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Innovation

Service users and academics teaching together in nurse education

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At London South Bank University, many healthcare modules are taught jointly by service users and academics. A small-scale study has explored the challenges and benefits of this co-teaching method

Abstract

There is currently a movement towards involving service users in the design and delivery not only of care services, but also of health professionals’ education. London South Bank University is embracing collaborative co-production by involving service users (called co-collaborators) into many interprofessional learning modules for nurses, midwives and allied health professionals. A small-scale, qualitative study was conducted into the views and experiences of service users and academic staff who co-taught seminars for an undergraduate nursing module. This article reports on the study outcomes, outlining the benefits and challenges of collaborative teaching.

Citation: Atwal A et al (2018) Service users and academics teaching together in nurse education. Nursing Times [online]; 114: 6, 47-51.

Authors Anita Atwal is associate professor in interprofessional learning; Helen Da Costa is a service user; Andy Mantell is senior lecturer in mental health nursing; Sarah Mobbs is senior lecturer in children’s nursing; Jessie McCulloch is senior lecturer children’s nursing and Darzi Fellow; John Barclay is senior lecturer in adult nursing; The People’s Academy and Ginger Giraffe are service user groups; all at London South Bank University.

Introduction

Collaborative co-production in interprofessional education (IPE) is a way of putting the voice and lived experience of service users at the centre of health professionals’ education. It provides an environment conducive to students learning the skills required for new collaborative ways of working in a service-user-led culture. This article describes the outcomes of a study on the views and experiences of service users and academic staff coteaching an interprofessional module for undergraduate student nurses at London South Bank University (LSBU).

Co-production

The concept of co-production emerged from the Nobel prize-winning American political economist Elinor Ostrom (Ostrom, 1996), who examined the use of collective action, trust and cooperation in the management of a common pool of resources. It was further developed by Edgar Cahn, who came up with the idea of time banking. Based on the principles of reciprocity and equity, time banking enables people to swap time and skills instead of money (Cahn, 2000).

Co-production emphasises the importance of collaboration between service providers and service users in both the design and delivery of health and social care services. It challenges the assumption that service users are passive recipients of care (Cahn, 2000), recognising their contribution to the successful delivery of services and elevating their relationship with service providers to “an equal and reciprocal partnership between professionals, people using services, their families and their neighbours” (Nesta, 2012).

Liberating the NHS: No Decision About Me, Without Me (Department of Health, 2012) firmly sets out the government’s vision to place the public and patients first. This vision is reflected in The Health Foundation’s ‘co-creating health’ initiative (Newbronner et al, 2013); this promotes self-management for long-term conditions such as pain, diabetes, depression and chronic obstructive pulmonary disease, with the aim of enabling service users to manage their health and wellbeing in collaboration with healthcare providers. However, Borger et al (2015) indicated that further research is needed to ascertain the views of service users, families, health professionals and commissioners on the outcomes of self-management, and this remains the case.

Integrated care and interprofessional education

There is growing awareness of the need for greater coordination between professionals, services and agencies. The 2014 Care Act (Bit.ly/GovCareAct2014) made it a statutory obligation that local authorities cooperate with public services as well as private care providers, to promote the integration of care between and within health and social care providers and other agencies.

Complex multidisciplinary care is often fragmented (King’s Fund, 2012). The consensus is that it is important to implement integrated care by building bridges between the groups involved. According to the Integrated Care Network (2004), “the integration of organisations or services into single entities is a further development which allows potential for greater transparency between partners and enhanced benefits for service users”.

To promote integration, health professionals need the skills to work in complex teams. The best way to obtain these is thought to be IPE (World Health Organization, 2010). On the Centre for the Advancement of Interprofessional Education’s website, IPE is defined as occurring when “two or more professions learn with, from and about each other, to improve collaboration and the quality of care”.

Interestingly, this frequently cited definition fails to recognise the voice of the service user in the process of integrating care provision or working together to improve the quality of care. We suggest that the definitions of integrated care and IPE should be updated to include the current thinking on co-production and service user involvement, and recognise and put the voice and needs of the service user at the centre.

