The Hidden Program of Care

After graduating from my doctoral program, I obtained a two-year post-doctoral fellowship in “environmental psychology.” Yes, I know it sounds like I was going to study the effects of climate change on mental health. In actuality, I was about to begin working with an architect.

Environmental psychology is a curious area of psychology that focuses on the interrelationship of environments and human behavior and mental processes. Thus, although studying the effects of nature, or climate change, on our mental health certainly falls within the purview of environmental psychology, my intent was to study the “built” environment; that is, environments that have been built by humans.

At the time, my research focused on gerontology – my focus is more properly referred to as environmental gerontology. Specifically, I was interested in on the quality of life of persons with dementia. Studying the built environment was an important aspect of my research, as many persons with dementia are cared for in built environments. Traditional models of nursing homes were (and still are) beginning to be replaced with more advanced models that are informed by an understanding of how humans interact with their environments. These models are more home-like and less institutional, reducing the often upsetting transition from living in one’s own home to living in an aging community. They take advantage of colors, smells, sounds, and other sensory stimuli to create an engaging environment. Many of the design features are intended to make “way-finding” easy. They are designed to promote “aging in place” rather than the constant moving to progressively more sophisticated care environments often associated with dementia care. The overall focus is to exercise and enhance the residents’ abilities, rather than protect them from their disabilities.

As I proceeded through my studies I was introduced to the concept of the “hidden program.” This is an important concept to the study of environmental psychology. Essentially, the hidden program is comprised of the implied expectations of a built environment. The best way to understand the hidden program is through an exercise. Consider the waiting room of a primary care practice. A typical waiting room has chairs in various arrangements, magazines, windows, a television, perhaps an aquarium and some toys for children, and a door through which a nurse will appear and call our name. The general construction of that room, its features, and the arrangements of the various amenities speak loudly. They inform people how to think and how to behave within that setting. What is a person expected to do? Generally, a person is expected to wait. And while they wait they can watch television, read a magazine, look at the pretty fish, or play with some toys. Nowhere are these behaviors written down – they are implied and expected. What also is implied is what we are expected not to do there. What would happen if I walked in with a sleeping bag and pillow, laid it out on the floor, and took a nap while I waited? That might be a bit unexpected. (So much so that I may be asked to either leave or make an appointment with a psychologist.) Or what if I brought in my two daughters and a bunch of blankets, and started re-arranging the chairs into a “fort” while I waited. No written rules against that.

Take a moment and reflect on the environment, or “place,” you are currently in, whether it be a small private room, a common area within a building, or somewhere outdoors. Seriously, consider for a moment what you are expected to do there? What are you not expected to do there, and why? What changes would you like to make to that place, and why? What would you like to do there? Why don’t you do that? How do others use that place? How does that differ from how you use it, and why?

As I moved beyond gerontology, and began research in other care settings, the hidden program revealed itself to me as an important organizing construct, one that certainly has implications well beyond environmental psychology. 

See the figure below, a simple Donabedian-type health quality model. On the left are the care elements, the inputs of the system. These inputs are filtered through the care practice, which basically consists of the attitudes and behaviors of the various players. Finally, there are outcomes: clinical, financial, and satisfaction. But perhaps the most important aspect of this model is the arrows, which represent the program. The light color is meant to emphasize the many “hidden” aspects of this program. In the phrase the hidden program, the “program” refers to the behaviors and attitudes the structure of the care elements afford, and how these, in turn, affect care outcomes. Not all elements of the program are hidden, of course. We know what our incentives are. We are aware of evidence-based care and how that impacts our care practice. But many elements are hidden to us. Thus, the word “hidden” suggests that we often do not (or cannot) consider many of the relationships among these three constructs. 

A Model of the Hidden Program of Care

Now pretend that you had the ability to “un-hide” all aspects of the program. How important would that be to your practice of care? Consider the ability to fully understand patient expectations, and what is driving those expectations. Consider completely knowing physician and staff attitudes, how those interact and influence their behaviors, and how those behaviors influence the client. What if we could reveal the full impact of care practice elements on care outcomes? Would that be helpful in structuring the care elements in such a way as to positively impact care practice and through it care outcomes?

Now, finally, consider measurement. This is precisely what we are doing when we obtain and consider operational, clinical, financial, satisfaction and other metrics. We are “un-hiding” the hidden program.   We are doing this when we analyze these data and uncover relationships. When we engage in quality improvement, we use these metrics to introduce changes to the structure of care elements that will lead to improved care outcomes:

• What is your hidden program of care?
• What steps are you taking to “un-hide it?”
• What aspects remain hidden to you and what can you do to un-hide them further?

The more our program of care remains hidden to us, the less control we have over it, and the less control we have over care outcomes.  The foundation of effective quality improvement is un-hiding and understanding our program of care.