Person-centred nursing education

Chapter 7
Person-centred nursing education


Deirdre O’Donnell, Neal Cook & Pauline Black


Ulster University, Northern Ireland, UK


While the promotion of person-centred practice among registered nurses has been widely embraced in health-care literature, less attention has been paid to how students are introduced to the principles of person-centredness in undergraduate education programmes. This chapter provides an overview of a developing body of work within one School of Nursing in constructing, implementing and sustaining a person-centred nursing curriculum.


How is person-centredness manifest in nursing curricula?


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.


Educational philosophy


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.


Constructing and sequencing the Person-centred Nursing curriculum


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.


Implicit in the philosophical basis of a person-centred, critical pedagogy is the belief that people who have experience of receiving care are best placed to determine the extent to which care is effective, meaningful and thus person-centred. In order to develop a person-centred curriculum it was considered imperative that the views of service users should be given due prominence and consideration through authentic dialogic engagement. A research study was conducted to explore service users’ and carers’ views about programmes that lead to registration as a nurse, and also to evaluate how this feedback impacted on curriculum development. The objectives of the study were to identify views about the design and delivery of programmes that lead to becoming a registered nurse and to map how this feedback influenced curriculum development (Table 7.1). Involvement in this study led to the development of a service users’ and carers’ forum to further inform education processes and practice.


Table 7.1 The impact of service user feedback on curriculum development






























Service user feedback Actions taken by curriculum development team
‘Importance of the person being valued’ Person-centred Curriculum Framework
‘We want to feel safe in the classroom’ Code of Practice for Public Engagement in Nursing Education implemented across all programmes
‘Visit me at home to understand who I am’ Opportunity for first practice learning experience to take place in the community
‘We know what makes a good nurse – being authentic, someone who really listens, who doesn’t have to be reminded, who makes time to explain and reassure, who picks up on my feelings, who identifies with me’ Primacy of communication approaches in all learning activities
‘Care for yourself as well as your patients’ Theme of self-knowledge developed across curricula
‘We would like to give feedback to students about the care they have provided’ All students will receive formative feedback from service users about the care provided
‘Don’t lose what is special about being students’ Service user involvement with students to explore why students are ‘special’ to patients and how they can carry this with them during their career
‘Get involved with us through volunteering’ Volunteering Charter

Once consensus was reached about the overall philosophy of the programme, the values and beliefs of the educators and the values and beliefs both inherent and to be moulded in students were identified. In general, these values and beliefs address the key concepts of person, health, environment and nursing, professionals and education. While the use of single models of nursing to underpin education programmes is considered outdated due to limits in their applicability to all care settings (Boore & Deeny 2012), the Person-centred Nursing Framework of McCormack and McCance (2010) is different in that it focuses on the two key collaborators in care – the nurse and the person – regardless of the setting and it is thus almost universally applicable.


Careful consideration was given to the Quality Assurance Agency (2001) subject benchmarks for nursing and the NMC (Nursing and Midwifery Council 2010) standards for pre-registration nursing education. These outlined domains and outcomes for nursing education focused on public confidence that all nurses in the profession will deliver quality care that meets the needs of all those with whom they come into contact in their roles. Barnett and Coate (2005) suggest a framework for curricula based on three domains of knowing, acting and being to determine the content and structure of curricula. Education programmes are ultimately concerned with knowing, and nursing as a profession is primarily about doing; it is the being aspect that can be ultimately informed by the principles of the Person-centred Nursing Framework and a Freirean approach. In addition, both facilitate not only the key skills of reasoning and decision-making, but also the sensitivity and sense of moral responsibility essential to enable self-determination (McCormack and McCance 2010).


After consideration by the staff of the School of Nursing, the curriculum development steering group explored how the Person-centred Nursing Framework might be used to guide the design of a programme to develop graduate nurses who have the knowledge, skills, values and beliefs to deliver professional, competent, safe and effective care that is person-centred in design, delivery and outcomes. It was envisaged that graduates would have the appropriate value system, ability and commitment to lifelong learning and developing professional practice in tandem with emerging evidence and changes in care delivery systems. Use of the framework was helpful in guiding the team to choose the elements that were essential – the key items to pack into the curricular suitcase. It supported the achievement of integration and cohesion and complements a critical pedagogical approach.


The Person-centred Nursing Framework addresses the prerequisites for person-centred practice, the nature of the environment in which care is provided, the process required to provide the care, and the means to measure the outcomes of the care. The aim of the programme is to produce new graduate nurses who are equipped with the prerequisites and are able to use their knowledge and skills to progressively enhance person-centred nursing by influencing care environments and care processes to produce positive outcomes for people, their carers and families – in other words, agents of transformation.