Collaborative co-production

A key driver to adopting the principles of co-production has been the effort to move away from the traditional biomedical model towards more personalised health and social care (Palumbo, 2016). Co-production can have a transformative effect in health and social care (Needham and Carr, 2009). The DH (2010a) framed the priorities of health and social care in seven principles – the ‘7 Ps’ – which are fundamental to collaborative co-production (Table 1).

table 1 the 7 ps and how they relate to collaborative co production

Collaborative co-production is the process by which service users, carers, and health and social care professionals work together to achieve patient-led and patient-centred services and outcomes. It means moving power from central to local providers, from governments to local people and communities, and from care providers to service users (DH, 2010b). Embracing the voice of the ‘expert’ patient in all areas of education, care delivery and interagency working is vital to achieve the ‘7 Ps’, and can help achieve safe and effective care that is led by service users and built around their needs, values and preferences.

Education

Over the past decade, there has been a move towards integrating service users not only in the delivery of care but also in its design. One way of achieving this is for service users to collaborate with academics in education and training courses. For education providers, this means integrating collaborative co-production into training courses and lifelong learning (Hassmiller and Reinhard, 2015). Higher education providers must demonstrate how service user and carer involvement add value to clinical practice (Morgan and Jones, 2009).

New terminology is developing around service user involvement in education and training. Collaborative co-production – the term we favour – brings together health professionals and/or academic staff with service users and/or carers to implement the principles of interprofessional practice.

As collaborative co-production moves the power from providers towards service users, health professionals – including nurses – will need to learn about these new, collaborative coaching roles and move away from a problem-based approach to using service users’ strengths and goals as the starting point of care planning.

The People’s Academy

Through an initiative called The People’s Academy, LSBU is incorporating collaborative co-production into many of its courses. All interprofessional modules at levels 4, 5 and 6 for student nurses and midwives, and level 6 for student allied health professionals, focus on collaborative co-production. Service users and/or carers from a diverse pool collaborate in:

  • Student recruitment;
  • Curriculum design, delivery, and assessment;
  • Research.

The interprofessional learning module took place in October and November 2016 for first-year undergraduate student nurses. In the first half of the module, weekly seminars for 10 groups of approximately 30 students each were held over six weeks on two sites. Each seminar was co-taught by at least one service user with a member of academic staff.

The second half of the module was seminar content only, in which students were encouraged to reflect on practice and introduced to Schwartz rounds, the benefits of which have been outlined by Goodrich (2013). Service users and academic staff were encouraged to meet beforehand to plan and prepare the seminars.

The 11 service users involved, referred to as co-collaborators, came from diverse backgrounds and had a wide range of experience as service users and carers. All were paid for their time. In most cases they planned and/or delivered the teaching sessions collaboratively with academic staff. They answered students’ questions and brought their lived experience of being service users or carers to the learning outcomes. It is vital that collaborative co-production is not just taught as a principle but also modelled in teaching practice.

Mid-module evaluation


At the end of the first half of the module, we gathered the views of the co-collaborators and academic staff involved. We were keen to understand, from both perspectives, the challenges and opportunities arising at that midpoint stage of the module.

All 11 co-collaborators were sent and completed an email questionnaire comprising eight open-ended questions that invited participants to candidly describe their experience of co-leading the seminars. Another LSBU service user analysed the data using thematic analysis. Three broad themes emerged:

  • Motivations for choosing to be a co-collaborator;
  • Challenges of the role;
  • Perceived contributions to student learning and benefits of co-teaching.

Nine academic staff and six service users attended two unstructured interprofessional community forums to express their opinions. Notes were taken during the forums, then analysed and shared.

Co-collaborators’ views: motivations

The motivations for being co-collaborators can be summarised as wanting to:

  • Share expertise;
  • Contribute to shaping health and social care delivery;
  • Bring insight from the service user experience;
  • Highlight the importance of the service user perspective and experience;
  • Ensure the service user voice is heard.

All co-collaborators felt that the involvement of service users in student learning was a positive change and wanted to be part of that process:

I wanted to see meaningful change in the NHS regarding patient-centred care and patient and public involvement.”

