Impact of national context and culture on curriculum change: a case study.

Background: Earlier studies suggested national culture to be a potential barrier to curriculum reform in medical schools. In particular, Hofstede's cultural dimension 'uncertainty avoidance' had a significant negative relationship with the implementation rate of integrated curricula.

Aims: However, some schools succeeded to adopt curriculum changes despite their country's strong uncertainty avoidance. This raised the question: 'How did those schools overcome the barrier of uncertainty avoidance?'

Method: Austria offered the combination of a high uncertainty avoidance score and integrated curricula in all its medical schools. Twenty-seven key change agents in four medical universities were interviewed and transcripts analysed using thematic cross-case analysis.

Results: Initially, strict national laws and limited autonomy of schools inhibited innovation and fostered an 'excuse culture': 'It's not our fault. It is the ministry's'. A new law increasing university autonomy stimulated reforms. However, just this law would have been insufficient as many faculty still sought to avoid change. A strong need for change, supportive and continuous leadership, and visionary change agents were also deemed essential.

Conclusions: In societies with strong uncertainty avoidance strict legislation may enforce resistance to curriculum change. In those countries opposition by faculty can be overcome if national legislation encourages change, provided additional internal factors support the change process.