In order to identify and build on any existing knowledge, the process of constructing a person-centred nursing curriculum began with an exploration of the literature. The initial focus was to become familiar with the extent of published studies pertaining to person-centredness in nursing curricula and to identify and explore any existing pedagogical approaches to the development and promotion of person-centred practice.

A one-year research project was undertaken to conduct a meta-synthesis of person-centredness in nursing curricula. Meta-synthesis involves the integrative secondary analysis and synthesis of findings from a range of existing qualitative studies, which normally share a common theme. The aim of meta-synthesis is to enable the application of qualitative findings to inform the development of practice and the generation of new knowledge that authentically represents the findings of any original studies. The Noblit and Hare methodological approach to meta-synthesis was employed (Noblit & Hare 1988).

A literature search was carried out using key terms derived from a definition of person-centred practice (McCormack 2004). Searches were restricted to those published in English language during the last 10 years. A total of 76 papers were identified from this process and the full sample was reviewed by a group of three academics with expertise in person-centred practice, qualitative methods and/or curriculum development. Following the initial review, 30 papers were considered eligible for inclusion. These papers were subsequently considered by an expert panel comprising six independent reviewers. Following completion of the individual review process, all members of the expert panel met to identify areas of consensus and to challenge refutational perspectives.

It was found that, while person-centredness was widely espoused in the literature, there was limited evidence of how this was made operational in curriculum development or how theoretical models or frameworks informed curriculum design or delivery. Four dominant discourses emerged from the meta-synthesis as follows:

1. Theme 1: Moving beyond mediocrity
   
2. Theme 2: Me, myself and I
   
3. Theme 3: The curricular suitcase
   
4. Theme 4: Learning elevators

The first theme relates to an expressed sense of discontent among nursing academics with the existing models and approaches to curriculum development. There was also a desire to engage in different approaches that bear witness to the ontological basis of nursing that would transcend theory and practice-based learning (Theme 1: Moving beyond mediocrity).

The theme of self-knowledge and the need for teachers and students to have multiple perspectives of self was commonly expressed within the literature. There was a view that there was great merit to be gained from valuing personhood by knowing and caring for all the dimensions of self and developing an empathetic connection with others as if oneself (Theme 2: Me, myself and I).

Significant attention was also paid to the multitude of competing factors that influence and define the content of curricula. There was a predominant theme that nursing curricula are overly influenced by bio-scientific knowledge. Achieving the optimal blend between the art and science of nursing was explored in terms of the value of some traditional core content and the need to shift the focus to embedding core skills that are important to people receiving care, such as communication skills. Dissatisfaction was expressed with the levels of cohesion and integration within and across different subject areas and disciplines in terms of how curricula are constructed (Theme 3: The curricular suitcase).

‘Theme 4: Learning elevators’ emerged as an expression of the need to prioritise learning experiences that illuminated and crystallised students’ understanding of person-centredness. It was suggested that person-centred learning was more likely to occur in safe yet highly challenging learning environments. Where person-centred approaches were reported to occur, these were achieved through service user involvement and through the use of specific teaching and learning methodologies at module level, such as problem-based learning, simulation, role-play and reflection.

The findings from the meta-synthesis provided valuable insights into factors to consider in the development of nursing curricula. The issues arising from the four dominant themes support the view that some nurse teachers are conscious of seeking evidence of the effectiveness and relevance of their teaching and learning strategies. Those who have taken action to address this have emphasised that curriculum change is slow, time consuming and demanding. It was concluded that there is a need for further research to explore how students, educators and clinicians perceive and seek to promote person-centred practice through the experience of nursing education. Furthermore, it was emphasised that there is a need to develop evidence-informed pedagogies so that nurse educators have some confidence and direction in determining effective ways to change their teaching practices to promote learning about person-centred practice.

In engaging in curriculum development, the team considered the educational philosophy underpinning the programme in order that the conditions of learning were created to match our vision of how students learn effectively. In engaging with the Person-centred Nursing Framework of McCormack and McCance (2010), the team was cognisant of the need for students to have skills in being able to mould and shape a culture of person-centredness, necessitating them to develop their critical thinking and reflective skills in order to be effective agents of change in practice.

