Jones, K., Black, D. (2008) Involving mental health service users in student education. This is an extended version of the article published in Nursing Times; 104: 29, 32-33.
This article describes an initiative that involved service users sharing their personal experiences of illness and mental health services with nursing students. Their experiences were delivered through the medium of story telling with opportunities for students to ask questions. The article will focus on the impact this has had on students and on service users by examining feedback comments from both groups about their experiences.
Kath Jones, BD, Dip.SW, ASW, is development officer on the Routes to Recovery Project, Interlink; Damien Black, MBA, BEd, RMN, RGN, PGCE, RNT,DN, PGDMS, PGCMS, is senior lecturer in mental health, the University of Glamorgan and practises as a counsellor in South Wales.
Over the last 20 years there has been a considerable drive politically, ethically, economically and socio-culturally to involve service users in the strategic planning and operational detail of mental health services. This has led to a number of policy innovations, for example Creating a Patient Led NHS (Department of Health, 2005), Stronger in Partnership (Welsh Assembly Government, 2004) and more recently in Wales a consultation document Stronger in Partnership 2 (Welsh Assembly Government, 2007).
These documents acknowledge that there should be service-user involvement in all aspects of healthcare provision including facilitation of education and training of mental health professionals. They give advice on why involving service users is not an option but a requirement and also offer practical advice on how this can happen. Repper and Breeze (2004) have conducted a review of the literature on this subject and new literature continues to appear (Haigh et al, 2007).
The role of the 'expert' patient is acknowledged in Stronger in Partnership 2 (WAG, 2007) especially for those service users who have long-term conditions. It states that: 'While recognising that clinicians give expert professional advice, it is patients, those people who use the service, who are the experts on how they feel and what the aims and ambitions for treatment should be, as well as how they can be improved in the future' (WAG, 2007).
The Chief Nursing Officer Review of mental health (DH, 2006) advocates that service users should be routinely involved in four key areas:
Teaching and assessing.
This article will concentrate on involving service users and occasionally informal carers in the education and training of mental health nursing students.
Involving services users in education of nursing students
This initiative involves two central agencies. The mental health nursing students are in their first year of the mental health branch programme of a BSc (Hons) nursing degree at the University of Glamorgan. The service users are all connected to a service-user network based within a local voluntary organisation called 'Interlink'. Interlink is an umbrella organisation that oversees voluntary activity within the county.
The people involved in delivering the sessions to students are part of the local service-user development project and also the Routes to Recovery project, both based at Interlink. These projects provided the speakers with training in how to present themselves and their stories.
Service users had been involved in the curriculum in the past but this partnership between Interlink and the university began four years ago following a service-user conference. Since then, service users regularly input into the teaching programme at a number of levels and they are also included at the selection and recruitment of mental health nursing students.
Objective of the service-user sessions
Service-user sessions referred to in this article normally take about two hours and the setting is informal. The overall objective for the session is for the student to develop a greater awareness of what it is actually like for service users to experience mental health problems and its consequences.
Students listen to the service users reflecting on the services that they have received, or are currently receiving, as part of their care and treatment. It also provides an opportunity for students to meet service users outside of the clinical situation allowing them the opportunity to interact on a basis where the balance of power in the relationship has shifted towards the client. Students also meet with service users who are models of recovery.
Role of the service user
An arrangement is established between Interlink and the university for the payment of fees for these training sessions. The fees reflect those paid to other independent expert trainers. The importance of a financial reward reflects the value of the service-user contribution and also equality among contributors to the course.
It is also important to highlight that service users are actually providing a service and are therefore receiving payment for their work. This validates what the service user does and the role is also intended to improve the individual's self-esteem and respect.
Thirty students provided feedback of their experience of service users presenting their stories in the classroom. The students were in their second year of nurse education and were just completing their first year of a mental health branch programme. The students all belonged to the same cohort on the mental health branch. They were selected randomly and all students submitted a response. The student group completed an evaluation form with space for comments.
Seventeen students were male and 13 were female. There are often a higher proportion of men in the mental health branch as opposed to other branches of nursing. Thirteen participants were aged between 31 and 40 (Fig 1)
The first question in the feedback sheet asked how their experience of listening to a service user telling their story impacted on the ways they think about their practice and was answered by all students. Fig 2 shows that 28 students felt that the sessions had quite a lot of impact on practice.
When students were asked if they thought it was important that service users were given time on the curriculum all responded positively. There was a unanimous view that service users have an important role in contributing to the curriculum of pre-registration mental health nursing students.
The experience had a significant impact on the ways students viewed their practice. One student wrote: 'I feel this part of the course has been valuable to my practice because you have a first-hand insight into clients' illnesses. When you are on the ward it is harder to find time to speak to these clients because of time constraints but this is changing now mainly because of service users being able to put their points across.'
The students had already had significant clinical contact with service users and their families. These contacts are often in acute phases of illness and may have influenced their perspectives so that they viewed service users as patients rather than people. For example, some feedback comments referred to service users as 'these people' which might indicate that in some instances a 'them and us' culture had already started to develop in the way students think about service users.
However, there were many positive feedback comments indicating a willingness and desire to work as partners in the service users' recovery process. A very positive aspect of the feedback indicated students were seeing service users as people in a situation where the balance of power has shifted towards the service user.
One student nurse said: 'I can see now why I need to actively engage in a therapeutic interaction on a daily basis with clients.'
