The National Service Framework for Mental Health states ‘Service users and carers should be involved in planning, providing and evaluating training for all health care professionals’ (Department of Health, 1999). In addition, the Department of Health has supported the ‘expert patient programme’ in acknowledgement of the invaluable experience patients with chronic disease have in terms of their condition and the management of their condition (Department of Health, 2001).
There are few publications concerning the involvement of service users in training psychiatrists, most are concerned with the training of medical students (e.g. Reference Butterworth and LivingstonButterworth & Livingston, 1999, Reference Spencer, Blackmore and HeardSpencer et al, 2000). Ikkos (Reference Ikkos2003) piloted a teaching programme in London that utilised the resource of a service user organisation. These 6-month courses aimed to teach ‘basic interview skills, elementary psychodynamic concepts, interviewing in organisations or with families and cultural considerations in the psychiatric interview’ to junior doctors in their first 6 months of psychiatry. The feedback from junior doctors was on the whole positive, although it was recognised that there was dissatisfaction among a minority of doctors. A further pilot by Haeney et al (Reference Haeney, Moholkar and Taylor2007) introduced service user teaching to psychiatric trainees. They reported a method of setting up a programme and some of the difficulties encountered, with seemingly positive feedback from participants (Reference Haeney, Moholkar and TaylorHaeney et al, 2007). Babu et al (Reference Babu, Law-Min and Adlam2008) in a recent questionnaire again demonstrated that the majority of trainees would embrace service user involvement in their education, but also highlighted that trainees have anxiety about its implementation, including confidentiality, ‘over-involvement’, the requirement for careful screening of the service users involved and their involvement in trainees’ exams.
In January 2007, the Royal College of Psychiatrists produced ‘A Competency Based Curriculum for Specialist Training in Psychiatry’. This curriculum provides the framework for training psychiatrists from August 2007 onwards. The curriculum identifies several areas involving service users in which the trainee must be competent before progressing in their career. This new curriculum provided the opportunity to update the Mid-Trent educational programme for psychiatric trainees and to incorporate specific teaching for workplace-based assessments. We ran a pilot course from February 2007 to August 2007 for registered doctors new to psychiatry (foundation year 2, speciality training year 1 (ST1), general practice vocational trainees) that included service user-led teaching.
Method
The pilot course was incorporated into the trainees’ 15-week half-day protected educational time; in total, 44 sessions were delivered and each individual session lasted 50 min. The course primarily focused on interview skills training. It had four components; psychopathology (7 sessions), emergency psychiatry (5 sessions), workplace-based assessments interview skills training (22 sessions) and service user-led interview skills training (10 sessions). Psychopathology and emergency psychiatry sessions were didactically taught by a senior psychiatrist. Workplace-based assessments interview skills training sessions were facilitated by a senior psychiatrist. The service user interview skills training sessions were service user led.
Workplace-based assessments interview skills training primarily focused on Mini-assessed clinical encounter (mini-ACE) exercises. A professional actor was employed to portray a service user; the brief given to the actor was decided by the facilitating psychiatrist. The trainees were tasked with interviewing the actor in front of the other trainees. Feedback and discussion was led by the psychiatrist. Each session focused on a major psychiatric diagnosis.
The service user programme was designed in conjunction with a local service user organisation, Making Waves. Initial contact was made by academic staff. A series of meetings were held between academic staff and Making Waves to create the outline and basic structure of the course. Making Waves is an organisation of people who have had a wide range of experiences of mental distress. The organisation has had experience in designing and delivering teaching programmes to mental health workers, students and schools. To set up the programme took approximately 15 h of academic staff time – this was in order to create the outline and to liaise with the service user groups. Making Waves spent approximately 30 h developing the programme and 20 h delivering the sessions. The service users were paid for time spent developing and delivering the programme. After much discussion it was decided that academic staff would only attend sessions relating to the administration and development of the programme; however, it was felt important that academic staff were available to offer support to the service user facilitators if required. The importance of confidentiality was stressed to all trainees during the initial session. It was also agreed that if a service user directly involved in the teaching was to be admitted to a psychiatric unit they could request not to be cared for by the academic staff involved in setting up this programme.
The service user programme ran for 10 consecutive weeks, each session lasted 50 min. The course had two main aims: first to teach interview skills and second to address areas of special interest to the service user organisation. The sessions took a variety of formats. First, it was decided that it was essential to set the context and reasons for introducing these sessions, hence the opening session was a didactically taught session ‘introduction to service user teaching’ led by G.A.D. Second, a number of sessions employed professional actors to facilitate role plays; these included ‘starting the interview’, ‘conducting the interview’, ‘ending the interview’, ‘the tricky situation’ and ‘carers and advocates’. These sessions were facilitated by two service users. Making Waves wrote the short brief for the actor based on the experiences of the members of Making Waves; however, the trainees were never informed of which service user the actor was portraying. Third, sessions were based directly on the experiences of the service users; these were ‘the ward round’, ‘medication and advanced directives’ and ‘the experience of psychiatric services’. Finally, a ‘feedback’ session was included to allow reflection, particularly concerning the dynamics of the group, and to discuss the future development of the programme. The basic points that were agreed to be covered in the session have been included in Table 1.
