The practice development project was a 10-month collaborative education programme for leaders of nursing practice in hospices across the United Kingdom (see Table 1). Participants included 24 clinical and practice development leaders from eight hospices—two in Scotland and six in England—who held pivotal roles in leading and implementing direct care and/or driving change and improvement within their organisations (see Table 2). Hospices were selected to ensure geographical diversity and were invited to participate in the project.

Invitation emails were sent to the nursing care leaders within each hospice, offering the opportunity for two to three members of staff to take part. The eligibility criteria required participants to hold a role in practice development or serve as an operational manager of nursing care. One hospice team withdrew from the programme midway due to time constraints and organisational changes, although they actively participated during the first half.

The programme comprised 7 workshop days delivered over a 7-month period. Of these, two workshops were held face-to-face—one at the beginning and one at the end of the project.

Each hospice received mentorship from one of three facilitators throughout the programme. All materials were hosted on a password-protected online learning platform, accessible only by participants and facilitators. A WhatsApp group was also created for those who wished to maintain direct contact during the programme.

The programme was designed to be flexible, allowing each participant to develop a contextualised practice development plan tailored to their own hospice setting.

ePD was the foundational approach to learning and development within the programme. Over the past two decades, ePD has evolved as a continuous process for cultivating person-centred cultures and care (17). Accordingly, the programme was designed with a flexible and reflective structure, enabling participants to gain insights and knowledge relevant to their personal and professional development and their specific contexts.

The ultimate purpose of the programme was to create conditions that would enable participants to develop the knowledge and skills necessary to transform care to be more person-centred. Through the lens of ePD, the focus was placed on the culture and context of care within each participant's practice area, with the responsibility for action falling to the participants themselves (18). The aim was to support the development of the participants' personhood, values, and beliefs as the foundation for their practice development and learning (19), ultimately enabling them to become person-centred facilitators in their own settings.

The programme remained true to the creative and reflective nature of ePD, recognising these as critical elements for transformation. The approach is grounded in critical social science, which is underpinned by the principles of enlightenment, empowerment, and emancipation (20). This involves raising consciousness, motivating participants to take action, and ultimately engaging in transformative practice (21).

Critical theory has been increasingly applied to healthcare research over the past two decades (22). As a philosophical approach, it challenges taken-for-granted assumptions, questions self-evident realities, and critiques unexamined policies, practices, and procedures. It explores power relations, knowledge formation, and claims to truth, offering tools to critically analyse ideological positions—an approach highly relevant to the findings of this evaluation.

Emancipatory Practice Development also draws on Habermas' dualist theory of society, which distinguishes between the lifeworld (the realm of human experience and meaning) and the system (the realm of economic and technological structures) (22). This theoretical positioning warns against reducing human experience to technical or economic considerations. In this programme, we intentionally focused on the lifeworld—i.e., the lived experiences of participants—rather than on technical skill acquisition alone.

The ePD approach fosters learning that is grounded in the realities of practice. It differs from traditional technical approaches by prioritising critical reflection and the development of the individual as a change agent. The aim is to support participants in identifying the gap between current and desired practice and to explore what is needed to bridge that gap to enable more person-centred care (23). The core focus of the programme was to support the development of new insights and understandings that are transformative in nature (17).

Facilitation is a core principle of ePD. It supports individuals and teams in understanding the context in which they work and identifying the characteristics of that context that may contribute to the gap between the current and desired practice. Thus, the central site of learning is everyday practice, with the goal of enabling meaningful change (17).

To further support participants, the Lantern Model of palliative care nursing was introduced as a theoretical framework. Developed by two of the authors (HR and MC), the Lantern Model highlights the specific skills and knowledge required in palliative care nursing (24, 25). It builds on the Person-Centred Practice Framework developed by McCormack et al. (7) and is rooted in the philosophy and principles of Dame Cicely Saunders. The Lantern Model adapts the person-centred framework to focus more specifically on the context, knowledge, and skills relevant to palliative care nursing in contemporary health and social care. It also reclaims Saunders' original vision as a guiding theoretical foundation for palliative care (24, 25).

The overall aim of the evaluation was to assess whether the programme had a transformative impact on the participants, as intended. The central research question was as follows:

The evaluation was underpinned by a robust ethical framework aligned with the principles of person-centredness and embedded throughout the programme's delivery and evaluation. The key ethical considerations included the following: •

Ensuring voluntary participation,

The Collaborative Critical Creative Inquiry method allowed for multiple forms of data to be collected throughout the programme (28), focusing on the participants' reflections and descriptions of “in-the-moment” experiences. These reflections captured the participants' perceptions as they engaged with the development process.

To support this, reflective aids were used during workshops, including a Claims, Concerns, and Issues session, where the participants critically reflected on their own practices and the influence of their organisational context (29). This enabled them to identify areas of strength, concerns, and priorities for change. The format was based on Fourth Generation Evaluation (29).

