Involving service users and carers in psychiatric education: what do trainees think?

In 2004 the Royal College of Psychiatrists made it clear thatit was committed to increasing the involvement of service usersand carers throughout psychiatric education. This has beenmandatory since June 2005 and it has been a compulsory aspectof psychiatric training for schemes to demonstrate a meaningfulinvolvement of users and carers in the training of psychiatrists.

The National Service Framework for Mental Health states that‘Service users and carers should be involved in planning,providing and evaluating training for all health care professionals’ (Department of Health, 1999). Service user involvement inthe NHS, in particular, service development and evaluation,has been central to national health policy (Department of Health, 1991, 2000, 2001). Moreover, the Postgraduate Medical EducationBoard (PMETB) is likely to require the involvement of usersand carers in postgraduate training and endorses the use oflay people as assessors and/or examiners (Southgate & Grant, 2003). There has been much discussion about this initiative (Crawford & Davies, 1998) and steps are being taken to ensure more active involvementof patients in training psychiatrists. The new curriculum inline with the Modernising Medical Careers (MMC) involves workplace-basedassessments, one of which is ‘patient satisfaction questionnaires’.These allow evidence to be gathered from patients, carers andothers on aspects of trainees’ performance such as politenessand responding to questions.

The inclusion of service users as teachers has been a slowerprocess but it is becoming increasingly recognised and valuedby health professionals. Direct contact with patients can beseen to play a crucial role in the development of clinicalreasoning, communication skills, professional attitudes andempathy (Spencer et al, 2000). The value of involving patientsin an active teaching role, where learners can benefit frompatients’ experience and expertise, is being recognisedand it has been found that the experience of being taught by a trained patient can increase confidence, reduce anxiety andgenerate new insights (Wykurz & Kelly, 2002). There areissues that need to be considered by those involved in psychiatrictraining who will be implementing the new guidance and thereis also the need to address any anxieties that trainees mayhave (Fadden et al, 2005).

The survey described here was designed to obtain an insightinto the views of both specialist registrars (SpRs) and seniorhouse officers (SHOs) and into what they perceive as benefits,any anxieties they may have and the form of training they wouldlike to receive from service users/carers. This involved allSHOs on the Solent and all SpRs on the Wessex rotation schemes(south of England).

Method

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Method

We developed an anonymous questionnaire that was sent to 52SHOs and 38 SpRs in the Solent and Wessex rotations respectively.The names of trainees were obtained from the postgraduate departmentat the Royal South Hants Hospital, Southampton. The questionnaireswere sent to the trainees by internal post with a self-addressedenvelope for return of the completed questionnaires. To increasethe response rate, reminders were sent after a period of 3weeks. Those on maternity leave were excluded. The traineesworked in a variety of areas such as adult mental health, oldage psychiatry, rehabilitation psychiatry, substance misuse,forensic psychiatry, psychotherapy, child and adolescent psychiatryand learning disabilities and had varying levels of experience(between 1 and 4 years at SHO level and 1 and 5 years at SpRlevel). The majority of trainees were employed by the Hampshire Partnership NHS Trust. There were trainees from six other trustsacross Dorset, Southampton, Portsmouth, Avon and Wiltshire,East Hampshire and the Isle of Wight. The results were analysedusing descriptive statistics with expert help from the auditdepartment of the Hampshire Partnership NHS Trust.

The anonymous questionnaire was piloted on a small number oftrainees before the final version was agreed and distributedamong participants. The questionnaire comprised leading questions,open-ended questions, questions requiring a ‘Yes’or ‘No’ answer, and questions on a five-point Likertscale.

Results

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Results

Out of the 90 questionnaires sent out 77 were completed andreturned - an 85% response rate. Out of the 77 questionnaires,SHOs completed 42 and SpRs completed 35 (Table 1).

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Table 1. Responses of participants

There were 36 out of 77 trainees (47%) who were aware of theCollege requirement for psychiatric trainees to receive trainingdirectly from service users and carers and 53% (n=41) had hada chance to hear a service user/carer’s perspective aspart of formal training in the previous year. Situations inwhich these perspectives were presented included case presentations,a carer’s group, the local MRCPsych course, a management meeting, third-year medical student teaching, a workshop, avideo and a play by a service user.

The majority of trainees (77%) agreed that the experience ofinvolving service users or carers in training was worthwhile,and argued that it is important to get an idea of the serviceuser perspective as it helps to understand mental illness ina ‘human context’. The trainees who felt otherwise(15% were unsure and 8% did not think it was worthwhile) commentedthat they were unsure how it can be put into practice, and that there could be confidentiality issues. There were 23 traineeswho had had no involvement of service users/carers in theirtraining and therefore could not answer the question.

The majority of trainees (84%) felt that users’ and carers’ involvement would be beneficial for their education, 6% didnot feel that it would be beneficial and 10% were unsure. Thosewho disagreed thought that service users and carers might betoo emotionally involved and have irrational expectations.Some trainees worried that the service users/carers might notbe able to provide training in a structured way.

A vast majority of trainees thought that service users’and carers’ involvement would probably make them betterpsychiatrists (84%); 38% of trainees expressed anxieties aboutthe involvement of service users/carers in their training andeducation; 46%, however, had no anxieties;14% were unsure.The main concerns were with regard to potential ‘conflictsof interest’ with users having their own agendas, ‘representativeness’of users’ views, and ‘over-empowerment of users’to the detriment of clinicians and resulting in lack of confidenceand dilution of their authority. Other concerns included issuesof appropriate training and standards, service users’objectivity and communication skills, confidentiality issuesand effect on users’ health.