Table 1. Outline of the service user programme
| Session | The agreed issues to be raised | Facilitators |
|---|---|---|
| Introduction | Historical perspective | Academic staff |
| Evidence for service user teaching | ||
| Experiences of psychiatric services | A personal perspective of psychiatric services | 4 service users |
| Starting the interview | The basic practicalities of the interview | 2 service users |
| Do you stand up/shake hands/wear a suit? | 1 actor | |
| How do you build rapport? | ||
| Conducting the interview | Consideration that the service user has previously been interviewed | 2 service users |
| Maintaining rapport | 1 actor | |
| Ending the interview | When and how to end the interview | 2 service users |
| The use of care plans | 1 actor | |
| The tricky situation | What would you do if you meet a service user outside a psychiatric setting? | 2 service users |
| 1 actor | ||
| What if you are given a present/card? | ||
| How to approach a distressed service user | ||
| The ward round | What is it like to experience a ward round? | 2 service users |
| Being asked personal questions in a ward round? | 1 actor | |
| Behaviour in the ward round | ||
| Medication | Experiences of medication | 2 service users |
| The sometimes differing opinion on medication and adherence | 1 actor | |
| The use of advanced directives | ||
| Carers and advocates | How to involve/utilise service users and carers into the interview | 2 service user/carers |
| Feedback | Review of the sessions and the group | All involved |
Evaluation
Twelve trainees underwent the pilot course: four general practitioners and six psychiatry ST1s and two foundation year doctors. After each session the trainees completed feedback forms which were rated using three criteria: content, presentation and relevance. Each criteria was rated on a ten-point Likert scale: 0 defined as very poor and 10 as excellent. Analysis was undertaken using SPSS 14.0 for Windows; t-tests were undertaken between psychiatrist-led and service user-led sessions.
Results
The feedback forms received represented 71% of psychopathology feedback, 59% of workplace-based assessments feedback, 100% of emergency psychiatry feedback and 50% of service user teaching feedback. No significant difference was found between service user- and psychiatrist-led sessions in content, presentation, relevance or total feedback score (Table 2). However, there was a trend towards a significant difference on the presentation criteria (P=0.074). Furthermore, in comparison to the psychiatrist-led sessions that were didactically taught (35% of sessions), the feedback for the service user sessions did not differ significantly, though again there was a trend towards significance in the presentation criteria (P=0.07).
Table 2. Mean feedback scores on ten-point Likert scale1
| Service user led, mean score (s.d.) | Psychiatrist led, mean score (s.d.) | P | |
|---|---|---|---|
| Content | 7.72 (1.27) | 8.08 (1.19) | 0.337 |
| Presentation | 7.27 (1.42) | 8.01 (1.32) | 0.074 |
| Relevance | 7.81 (1.47) | 8.24 (1.37) | 0.328 |
| Total | 22.82 (3.99) | 24.33 (3.62) | 0.181 |
Discussion
This study has demonstrated that service user-led teaching can be integrated into a trainee's education programme without reducing the self-perceived quality or relevance of the education. In addition, a well constructed service user-led teaching programme could offer an invaluable perspective on the psychiatric services and the trainee's interview style. However, setting up this service user-led teaching in a way that seeks to negate tokenism requires a significant commitment of time and incurs some financial costs.
We considered this educational programme to be a success. Our feedback showed that there was a trend towards a difference in the perceived presentation quality of service user-led teaching compared with psychiatrist led teaching. This difference, though not significant, is likely to be as a result of differing organisational styles and the level of experience in teaching that service users have in comparison with academic staff. This could potentially be addressed by providing the service users with the opportunity to attend a medical education course. However, we must also consider that the dynamics of the learner/teacher group, preconceived learner attitudes and the perceived relevance of the subject being taught may also have influenced the ratings obtained. The possible influence of these factors is supported by the varying percentage of returned feedback forms; the service user-led and workplace-based assessments sessions only achieving 50% and 59% respectfully, whereas the didactically taught sessions achieved 71% and 100%.
Service users are a valuable educational resource. To date, service users have been relatively under-utilised in psychiatric training programmes. We are currently running the programme for the second time and envisage that service user teaching will remain an integral part of educating our trainees, especially in the first 6 months of their psychiatric experience.
Declaration of interest
None.
Acknowledgements
The study team are indebted to the members of Making Waves for their time and effort taken to develop and deliver the programme.
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