Person-centered care (PCC) has received considerable attention in nursing and other health disciplines and is considered instrumental to the delivery of quality care (Kitson, Marshall, Bassett, & Zeitz, 2013). A positive regard for individuals’ experiences, values, and beliefs is central to PCC; accordingly, PCC is grounded in therapeutic interpersonal relationships that foster opportunities for individualized and holistic care (Morgan & Yoder, 2012). PCC is a dynamic process that is adaptable to each patient’s context (Lapum et al., 2012b). Among the positive outcomes attributed to PCC are respect, autonomy, empowerment (Morgan & Yoder, 2012), and effective clinical decision making, which is developed based on patients’ personal information (Radwin, Cabral, & Wilkes, 2009). In keeping with the underlying philosophy of PCC, nursing student educational encounters should mirror these values as a way of cultivating these attributes in future practitioners. Furthermore, faculty can help position students to enact PCC in their practice by creating experiential opportunities for genuine and respectful dialogue through approaches that foster reflection, self-awareness, personal knowing, and critical thinking.
This article provides a brief background of PCC and discusses some curricular approaches for supporting the development of PCC described in the current health care literature. Specifically, the role of creative pedagogical approaches in supporting the development of attributes (e.g., self-knowledge) that are essential to the provision of PCC (McCormack & McCance, 2006) is examined, and several exemplars of these approaches used by faculty in the school of nursing are provided.
The idea of person centeredness was first described by psychologist Carl Rogers in the 1940s (Morgan & Yoder, 2012). Since the mid-1990s, PCC has become popularized as the standard for quality care (Kitson et al., 2013). Initially, PCC was primarily associated with the discipline of medicine; however, it has transitioned across various health care professions over the past 20 years (Kitson et al., 2013). A common definition of PCC has not been identified, and considerable variability in the terminology used to describe it (i.e., patient-centered care, family-centered care, client-centered care, person-centered practice) exists. However, agreement exists that a range of attributes across a number of domains is required for PCC approaches. These attributes include (a) individualized care, (b) respect for individuality, (c) patient preference, (d) empowerment, (e) acknowledging individual circumstance, (f) holistic care, and (g) recognition of personhood (McCormack, 2003; Morgan & Yoder, 2012; Slater, 2006).
The work of McCormack and McCance (2006) is of particular importance to the current article. McCormack and McCance developed a conceptual framework for person-centered nursing, which encompasses four key components: prerequisites (i.e., attributes of the nurse); the care environment; person-centered processes; and expected outcomes. The current article focuses on the prerequisites aspect of this model (i.e., the attributes of the nurse). The attributes of the nurse are foundational to the delivery of PCC and allow for consideration of how nurse educators can best prepare future caregivers to be knowledgeable, skillful, and caring practitioners. These attributes include (a) professional competence, (b) interpersonal skills, (c) commitment to the job, (d) ability to clarify personal beliefs and values, and (e) self-knowledge (McCormack & McCance, 2006).
The latter attributes (i.e., clarity of values and beliefs, self-knowledge) reflect “the assumption that before we can help others we need to have insight into how we function as a person” (McCormack & McCance, 2006, p. 473). These attributes highlight the importance of personal knowing (Carper, 1978; Chinn & Kramer, 2008) as central to the delivery of PCC. Chinn and Kramer (2008) suggested that “personal knowing is the basis for expression of authenticity, the genuine self, which in turn is essential in healing relationships” (p. 133). Whether caregivers “intentionally engage or disengage with people, they are always in relation […] affecting and shaping the health and healing process” (Doane & Varcoe, 2005, p. 175). Thus, it is the caregiver who is charged with creating safe care environments in which an ill person can heal. However, to do this, caregivers need to develop personal knowing of what they bring to therapeutic relationships. Through deep self-reflection, which can take different forms, caregivers become more fully present with those in their care. Their personal knowing, which is “expressed as mind-body-spirit congruence, authenticity, and genuineness” (Chinn & Kramer, 2008, p. 135), opens the possibility for the ill person to do the same. The caregiver and the care receiver thus co-construct the therapeutic relationship, “making possible wholeness of self and other in context of relational experience” (Chinn & Kramer, 2008, p. 135).