We also asked trainees whether they saw it as being differentfrom other aspects of their training; 49% thought it was and32% thought it was not and that it was an integral part oftraining to be a psychiatrist. Box 1 shows trainees’ views on how they considered service users and carers shouldbe involved in training.

Most trainees were opposed to having service users as assessorsor observers in their examinations; less than a quarter werein favour. Overall 22% thought it was a good idea to have users/carersas observers in examinations and 16% thought that it wouldbe useful to have them as assessors. A majority of traineesexpressed concerns with regard to issues of validity and reliabilityof such user roles and many felt this would only provoke furtherunnecessary anxiety in an already stressful situation. Some felt there was a need to ensure consistency and standardisationthrough proper training. Trainees also felt that they wouldbe seen as fallible humans, which may reduce their confidence.

Despite concerns about the involvement of users/carers in examinations, trainees were generally welcoming of the input from serviceusers and carers in their education. Feedback from serviceusers and carers on the trainees’ interviewing skills,their views on the quality of services and most of all theirexperience of mental illness were seen as useful aspects oftraining.

Box 1. Forms of training from service users/carers suggestedby trainees
Settings

Case conferences

Service users’or carers’ perspectives, for example at inductions, MRCPsychcourse workshops and/or forums

Specific topics

What is itlike to be seen by junior doctors?

Experience of the servicefrom an individual from a minority ethnic group

Expectationsof service users, for example on treatment goals

Views on theservice

Experience of being detained under the Mental HealthAct

Experience of illness

Communication/interview skills,for example empathy, dealing with sensitive issues

Issuesaffecting users and carers, for example impact of illness

Impactof illness on children of people with mental illness

Demonstrationof symptoms/signs of illness

A voluntary organisation’sperspective

Discussion

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Discussion

The survey provides a useful insight into the views of bothSHOs and SpRs and their feelings and anxieties about the involvementof service users/carers in their education. The questions wereopen-ended rather than MCQ-type, which helped trainees expresstheir own views. Furthermore we were able to compare the viewsof SHOs with that of SpRs.

Although trainees were generally welcoming of this concept (over80% thought that this would be beneficial and would help themto be a better psychiatrist), a majority of trainees had anxietiespertaining to the involvement of users/carers in examinations.Whereas Vijayakrishnan et al (2006) found that over 60% oftrainees were in favour of user involvement in MRCPsych examinations, our trainees were less keen. We found that only a very smallpercentage were in agreement with it, 22% being in favour ofa user and/or carer being an observer and 16% being in favourof a user and/or carer being an assessor. The reason for sucha difference could be the limited exposure to such a modality of training.

Trainees felt that it would be intimidating and/or underminingof doctors’ knowledge and would raise the stress andanxiety of the examination situation. Some felt that users/carersmay be biased and may place too much emphasis on what is importantfrom their perspective. A few trainees were of the opinionthat it would be difficult for a user/carer to assess the levelof knowledge of candidates. The trainees who were in favourof user/carer involvement in exams were of the opinion thatthey need to be trained for this purpose. This echoes the viewof Livingston & Cooper (2004) that there is a need to improvethe training of service users and carers as educators and toevaluate their teaching in line with that of other health serviceeducators.

Trainees generally felt that service user/carer involvementwould be beneficial to their education, as long as they werecarefully screened and issues of confidentiality and ‘over-involvement’were carefully considered. Our survey found that trainees seethis form of training as a deviation from traditional teachingmethods, and less structured, but nevertheless an important,interesting and holistic approach. However, in previous studiestrainees have reported that carers were insensitive to their emotional needs and had their own agendas (Ikkos, 2003). Thereforeprior discussions with service users/carers regarding thiswould be a helpful step. It is important to make sure thatthe patients give a balanced view of the service, their positiveas well as negative experiences. It would be vital to ensurethat they do not come across as antidoctor and alienate theaudience, but at the same time they should be able to pointout the inadequacies of services so that they can be improved.Otherwise it will defeat its very aim of increasing understandingbetween users and doctors.

Conclusion

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Conclusion

The involvement of service users and carers in the educationof psychiatric trainees is an important aspect of modern medicaltraining both at undergraduate and postgraduate levels. Thisis especially so with MMC and the new curriculum which is cominginto place. It is important to recognise that it is our humanityand our professionalism that makes us good doctors and, moreimportantly, good psychiatrists. With the competency-based curriculumof the MMC, the involvement of users/carers would help to instilthese values at a very early stage of training.

Our survey found that only a quarter of SHOs (26%) were awareof the College’s mandatory requirement and less thanhalf of them (36%) had had the opportunity to hear a user’sand/or carer’s perspective over the previous year. Thismay suggest that still more work needs to be done by trainingschemes, whose future accreditation would depend on implementationof this requirement. The results of this survey, however, representthe views of trainees in a particular area of south Englandonly. It would be useful and informative to survey other regionsto obtain a national perspective on this subject.

Although the majority of trainees embrace this concept, manyhave expressed anxieties that need to be addressed if theyare to have confidence in the role of users/carers as educators.One way to allay trainees’ anxieties would be to incorporatestructured sessions by service users/carers in in-house academicprogrammes, which has already been initiated in some training schemes. However, formal training of service users/carers wouldbe vital, before their involvement as observers or assessors.So far, there has not been any reported harm linked with thisapproach, and therefore with careful preparation and continuedevaluation in the form of audits, this could prove to be anextremely useful tool in psychiatric training.

Acknowledgments

The authors wish to thank all trainees who took part in thissurvey.

References

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