Utilising the Person-centred Nursing Framework to inform practice development means that nurses bring with them their experiences of practice and the knowledge gained from experience. When integrating Person-centred Nursing Framework into curriculum design, educators must be aware that students may come representing a diversity of experiences of life and previous caring, whilst others may not have that past to reflect upon. Indeed, Freire (1972) views our historicity as central to our authentic knowing of self. There was a need to develop a shared starting point for all students commencing the programme. The framework guided the structuring of learning priorities and the design of learning elevators – the activities and experiences, commensurate with the stage of the programme, that engage students in understanding their practice.


The programme starts by focusing on the attributes of the nurses and how students can develop knowledge of how their beliefs and values can impact on the care that they provide. Students are encouraged to become more self-aware – to help them understand they need to have an insight into who they are before they can help others. They examine the nature of commitment to provide the nursing care that is best for the people for whom they are providing care. The development and practice of effective interpersonal skills to enable them to communicate at a variety of levels is a fundamental outcome in many modules. The development of knowledge and skills to make decisions and prioritise care is also crucial, and students are guided in this process throughout the programme. These key prerequisite qualities are revisited and reflected on in increasing depth throughout the stages of the course.


Once students experience practice learning and progress through the first year, other aspects of the Person-centred Nursing Framework are introduced. The nature of the care environment is highlighted in terms of the composition of the health-care team and the sharing of decision-making and power in effective relationships between staff and the people they provide care for. In the second year, students gain an understanding of the nature and influence of organisational culture and environment that is crucial if they are to make a difference to people by the way they provide care. An appreciation of organisational systems that support innovation and creativity in care-giving is key to the development of entrepreneurial nursing practice during the final year of the programme.


Person-centred care processes are highlighted throughout the course, beginning with a focus on engagement with people requiring care and support and working with their beliefs and values to gain an insight into what it is that is valued by the individual and their family. The need for a holistic perspective in nursing care underpins all activities undertaken by students. Students will develop an awareness of the importance of a sympathetic presence and shared decision-making and will gain the skills necessary to incorporate this into their practice. The need for graduates who are skilled and competent in these aspects of care has been highlighted by feedback from the service user and carer forum, whose input provided a key insight into what nurse characteristics are valued by service users.


The final year brings the ideas of prerequisites, environment and processes together in considering the outcomes of care. The evaluation of outcomes of person-centred care involves knowledge and skills to which students are introduced cumulatively during the programme. From assessing the satisfaction and well-being that people, their carers and families experience when involved with care, to the creation and maintenance of a therapeutic culture based on transformative leadership, the focus is on the creation of graduate nurses who can provide effective person-centred care.


Designing the learning and teaching culture and experience


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).



Box 7.1 Culture Change Project


Vision


The School of Nursing will have a positive influence on the lives of students, staff and all those we engage with and will be recognised nationally and internationally as progressive.


Purpose


Our purpose is to develop a flourishing person-centred culture that:



  • positively influences:

    • students’ experience and learning
    • staff’s experience, learning, development and inquiry
    • people’s health-care experience

  • establishes and maintains a positive legacy for the university and society.

Values and behaviours framework
























Shared purpose

Flourishing students and staff Flourishing person-centred culture Positive impact on university and society
Our values: Inclusiveness Integrity Professionalism
Our commitments to each other People will feel valued, respected and involved as individuals People will feel trusted to work in committed and integrated teams to learn from and with each other People will feel confident and committed to make a difference to society based on their complementary talents and expertise
Standards

  • Respect people and their dignity
  • Be person-centred, positive and caring
  • Appreciate and celebrate each other
  • Listen and clearly communicate
  • Consistently work to nurture and develop the potential of each other


  • Consistently work together towards the common purpose
  • Consistently support each other to reflect, learn and develop
  • Courage to give and receive feedback
  • Work with personal and professional commitment and passion
  • Work as a team with individual and team role clarity
  • Take responsibility and are accountable for own actions and decisions
  • Walk the walk


  • Deliver the best outcomes for students, the school, university and society within resources available
  • Draw on the different gifts and talents of all
  • Always improving
  • Always using and developing evidence to underpin actions, decisions and professional practice
  • Maintain equity in work-life balance for self and others

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May 30, 2017 | Posted by in NURSING | Comments Off on Person-centred nursing education

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