The impact of service user teachers on mental health education

Introduction

The Francis (2003) report on the Mid Staffordshire NHS Foundation Trust Public Inquiry stressed the need for patient involvement in educating students and the Department of Health (2014) firmly set out the UK government’s vision to place patients at the centre of all avenues of care, including education. The Department of Health and Social Care has subsequently set the goal of giving “patients, carers and service users more information about, and control over, services that will work around their needs”.

All training programmes in nursing and life sciences approved by the Health and Care Professions Council must involve service users and carers; to develop this further, several universities have adopted the role of service user and carer lead. Mental health academics are among those starting to make use of learning theory to design and implement strategies for service user teachers. Their work is helping to expand the narrative around the coproduction of service users in teaching, engagement and assessment (Chambers et al, 2021).

In a patient-led NHS, a clear move from paternalism towards partnership working with service users is being emphasised – in mental health education, service user involvement is embedded at many levels (Tew et al, 2004). The Nursing and Midwifery Council’s (2018) new education standards expect patient involvement to be integrated into all regulated nursing curricula. Benner et al (2009) highlighted that both the education received by health professionals and the pedagogical strategies employed in their training are important for improving student engagement and academic outcomes. As Canadian doctor, Sir William Osler’s (1904) famous quote states: “It is a safe rule to have no teaching without a patient for a text, and the best teaching is that taught by the patient himself…”

Evidence shows that involving service users and carers in education programmes enhances students’ learning and positively influences their future professional practice (Robinson and Webber, 2013). Speaking with service users has been shown to:

• Develop students’ empathy;
• Improve communication and negotiation skills;
• Promote effective shared decision making and partnership working;
• Have a positive impact on service users’ experience and mental health recovery outcomes (Tanner et al, 2017).

Sustained interaction with service users and carers helps students become more sensitive to the perspectives of those for whom they are caring and appreciative of their diverse needs (Tew et al, 2011). In turn, patients and carers report feeling empowered when involved in education programmes, because of increased confidence and improved feelings of self-worth (Mckeown et al, 2012).

Questions remain as to whether service user teachers can provide training that improves knowledge and skill in a way that best prepares mental health nursing students for professional practice. There is evidence that learning from lived experience provides students and practitioners with unique insights that help professional compassion, expand understanding, challenge negative and stigmatising attitudes, and facilitate skill development (Scammell et al, 2015).

Miller (2016) embraces the idea of an inclusive culture in higher education, in which all academics and non-academics thrive. This would mean service user teachers and academic staff navigating the interplay between the expert academic and expert patient in a collaborative way. This can be achieved by embedding supportive systems that normalise service user teacher involvement in all lectures. Towle et al (2010) suggested this culture change should also involve paying attention to the language used during teaching and assessment activities to ensure accessibility for service users and students and diversity in the way students are exposed to patient-led involvement in higher education.

How do we learn?

Lessons involving a patient need to be informed by a wide range of theoretical and conceptual perspectives (Shippee et al, 2015; Chambers and Hickey, 2012). In social learning theory, authenticity is one of the characteristics that promotes learning (Kreber et al, 2007). Often service user teachers are truly themselves during lectures and naturally create an atmosphere of mutual trust.

Behaviourist theorists believe learning happens through conditioning processes. Service user teachers can be considered as the stimulus and the learned behaviour as greater compassion towards patients. Gilbert (2016) suggested that social learning experience and the use of compassion in lectures can help improve the student experience and grades. Constructivism theorists support the value of service user teachers’ past experiences in active learning. Listening to an experience is not enough; doing something to reflect the value of the experience is what matters. Frankel (2009) described nurses as preferring a visual and kinaesthetic learning environment, but Alkhasawneh (2013) concluded that nursing students’ preferences for learning varied.

Middendorf and Pace (2004) stated that course content needs to stretch to higher-order thinking – that is, teaching students not to just memorise facts, but to understand, infer, connect, manipulate and apply the facts, in context, to real-life situations (Anderson et al, 2001). It also helps to increase students’ knowledge of analysis, synthesis and evaluation. To achieve this, there needs to be clear learning objectives set by both the academic and service user teacher.

A ‘flipped’ classroom approach, making use of videos that can be accessed via mobile or electronic devices, can help engage students and prepare them for the active learning experience later in the classroom and encourage higher-order thinking (Heffernan et al, 2010). It means students can revise the taught content in their own time; in addition, service user teachers who cannot physically attend sessions can video their lectures and give feedback via learning platforms such as Moodle or Canvas.

For a positive learning experience and engagement, it is also the responsibility of the student to actively communicate what they need (Popovich et al, 2010).

The narrative interpretive method explores the role of storytelling in sharing a lived experience. A service user’s personal narrative can highlight unspoken issues and constraints of a particular situation; this approach can involve patient simulation of a scenario, challenging stereotypes and delivering thematic teaching. It needs to be managed sensitively to avoid re-enactment of potentially traumatising events.

Brown et al (2008) discussed the positive effects of different ways of embedding a narrative pedagogy in nursing programmes, including on a student’s ability to interpret information, analyse concepts and reflect critically on situations. Arguably, use of the narrative interpretive method is not the only way to incorporate a lived experience: fictional and autobiographical literature can also validate service users’ lived experiences and develop reflective thinking skills.

‘Real-world’ mental health stories can be used to highlight a human response to psychological health. Learners can begin to:

• Notice what is happening in a clinical situation;
• Interpret what it means;
• Respond and reflect on how to improve (Goodrich, 2013; Miller, 2005).