Approaches for Teaching PCC
Pedagogical approaches that support the development of skills and abilities necessary for PCC among students and health care practitioners have been considerably examined. For example, role modeling has been described as an important strategy used by clinical preceptors and supervisors to educate developing practitioners about PCC and caring behaviors (Hinds, 2013; Markakis, Beckman, Suchman, & Frankel, 2000; Sawatzky, Enns, Ashcroft, Davis, & Harder, 2009; Titchen, 2003). In addition, experiential approaches, such as simulation (Cooper et al., 2011; McKeon, Norris, Cardell, & Britt, 2009) and real-life experience (Rapport, Rodriguez, & Bade, 2010; Spencer et al., 2000), have been described as effective strategies to improve student knowledge of PCC and to support the development of PCC competencies, including clinical reasoning, communication skills, professional attitudes, empathy (Spencer et al., 2000), patient-centered communication (Cooper et al., 2011), and patient and team collaboration (Fay-Hillier, Regan, & Gallagher-Gordon, 2012).
Although these strategies show promise in fostering the development of PCC attributes, such as professional competence and interpersonal skills, less attention is paid to specific approaches that address personal knowing as significant to the development of PCC qualities. McCormack and Titchen (2006) described how engaging in creative activities is a critical element necessary for effective and responsive PCC. Because personal knowing does not emerge from logical theoretical constructs, it is best approached through creative, experiential, and reflective processes. It is through creative self-expression that knowing, too premature for words, can be brought to consciousness to inform who we are as persons and professionals (Schwind, 2003). Thus, creative pedagogical approaches that offer experiential student engagement, coupled with faculty professional knowledge, are necessary to support the development of personal knowing.
At the authors’ institution, various faculty members engage in creative approaches to nurture the development of personal knowing among nursing students, which ultimately informs PCC. The following are five exemplars of these creative pedagogical approaches.
The use of reflection by nursing students and medical residents is commonly reported in the literature as a valuable approach to enhancing caring practice (Freshwater & Stickley, 2004; Kleiman, 2007; Price, 2006; Titchen, 2003). Although reflective practice approaches vary, their main focus is on developing self-knowledge, which is intended to enhance the quality of PCC within therapeutic relationships. The following two exemplars highlight how faculty members use creative reflection to guide students in years 1 and 3 of their undergraduate program.
Exemplar I: Using Individual Reflection and Group Creative Expression to Promote an Awareness of Self as a Future Health Professional. One faculty member (D.R.) shared her story:
I guide my first-year nursing students to reflect on the persons they are and on the professionals they are becoming, while recognizing that each will influence the other and change as they evolve. I encourage self-awareness, as students are asked to record their hopes, fears, and expectations for their clinical practice experience as it begins, and then to reflect on these once placement is completed. Each clinical group creates a collage representing each student’s practice experience. Students share these collages with classmates to facilitate discussion of their practice experiences. These activities exemplify active learning, which is a learning approach based on engagement with personal experience that contributes to learners’ knowledge of self
Exemplar II: Aesthetic Reflection to Foster a Sense of Connection With the Person. A third-year faculty member (S.E.) shared her experience:
The focus of year 3 in our undergraduate nursing program is community health, population health, group work, and various models of community assessment. Due to the focus on the community, students may lose their sense of connection with the person. To counteract this, students are asked to develop an aesthetic reflection, which depicts what community health means to them. This reflection is a creative endeavor that can be a picture, video, poster, poem, or story. Students share their reflections verbally with their clinical group, as there are often nuances to their creations that may be missed by an observer. For example, one student built a dream catcher. At first glance, this item seemed unremarkable, but the explanation was personal and moving. The dream catcher was difficult for the student to construct, as it was made with wire and beads. She explained that her journey in understanding community health had also been difficult, but as she moved through the course, her comprehension of the theoretical components wove together much like the dream catcher. The dream catcher hanging in a window, which changes when viewed from different angles, was representative of how she was changed by her experiences during the course.