At both practice and educational levels, achieving development in both students and practice necessitates a process that awakens a student to the possibilities and potential by which they are surrounded. This is necessary to enable them to emancipate themselves in order to optimise practice. These concepts are aligned with a critical pedagogical approach to education, emanating from the pioneering work of Paulo Freire (1974).

Freirean principles of education contend that effective education must be transformative. Freire contends that this is achieved through the development of a radical consciousness whereby the student is awakened to having a critical awareness of their relationship with society, history and influential powers (Freire 1972). Being aware is central to developing an understanding of how oneself and others are conditioned by such factors; without awareness one cannot self-actualise and hold the innovative and entrepreneurial skills of contemporary graduates. Within the context of the Person-centred Nursing Framework, these principles filter through many layers, influencing students’ abilities to engage with macro-influences, to truly know themselves and to be aware of their beliefs and values, and to have the skills to engage with the complexity of the care environment.

Freire (1972) believed that students come to education blinded by their conditioning, of which they may not be aware. To achieve social awakening, a ‘banking’ approach to education must be averted, where students are seen as recipients of narrations from teachers. Rather, they must be enlightened through a student-centred approach where educators and students engage in a dialogic process in which they are collaborative explorers of knowledge. This critical engagement shares power, whereby the educator is a mediator of knowledge, harnessing the skills of critical reflection that are core to transformation. This critical awareness and awakening are considered to lead to authentic knowledge, which leads to action that is morally laden.

The role of learning facilitators (including teachers and mentors) is therefore to create the conditions for such critical dialogue through creative, challenging and multi-directional communicative spaces in both the university and practice learning setting. This flourishing approach to education has a strong synergy with the Person-centred Nursing Framework of McCormack and McCance (2010), aligning the curricular structure with the principles of education.

Furthermore, a Freirean approach aligns with Theme 1 of the meta-synthesis, enabling both educators and students to understand the factors that lead to discontent and empower them to be moral agents of change. It further aligns with Theme 2 in that it embraces a culture of learning that focuses on personhood and knowing self, not in a singular sense, but in a relational, worldly sense. Theme 4 comes alive in a Freirean approach as students are facilitated through critical learning processes that are learning elevators, in illuminating their understanding of personhood.

For a curriculum to be developed effectively, consideration needs to be given to the definition and philosophy behind the type of nurse it is hoped will emerge on successful completion of the programme. The processes through which educators support students to learn in a way that prepares them to act autonomously with integrity and keen decision-making skills must be clearly planned and articulated. It is often at this stage that discontent with the status quo can be identified and innovative ideas for achieving excellence in education can be shared and explored – this can be seen as an opportunity to move beyond mediocrity and the required minimum standard for registration or certification, principles aligned with critical pedagogy.

The concept of a curriculum does not exist in a standalone state. The historicity and socio-political context within which we exist shapes and is shaped by our worldly relationships. The development, planning, delivery and evaluation of education are largely influenced by the beliefs and values of teachers and students and the culture in which the curriculum exists. It is important for those involved in curriculum planning to develop self-knowledge and insight into the motivation that drives their roles, prior to developing a strategy to create an aligned cultural and curricular reality.

A crucial aspect was the preparation and support of staff to think differently and to encourage innovative and creative approaches to learning and assessment. The challenge for all staff was to role-model person-centredness as embedded in the role of the educator. This required deeper consideration of our roles in the context of adult education, developing technologies and fiscal pressures. We needed to reflect on how we wanted to interact with students to demonstrate the types of behaviours we wanted students to emulate with those in their care and their working teams. Staff engaged in a series of workshops and creative thinking zones to unpack the concepts of the Person-centred Nursing Framework and identify the beliefs and values held as a team of teachers and educators. Attributes considered essential for effective facilitators included genuineness, and empathy or empathic understanding, as described by Rogers and Freiberg (1994). They also underpin dialogic engagement at the heart of critical pedagogy. This process of reframing traditional approaches resulted in a changing culture within the School driven by the motivation to make the curriculum real (McCormack et al. 2014). As a result a School-wide culture change project was established following the completion of the curriculum, guided by a coordinating group in partnership with an external facilitator. This project aimed to promote a sense of belonging and integration between colleagues, where staff felt autonomous, motivated and responsible for personal and professional development and true participants in decision-making in the School. As a consequence, staff teams work closely to focus on how colleagues can support and challenge each other to live the espoused vision, purpose and values (Box 7.1).