Transforming a Psychiatry Curriculum: Narrative Review of Essential Elements

Abstract

Introduction: In this narrative review, we identified concepts related to the process of transforming a psychiatry curriculum for New Zealand medical students. Method: A literature search was performed on four databases (Embase, Medline, PsycInfo, and Scopus) for articles related to curriculum development in psychiatry, including relevant aspects of culture and technology. Results: Ninety-three articles met the inclusion criteria. Three main themes were identified: the needs of learners; curriculum frameworks that optimise learning; and the role of technology. The key features of an effective psychiatry curriculum are the extent to which it integrates with other disciplines, develops key competencies, supports authentic learning, and promotes cultural safety. Conclusions: Transforming curricula is an iterative process that prioritises learners’ needs, establishes psychiatry within the teaching context, integrates learning evidence, and responds to the changing demands of society. The findings from this review apply to medical curricula more generally: a well-integrated specialist curriculum, in this case psychiatry, enables medical students to build essential competencies and depends upon effective collaboration with stakeholders, attention to cultural safety, and incorporating technology into the teaching context.

1. Introduction

Medical curricula have typically prioritised the stepwise acquisition of discipline-focused knowledge and skills [1], but there is increasing recognition of overlaps, leading to the integration of core content across multiple disciplines. Psychiatry is a vital component of medical curricula and is relevant to a wide range of clinical presentations [2,3]. However, there is no consensus on what constitutes an optimal psychiatry curriculum for medical students [4,5]. Ideally, curricula should include psychological first aid skills [6], and measures to safeguard medical students’ own psychological health and wellbeing [7,8].

Curriculum development includes both a body of knowledge and a process of constructively aligning learning objectives, teaching methods, and assessments [9]. Learning theories provide essential guidance for determining core content [10], methods [11], and resources [12] for different learning styles [13]. Students’ knowledge is based on cognitive, psychomotor and affective dimensions of learning [14]. Treating medical students as emerging adult learners encourages them, inter alia, to be agents of their own learning [15]. Explicit learning objectives [16] help to clarify learning content that optimally aligns with assessment [17].

The aim of this review was to develop a conceptual framework of a psychiatry curriculum, focusing on student needs, teaching practice, collaboration with other disciplines, and the role of technology, the latter was highlighted by the demand for remote learning during the COVID pandemic. We are part of a network that includes Australian and Canadian psychiatry educators who acknowledge and value indigenous knowledge; therefore, we also aimed to identify and critique attempts to integrate cultural concepts into psychiatry teaching. Cultural safety is of particular relevance and is emphasised in medical practice within legally bicultural Aotearoa/New Zealand [18]. Medical curricula in New Zealand are distinctive in incorporating aspects of the Treaty of Waitangi, the country’s founding document mandating both the rights and participation of the indigenous Māori population. Medical curricula incorporate Māori models of health [19], and recognise how Māori health inequities relate to socio-economic disadvantage and the impacts of colonisation.

2. Methods

2.1. Setting

We teach at a medical school that comprises New Zealand’s largest Māori and Pacific community. The students are a mix of undergraduate (accepted to medical school after one year of university in a competitive entry process) and postgraduate (after completion of a degree). The early curriculum (years 2 and 3) of the medical programme contains eight core modules that emphasise aspects of professional, personal, and core clinical skills. At the early stage of training, the professional and clinical skills module comprises five broad domains: applied science for medicine; clinical and communication skills, personal and professional skills; Hauora Māori (covering aspects of indigenous health); and population health. This prepares students for clinical practice in years 4 to 6. Our teaching combines clinical time with patients, didactic lectures, and interactive small group work. Students can access an e-learning resource that contain videos and tutorials for self-directed learning on core topics in psychiatry. In years 5 and 6, students undertake a clinical psychiatry rotation of six and four weeks, respectively. Teaching is usually in person in small groups with an apprenticeship model while on clinical placements. Given the COVID-19-related disruptions, we were faced with the urgent need to transition to online teaching that would include critical aspects of the psychiatric curriculum without losing its fundamental ethos.