Narrative writing was used to surface stories from practice, highlighting both positive examples and areas requiring improvement (30). Participants were also introduced to Haiku writing as a creative method for expressing their feelings and progress. While the traditional five-seven-five syllable structure proved restrictive, this was adapted into more flexible short poems of three to four lines (31).

An evaluation workshop was held on the final day of the programme, focusing on the enablers, challenges, and achievements throughout the change process. Each activity within the programme served a dual purpose: supporting individual and group learning and simultaneously generating data that reflected significant insights, learning, transformation, and outcomes.

Analysis was an iterative process embedded within the programme. It was guided by hermeneutic and interpretive approaches (18) and was conducted collaboratively with all the participants during the final workshop. This included a reflective exercise based on the following questions: “What do I see?”, “What do I feel?”, and “What do I imagine?”

The participants reported a strong sense of rekindling their vision for palliative care nursing practice during the programme. This renewed clarity and purpose translated into a deeper commitment to person-centred care and a strengthened engagement with practice development in their own settings. It was also evident that the programme enabled the participants to develop a clearer sense of themselves as leaders in person-centred palliative care.

The analysis demonstrated that the programme enabled the participants to gain new insights into and an understanding of their roles and of practice development. They became more able to recognise incremental change, even when progress was slow or subtle. It was also evident that the participants developed a heightened awareness of their role within the organisation, and a deeper appreciation of its essence and significance. Furthermore, there was a newfound confidence and resilience in viewing practice development as an ongoing journey—one marked by both high and low points, but sustained by purpose and reflection.

It was evident throughout the programme that the participants felt supported in their role as practice developers, which in turn enabled their personal and professional growth. This is reflected in the following quote from one participant:

Alongside this sense of empowerment, participants also expressed an appreciation of the challenges inherent in the role. One participant noted the following:

The analysis highlighted that the participants began engaging with greater intentionality in making changes to enhance person-centredness in their practice following the programme. This was evident in how they applied newly acquired knowledge and approaches within their workplace settings, as demonstrated by the following quote:

Many of the participants adopted methods introduced during the programme, such as storytelling and positive reflection, to illuminate good practice and foster a culture of appreciation and learning. One participant stated the following:

The participants also recognised the importance of developing a shared vision and clearly articulating the values and beliefs underpinning person-centred care. Several facilitated workshops within their own teams to promote this focus, with one participant stating the following:

The programme fostered a stronger sense of role clarity and commitment to practice development within hospices. The participants became more intentional in their actions to influence and shift organisational culture, as evidenced by the following quote:

The analysis revealed potential macro-level impact stemming from individual transformation during the programme. Most of the participants felt that being part of a community of learners had strengthened their vision and resilience. They reported feeling better equipped to face challenges and setbacks in their roles, including efforts needed “to raise awareness of person-centred development within the hospice” (p7) and to “open their organisation's eyes to new opportunities” (p11).

Despite this, participants expressed concerns about the implementation of change within their practice environments and questioned how well their organisational contexts were prepared to support transformation, as evidenced by the following quotes:

On the final day of the programme, the participants worked in hospice-based teams to plan future intentions. They identified small-scale initiatives that could support the transformation towards more person-centred care. Many of these were micro actions with the potential to influence the macro system. Examples included the following: •

Facilitating workshops within their hospices based on learning from the programme,

The participants were able to identify elements of behaviour and actions within their practice that reflected a person-centred orientation—values they strongly believed in but had not previously recognised or articulated. These aspects of their professional identity had remained hidden prior to the programme and were brought to light through reflective learning. This realisation fostered a sense of confidence and excitement about their practice, the care they provided, and its impact.

Through the programme, the participants gained a new understanding of their professional ideology. Ideology refers to the shared meanings and values of a group; it is socially constructed and does not exist as an objective truth but is made visible through the behaviours and actions of its members (32). It became evident that the ideology of the palliative care nurses and leaders—particularly those leading person-centred practice development—aligned closely with Cicely Saunders' philosophy, as articulated in the Lantern Model of Palliative Nursing (24, 25). Awareness of this alignment strengthened the participants' professional identity, which had previously been unspoken and obscured.

Trede et al. (32) argue that when professional ideology remains hidden, it is often because another profession has gained authority, social status, and dominance. Within traditional healthcare systems, the medical-biological model holds an authoritative position, shaping practice and discourse. James and Field (33) highlight how the hospice movement became over-medicalised as it was integrated into mainstream healthcare. Power and domination within organisations influence who determines actions, what topics are discussed or avoided, and who has a voice in decision-making (34).

By raising awareness of power dynamics and ideological bias, the participants became more attuned to how authority was exercised within their organisations and how this influenced practice. They recognised that unexamined ideological biases could hinder the development of person-centred care. Identifying and challenging these biases became a vital part of their role as leaders in care transformation.

