VOL: 103, ISSUE: 1, PAGE NO: 30-31
Joy Duxbury, PhD, BSc, PGdip, RMN, RN, is divisional leader for mental health; and Susan Ramsdale, MA, BSc , RN (MH), MA, PG Cert LTHE is senior lecturer in the mental health division, both at University of Central Lancashire.
In the UK, public involvement in the provision and planning of healthcare is being encouraged increasingly at many different levels (Allen, 2000). The users’ movement can be traced back to the 1980s and continues to gather momentum (Edwards, 2000). The second half of the 1990s saw an upturn in the amount of attention paid to eliciting service users’ views.
The notion of user involvement in nurse education has been gaining momentum for some time (Forrest et al, 2000). This has been particularly noticeable in the mental health field. The recent Chief Nursing Officer Review of mental health nursing has suggested that service users be at the forefront of their care, including providing significant input into such things as education and training (Department of Health, 2005).
Hickey and Kipping (1998) argued that there are two approaches to user involvement: a consumerist approach and a democratisation approach.
The consumerist approach has two strands: consumerism and the adoption of consumer solutions. This is largely about increasing choices and borrowing techniques from commerce to increase the responsiveness of the service to users.
The democratisation approach involves users in decision-making and is therefore more akin to the educational input encouraged today.
It has been noted that for service-user involvement to be a positive and active process it must be underpinned by the key principles of negotiation, partnership and mutual support (Appleby 2004). However, the challenge of achieving this can be huge, particularly when aiming to avoid a tokenistic approach.
Service users and pre-registration nursing
Several studies have looked at service users working with academics to design curriculum and deliver and evaluate courses in pre-registration nursing.
McAndrew et al (2003), for example, acted upon the directive given in the National Service Framework for Mental Health (DH, 1999) to involve service users and carers in the care planning and delivery of mental health services. Their project aimed to develop nursing programmes that were able to sustain levels of involvement through the theme of learning together through reflection. This echoed the earlier work of Barker and Whitehill (1997), who created the phrase ‘caring with’ rather than ‘caring for’, placing the emphasis again on students learning with service users and carers.
Masters et al (2002), responded to recommendations made in Fitness for Practice (UKCC,1999) for increased service user/carer involvement by setting up a project to discover their views on the knowledge, skills and attributes that they felt mental health nurses should have.
Despite a growth in important work of this nature that focuses upon user involvement, little has yet been written on the involvement of service users in the process of assessment in education.
A systematic approach
Community Engagement and Service User Support (Comensus) is a project established by the Faculty of Health at the University of Central Lancashire in 2003. It aims systematically to enhance service user, carer and community involvement within all academic activity. The unusual aspect of the project is that it is led by service users and carers.
This project raises awareness of the issues that service users and carers face and equips academic staff and students with the knowledge and skills needed to build strong, therapeutic relationships that empower and support those involved.
In developing the course, Teaching Effective Aggression Management (TEAM), for qualified nurses (and other healthcare practitioners), it was felt from the outset that service user input at all levels was vital.
A number of service users were invited to the initial development meetings, along with practitioners, academics and clinical managers. The meetings, although planned with the best of intent, resulted in a sense of tokenism.
One way to foster tokenism is to involve people in tasks in which their role is unclear. A lack of adequate resources and time can be a barrier to developing any skills required (Masters et al, 2002). This was certainly how it felt at the initial stages of the programme development; however, this was to change as the course was delivered.
The final module of the TEAM course brings together the theoretical aspects of managing violence and aggression with the teaching of preventative approaches, de-escalation, cultural awareness and sensitivity to personal needs, interpersonal skills andphysical interventions.
In the past there has been a lack of consultation with service users on the management of patient aggression. However, recent policy directives and subsequent recommendations have begun to highlight this issue.
The NICE and NIMHE guidelines, for example, both advocate that service users be consulted, their needs understood and addressed and their collaboration sought (DH, 2005; NIMHE 2004). The HealthCare Commission (2005) has also identified gaps in this area of practice (2005), although the earlier Zero Tolerance Campaign did much to damage the relationships between practitioners and service users.
A significant component of the final module is the learning of physical skills. Students of the course would later be assessed on these skills and would also need to demonstrate an ability to teach them to fellow students. The panel assessing these skills comprised lecturers, instructors and service users.
On completion of the course, the students should be able to teach - competently and to the required standard - the prevention and management of violence and aggression. For this reason, they were assessed a number of times on their teaching skills as well as in their theoretical work. The whole group, 13 in all, initially objected vociferously to the suggestion that service users should be involved in their final summative teaching assessment. Their objections included that they felt:
- That too many people would be present;
- That service users should have attended the preparatory training sessions.
After much discussion, it emerged that their fears were really underpinned by uncertainties over what they felt was expected of them at the presentation. When these were resolved the atmosphere was much calmer, anxieties were greatly reduced and the attitude towards the make up of the panel improved significantly.
