of theology. Prior to the formation of the Canadian Association of Social Workers in 1926, Canadian social workers were members of American organizations and heavily influenced by political and social events occurring beyond Canada. The formation of a Canadian national professional organization created a foundation for standardizing social work curricula and practices among the provinces.

Physiotherapists. Initially educated under the auspices of medical schools, physiotherapists at one time were able to practise only in hospitals and under the direction of physicians (Fornasier, 2017). Early physiotherapists, most of whom were female nurses, were known as “reconstruction aides” for their work supporting injured First World War veterans to rebuild wasted muscles and use prosthetic limbs (Evans, 2010). Later, during the outbreak of polio in the 1920s, physiotherapists’ groundbreaking use of massage and exercise treatments contributed to the treatment and rehabilitation of patients living with polio (Evans, 2010). In the 1950s, physiotherapy education moved away from medical schools and into independent schools of physiotherapy at universities (Fornasier, 2017).

Occupational therapists. Likewise, occupational therapists, known as “ward aides” in the 1920s, first practised under the direction of physicians in tuberculosis sanatoriums and mental hospitals (Prince Edward Island Occupational Therapy Society, n.d.). Early educational programs initiated in vocational training institutes in the 1930s later moved to universities in the 1950s and 1960s. As was the case with nurses, social workers, and physiotherapists, occupational therapists were slow to situate their education in universities. The formation of a Canadian national association helped occupational therapists to achieve standardized curricula and processes of accreditation and to become recognized as autonomous professionals (Prince Edward Island Occupational Therapy Society, n.d.).

Present-day academic curricula. Today many health professionals require university degrees at the entry to practice level. For example, RNs (Canadian Nurses Association, n.d.) and social workers (Canadian Association of Social Workers, n.d.) require a baccalaureate degree; physiotherapists (Canadian Physiotherapy Association, n.d.) and occupational therapists (Canadian Association of Occupational Therapists, n.d.) require a master’s degree. Professional associations have played a key role in ensuring that opportunities for a university education are now available to most health professionals. Stories of how professional associations moved people who cared for the sick away from service for training models of instruction and into universities can shed new light on curricular activities in which learners are required to engage. When educators invite learners to picture what a member of their profession might have looked like many decades ago, it can add a genuinely human element to information that might not seem to be immediately relevant.

In many instances, the current regulations, processes for approving programs, required curricula, and competencies expected of graduates imposed by professional associations have stemmed from past experiences of being subjugated by other professional groups or countries. Shifts away from service for training, the titles of assistant or ward aide, and the achievement of national standards did not come easily. Examining present-day academic curricula in relation to these shifts can provide valuable insights into why certain educational practices are valued more than others. Since most health professionals are now educated in universities, in addition to recognizing historical influences, it is important to consider how overarching university governance structures play a role in the instruction provided by specific programs. The strategy below can help educators to encourage learners to understand more about the historical backdrops that influenced their professions. Importantly, the activity reminds learners that real people (who had their own ideas, values, and beliefs) were the authors of the histories that comprise the foundations of their disciplines.

GOVERNANCE STRUCTURES

As the previous discussion illustrated, institutions that provided educational programs for health professionals, whether they were hospitals, universities, or other postsecondary institutions, exerted significant control over curricula. Governance structures dictated how institutions were financed and managed. In turn, these structures (and the people who worked and learned in them) affected specific programs. Next, we provide a brief overview of key governance structures common to most Canadian universities.

Bicameral Governance

Historically, postsecondary institutions, particularly universities, were governed under a bicameral structure in which the responsibility for administrative and fiscal matters was assigned to a governing board and the responsibility for academic matters was assigned to a senate or academic council (Jones, Shanahan, & Goyan, 2004). Governing board members were usually external to the university and appointed by the provincial government, whereas senates were largely composed of a select group of internal members such as academic administrators and senior faculty (Jones, 2014). The bicameral structure afforded external accountability and provided clarification of the separate responsibilities expected in university-government relationships (Jones et al., 2004).

After the Second World War, mainly during the 1960s and 1970s, systems of higher education, which included both university and non-university postsecondary sectors, expanded from an elite to a mass system as more and more people expected to obtain an education that extended beyond high school (Jones, 2013). In response to swelling enrolments at universities, provincial funding was supplemented by transfer payments from the federal government, though the provinces retained control of postsecondary institutions.