2.2. Search Strategy

We conducted a scoping literature search via four online databases (Embase, Medline, APA PsycInfo, and Scopus) using MeSH and keyword terms encompassing the development of psychiatry curricula for medical students. A specialist librarian further refined the search terms for each database (

Table 1. MEDLINE medical subject headings.

Ovid MEDLINE® Subject Headings	Keywords
Curriculum	curricul*.mp.
exp Psychiatry, Mental Health	psychological medicine.mp. or psychiatr*.mp. or mental health.ti,ab,kw. or psychological medicine.ti,ab,kw.
Education, Medical, Undergraduate, Schools, Medical, Students, Medical	(medical adj5 (school* or student*)).mp. or medical education.ti,ab,kw.
	co-design$.mp. or codesign$.mp.

). The search was conducted on 28 September 2021. As outlined in Figure 1, PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) method was used to refine the articles.

Criteria for inclusion were curriculum-related research and commentaries in higher education, empirical research, and commentaries on psychiatry curricula in undergraduate medical education, in English and German languages (one author was proficient in German). We also included search terms that considered Māori, indigenous populations generally, and the role of technology in curriculum development. Studies were excluded if they were published pre-2000; reported on fields of medicine unrelated to psychiatry; referred to specialist medical education, post-graduate residents/registrars, medical specialists, or allied health professionals; niche topics not relevant to undergraduate programmes; or focused on the wellbeing of medical students without reference to curriculum development. The reference lists of included studies (N = 93) were also scanned to identify additional eligible studies.

2.3. Data Analysis

The search results were imported into NVivo^® (QSR International, Burlington, VT, USA) and duplicates removed. Articles were divided into categories according to whether they met, possibly met, or did not meet the inclusion criteria. Five authors were involved in the review process. Titles and abstracts were further screened for eligibility using PRISMA guidance to identify relevant articles (Figure 1). Full text articles were retrieved, imported to NVivo, and re-checked against the inclusion criteria. One author screened articles with cultural and indigenous themes. We used an inductive approach [20] to develop themes from the reviewed articles. The articles were read closely. The content of the articles was synthesised in an annotated bibliography. The content of each article generated from the list of included studies was coded by two of the authors. Two other authors reviewed the articles to confirm their inclusion in the final review. The coders discussed the coding and the conceptualisation of broader, overarching themes. The team contacted and met with international medical curriculum researchers as part of the review process to discuss themes and questions that had arisen. The final themes were discussed among the authors and further refined and agreed on.

3. Results

The initial search yielded 12,625 articles, of which 3610 were duplicates and were removed, leaving 9015 to be screened. The full texts of 93 articles were included in the final review (Table S1).

The selected articles provided insights and critiques of curriculum development, emphasising purposeful alignment of the curriculum with learner needs, faculty and societal needs [3,21,22,23], learning models [4], and reforms in undergraduate medical education [24,25,26]. We identified three themes (Figure 2): (1) the needs of learners, the community they serve, and psychiatry as a discipline; (2) curriculum frameworks that optimise learning within a psychiatry curriculum; and (3) the role of technology. Subthemes recognised the individual and societal costs of the increasing global burden of mental illness and the need to train culturally and clinically competent doctors [26].

3.1. Learner-Focused Core Curricula and Teaching

A learner-focused, strategically planned core curriculum includes evidence-based medicine and teaching methods [27,28]. While emphasis should be on core curricula that are practical and applicable to various clinical contexts [22], medical schools often teach in a siloed, discipline-specific manner [29]; students may not be aware of this [30,31] and, as a consequence, may be inadequately prepared for practice [4] as junior doctors [32]. Addressing unmet student needs [21] in psychiatry includes content on attitudes towards practice, patients, and families; knowledge of psychiatric syndromes; and information gathering, evaluation and reporting skills, treatment, and teamwork [33]. The tacit acculturation of students into medicine [34,35] emphasises professional growth and humanistic, well-rounded, compassionate, and empathic qualities [34]. Additionally, the development of professional identity is influenced by student observation of senior colleagues, for example, the handling of boundary issues, confidentiality, and diagnostic complexity [36].