By considering the situation from a variety of perspectives, learners are helped to develop clinical judgment. Narrative pedagogy is designed to encourage learners to ask questions, be aware of situations and seek evidence-based best practices.

Modern technology offers the opportunity for electronic narratives, such as virtual simulation, as a way of providing realistic narratives from people with mental health experiences.

Power sharing

The ‘expert professional who always knows best’ model has shifted in recent years, with greater focus on service user-lecturer partnership models (McCutcheon and Gormley, 2014). However, we cannot ignore the potential power struggles that can arise between service users and academic teachers. 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.

Ideally, service user involvement is an opportunity to listen to perspectives and add the user’s voice into theoretical teaching so students can relate theory with practice (Spencer et al, 2011). Evidence shows that, when students felt that service user involvement was non-representative, students were less satisfied with the learning experience (Tanner et al, 2017). Visible cooperation and power sharing between the lecturer and service user teacher, together with reflection on the service user narrative, can:

• Strengthen students’ awareness of different perspectives;
• Increase their compassion for service users;
• Challenge patient stereotypes.

As collaborative coproduction shifts the power from lecturers towards service user teachers, we need to move away from a problem-based teaching approach to more of a coaching role. This can potentially reinforce service user teachers’ strengths and lead to a sense of empowerment and altruism (Bleakley and Bligh, 2008).

There is a demand for nurses who can self-evaluate, work autonomously and view the patient experience from a variety of perspectives. Including service users’ perspectives during teaching could help translate past, present and future knowledge (Kuiper, 2002), and empower students to become critical thinkers and reflective practitioners. Critical reflection can be enhanced by service user teachers who encourage discussion about unconscious biases that can potentially affect decision making and quality of care, which could translate into more meaningful and compassionate relationships with patients in practice.

Much of the current literature relating to power sharing in learning and teaching is descriptive and lacks rigour. Not only have outcomes not been studied, but the educational theory underpinning patient involvement is lacking (Towle et al, 2010; Morgan and Jones, 2009).

“Patients and carers report feeling empowered when involved in education programmes, because of increased confidence and feelings of self-worth”

A progressive pedagogy

McKeown et al (2012) supported the notion of service user involvement as transformative. Whether explicitly spoken about or not, service user pedagogy can be explained in terms of a contemporary learning theory, in which learning occurs when there is frequent interaction between an individual and the social, cultural context. The idea is that student interaction with people who have personal experience of professional care should lead to more compassionate professionals. However, according to Tobbell et al (2018), increasing the presence of service users is not enough to reach this goal. There must be a concurrent understanding of collaborative working with service users in all aspects of the curriculum.

If students are only exposed to patients in clinical practice and not university, this would serve to separate theory from practice, thereby undermining the presence and power of service users in health and education. Tobbell et al (2018) only looked at outcomes from two universities and more research is needed. Although service user teaching can work effectively, depending on its application, disingenuous involvement of service users can have a negative effect on its impact if lecturers continue to make decisions without meaningful engagement with service users.

Self-efficacy

Skills such as modelling and action planning, which are already used by people in the self-management of their mental health, are transferable to an educational environment. Maslow’s hierarchy of needs shows that students need esteem; this includes being perceived as competent and having confidence and independence, and status recognition and appreciation (Braungart et al, 2017). It is still unclear how much students value the improved self-efficacy gained through service user teaching. While there is evidence that self-efficacy can be increased (Schunk et al, 2008; Usher et al, 2008), there is little evidence on whether it changes behaviour.

UK research into mental health and wellbeing in later life found that peer support, through social networking, alleviated the isolation and hopelessness associated with mental health problems (Mead et al, 2001). Surely, the same outcomes could result if service user teachers were involved with students? Despite ambivalence over the true efficacy of service user teaching, health-based teaching still thrives on a patient-empowerment model that values the accounts of service users’ lived experiences.

Research and outcomes

There is very limited evidence on the impact of patient involvement in mental health education, in terms of long-term outcomes in academic and professional practice behaviour. However, there is good evidence of short-term benefits to students and the service user involved, especially around learner satisfaction (Morgan and Jones, 2009).

Students identify benefits of having service user teachers, such as improved understanding of patient perspectives and increased confidence talking to patients (McKeown et al, 2014). They also report being more attuned to the needs of vulnerable people during service user teaching (Towle et al, 2010). Patients are also able to provide immediate and more in-depth feedback to students in a non-threatening way, thereby reducing student’s anxiety in learning clinical and academic skills.

Good-quality research of service users’ involvement is needed to further develop the evidence base. This needs to go beyond the common descriptive studies and short-term evaluations; service users should be able to participate in developing learning materials and assessment tools, including a database of innovations and materials that can facilitate knowledge transfer.

A consistent theme in the research on patient involvement is the lack of clear and measurable educational outcomes (Towle et al, 2010). Tanner et al (2017) conducted a mixed-methods study to investigate service user impact on social worker education and practice. They recommended a model for students, educators and service users that invites a focus on student dispositions to context driven practices. It was a small study but does show the need to understand the impact of service user involvement.

Conclusion

Most studies on service user involvement in formal education are descriptive and few interventions have been rigorously evaluated. Methodological weaknesses and the lack of specificity of objectives and intended outcomes, as well as their diversity, make it difficult to draw conclusions about the effectiveness of patient involvement. However, the literature does highlight how power, self-efficacy, students’ preference and identifying service user teachers as a specialist pedagogy can all have a positive impact on the student experience.

Evidence indicating that those teaching strategies that include participation, engagement and the coproduction of service users and carers are beneficial needs to be considered in the context of the Covid-19 pandemic, which has made communication with service users – at least by traditional means – challenging.