As individual postsecondary institutions became increasingly more dependent on government funding, their autonomy eroded significantly. Curricula in all programs were affected by funding decisions. Provincial governments increased their involvement in the institutions that they funded, resulting in frequent conflicts. Boundaries between responsibilities that politicians could undertake and those previously assumed by institutional leaders were seldom clear (Jones, 2014). Universities were no longer the not-for-profit institutions attended by the privileged few as they once were.

Accountability for public funding, and demands for more inclusive governance, led to lasting reforms of the bicameral board/senate model. The Duff-Berdahl Report called for more faculty, student, and community representation on university boards and senates (Duff & Berdahl, 1966). To increase openness and transparency, interaction and communication between boards and senates increased, and meetings previously held behind closed doors were opened to public observation (Jones, 2014). Since the 1970s, most Canadian institutions have continued to be governed by this reformed bicameral model.

Faculty Employment

Over the past five decades, mass attendance, governance reforms, and public accountability, particularly during times of economic downturn, also led to changes in the employment of postsecondary teachers. Faculty are employed either in full-time continuing positions or in part-time contract positions. At universities, full-time faculty are expected to engage in a combination of research, teaching, and service activities (Jones, 2014). For many full-time faculty, maintaining a robust program of research and publication accomplishments leaves limited time for creating teaching innovations or participating in curriculum planning. In turn, the critical tasks of developing, revising, and evaluating curricula might be done by only a small group of faculty members. If the team tasked with curriculum development or revision embraces the value of creating a humanizing curriculum, then the outcome can be courses and programs focused in this way. Alternatively, because in reality only a few faculty members usually undertake curriculum development/redevelopment, if they are limited in their humanizing focus, then the outcome can be an educational experience void of a focus on the humane.

Funding issues continue to dominate employment practices at postsecondary institutions. Labour cost efficiencies have been created by increasing the use of part-time contract teachers (Jones, 2013). It is estimated that more than half of all undergraduates at Canadian universities are taught by part-time contract faculty (Basen, 2014; Ellis-Hale, 2017).

Over the past decade, contract faculty have become the new majority at universities (Fitzpatrick, 2017; Gappa, 2008; Meixner, Kruck, & Madden, 2010). Part-time faculty contracts can offer positions such as limited-term full-time faculty (Rajagopal, 2004), part-time faculty, sessional instructors, term instructors (Puplampu, 2004), and adjunct faculty (Meixner et al., 2010). Many of these faculty “are paid per course taught and are seldom offered benefits such as health insurance or access to retirement plans” (Meixner et al., 2010, p. 141).

The trend toward employing short-term contract faculty “spotlights a new norm of precarious labor in academia” (Fitzpatrick, 2017, para. 2). At many institutions, part-time contractual and full-time continuing faculty are members of separate unions (Jones, 2014). Part-time contract faculty generally have limited opportunities to develop and evaluate the curricula that they deliver. In some sense, when individuals are unsure of how committed the organization is to them as real people with individual needs, likes, and priorities, they can experience their workplaces as dehumanizing. Creating a humanizing workplace is foundational to inspiring educators (and subsequently learners) to practise humanely.

Balancing Multiple Governance Structures

In Canada today, most universities are secular institutions reliant on provincial funding, though small private universities, often associated with a religious denomination, are allowed in some provinces (Jones, 2014). Other postsecondary institutions include public and private colleges as well as technical/vocational institutes. Programs for health professionals are offered at most of these different institutions, and students often transition between sectors.

Additionally, clinical agencies and professional associations offer staff development, continuing education, and certification programs, usually for in-service learners. Not unexpectedly, the structures governing individual institutions in each sector are very different. Infusing curricula with humanity while balancing the requirements of multiple governance structures poses a unique challenge to educators of health professionals.

Student attendance at multiple institutions requires educators in health profession programs to comply with a range of administrative and fiscal governance structures. Universities and clinical agencies have separate systems for governance and regulation. For example, at universities, where funding is dependent on provincial governments, politicians can determine that funding for a program will be reduced. Because staffing decisions are made by governing boards, a board of governors can require more part-time than full-time employment of faculty. A university senate committee, with responsibilities for academic matters, can provide input into practicum courses even when members of the committee are not health professionals.

Furthermore, the clinical agencies at which students complete required practicums are governed by health-care boards. Issues of patient/client safety, capacity to integrate learners, and funding cuts dictate the extent to which boards can support health profession programs. The structures governing the many different institutions where health professionals learn play important roles in the specific programs offered. In the next section, we provide an overview of a common curricular model frequently used to guide educational and instructional practices. Before reading about this model, consider ways in which you can find out more about the governance model at your institution. How does governance structure affect curricula and how you work with learners? The strategy below suggests a way to view governance structures as simply being a group of people.