3.2. Integrated Learning

Psychiatry curricula should not be treated as siloed from other medical disciplines. Learning resulting from collaboration between medical educators from different specialties demonstrates psychiatry’s integration into the overall curriculum [17,37,38,39] and its relevance to real-world practice, where multidisciplinary collaboration is necessary in primary and secondary care [40]. Although there may be challenges in effectively integrating psychiatry teaching within broader medical school education [41], there is a high yield through partnerships across medical specialties [31,36,42,43,44,45,46]. Shared goals across specialties mapped to overarching curricular objectives can help to minimise gaps and repetition [47]. Collaborative partnerships highlight the value of collegiality and cooperation as part of a holistic approach to patient care [48]. Collaboration between specialties helps define relevant core competencies, irrespective of students’ future specialty [49]. Such initiatives may lead to more sophisticated learning outcomes, enabling students to appreciate complex patient narratives and a more holistic perspective of management options [50]. Moreover, introducing students to different settings for learning psychiatry will convey that psychiatric knowledge is essential in various contexts, including both general hospitals and primary care [38,51].

3.3. Authentic Learning Experiences

Students prefer learning derived from actual experiences and interactive case-based discussions that emphasise problem solving, critical thinking and collaboration [52]. Graduating doctors value relevant teaching on high prevalence conditions [32,38] that align with actual work they are expected to perform [53]. Learning may be enhanced by rich clinical, research, and humanistic experiences with specific learning objectives and a suitable environment to support learning [54,55]. Exposure to patients with psychological and physical illnesses [43,56] and complex comorbidities prepares students for what they are likely to meet in clinical practice [57]. Interactive learning, such as role play, supports experiential and higher order learning processes [52] in more complex topics [58]. Role modelling in clinical training develops students’ awareness of both physician–patient and mind–body interactions [35]. Exposure to, and teaching on, undifferentiated presentations, for example, anxious patients in different settings, promotes clinical reasoning [28,34] and awareness of predisposing and protective factors relevant to illness and impairment [34,59].

Enabling reflection on negative experiences in the clinical learning environment, for example, critical incidents, may lead to salutary shifts in beliefs, attitudes, and behaviours [60]. Practical learning on first-line psychological interventions exposes students to early presentations of illness [32,61] and introduces the relationship link between illness, stress, and psychosocial factors [29].

3.4. Mental Health Literacy

The importance of mental wellbeing is well recognised, as is the global burden of mental illness over the lifespan [48,62,63,64]. During the course of their professional and/or personal lives, all doctors will have contact with people experiencing mental illness [32]. Robust training is required to enable non-specialists to deliver psychological first aid and refer, as appropriate, to secondary services [65]. Educators who plan and develop curricula must balance student interest with teaching the fundamentals of a specialty [38,62]. This is an important consideration in psychiatry as students may not appreciate the relevance of basic psychiatric knowledge and skills until later in their careers [38]. Students may overestimate their clinical skills with more complex cases “not knowing that they do not know” [66].

Experiences in psychiatry influence students’ attitudes towards people with mental illness [64]. Stigma can be perpetuated if students experience psychiatry as dispiriting or are exposed to a traumatic view of psychiatry [4,62,63,67]. Positive exposure, by contrast, helps students to be more comfortable and confident in interviewing and assessing patients [68]. Despite changes in the way mental health is portrayed in current media, students may be influenced by society’s aversion to discussing psychological health as reflected in the behaviours of patients, supervisors, and other clinicians [29,68].

Fostering medical student awareness of self-care and wellbeing is important as it supports the attitudes, knowledge, and skills they will need to assess and manage psychiatric illness [4] and to process emotional content arising from difficult encounters [69,70].

3.5. Cultural Safety

Cultural safety requires ongoing self-reflection and self-awareness and is distinct from cultural competence [71]. Medical curricula typically include cultural competence based on awareness, attitudes, knowledge, and skills [72], but these alone cannot deliver health equity improvements [71]. Cultural safety is thus an essential ingredient in curriculum development.