As these exemplars demonstrate, reflection allows students to examine their own experiences, values, and beliefs, while considering those of others. Students in their first and second years of the undergraduate program are introduced to reflection as part of their professional responsibility. The use of creative approaches allows for students to share their thoughts and opinions in a safe environment of small peer groups. This process also helps students gain an appreciation for the value of hearing another person’s story. Through reflection, students are able to explore potential biases they may hold and to understand more fully how personal beliefs may influence practice and therapeutic relationships with those in their care.
Narrative and Arts-Informed Approaches
Narrative and arts-informed approaches offer opportunities for students to explore personal knowing; specifically, they can come to appreciate what is “within and [come] to live with, accept, and love what is within” (Chinn & Kramer, 2008, p. 137). Accessing personal knowing can be achieved through creative self-expression, such as drawing, which “is known to elicit the depths of our being unreachable by words” (Schwind, 2003, p. 25). These creative narrative and arts-informed approaches focus on bypassing the logical and linear mind and accessing the inner wisdom that Polanyi (2009) referred to as the tacit dimension of being. The personal knowing that emerges from these approaches informs who we are as instruments of care and how we, as caregivers, are in relationships with those in our care (Schwind, Cameron, Franks, Graham, & Robinson, 2012).
In the school of nursing, several faculty use narrative and arts-informed approaches in their teaching–learning encounters. The following are two such exemplars:
Exemplar I: Experiential Teaching–Learning: Narrative Reflective Process. A faculty member (J.K.S.) explained her approach:
I use the narrative reflective process (NRP) (Schwind, 2008), which is an experiential teaching–learning strategy and an arts-informed data collection tool. This teaching–learning strategy is informed by narrative inquiry methodology (Connelly & Clandinin, 1990, 2006) and mindfulness philosophy (Kabat-Zinn, 1990). NRP is a creative self-expression strategy that mindfully incorporates stories, metaphors, drawing, and writing, among other approaches. For example, I incorporate NRP with my fourth-year nursing students to help them increase self-awareness and personal knowing, which is intended to enhance the quality of their professional therapeutic relationships within PCC contexts. We use personal life stories, metaphors, and drawings; students share “safe” stories in small groups, while engaging in creative and reflective writing throughout the process. Subsequently, the process is repeated with a focus on students’ professional practice and their role as caregivers within therapeutic relationships. At the end of the reflective process, students review their stories, metaphors, and writing to look for narrative patterns. They also access scholarly literature for their reflective exploration as necessary. In small groups, they engage in reflective dialogue, which prompts deeper consideration of personal knowing as revealed through the creative activities.
Exemplar II: Fostering PCC Through Arts-Informed Teaching Strategies. A faculty member (J.L.) reflected on how she fosters students’ capacity for PCC:
I teach a health assessment course to first-year nursing students. Taking into consideration the dominant discourse of health care in which the physical body often takes precedence, different teaching strategies are used to develop student capacity to focus attention on the whole person during health assessment. A prime example of this is related to my class on cardiac assessment. I share poems and images from “The 7,024th Art Installation,” which was created based on research about patients’ experiences of open-heart surgery; these poems and images represented patients’ embodied and emotional experiences (Lapum, Church, Yau, David, & Ruttonsha, 2012a; Lapum, Ruttonsha, Church, Yau, & David, 2012c). By sharing poems and images about the patient experience, students are prompted to engage in personal and aesthetic knowing. This activity provides the opportunity for students to shift their frame of reference to that of patients and informs how they interact with patients when conducting health assessments.
As these exemplars demonstrate, narrative and arts-informed approaches offer opportunities for active engagement between faculty and students, which allows students to develop an awareness of the experiences of persons in their care and their developing professional self. Personal stories are one vehicle of interaction; they “convey essences of experience that are not communicated in theories or clinical histories, [and they] provide the opportunities for shared understanding of what it means to develop the self” (Chinn & Kramer, 2008, p. 135). The invitation for telling a safe story during creative activities is intended to encourage students to share to their own level of comfort, as well as to safeguard against too much self-disclosure.