THE TYLER ACADEMIC CURRICULUM MODEL

Curricula can be viewed as the plans or roadmaps that guide student learning. In academic or formal learning settings, curricular models can be used to represent activities expected of educators and learners. These models can be used to map activities at program, course, and even individual levels. Most programs make overarching outcomes expected of graduates available to the public; study guides or course outlines available to students and faculty involved in the course; and individual orientation/assessment activities available to the faculty, students, and clinicians participating in them. Curricula (especially in health professions in which there are continuous changes to elements such as medications, treatments, and procedures) are dynamic and require ongoing development, evaluation, and revision.

Various curricular models are implemented in programs educating health professionals. Iwasiw, Andrusyszyn, and Goldenberg (2018) emphasize the importance of evidence, context, and unity in any model of curriculum development. Neville-Norton and Cantwell (2019) highlight the value of collaboration and collective dialogue among faculty throughout the process of designing and delivering curricula. A full description of the complexities inherent in understanding and applying models to develop, evaluate, and revise curricula is beyond the scope of this chapter. Rather, we provide a brief introduction to the classic Tyler Model, which has guided educators in creating curricula in both general and health profession programs since the 1950s (Meek, 1993; Tyler, 1949). Clearly, there are many potential links between the curricular model endorsed by an educational institution and the nature of the curriculum designed. The model used helps educators designing courses and programs to make decisions about what is taught and how educators interact with learners. A more human-focused model should bring about a more humanizing curriculum.

The Tyler Model has been criticized for presenting a prescriptive, linear, and objective-centred approach that neglects the cyclical and constantly evolving nature of curricula (Hlebowitsh, 1992, 1995; Kliebard, 1970, 1995). Critical thinking, problem solving, and professional values can be difficult to articulate into behavioural objectives that can be measured. However, understanding the underlying principles of teaching that frame the model provides important and enduring guidance for educators in competency-based health profession programs (Cruickshank, 2018; Wraga, 2017).

Tyler (1949) identified four critical teaching principles to consider when creating curricula. First, determine the purpose or objectives of the program/course/individual activity. This principle requires educators to consider what learners need, and what they must do, in order to be successful. Standards and competencies required by educational institutions, professional associations, and national licensing boards must always be considered. The purpose of activities in programs or courses is also expected to be consistent with the needs of society in general. In health professions education, public safety is a critical factor in planning learning experiences, particularly those in which novice students/practitioners provide care to patients/clients. Furthermore, the purpose of all activities should be consistent with the philosophy of the school or discipline. In other words, links between learning activities and necessary disciplinary knowledge should be clear. As educators and learners work collaboratively through curricula, the purpose of the activities that they engage in should clarify both the behaviour or competency to be developed and the content to be applied.

Second, provide useful educational experiences to support that purpose. This principle calls educators to examine the design and content of educational activities in relation to the purpose of the program/course/activity. Contextual factors play important roles in providing useful educational experiences. For example, clinical practice opportunities differ between rural and urban areas. Some learners might not have access to pre-clinical skill labs and simulation equipment. Non-traditional clinical placements (e.g., at shelters for the homeless) might or might not align with course objectives designed for traditional clinical agency placements such as hospital units. Specific preparations for national licensing exams might be useful educational experiences that planners of curricula had not previously considered. Taking these and other contextual factors into consideration, the importance of educators and learners continuing to question whether an experience is useful, not useful, or in need of evaluation becomes clear.

Third, organize learning experiences to have a maximum cumulative effect. Here imposing a logical order on the content presented and the experiences in which learners participate is important. Individual learning activities should be organized in ways that demonstrate continuity, sequence, and integration into the courses and programs with which they are associated. Content and learning activities during the early stages of courses and programs should be less complex than at the later stages. Once again, the unique nature of education in the health professions poses challenges when providing activities that progress from less difficult to more difficult, especially in clinical courses. High-acuity clinical agencies limit educators’ ability to scaffold experiences in which learners first care for stable patients and then later, as their knowledge and confidence increase, provide care to very ill patients. In essence, this principle casts a spotlight on the importance of understanding student learning beyond activities in a specific course.