Psychiatry may consider the impact of culture on patients and their care more than other medical specialties [73]. A patient’s background is fundamental to psychiatric formulation, as there may be cultural, gender, religious, or disability backgrounds that influence their understanding or experience of illness [55,73,74].

A common critique of curricula is the lack of tailoring to specific needs such as the cultural background of patients or those living rurally [75]. Even if cultural issues are integrated into clinical vignettes [45], the methods of teaching patient-centred culture-sensitive care may nonetheless be suboptimal [35]. For example, Australian students report feeling more comfortable and prepared to discuss mental health concerns with Aboriginal and Torres Strait Island minorities following locally relevant, practical training [75].

Our literature search did not find reports of Mātauranga Māori (Māori knowledge), an indigenous knowledge that spans culture, values, and world views. These concepts are often excluded from mainstream education. Māori struggles for self-determination, mandated by the Treaty of Waitangi, have driven the development of Māori perspectives in theory and research [76,77,78]. In New Zealand, Māori immersive experiences such as the powhiri (formal welcome ceremony) offer authentic learning outside the lecture theatre or teaching hospital. Such cultural experiences require additional time, effort and resources to facilitate, but students value such experiences [79,80,81]. Some subjects are amenable to online teaching, such as the principles of the Treaty of Waitangi, while others are best experienced in-person, such as self-reflection or learning about the Māori value of manaakitanga (kindness and hospitality). These emphasise relational dimensions of Māori knowledge systems. Aspects of Mātauranga Māori and its influence on the New Zealand psychiatry curriculum will be further explored in a follow-up paper.

Incorporating indigenous cultural competency into the curriculum requires flexibility to accommodate diverse learning needs or else educators may risk facing resistance from students. Cultural safety and cultural competency programmes are not standardised and should be tailored to the needs of students, universities, health systems, and the communities they serve [82], complicating the evaluation of teaching in different contexts.

4. Frameworks That Optimise Learning within a Psychiatry Curriculum

4.1. Context, Lived Experience, and Service User Perspectives

Students value learning that is meaningful [83], and it is valuable to incorporate the authentic, lived experiences of service users. However, this needs to be aligned with the learning goals and ethical considerations [84]. Teachers and students are relevant stakeholders who can identify potential curriculum topics for assessment, determine core content, and design teaching resources [85] that highlight broader treatment, psychosocial [45], and ethical concerns within cultural [42] and system [86] contexts. Adult learning principles in narrative medicine may be incorporated into medical curricula, as a patient’s narrative is of particular value in psychiatry [87]. This highlights the service users’ perspectives, for example, regarding personal choice, consent, and patient-centred care [83].

4.2. Key Competencies

Focusing on building skills and confidence, in addition to acquiring and assessing knowledge, enhances mental health literacy. Moreover, assisting students in processing emotions and challenging stereotypes about people with severe mental illness may shift attitudes towards psychiatry [88]. A robust process is also required to define learning objectives that enable graduating doctors to deliver competent, culturally safe care.

Some educators have promoted ‘conceptual competence’, that is, increasing awareness and the shaping of aspects of clinical care by challenging assumptions [2] and the identification of ‘threshold concepts’ (such as the biopsychosocial model) to prioritise potentially transformative areas of the curriculum [70]. Learning about diagnosis, treatment initiation, and specialist referral should be performed while considering the differences between primary and secondary care, specialist and general medical settings, and service user and family perspectives [74]. These essential skills are relevant to all doctors working with patients in different settings with mental distress or at risk of suicide [38].

For example, an estimated 30% of general practice consultations contain a mental health component, and a similar proportion of medical inpatients present with delirium [89]. Additionally, when encountering cases that reflect real-life complexity, students become more clinically astute, such as when patients report a complex array of symptoms and stresses [90].

4.3. Spiral Curriculum

Medical students at the initial stages of training may be considered ‘undifferentiated’ in terms of specialty [45], with the potential [4] to build core psychiatric competencies as they progress [39]. Introducing psychiatry earlier in the medical curriculum [91] allows students to reflect on mental health-related issues throughout the course of their training, as opposed to compartmentalising learning during a psychiatry attachment late in the course [48].