More than two decades ago, McCormack et al. (17) emphasised the importance of attending to cultural and contextual factors in humanising healthcare. Without this focus, they argued, the system cannot truly place the person at the centre of care. McCormack also called for a revolution in healthcare education, advocating for programmes that prioritise human elements alongside technical development (12).

More recently, Cook et al. called for innovative approaches to healthcare education, promoting congruence between education and practice to support the transformation of care and the humanisation of healthcare (35). Despite these calls, educational programmes have been slow to shift from a technical focus to more transformative and emancipatory approaches.

There is a need for organisational bravery among nurse practitioners and leaders to invest in learning and teaching programmes that enable teams to step back from routine practice and reflect on the deeper meanings attached to their work (36).

During the programme, the participants came to recognise that their approach to care was deeply rooted in moral and ethical intent. This realisation was significant, as they began to see how their values aligned strongly with person-centred practice and Cicely Saunders' philosophy of palliative care. These insights helped the participants understand that both models of care emphasise this orientation, which Saunders formulated as the expert practice knowledge essential for palliative and end-of-life care (1).

Throughout the programme, the participants also realised that the knowledge they considered central to their expertise was often subjective, embedded in experience, and taken for granted. The programme created conditions for consciousness-raising, enabling the participants to become aware of how their actions and behaviours were guided by deep, experiential knowledge. They began to recognise the knowledge base they operated from and its contribution to positive health outcomes for those they cared for.

This form of knowledge aligns with what Habermas described as practical knowledge (37). Habermas proposed that all knowledge is shaped by personal and professional interests and can be categorised into three distinct domains: technical, practical, and emancipatory. Each domain generates different types of knowledge, poses different questions, and influences different actions and perceptions of reality.

Practical knowledge is “stored” knowledge that guides practitioners' actions. It involves understanding intentions, meanings, values, and interests—both one's own and those of others—and is based on a reflexive and evolving understanding of the situation in which one is practising. Within nursing, this has been described as practice wisdom and professional artistry (38).

In contrast, technical knowledge, as defined by Habermas, is driven by a desire for control, prediction, and certainty. This aligns with the traditional biomedical model of healthcare, which prioritises efficiency, measurable outcomes, and curative approaches.

While Habermas argued that both types of knowledge are equally important (37), the modern healthcare system has inherited a hierarchy of knowledge that places technical knowledge—rooted in biomedical science—above practical and emancipatory knowledge. In the context of humanising healthcare, it is essential to challenge this hierarchy and recognise the value of practical knowledge and wisdom as equally vital.

Indeed, it is this form of knowledge that enables care to meet the needs of many individuals, particularly those with complex, long-term, or end-of-life conditions—as Cicely Saunders identified in the 1960s. The traditional biomedical model is increasingly ill-suited to address the challenges posed by an ageing population and the growing burden of chronic illness.

Person-centred practice development seeks to humanise healthcare by valuing both technical expertise and practice wisdom, ensuring that care is not only clinically effective but also ethically grounded, relational, and responsive to individual needs.

The programme created conditions for raising awareness of the nature and importance of practice-oriented knowledge. This enabled the participants to recognise the need for applying the third type of knowledge described by Habermas—emancipatory knowledge. For Habermas, this form of knowledge is driven by the desire for liberation from unnecessary constraints and limitations (37). Emancipatory practice emerges when care is guided by less hierarchical, critically examined knowledge, and when the values and voices of all involved, including the patient, are treated as equal.

This orientation is foundational to Cicely Saunders' development of palliative care in the late 1950s and early 1960s, which challenged the dominance of technical knowledge in healthcare. Saunders responded by advocating for a model of care grounded in practice wisdom, relational expertise, and ethical intent (2).

Over recent decades, concerns were raised about the over-medicalisation of palliative care, particularly as it transitioned from its grassroots origins into mainstream healthcare systems (33). The programme enabled the participants to reflect on their own values and intentions, and to recognise when these were misaligned with the organisational values driving day-to-day practice. This critical awareness led to new insights into how organisational culture could either hinder or facilitate person-centred care, challenging the medicalisation of palliative care.

Throughout the programme, the participants gained a deeper understanding of how their roles involved challenging existing cultures and aligning with an emancipatory orientation to knowledge. They recognised their responsibility in addressing the imbalance within the hierarchy of knowledge, where technical expertise often overshadows relational and ethical dimensions of care. Emancipatory practice in palliative care embraces the complexity of practice, where facts, technical knowledge, values, and professional wisdom co-exist and inform one another.

The participants also developed greater insight into the need for cultural change, recognising their role in navigating and leading this journey. They became more aware of their organisational structures and contexts, and how these influenced the potential for transformation. Importantly, they acknowledged the emotional and professional demands of their role, including the need for self-care and resilience.

The programme helped the participants reframe change and transformation as a process or journey, rather than a series of immediate outcomes. This perspective enabled them to appreciate incremental progress and to develop new ways of measuring success through small but meaningful steps. See summary of key findings in Table 3.