Fourth, evaluate curricula and revise ineffective aspects. Tyler’s (1949) model was designed to measure the degree to which predefined objectives and outcomes were attained. Therefore, this teaching principle involves the complex process of evaluating individual students’ learning as well as the curricular experiences with which they were provided. For example, information that students completed a learning activity and were able attain an objective would contribute to evaluation of their curriculum. Alternatively, information that some students were not able to attain an objective also contributes to evaluation of their curriculum. In this instance, part of the evaluation includes further investigation. Questions must be asked about the adequacy of the learning experiences provided, the individual student’s participation in those learning activities, the degree to which other students were/were not able to attain the same objective, and the methods of evaluation implemented to measure the degree to which the student was able/unable to attain the objective. In turn, these questions open the door to discussions about curricular revisions.

Although at first glance the Tyler Model might not seem to be especially compatible with deriving a humanity-focused curriculum, some elements of the model do aid in this outcome. For example, there is a focus on individual student learning. This is a recognition that each person is unique and might obtain learning outcomes at a pace or in a way unlike other learners. This recognition of individuality is humanizing. Tyler (1949) also emphasizes the humanizing principle of collaboration, working together respectfully to attain more than any one person could attain alone. The respect essential in true collaboration is predicated on a level of trust within relationships among collaborators. Trust is also essential in acting humanely. Finally, Tyler recognized the importance of context. Human lives are embedded in unique contexts, and recognizing the roles of context in lives, relationships, actions, and interactions is essential to behaving humanely.

Determining whether an aspect of a curriculum is ineffective and in need of revision is seldom straightforward. Inclusive, collaborative, and ongoing discussions among all of the educators and clinicians who teach students are necessary. Facilitating these discussions can be difficult when educators work in different academic or clinical institutions and have employment contracts that do not include curricular planning. The strategy below might be a useful starting point if you are considering evaluation and possible revision of a curriculum. It also provides a means to include student voices in this process, essential to forging a curriculum that embraces the value of all participants.

Educators’ and learners’ experiences with curricula are not limited to those outlined by academics through models such as the Tyler Model. Less formal activities also make significant contributions to what, and how, students learn. In the next section, we provide a brief overview of how informal curricula can influence learning in the health professions.

INFORMAL CURRICULA

Beyond the structured academic curricula that guide classroom and clinical practicum courses, students in the health professions are also influenced by informal curricular experiences that can contribute to their learning. Depending on institutional capacity, these informal experiences can include opportunities to interact with faculty and fellow learners, support/counselling services or help centres, sport and fitness programs, religious/cultural gathering places, and children’s daycare, to name just a few. Unfortunately, clinical agency requirements and busy schedules can limit participation in some of these experiences.

Clinical agency requirements in off-campus practicum courses include early morning, evening, and weekend shifts, making it difficult for learners to take advantage of support services and participate regularly in extracurricular activities. Clinical agencies are often unable to accommodate student requests for changes to the days or times that they are scheduled to attend their placement sessions. Learners must be supervised by clinical instructors or preceptors, and most clinical sites host students from multiple programs, so placement spaces are restricted and often scarce. This can greatly affect whether or not students experience their practice learning experiences as humane.

Hectic schedules sway students’ thinking in relation to informal curricula that they perceive as optional. Learners in health profession programs include both traditional and non-traditional students. Traditional students are those who recently graduated from high school. Non-traditional students, also referred to as mature students or adult learners, are over 25 years of age. They might have one or more of the following characteristics: they have delayed their postsecondary enrolment or are returning to their studies, have one or more dependants, attend school part time, and/or are employed full time (Ross-Gordon, 2011).

Since 1996, nearly 70% of all undergraduate students also possess at least one non-traditional characteristic (National Center for Education Statistics, 2015). Academic demands, full schedules, and family/employment commitments can limit the time that students spend engaging in activities not directly related to program requirements. However, two key areas of informal curricula are of particular relevance to health profession students: opportunities to interact with faculty and fellow students and support services for language learning. These elements of the informal curricula are often the essentials that humanize learning experiences for students.

Opportunities to Interact with Faculty and Students

Times when students can informally interact and connect with their teachers and one another can bring content to life in new and exciting ways. Interpersonal relationships between students and their teachers are highly valued (Collier, 2018). These relationships create opportunities in which educators can reveal their own processes of thinking critically, and they allow educators to model problem-solving approaches (Raymond, Profetto-McGrath, Myrick, & Strean, 2018). Similarly, peer relationships have been shown to develop students’ skills in communication, critical thinking, and self-confidence (Stone, Cooper, & Cant, 2013).