Topics taught as a spiral curriculum reflect increasing complexity as students advance through medical school [92]. Educators may be guided by national or best practice guidelines and find it useful to map specific topics for knowledge, skills, and attitudes related to expectations for the stage of training [62]. The early exposure of students to positive role models and experiences in psychiatry also influences attitudes towards the discipline [4,69,84,89].

4.4. Teaching and Assessment

Active learning has gained prominence as a means for developing students’ critical thinking for the long-term retention of concepts. A range of active learning techniques are used: problem-, case-, and team-based [45]; simulator-based [93]; the use of worksheets, personal response systems, small group tutorials, and the flipped classroom [94]; role playing [74]; and live or videotaped patient interviews [41]. Students may have an emotional response to learning, for example, feelings of performance anxiety or embarrassment when they err. Teachers support students by role-modelling attitudes towards mistakes and providing constructive feedback [57].

Theoretical knowledge integrated with cases in a problem-based learning format assists the development of clinical reasoning [95] and an appreciation of complexity. Active learning techniques such as patient interviews increase student satisfaction in psychiatry and enhance clinical competence compared to traditional lectures [96]. Learning may be reinforced by writing up mental state examinations and case discussion in small groups.

Medical educators have sought to align educational methods with learning objectives [94], resulting in the use of blended learning approaches [97] that incorporate interactive and reflective case discussion [23]. Teaching with patients [4] may be complemented by simulated learning based on role-playing [57]. Training in practical clinical skills may be supported by methods such as iterative hypothesis testing to deepen decision making skills [22].

Combining these formats may be valuable at the early stages of training even for topics perceived as more complex, such as trauma care [98]. As students transition from learning basic sciences to clinical rotations, learning may be reinforced by modules that are developed to minimise overlaps and gaps in knowledge [43]. Integrating active learning practices into psychiatry education focuses on applying, rather than acquiring knowledge [95]. Knowledge retention may be supported by reflective practice and learning in a supportive environment [99].

The achievement of defined and measurable learning outcomes is fundamental to implementing a curriculum [37,100,101]. Constructive alignment of teaching with intended outcomes is meant to encourage deeper, meaningful learning, but students may still adopt a surface learning approach [102]. Through assessment, students can demonstrate that they have mastered core competencies, although this is difficult to standardise [27]. Coupled with more high stakes summative assessment strategies such as Objective Structured Clinical Exams (OSCEs), formative tasks can enable students to track their progress and improve their performance over the course of the programme [103]. More sophisticated methods of assessing learning should be considered for the difficult-to-measure qualities such as communication and professionalism [95].

The achievement of competency-based learning objectives is an alternative way to assess skills [104] for tasks such as taking a psychiatric history, assessing mental state and risk, developing a formulation, ordering and interpreting investigations, initiating treatment, recognising and treating psychiatric emergencies, documenting and presenting a clinical encounter, and identifying opportunities to improve patient safety [104] such as critical incident or adverse drug reaction reporting.

4.5. Implementation and Evaluation

Fundamental to implementing changes to curricula is student agency and engagement with activities that enable the achievement of defined and measurable learning [37,100]. Constructive alignment of teaching with intended outcomes encourages deeper, meaningful learning, but students may still adopt a surface learning approach [102]. There is tension between passing undergraduate exams and acquiring real-life competence. Students’ focus on passing exams and their preoccupation with assessments [57] lead them to prioritise requirements ‘for the test’ [43] rather than lifelong learning. Through carefully crafted assessments, students can demonstrate that they have mastered core competencies, although this is difficult to standardise [27].

Curriculum design is also influenced by the values and beliefs of the teachers who lead the process. We did not find specific studies that explored teachers’ perspectives in this review but will mention that learner input is clearly important [105]: curriculum evaluation from current students, recent graduates, and educational staff informs the development of course goals and objectives [23]. The evaluation of the teaching and assessment methods of undergraduate psychiatry indicated that the length of experience in psychiatry, together with the course structure and assessment, influenced the development of appropriate attitudes and skills [5].