In preparation for the assessment, the module leader met a number of service users on several occasions to identify the aspects they wished to address and the types of questions they might ask. This process was supported by a facilitator from the Comensus project. From these meetings, an assessment-marking grid was created. This mirrored the ones used by lecturers and clinical staff but included the qualitative aspects that the service users felt were important. The emphasis lay on attitude, interpersonal skills and recognition of client needs.
The assessments took place over two days, with the students on the course demonstrating a pre-planned skills session and one that they had to present with only minutes to prepare. They were given feedback from each of the panel members and were able to respond to this.
The evaluation from the nurses on the day was that they felt that the panel had delivered excellent, productive feedback. They had found the service users’ contribution to be enlightening and thought-provoking. It also made them feel confident that they were endeavouring to promote good practice.
The evaluations by the students were unanimous in asking for increased service-user involvement throughout the whole course, especially during the physical training sessions.
Several authors have noted the benefits of involving service users in education. One significant benefit is that students’ understanding of individuals’ experiences and their distress is enhanced, as is respect for their perspectives on health care (Forrest et al, 2000). This is particularly important as service users’ perceptions of their needs and the help that they would prefer often differs from the views of the professionals (Murray, 1997). Rather than service users being the passive recipients of nursing interventions, participatory models of practice based upon active involvement are proposed (Allen, 2000).
The inclusion of service users on the assessment panel added richness to the process that it was unlikely could have been achieved any other way. Their unique insight into what the students were trying to achieve gave the feedback a level of credibility that we could hardly have hoped for. There had been fears that the exercise could have been too distressing for those involved or that the feedback might not have fitted comfortably in the world of academia. However, it successfully highlighted the fact that programme developers should ‘not assume that there are areas where service users are not competent to take part’ (Campbell and Lindow, 1997).
While the advantages are clear, there are invariably difficulties in adopting a user participation approach with the consequent redistribution of power between practitioners, educationalists, service users and students.
These difficulties can be divided into four groups: user views; organisational culture; professional culture; and, wider society (Hickey and Kipping, 1998).
Although it is generally assumed that involving users in decision-making is a positive step, some may not want to take part. Trnobranski (1994) suggested that characteristics such as cultural background, age, gender, diagnosis and previous healthcare experience and educational background can influence the extent to which service users want to be involved.
A lack of commitment from an organisation can be a huge stumbling block. Professional culture can also be problematic in that some professionals assume that patients are unable to hold valid opinions.
Finally, the attitudes of wider society in accepting approaches of this nature can be negative and damaging, particularly as they are often uninformed. This invariably underpins an over-arching culture that impacts upon all aspects of the challenges faced.
The implementation of user involvement in identifying health trends and shaping health services requires a series of cultural shifts (Allen, 2000). While it is recognised that curriculum innovations that promote user involvement are crucial, they have to be considered carefully and integrated within a structured and supportive framework. Furthermore, they need to be introduced in a way that includes agreement from all parties, including students. They cannot just be added on to the existing curriculum.
User involvement is increasingly accepted as good practice (DH, 2005) and is undoubtedly the way forward in educational preparedness. However, Edwards (2000), argued that in order to achieve this more value needed to be placed upon human caring qualities with appropriate attitudes and interpersonal skills within genuine therapeutic relationships. This needs to be placed high on the education and training agenda.
Models such as that used at the University of Central Lancashire require a great deal of preparation, commitment and enthusiasm at an institutional, community and individual level. The process must be accepted as evolutionary; a great deal has been learnt so far. Involving service users in the assessment process has been extremely fruitful. There were anxieties to start, such as support, information sharing and transparency, nevertheless the provision of feedback to students undertaking the course was greatly enhanced and made more meaningful.
Allen, D. (2000) I’ll tell you what suits me best if you don’t mind me saying: lay participation in health-care. Nursing Inquiry; 7: 3, 182-190.
Barker, P., Whitehill,I. (1997) The craft of care: towards collaborative caring in mental health nursing. In: (Tilley, S. (ed.) The Mental Health Nurse. Views of Practice and Education.Oxford: Blackwell Science.
Campbell, P., Lindow, V. (1997) Changing Practice: Mental Health Nursing and User Empowerment. London:RCN Learning Materials/MIND.
Department of Health (2005) From Values to Action: The Chief Nursing Officer’s Review of Mental Health Nursing.London: DH.
Department of Health (1999) The NationalService Framework for Mental Health.London: DH.
Edwards, K. (2000) Service users and mental health nursing. Journal of Psychiatric and Mental Health Nursing; 7: 6, 555-565.
Forrest, S. et al (2000) Mental health service user involvement in nurse education: exploring the issues. Journal of Psychiatric and Mental Health Nursing; 7: 1, 52-57.
Healthcare Commission (2005) The National Audit of Violence.London: Healthcare Commission.
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Murray,I. (1997) How can clients and carers become allies? Nursing Times; 93: 27, 40-42.
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