Despite their value, opportunities for informal interactions to occur among faculty and students can be overshadowed by the demands of academic curricula. Faculty schedules, like student schedules, are often hectic. Teaching in multiple institutional and clinical settings can leave faculty with only limited time for impromptu hallway conversations, after-class question-answer sessions, pre-/post-assignment discussions, and bedside patient/client debriefing reviews with individual students.

Part-time employment categories can stipulate the times when, places where, and planned activities in which contact with students occurs. Full-time faculty committed to research projects might have fewer teaching responsibilities, leaving them with infrequent opportunities to interact with students. When clinicians interact with students, their priority must always be their patients/clients, and interruptions during conversations with learners happen frequently as clinicians are called away to provide patient/client care.

Educational institutions can implement student success centres in which call centre models respond to common student questions and concerns. Such centres were initially developed to improve student persistence and program completion, but there is considerable variation in how they are managed across educational sectors and by individual institutions (Smith, Baldwin, & Schmidt, 2015). For institutions that implement call centre models, teaching time can be managed efficiently, and responses to students can be expected to be prompt, consistent, and accurate. Nevertheless, once student callers have answers to their questions, further dialogue and spontaneous conversation (which can be humanizing) are unlikely.

Peer interactions often occur naturally among students before, during, and after shared learning experiences. Gathering spaces where students can come together to debrief activities, form study groups, and share strategies are an important aspect of informal curricula that should be cultivated. When physical spaces in educational institutions or clinical facilities are not available, students can meet at nearby coffee shops or on video conferencing call programs. In online settings, students also value having gathering spaces in which they can discuss common interests and support one another (Melrose, Moore, & Ewing, 2013). Creating spaces for informal peer interaction, and encouraging learners to use them fully, can easily infuse humanity into curricula. The following idea emphasizes the importance of creating opportunities for interactions with students by establishing office hours.

Language Learning Support

Another key area of informal curricula relevant to health professions education is language learner support. Like most students in developed countries, Canadian postsecondary students come from a variety of educational and socio-cultural backgrounds with as many as 22% needing explicit support with language learning (Brancato, 2016). In health professions education in predominantly English-speaking areas of Canada, challenges that many English as a Second Language (ESL) students face include difficulty communicating effectively with patients in English, inability to succeed academically throughout their programs, and struggling to pass national licensing exams (Choi, 2005, 2016).

Learners are expected to be proficient in the language used by the institution that they are attending, whether it confers degrees, diplomas, certificates, or continuing education credits. When institutions have the capacity to provide services for language support, it is essential to ensure that students who need them have opportunities to access them. When institutions do not provide this support, explore other resources in the community that learners can access. The strategy below suggests how you could achieve this.

HIDDEN CURRICULA

Implicit Messages

Hidden curricula are the implicit messages about values, norms, and attitudes that learners infer from the role models and structures that they observe around them (Hafferty & Franks, 1994). Educators do not intend to communicate these messages, and they are often unaware of their existence (Cowell, 1972). Dewey (1938) used the term “collateral learning” to describe hidden curricula.

At the institutional/organizational, interpersonal/social, contextual/cultural, and motivational/psychological levels, these implicit messages shape how learners make sense of the environments that surround their learning (Lawrence et al., 2018). When institutions fund some programs but not others, when educators spend time discussing a specific topic, when clinicians pay attention to a particular condition/illness, and when a certain behaviour is acknowledged with awards or promotions, learners inherently draw conclusions about the highly valued aspects of their profession.

Similarly, vision and mission statements might espouse a value, but ways of speaking or “institutional slang” used at the institution can suggest that the value does not translate fully into practice (Hafferty, 1998). As Semper and Blasco (2018, p. 11) emphasize, transmitting values important to disciplines, institutions, and programs through explicit official documents such as statements on mission, vision, and values is incomplete “because it is the teacher who teaches, not the official documents.” Educators are essential in helping learners to understand and internalize the visions and missions of the organizations in which they study and practise and in guiding students to enact the associated values.

Logically, when implicit messages, rewarded behaviours, and organizations’ missions, visions, and values are humanizing (or promote the humane), all participants are made aware that these types of relationships are the goal and valued more highly. To create a humanizing educational institution, program, or curriculum, the first step might be to infuse the hidden curricula with the same elements.

Parallel Education

As learners begin their programs, they receive what Chen (2015, p. 7) refers to as a “parallel education in professional socialization” through hidden curricula. Their parallel education or hidden curricula “does not explicitly dismiss or contradict the formal . . . curriculum. Rather, it runs subtly alongside or underneath the formal curriculum, and permeates its interstitial spaces” (p. 8). As Chen notes, hidden curricula vary from discipline to discipline and among programs, depending on the history, culture, structure, and practices that have evolved. A common denominator is that what educators and clinicians do can exert more influence than what they say.