Challenges to implementing curricular changes include training the staff, providing technical support, and creating and updating teaching materials [95]. Encouraging active learning is limited by the capacity of teaching staff and facilities [103] and the preparation time required from both teachers and students [95]. Constraints on providing teaching may be more pronounced in rural areas [106]. Postgraduate psychiatry trainees can be useful in teaching clinical skills and enhancing the experience of undergraduate medical students [101,107]. There are practical measures to support learners such as having a named tutor to contact during clinical placements, shared expectations of outcomes, monitoring during a placement, and timely and confidential feedback [101].

5. Role of Technology

5.1. Online Teaching and Learning

Online learning materials in psychiatry for medical students is an essential means to replace or supplement face-to-face lectures [42] and support self-directed learning related to case material [93]. Online learning allows ease of access and flexibility, may improve interactions between students, and has advantages for learners in remote locations. Online resources can supplement interactive learning and community placements [93]. Enabling students to engage with virtual learning may facilitate engagement and improve course performance and satisfaction in psychiatry [108]. Teaching resources to enhance student learning and experience include fictionalised video diaries, virtual patient cases, and online workbooks [93]. Educators providing group learning using videoconferencing observed different group dynamics [109], suggesting active learning through social interaction [55]. However, suboptimal student–teacher interactions, feelings of isolation, the inability to clarify concepts in person, and inequitable access [55,110] are disadvantages. Additionally, tutors find online teaching to be draining, as some students require encouragement to engage [109].

5.2. Reassessing Aims of Technology

The COVID pandemic highlighted the need for medical educators to adapt to changing circumstances. In response, teaching psychiatry to medical students has transitioned to online platforms in many countries [111,112], potentially increasing inequitable access to technology and learning opportunities [105]. Some institutions relied on previous experience to develop their existing structure for online teaching. The necessity of creating new remote learning experiences resulted in a mixture of virtual learning, peer and tutor interactions, modified assessment, and support [111]. A lack of planning and resources, usability problems, and limited interactivity between teachers and students [113] were some barriers to technology use.

5.3. Technology Adoption

Technologies used in medical education can range from ubiquitous information and communication solutions—familiar to staff and students—to highly specialised and complex ones such as simulations and virtual reality. Developing faculty infrastructure with adequate resources, dedicated time, and institutional support for teachers’ skill development are necessary for the effective use of new technology [28,94,103]. Delivering course material online can be costly, time intensive, and challenging for large class sizes [109]. Specific content and administrative expertise are both required to maintain communication and optimise learning.

6. Discussion

Essential elements in transforming a curriculum should consider, and proactively address, the need for change, learners, teachers, and contextual factors [114]. Psychiatry is a craft that emphasises lived experience and a thoughtful, holistic approach to working with patients. In developing a psychiatry curriculum, we ask: What kind of psychiatrists will patients need in the future [22]? What core psychiatric knowledge and essential skills does every doctor need? What aspects of technology are effective for online learning? In this narrative review, we aimed to identify critical aspects of curriculum change, with the rationale being to evolve and tailor psychiatry curricula to the needs of our students, improve teaching practice, and optimise collaboration with other disciplines. We deem curriculum transformation to be an iterative process of considering learners’ needs, placing psychiatry within its social context, integrating evidence-based curriculum frameworks that optimise learning, and adapting curricula to incorporate new technology.

Conceptualising the curriculum as a process focuses on student engagement and experience, ultimately aiming to enable students to have agency in learning and to master complex decision making [94]. If we are to equip doctors with reasonable knowledge and skills to provide patient care and promote health, considering learners’ needs should be central. We want to train future psychiatrists, and, equally, we want to ensure that other future medical doctors deepen their understanding and have practical skills to enable an integrated approach to clinical care. Relatively small proportions of medical graduates specialise in psychiatry, but all doctors need core psychiatric skills, regardless of specialty.