Practice development (McCormack, Dewing, & McCance, 2011; McCormack et al., 2009) emphasizes learning through everyday practice, which has been described as active learning. Active learning is an approach for in-depth learning that draws on creativity and synthesizes and integrates numerous learning methods, such as critical reflections, engagement with the senses, using multiple intelligences, and interacting with other people (Dewing, 2010). The following exemplar demonstrates how practice development methods offer an experiential approach to developing personal knowing of the self that engages in nursing practice.
Exemplar: Using Practice Development Methodologies to Cultivate Graduate Nurses’ Capacity for PCC. A faculty member (K.L.), who works with graduate students, articulateed her method:
I use practice development methodologies to cultivate graduate nurses’ capacity for person-centered practice. In seminars and practicum of professional nursing advancement courses, I engage students with their senses through the use of personal artifacts and EVOKE cards ( http://www.evokecards.com), which provide visual images that stimulate creative exploration of personal values and beliefs. I then ask students to complete critical reflection on this experience. The combination of reflection with engagement of the senses allows for multiple types of learning and transformations to take place, all of which inform personal knowing. Thus, this learning opportunity provides graduate students with examples of ways to engage with self, their patients, and their families in a person-centered care manner.
Implications for Nursing Education and Practice
For nurse educators, teaching–learning relationships are the fertile ground for role modeling and reflective dialogue to take shape, with both the teachers and the students having the potential to be transformed by gaining new perspectives from each other (MacDonnell & Macdonald, 2011). Creative strategies, such as reflection, narrative and arts-informed approaches, and practice development, can be used in a variety of teaching and learning contexts to enhance personal knowing and to help develop PCC qualities of future caregivers. Experiential student engagement creates opportunities for thoughtful and meaningful dialogue with ourselves and others. Purposefully designing curricula to include opportunities for student engagement in experiential creative activities that foster and develop personal knowing is one of the key approaches to nurture PCC qualities in future practitioners.
Student feedback on faculty and course evaluations suggests that creative experiential reflection and critical thinking are meaningful approaches that foster personal knowing and professional development; however, more formal evaluation of the impact and sustainability of these approaches is required. Future research is needed to explore the effectiveness of specific strategies in supporting the development of personal knowing and to examine the relationship between personal knowing and person-centered practices.
Attention should also be given to develop strategies that help nursing students sustain person-centered practices. Once PCC is learned and understood by nursing students, it is important that they continue to be appropriately supported when they enter the workplace as new graduates. Research shows that after 2 years of practice, new nursing graduates experience some level of burn-out regarding their ideals of PCC, which can be attributed to the realities of the workplace (Maben, Latter, & Clark, 2007). This burnout can lead to disillusionment and cause some nurses to leave the profession (Maben et al., 2007). Therefore, the current article’s authors believe that once PCC qualities are developed in nurses, it is important for nurse leaders to continue to act as role models when engaging with their peers and with patients and families. To overcome these challenges, it has been suggested that organizations enact change, including educating supervisors and others in the unit about PCC, broadening hospital awareness, and involving leadership in creating a supportive infrastructure for PCC (Fredericks et al., 2012; Moretz & Abraham, 2012). For PCC qualities to be sustainable, it is not enough to teach nursing students how to provide PCC; rather, they must continue to be supported once they graduate within the workplace by their peers, managers, and the organizational system. Creative approaches for fostering the development of personal knowing as described in the current article may also help support person-centered approaches in the practice setting.
- Carper, B.A. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1, 13–24. doi:10.1097/00012272-197810000-00004 [CrossRef]
- Chinn, P. & Kramer, M. (2008). Integrated theory and knowledge development in nursing (7th ed.). St. Louis, MO: Mosby Elsevier.
- Connelly, F.M. & Clandinin, D.J. (1990). Stories of experience and narrative inquiry. Educational Researcher, 19(5), 2–14. doi:10.3102/0013189X019005002 [CrossRef]
- Connelly, F.M. & Clandinin, D.J. (2006). Narrative inquiry. In Green, J.L., Camilli, G. & Elmore, P.B. (Eds.), Handbook of complementary methods in education research (pp. 477–488). Washington, DC: Lawrence Erlbaum Associates, Inc.