The comments clearly indicate the value of student placements which provide a contrasting perspective to the service-user session. Seeing people outside the clinical context allows comparisons to be made between the clinical situation and the person who is managing their illness and their lives.
Timing and the location of this session within the curriculum is therefore important. As students involved in the sessions have already had the experience of working within a clinical setting they were able to hear the service users' stories and reflect on the most useful and not so useful interventions that a patient has been offered. This challenges the students to become committed to service-user participation in care decisions and treatment processes.
There were many comments from the feedback forms to support this. One student suggested: 'It will help me to think more about my approach to future placements as service users have outlined what they would like us to do.'
Many students also reflected on service users' views on what were helpful and less helpful interventions in their care and treatment.
Service users' feedback
Eleven service users were selected on the basis that they had presented their story to a student mental health nurse group in the last three years. This represented the total number of service users who had been involved in the initiative and all were sent an evaluation form.
Eight service users submitted evaluations on the impact that presenting to students had on them.
The most overwhelming feature was the personal benefits that people received from delivering the talks. They all reported an increase in their perceived value as a person. This was linked to a growth in their confidence and an increase in their self-worth and a subsequent improvement in their mood levels. For example one service user wrote: 'I feel very confident now, I feel that I could tackle anything.'
Another person reported: 'I feel a lot better since doing the talk because I got things out of my system.'
An emerging theme in the comments from service users was that the initiative resulted in an improvement in themselves and their capabilities which also has a positive impact on their mental health. The comments reflected the idea of them being heard which indicates that they may have felt disempowered. Taking on the role of expert service users has given them a real sense of empowerment. Moreover they almost unanimously indicated that they thought they were directly improving services by improving the attitudes of students.
The sessions also provided personal satisfaction and enjoyment. The service users felt that through doing the talks they were able to input something worthwhile back into the mental health system from which they had received so much input themselves.
One commented: 'Because I am inputting into the system I feel a lot better about myself.'
It should be noted that service users not only talked about their own experiences of mental health problems but also spent a considerable amount of time speaking about how they have experienced service delivery in all its forms. This is not only focused on negative aspects but also stresses the importance of good interventions that they have received and the good practice they have witnessed.
The benefits to the person's own mental health are reiterated time and time again with service users' comments through the evaluations. It has helped with coping strategies, confidence building, and personal evaluations of circumstances and has helped them to feel worthwhile. One person said that they felt 'back in the world' which suggests that mental illness is an isolating experience that has the effect of leaving you detached and distant from everything and everybody.
It is interesting to note that giving these talks is not an easy experience for service users and this was reflected in some of the comments. One person wrote that 'how you feel on the day has an impact in terms of how well you think that you have delivered the presentation'. Another said that they found it 'very difficult to speak in front of people'.
It is important to consider that while no one is under any compulsion to deliver a talk, it can be a stressful activity. However, for many service users it is one that is worth going through as the advantages and benefits clearly outweigh any disadvantages.
Another feature of delivering this kind of talk is that it also provides a therapeutic value. One service user wrote: 'It has made me put my illness on the back burner because I have more to think about.'
The sessions provide an alternative focus and distraction for the service user which is seen to be of benefit to them. Others commented that it helps them to 'think' through doing a specific activity. Service users felt valued by those that they presented to and this cannot be underestimated in people who often do not feel any personal value in themselves.
Self-help is also seen to be part of doing the talks and one person made the comment: 'By helping others I feel like I am helping myself.'
Service users valued the role of education and exposure to this environment has led one person to begin a college course. They were more than aware that through telling their stories they were contributing to the breakdown of myths, stereotypes and discrimination about mental illness.
One person commented: 'It helps me to understand my illness a little more. It promotes a better and more positive image of mental health - shows a person not an illness. I believe educating others is a positive way of combating prejudice.'
Service users expressed gratitude for the opportunity to talk about their experiences in such a specific way and were always willing to participate when asked.
This article draws some conclusions from the written evaluations of service users and mental health nursing students on an innovative curriculum development. Much of what has been identified is worthy of further exploration and enquiry, for example, researching whether positive impacts identified here are sustained in the medium and longer term. If so, this would provide evidence for the continuance and progression of this innovation and indicate the need to increase this curriculum activity.
It has been a shared journey of discovery and has been of mutual benefit to both groups of participants. There are plans to continue with this initiative and develop it in line with government policy.
Since embarking on this project the university has developed a service user research group (SURE). The authors contend that research into the positive and negative impacts of user involvement on service users, students and service development could be priority areas to consider.
Finally the authors gratefully acknowledge the participation of students and service users in allowing their evaluations to inform this article.
Department of Health (2005) Creating a patient-led NHS: Delivering the NHS Improvement Plan. www.dh.gov.uk
Department of Health (2006) From Values to Action: The Chief Nursing Officer's Review of Mental Health Nursing. www.dh.gov.uk
Haigh, R. et al (2007) Service user involvement in the National PD Development Programme. Mental Health Review Journal; 12: 4, 13-22.
Repper, J., Breeze, J. (2004) A Review of the Literature on User and Carer Involvement in the Training and Education of Health Professionals. www.shef.ac.uk
Welsh Assembly Government (2004) Stronger in Partnership. Involving Service Users in the Design, Planning, Delivery and Evaluation of Mental Health Services in Wales. Policy Implementation Guidance. Cardiff: WAG.
Welsh Assembly Government (2007) Stronger In Partnership 2: A Consultation Draft. Involving Service Users and Carers in the Design, Planning, Delivery and Evaluation of Mental Health. Cardiff: WAG.