There is evidence that adult learning principles promote agency, a safe learning environment, critical reflection, awareness of one’s limitations, and a commitment to lifelong learning. We propose that learners benefit from psychiatry educators collaborating with other medical disciplines and with the community being served. Spiral integration of psychiatric concepts and syndromes reinforce learning as students acquire theoretical knowledge, observe and reflect on clinical experiences, and apply learning to other situations [115]. Structuring curricula around core competencies provides a learning scaffold that reflects the clinical environment and drives learning [104]. Assessing competence identifies what students will do when faced with patients, to demonstrate they have knowledge and competence and can perform tasks and exercise judgement [116]. Honing critical skills in interpreting clinical data and translating findings to management constitutes the ultimate application of knowledge and skills to patient care.

The delivery of psychiatry curricula varies in terms of content and quality [41] and may be subject to the requirements of a governing medical body. Curriculum revision may be warranted if, for example, there is a lack of training resources, teaching materials are outdated, and/or feedback on learning activities shows a mismatch with expected clinical tasks [22]. Implementing a well-integrated curriculum is an iterative, long-term process. To deliver a sufficiently broad-based psychiatry curriculum that meets student needs, teachers must address issues that reflect both the societal burden of mental illness as well as the limitations of the traditional biomedical model. Undergraduate medical education should develop essential qualities doctors need in clinical practice. The goal of an integrated curriculum is to break down barriers between basic and clinical sciences and to promote the retention of knowledge through the repetitive and progressive development of concepts and their application [1].

Curriculum re-design can promote engagement and motivation [108]. Based on this review, we recommend planned technology integration, recovery-oriented perspectives, and cultural awareness in an evolving curriculum. Online learning approaches to teaching and learning are essential supplements to traditional campus- and hospital-based education. However, proper planning needs to be part of curriculum design to ensure the suitability and adaptability of appropriate technologies. Integrating the concepts of recovery and self-determination in curricula makes for more comprehensive and integrated patient-centred care [83].

In many settings, teaching regarding cultural diversity is often fragmented [117]. In New Zealand, the concept of cultural safety is fundamental to curriculum transformation [118]. There are, however, significant challenges to implementing such transformational change. While a spiral curriculum is beneficial in many respects [93], it could disadvantage students unfamiliar with indigenous culture. Māori workforce expansion is required to meet aspirations and avoid unpaid obligations on Māori staff [119]. The breadth of expertise necessary to address the Treaty of Waitangi obligations, including cultural safety and indigenous approaches to theory and research, is substantial. Cultural supervision and input from respected elders are necessary to ensure a culturally safe and informed learning environment.

7. Limitations and Directions for Future Research

A limitation of this review is the search for articles on curriculum development within the psychiatry context. The literature revealed little empirical evidence and a large volume of commentary on curriculum development. We acknowledge that the inclusion of perspectives may have skewed the themes of the narrative review and that there is also some overlap between themes. In our analysis of the empirical data, we did not place a weighting on the research methodology. This is a limitation; future analysis should more sharply distinguish studies with methodological advantage. It was evident that some aspects of curricula are difficult to evaluate. Missing in the literature are teachers’ perspectives, and there is limited evaluation of what constitutes cultural safety and the impact of unconscious bias on clinical care. Based on this review, we suggest the impetus for future research focus on contextual, institutional, and systemic influences supporting or inhibiting teaching and learning. We favour qualitative methods to examine the nature of learning within specific cultural and socio-political contexts [120]. Participants to recruit in further research should include mental health service users, tutors in psychiatry and other specialties, medical educators, recent medical graduates, students, family, and indigenous experts and elders. Investigating the changing role of technology in promoting connection and collaboration is a crucial domain for future curricular development.

8. Conclusions

Transforming curricula is ideally an iterative process that prioritises learners’ needs, establishes psychiatry within their context of learning, integrates learning evidence, and is responsive to society’s changing demands. Educators striving for integrated, authentic learning enable students to build competencies. This form of learning depends on effective collaboration with stakeholders, attention to cultural safety, and incorporating technology into the teaching context across all stages of a medical programme.