I think the involvement of service users in the learning process of nursing students is essential to training in the kind of empathic listening that you want to experience as a patient. Sometimes being given the opportunity to speak is not enough. Health professionals need to know how to empower you to speak and participate actively in making decisions about your health.

Co-collaborators’ views: challenges

The co-collaborators had different experiences of working alongside academic staff. In most cases, the experience was positive. Several said their ability to participate in the planning and delivery of teaching grew from week to week, as their role became more defined and their confidence grew. Most met staff before the seminar to plan how they would deliver it jointly. When such collaboration took place, both lecturer and co-collaborator reported a positive experience, student feedback was positive, and learning outcomes were achieved.

Three co-collaborators reported that their academic partner did not always seem to have a clear idea about what the role of the service user should be. Sometimes, they would be present in the classroom but not be introduced or invited to participate. In such instances, the co-collaborators did not enjoy the experience or feel able to contribute effectively. Those who worked with more than one member of academic staff also cited adapting to different teaching styles as a challenge.

Six co-collaborators mentioned organisational issues that negatively affected the delivery of the module, such as inadequate room scheduling, being asked to teach with a different academic part-way through the course, and not receiving the prerequisite reading in time. Some felt that not all students actively engaged with the required reading, which had a negative impact on the effectiveness of the seminar and the service user’s contribution. There was also doubt, among some co-collaborators, as to whether all academic staff were happy to have them in the classroom:

We are no doubt appreciated by the majority of lecturers, yet I wonder if there are some who resented us being in the classroom, as it has always been their solo domain.”

Co-collaborators’ views: contributions and benefits

Co-collaborators felt they made the following contributions to student learning:

  • Sharing of their experiences, and reflections about them, with students;
  • Bringing the lived experience to the taught concepts;
  • Helping students to consider the impact of their practice on the service user’s experience;
  • Challenging students on what person-centred care really means.

Box 1 features quotations from co-collaborators, indicating the perceived benefits of co-teaching.

Box 1. Co-collaborators’ views: benefits of co-teaching

It was interesting to observe different teaching styles. I enjoyed all of [the seminars] and felt my confidence growing in sharing my stories and experiences. I was encouraged by how the students responded to me, listening attentively and sharing their own feelings and responses.”

It was highly rewarding to share with the students, the majority of whom were very motivated to learn. I enjoyed feeling that I was contributing positively to the learning process of the students. I learned new things from the lectures and felt really supported to share my experiences. The lecturer and the students were really moved by some of my stories.”

Academics’ views

Some challenges cited by most lecturers in the two forums related to organisational issues such as room scheduling, timetables and pay. Academic staff did not express opposition to the concept of interprofessional working, but these practical issues negatively affected their perception of it. One complaint was that rooms allocated to the seminar were not accessible for co-collaborators who were wheelchair users.

Another major challenge noted by academics was that co-production had been introduced within a short timeframe and there had been a lack of consultation on, and training for, co-teaching with service users. Despite having worked closely with service users in clinical settings, many academics had not previously co-taught with them. For some, it was daunting to have their teaching evaluated through this lens. It is evident from our findings that it takes time to establish a working relationship between teaching staff and service users. When academics and service users met beforehand to plan the seminar and afterwards for a debrief, it was possible to break down barriers.

Five academics noted that co-production required a teaching style akin to coaching, involving the sharing and exchanging of skills and knowledge. All academics observed that students listened to the service users’ opinions, valued their experience and stories, and understood the importance of person-centred care. One group of students, while debating an interprofessional issue, specifically asked the co-collaborator for their viewpoint.

Box 2 gives some academics’ views on the challenges encountered when co-teaching.

Box 2. Academics’ views: challenges of co-teaching

For some sessions we were timetabled into a small lecture theatre. Wheelchair access both to the room, and within the room, was difficult and [the room was] not conducive to group work or to the full and equal participation of the service user. We had planned the seminar together but it was challenging to work in this setting.”

For co-teaching to work optimally, it is important that all the parties involved meet beforehand to plan the session and prepare how each will contribute. In this instance I did not have this opportunity and had to co-teach with a service user I did not know. We also did not have time scheduled to debrief after the seminar and learn as we went along. Planning and reflection on the process are essential to work together in a way that is truly collaborative.

