Addressing the hidden curriculum in the clinical workplace: A practical tool for trainees and faculty

Figures & data

Table

Practice points

The hidden curriculum in a clinical workplace refers to the transfer of the culture of that workplace. REVIEW, based on Q-methodology, is a practical method to facilitate reflection on the hidden curriculum in the clinical workplace. Faculty and trainees prioritize 50 statements, reflecting their perception of a particular clinical culture. Ranking results facilitate discussions on perceived versus desired team culture.

Figure 1. 50-items Q sorting grid.

Table 1. The Q-set: themes and statements.

A. Dealing with patients

1. Abandon treatment when a patient will not benefit from it

2. Take time for every patient

3. Pay attention to (secondary) prevention in patient contacts

4. Discuss with patients the option of doing nothing or stopping treatment if appropriate

5. Ask about and listen to the patient’s own needs

6. Practice shared decision making

7. Always treat each patient respectfully under all circumstances

8. Have an eye for patient’s quality of life

9. Show empathy as a professional quality in patient contacts

10. Keep our professional distance from patients

11. Take critical patients seriously

12. Talk respectfully about patients, whether they are present or not

13. Organize our work in such a way that patients don’t have to wait

14. Adequately inform our patients

15. Regard the patient as a whole person

16. Deal carefully with privacy and confidentiality of patients

17. Take patient’s medical complaints and worries seriously

B. Dealing with work – life balance and presence/absence

18. Accept the absence of a sick colleague without comments

19. Work together to compensate the absence of a colleague

20. Live a healthy life and take care of ourselves

21. Accept working more hours than required by our schedule

22. Subordinate personal needs (pausing, eating, drinking) to the workflow

C. Dealing with colleagues

23. Discuss inadequate performance of colleagues with them

24. Show appreciation to colleagues

25. Ask colleagues for emotional support

26. Offer colleagues emotional support

27. Discuss with colleagues aspects of our work we feel uncertain about

28. Discuss with colleagues overload of work

29. Inform colleagues about our private problems

30. Talk respectfully about all other medical specialties

31. Treat colleagues from other disciplines, e.g. nurses, respectfully.

32. Know our hierarchical place

D. Dealing with education, trainees and our own development

33. Treat interns respectfully

34. Entrust residents responsibilities that align with their level of competency

35. Take time to supervise residents

36. Take time to supervise interns

37. Systematically take time for our own professional development

38. Ask questions when there is something we don’t know

E. Dealing with rules and regulations and guidelines

39. Adhere to guidelines

40. Account for deviations from guidelines

41. Comply with rules and regulations of the organization

42. Administer and register properly

F. Dealing with resources, cost consciousness

43. Discuss with colleagues their production (numbers, output)

44. Discuss with colleagues the costs of their examination and treatment of patients

45. Weigh costs of examination and treatment of patients in the consulting room

G. Dealing with quality of care, errors, and incidents

46. Evaluate the quality of delivered care and discuss opportunities for improvement together

47. Always mention incidents in patient care

48. Try to learn from errors

49. Apologize to each other for mistakes

50. Apologize to patients and their family for errors

Table 2. Recommended procedure.

Version A (online tool version)

1.  Group members individually and anonymously Q-sort statements on a computer screen. They generate their own individual report

2.  Team leader (department head/program director) or facilitator generates group reports. To guarantee anonymity, results of subgroups – e.g. faculty, residents – are visible only when each subgroup has at least four members

3.  Team leader and/or small committee analyze the results of exercise with a focus on statements perceived as most or least characteristic; satisfying and unsatisfying aspects of the perceived culture; unexpected results; statements with large variation in prioritization between group members. Based on this analysis, they select specific statements for discussion with the whole group

4. Group discussion is facilitated by department head or program director. Recommended questions for structuring discussion:

a. Whether group members recognize the reported results as an adequate representation of their culture

b. How differences in perceptions might be explained

c. Results group members are particularly satisfied with

d. Aspects of the culture that group members desire to change or work on

e. How this change could be possible

Version B (card game version)

1. Ranking of statements by subgroups in a workshop setting; results are saved by photographs

2. Subgroups answer two questions:

a. What do you consider the most important positive aspects of the actual team culture?

b. Which aspects of the team culture should be worked on according to you?

3. Plenary presentation of subgroups’ ranking results and answers to questions 2a and 2b

4. Plenary selection of aspects of the culture to work on; formation of new subgroups to do so (based on individual participants' preference)

5. Subgroups formulate action plans

6. Plenary presentation of action plans by subgroups

Figure 2. Group report (sample of two statements). res = residents (N = 11); fac = faculty (N = 7); int = medical students (in this example N = 0). Number of respondents placing the statement in positions 1 (most left: least characteristic) to 11 (most right: most characteristic). Black bars represent all respondents (N = 18). A complete group report contains histograms for each of the 50 statements, offering an overview of the perception of statements as relatively more (e.g. X) or less (e.g. Y) characteristic for a specific culture, and of divergence of perceptions between respondents.