Adapting the implicit messages inherent in parallel or hidden curricula, many of which are negative, outdated, and even unjust, into tools that can support learning is not easy. Without intentionally addressing these implicit messages, their influence can dilute content presented in planned curricula. When educators in classrooms present a theoretical position, but that position is not reflected in the actions and practices of learners in their interactions with educators and clinicians, it is likely to be disregarded. Making implicit messages more explicit begins with acknowledging them (Chen, 2015; Semper & Blasco, 2018).

Instead of ignoring or denying hidden curricula, when educators acknowledge the inadvertent and often conflicting messages that learners experience, they communicate a willingness to engage in further conversations. Chen (2015) asserted that the purpose of acknowledging and talking about the hidden curriculum is neither to eradicate it nor to create more content for lectures and other learning activities in formal academic curricula.

Sensitive, open discussions when learners feel conflicted provide occasions for educators and clinicians to share their own experiences and processes of working through issues. Such an approach can be experienced by all as respectful of their unique humanity. These discussions tap into the parallel education that is occurring and offer opportunities for educators to model critical thinking. As Chen wrote,

when we address messages in the hidden curriculum with moral imagination and practical wisdom, students tune in; they observe our approaches to situations that arise, and how we respond. This gives us an opportunity to play a positive role in the formation of students’ professional identity. Modelling these behaviours for our students helps them to develop and internalize a nuanced approach to professional practice. (2015, p. 14)

Taking opportunities that arise to discuss aspects of the hidden curricula can provide educators with openings to share their humanity with learners.

Making implicit curricula more explicit does not mean that educators are expected to have all the answers. Just as learners are continually piecing together messages from people with whom they interact in their classrooms and practicum sites, so too educators are sorting through messages from their professional associations, employment contracts, and governance structures at multiple sites.

To serve as meaningful role models to students, educators must also acknowledge that hidden messages exist and engage in open discussions about their impacts. Perhaps most importantly, educators must maintain an ongoing process of self-questioning about how they might contribute to and perpetuate negative values, norms, and attitudes. Shedding light on hidden curricula is not a one-way transmission of insight and wisdom from educators to learners. Rather, it is a dialogue rooted in curiosity, personal perceptions, and shared reasoning. And what could be more humane or a greater factor in promoting humanity than sensitive, other-focused, attentive dialogue?

CONCLUSION

In this chapter, we explored ways of infusing curricula with humanity. Like roadmaps, curricula provide predetermined structures to guide educators and learners. Curricula in health professional education often reflect connections to the past. To illustrate this connection, we offered a snapshot of Canadian postsecondary educational and instructional practices at different points in time. Professional associations have played key roles in establishing national standards and making opportunities for a university education available, and they continue to exert significant influence on the competencies expected of practitioners.

Pre-service and in-service learners in the health professions access educational activities from a variety of organizations. Programs and learning experiences can be provided at universities, other postsecondary institutions such as colleges or technical institutes, and clinical agencies. Governance of these organizations, particularly control of finances and management, also exerts influence on curricula. Furthermore, employment contracts can stipulate the nature of contact between educators and learners. Governance structures can restrict opportunities for educators and clinicians to collaborate on developing, evaluating, and revising curricula. Despite these restrictions, when educators make efforts to reach out to colleagues and learners, they can find ways to begin establishing the human connections so essential to bringing curricula to life.

One model of academic curricula, the Tyler Model (Tyler 1949), highlights four teaching principles that educators can apply to support learners in achieving required competencies. With any learning activity, course, or program, the principles can be summarized with the following questions. What is the purpose? Is this the most useful approach to attain this purpose? Where does it fit within the organization of other activities? Which revisions are needed?

Finally, we commented on how informal and hidden curricula also influence learning experiences. Beyond the program outcomes and course syllabus structures commonly planned in academic curricula, informal structures, such as designated spaces where learners can interact with educators and one another, and access to language learning supports for those who need them must also be considered. Hidden curricula affect professional socialization, and educators and clinicians must remain vigilant in examining whether what they say actually matches what they do. The heart of meaningful curricula—whether academic, informal, or hidden—is the essential human connection between educators and learners. Conversations with faculty, peers, and clinicians create lasting and impactful memories for learners.

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