To co-teach in this way required advanced communication skills. Being able to collaborate with different service users who may bring different things to the table, and negotiating the roles we filled in the classroom required me […] to react in a constantly dynamic way. I needed to draw on the teamwork skills I frequently use in practice, but have not previously used in the classroom.

While the experience and skills of service users bring a new richness to the learning experience, without specific training, academic staff will have different capacities for adapting to co-production, and this may have a negative impact on the consistency of the teaching offered.”

“Working collaboratively with service users is a different style of teaching […] it has been a steep learning curve in relation to bringing the focus of service users at the centre of care delivery to the classroom.”

Discussion

Arnstein’s (1969) ladder of citizen participation is a valuable tool to explore where an organisation or service might be in its journey towards co-production. We have adapted it to conceptualise how co-production is achieved, starting from no service user involvement, progressively moving through greater levels of involvement, and finally reaching a place of partnership.

Introducing IPE in its interprofessional modules is a new venture for LSBU. For many academics and some service users, it was their first experience of collaborating in a teaching setting. We quickly moved from little or no service user involvement to co-production. In some instances, collaboration and even partnership were achieved; in others, the experience was described as either ‘emerging’ or ‘growing’ involvement.

Our experience illustrates the move away from traditional teaching techniques to a coaching approach. Bleakley and Bligh (2008) suggested that, in collaborative knowledge production, the teacher’s role moves from knowledge production to meaningful facilitation. Coaching is a key component of co-production and nurses will need to acquire coaching skills in professional practice to promote patient self-management (Van Nieuwerburgh, 2012).

Service users described benefits including:

  • Feelings of empowerment and altruism;
  • Being valued, listened to and respected;
  • Contributing to students’ development in terms of skills and attitudes;
  • Contributing to shaping future practitioners and improving service provision.

These views are echoed in Walters et al (2003) and Stacy and Spencer (1999).

Chambers and Hickey (2012) highlight three factors influencing the success of service user involvement in IPE:

  • Infrastructural issues;
  • Cultural issues;
  • Service user issues.

Infrastructural issues include: support and training for service users, students and staff; payment and reimbursement; and accessibility. Practical issues cited by academics in our study, such as room scheduling and timetabling, are also documented in Sunguya et al (2014).

Cultural issues include recognising and respecting the expertise of service users. Most academics recognise the need to involve service users in their teaching and to develop this aspect of the curricula. However, according to some service users, some academics did not seem to know what the role of service users should be or how to incorporate them into their teaching. Other studies report service users’ concerns regarding how they will be perceived by students (Towle et al, 2010), but service users in our study did not express such concerns.

Simons et al (2006) recognised that teachers can feel threatened if they perceive that service users are usurping their role in the classroom; they may also doubt the expertise of service users. The academics in our study saw great value in students having the opportunity to listen to service users’ experiences and stories, and thought the service user voice complemented theoretical teaching, enabling students to relate theory with practice. These positive views are echoed by Spencer et al (2011).

Conclusion

To continue to move up the ladder towards partnership in IPE, the challenges highlighted in this study must be addressed. Infrastructural issues, such as room scheduling and making reading materials available, are easily remedied. Solving cultural issues requires training and support, along with a cultural shift, to ensure both academics and service users know what the service user role is, are willing to use collaborative co-production and have the necessary skills to do so. Service users and academic staff will need to continue to learn how to navigate the interplay between ‘expert academic’ and ‘expert patient’, and work together towards a collaborative partnership.

This study will be followed by an ongoing evaluation of the experiences of students, academic staff and co-collaborators after completion of the module. We also hope to evaluate, in the future, students’ experience of applying the principles of co-production in clinical practice, as well as the impact of specific attempts to overcome challenges and barriers to IPE.

Key points

  • Interprofessional education is the best way for health professionals to obtain the skills needed for care integration
  • Service users are increasingly involved in the design and delivery of both healthcare services and education
  • Collaborative co-production in education can help future nurses to implement patient-centred care in practice
  • At London South Bank University, service users collaborate in student recruitment, curriculum design, delivery and assessment, and research
  • Embedding the principles of collaborative co-production in nursing curricula comes with challenges
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