- Cooper, L.A., Roter, D.L., Carson, K.A., Bone, L.R., Larson, S.M., Miller, E.R. III. & Levine, D.M. (2011). A randomized trial to improve patient-centered care and hypertension control in underserved primary care patients. Journal of General Internal Medicine, 26, 1297–1304. doi:10.1007/s11606-011-1794-6 [CrossRef]
- Dewing, J. (2010). Moments of movement: Active learning and practice development. Nurse Education in Practice, 10, 22–26. doi:10.1016/j.nepr.2009.02.010 [CrossRef]
- Doane, G.H. & Varcoe, C. (2005). Family nursing as relational inquiry: Developing health-promoting practice. Philadelphia, PA: Lippincott Williams & Wilkins.
- Fay-Hillier, T.M., Regan, R.V. & Gallagher-Gordon, M. (2012). Communication and patient safety in simulation for mental health nursing education. Issues in Mental Health Nursing, 33, 718–726. doi:10.3109/01612840.2012.709585 [CrossRef]
- Fredericks, S., Lapum, J., Schwind, J., Beanlands, H., Romaniuk, D. & McCay, E. (2012). Discussion of patient-centered care in health organizations. Quality Management in Health Care, 21, 127–134. doi:10.1097/QMH.0b013e31825e870d [CrossRef]
- Freshwater, D. & Stickley, T. (2004). The heart of the art: Emotional intelligence in nurse education. Nursing Inquiry, 11, 91–98. doi:10.1111/j.1440-1800.2004.00198.x [CrossRef]
- Hinds, L.E. (2013). Patient-centered care: A nursing priority. The Journal of Continuing Education in Nursing, 44, 10–11. doi:10.3928/00220124-20121227-70 [CrossRef]
- Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York, NY: Delta Trade Paperbacks.
- Kitson, A., Marshall, A., Bassett, K. & Zeitz, K. (2013). What are the core elements of patient-centred care? A narrative review and synthesis of the literature from health policy, medicine and nursing. Journal of Advanced Nursing, 69, 4–15. doi:10.1111/j.1365-2648.2012.06064.x [CrossRef]
- Kleiman, S. (2007). Revitalizing the humanistic imperative in nursing education. Nursing Education Perspectives, 28, 209–213.
- Lapum, J., Church, K., Yau, T., David, A.M. & Ruttonsha, P. (2012a). Arts-informed research dissemination: Patients’ perioperative experiences of open-heart surgery. Heart & Lung, 41, e4–e14. doi:10.1016/j.hrtlng.2012.04.012 [CrossRef]
- Lapum, J., Fredericks, S., Beanlands, H., McCay, E., Schwind, J. & Romaniuk, D. (2012b). A cyborg ontology in health care: Traversing into the liminal space between technology and person-centred practice. Nursing Philosophy, 13, 276–288. doi:10.1111/j.1466-769X.2012.00543.x [CrossRef]
- Lapum, J., Ruttonsha, P., Church, K., Yau, T. & David, A.M. (2012c). Employing the arts in research as an analytical tool and dissemination method: Interpreting experience through the aesthetic. Qualitative Inquiry, 18, 100–115. doi:10.1177/1077800411427852 [CrossRef]
- Maben, J., Latter, S. & Clark, J.M. (2007). The sustainability of ideals, values and the nursing mandate: Evidence from a longitudinal qualitative study. Nursing Inquiry, 14, 99–113. doi:10.1111/j.1440-1800.2007.00357.x [CrossRef]
- MacDonnell, J.A. & Macdonald, G. (2011). Arts-based critical inquiry in nursing and interdisciplinary professional education: Guided imagery, images, narratives, and poetry. Journal of Transformative Education, 9, 203–221. doi:10.1177/1541344612441083 [CrossRef]
- Markakis, K.M., Beckman, H.B., Suchman, A.L. & Frankel, R.M. (2000). The path to professionalism: Cultivating humanistic values and attitudes in residency training. Academic Medicine, 75, 141–150. doi:10.1097/00001888-200002000-00009 [CrossRef]
- McCormack, B. (2003). A conceptual framework for person-centred practice with older people. International Journal of Nursing Practice, 9, 202–209. doi:10.1046/j.1440-172X.2003.00423.x [CrossRef]
- McCormack, B., Dewing, J., Breslin, L., Coyne-Nevin, A., Kennedy, K., Manning, M. & Tobin, C. (2009). Practice development: Realising active learning for sustainable change. Contemporary Nurse, 32, 92–104. doi:10.5172/conu.32.1-2.92 [CrossRef]
- McCormack, B., Dewing, J. & McCance, T. (2011). Developing person-centred care: Addressing contextual challenges through practice development. Online Journal of Issues in Nursing, 16. Retrieved from http://nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-16-2011/No2-May-2011/Developing-Person-Centred-Care.aspx
- McCormack, B. & Titchen, A. (2006). Critical creativity: Melding, exploding, blending. Educational Action Research, 14, 239–266. doi:10.1080/09650790600718118 [CrossRef]
- McKeon, L.M., Norris, T., Cardell, B. & Britt, T. (2009). Developing patient-centered care competencies among prelicensure nursing students using simulation. Journal of Nursing Education, 48, 711–715. doi:10.3928/01484834-20091113-06 [CrossRef]
- Moretz, J.G. & Abraham, M. (2012). Implementing patient- and family-centered care: Part II—Strategies and resources for success. Pediatric Nursing, 38, 106–109, 171.
- Morgan, S. & Yoder, L.H. (2012). A concept analysis of person-centered care. Journal of Holistic Nursing, 30, 6–15. doi:10.1177/0898010111412189 [CrossRef]
- Polanyi, M. (2009). The tacit dimension. Chicago, IL: University of Chicago
- Price, B. (2006). Exploring person-centred care. Nursing Standard, 20(50), 49–56. doi:10.7748/ns2006.08.20.50.49.c4487 [CrossRef]
- Radwin, L.E., Cabral, H.J. & Wilkes, G. (2009). Relationships between patient-centered cancer nursing interventions and desired health outcomes in the context of the health care system. Research in Nursing & Health, 32, 4–17. doi:10.1002/nur.20302 [CrossRef]
- Rapport, M.J., Rodriguez, J. & Bade, M. (2010). Use of a community volunteer program to develop value for patient-centered care in physical therapist professional education. Journal of Physical Therapy Education, 24, 53–59.
- Sawatzky, J.A., Enns, C.L., Ashcroft, T.J., Davis, P.L. & Harder, B.N. (2009). Teaching excellence in nursing education: A caring framework. Journal of Professional Nursing, 25, 260–266. doi:10.1016/j.profnurs.2009.01.017 [CrossRef]
- Schwind, J.K. (2003). Reflective process in the study of illness stories as experienced by three nurse teachers. Reflective Practice, 4, 19–32. doi:10.1080/1462394032000053521 [CrossRef]
- Schwind, J.K. (2008). Accessing humanness: From experience to research, from classroom to praxis. In Schwind, J.K. & Lindsay, G.M. (Eds.), From experience to relationships: Reconstructing ourselves in education and healthcare (pp. 77–94). Charlotte, NC: Information Age.
- Schwind, J.K., Cameron, D., Franks, J., Graham, C. & Robinson, T. (2012). Engaging in narrative reflective process to fine tune self-as-instrument-of-care. Reflective Practice, 13, 223–235. doi:10.1080/14623943.2011.626030 [CrossRef]
- Slater, L. (2006). Person-centredness: A concept analysis. Contemporary Nurse, 23, 135–144. doi:10.5172/conu.2006.23.1.135 [CrossRef]
- Spencer, J., Blackmore, D., Heard, S., McCrorie, P., McHaffie, D., Scherpbier, A. & Southgate, L. (2000). Patient-oriented learning: A review of the role of the patient in the education of medical students. Medical Education, 34, 851–857. doi:10.1046/j.1365-2923.2000.00779.x [CrossRef]
- Titchen, A. (2003). Critical companionship: Part 1. Nursing Standard, 18(9), 33–40. doi:10.7748/ns2003.11.18.9.33.c3502 [CrossRef]