Service user involvement in training: the trainees' view

AIMS AND METHOD

A questionnaire survey was conducted of trainees across the South-West London and St George's Basic Specialist Training Scheme in Psychiatry to explore their attitudes towards service user involvement in training.

RESULTS

Fifty-two completed questionnaires were received; 20 trainees (38%) had not attended teaching sessions where auser was present;35 trainees (67%) were agreeable to service user involvement in examinations. Reservations concerned the objectivity of service users in examination rating and their role as an expert on assessing the trainee's skill. Awareness of user involvement strategies and policies in their trusts were not matched with actual participation.

CLINICAL IMPLICATIONS

Service users should be involved in teaching in an expert capacity and also in examinations, with safeguards regarding transparency and objectivity of the marking schemes in place.

A questionnaire survey was conducted of trainees across the South-West London and St George's Basic Specialist Training Scheme in Psychiatry to explore their attitudes towards service user involvement in training.

RESULTS
Fifty-two completed questionnaires were received; 20 trainees (38%) had not attended teaching sessions where a user was present; 35 trainees (67%) were agreeable to service user involvement in examinations. Reservations concerned the objectivity of service users in examination rating and their role as an expert on assessing the trainee's skill. Awareness of user involvement strategies and policies in their trusts were not matched with actual participation.

CLINICAL IMPLICATIONS
Service users should be involved in teaching in an expert capacity and also in examinations, with safeguards regarding transparency and objectivity of the marking schemes in place.
From June 2005 all trainees in psychiatry were required to receive training directly from people with mental health problems. The medical profession has often been reluctant to change its traditional beliefs (Crawford, 2001). Many doctors accept the idea of user and carer involvement in education in principle but still view it as a threat. It involves a fundamental shift from an 'expert doctor'centred model to one focused on the patient's need (Pietroni et al, 2003).
The South-West London and St George's Mental Health NHS Trust has developed a policy on service user involvement in service planning and development entitled 'Putting Users at the Head of Services: A Framework for Involving People with Mental Health Problems and Their Relatives/Friends'. The trust has collaborated with service users to develop guidelines and a teaching tool for interacting with users with personality disorders (Barlow et al, 2006). In many medical schools there is increasing emphasis on empathy with the patient. For example, during the objective structured clinical examinations in psychiatry at St George's Hospital Medical School the trained actors or service users are asked to rate the student's rapport.
Despite Mukherjee & Nimmagadda's (2005) assertion that trainees accept user involvement in education, we found no evidence that trainees' views had been collected and analysed in a systematic way. Fadden et al (2005) stressed the need for preparation of trainees and exploration of their anxieties prior to receiving training from service users and carers.
In light of a dearth of studies, we decided to survey the trainees attending the MRCPsych part 1 and 2 courses at the South-West London and St George's Basic Specialist Training Scheme in Psychiatry for their views on user involvement in teaching, during examinations and in service planning.

Method
We developed a questionnaire with a focus group of senior house officers (SHOs) to assess attitudes and experience with user involvement; users were not consulted about the questions as this study concentrated on the views of the trainees. The questionnaire was piloted with general practice trainees during their psychiatry attachment; their comments regarding clarity and validity were incorporated.
In the main phase of the study, the questionnaire was given to trainees belonging to the St George's Senior House Officer Training Scheme on two consecutive days of the part 1 and part 2 MRCPsych teaching course. The purpose of the questionnaire was explained to the trainees.

Results
Accurately completed questionnaires were received from all 52 attendees on the 2 days (25 from the part 1 course and 27 from the part 2 course). The majority of trainees were employed by South-West London and St George's Mental Health NHS Trust (covering the London boroughs of Merton, Sutton, Wandsworth, Kingston and Richmond). There were trainees from seven other NHS trusts (3 mental health trusts, 3 primary care trusts and 1 acute trust) across Surrey and Hampshire. They accessed a total of five different in-house academic programmes. The number of trainees from some trusts was small and so we analysed the results by combining the two courses and using descriptive statistics.
Thirty-two trainees (62%) had attended sessions where service users were present and 30 of these (94%) reported that the user was given an opportunity to express their views. Nineteen trainees (37%) had attended a teaching session where the aim was to learn from the user. However, 20 trainees (38%) had never attended a teaching session where a user was present.
There was a remarkable similarity in the trainees' view on different grades of psychiatrists and medical students being receptive to the views of users. Senior house officers were rated to be very or partially receptive by 46 trainees (88%), consultants and specialist registrars by 45 trainees (87%) and medical students by 44 trainees (85%).
An overwhelming majority agreed that neither the patient (n=44, 85%) nor the doctor (n=39, 75%) in isolation could be right about the illness and its treatment.

Service user involvement in examinations
Overall, 35 trainees (67%) said that the user's opinion of the candidate should be taken into account in examinations. More respondents were in favour of user involvement in MRCPsych clinical examinations (34 (65%) for part 1 and 33 (63%) for part 2) than in medical undergraduate examinations (26 (50%) were in favour of a rating in the psychiatry module, with 24 (46%) wanting user involvement in the final MB).
Potential reasons why the trainees might favour or fear service user involvement in MRCPsych examinations were presented as multiple choice questions. The format of the question allowed the trainee to express several views. Table 1 shows the reasons in order of frequency.
Of the 42 trainees who overall favoured user opinion, 31 (74%) were confident in their skill and 29 (69%) in their ability to form a rapport; 24 (57%) were also optimistic that the user's views might influence the examiner to improve their marks. However, even among these positive responders there were reservations about the user's rating being subjective and not indicative of the clinical skills of the candidates.
The main anxiety of the 25 trainees who were not in favour of user involvement in examinations was that the stress of an examination situation might render them less empathic than normal (17 trainees, 68% of this group). The fear that the user might take a dislike to the candidate or give a deliberately poor rating was also expressed.

Awareness of user involvement policies
Although many trainees were aware of user involvement strategies within their trusts and relevant Department of Health publications (Department of Health, 1999), few (12, 23%) had actually read them. Half of the trainees were aware of service development committees and working parties in their trust that involved users; however, less than half had been part of any such committee.

original papers
Vijayakrishan et al Trainees' view of service user involvement

Discussion
The current survey only examined the views of 52 trainees based in one Basic Specialist Training Scheme in Psychiatry. Despite this limitation the results fuel the discussion on how to successfully include service users in psychiatric education. First, although many trainees have the opportunity to learn from service users, this is still patchy and not necessarily incorporated in local in-house academic programmes. It is perhaps surprising that 20 trainees (38%) had never attended a teaching session with a service user. Despite this, trainees were keen to have this experience and over three-quarters were enthusiastic for user involvement in education.
Second, trainees who favoured user involvement did not seem to find the idea of a user rating being given to them in formal examination as threatening. This supports the current emphasis on rapport building with the user in clinical examinations (Livingston & Cooper, 2004). Some trainees remained concerned about the user's objectivity in an examination setting, particularly if the stress of the examination rendered the trainees less empathic than usual. There were also fears that the individual users might be insufficiently robust to withstand the stress of the examination process.
These views highlight the fact that user involvement is not a straightforward issue for trainees. Successful involvement of service users and carers requires careful preparation on both sides. It is recognised that contact is helpful in reducing stigma, especially when participants are of equal status in the interaction (Corrigan & Penn, 1999). Exploration of any anxieties and doubts trainees are experiencing in relation to receiving training and evaluation from service users and carers should be addressed by psychiatric educationalists (Fadden et al, 2005).
Third, over three-quarters of the trainees' viewed all grades of doctors to be very or partially receptive to learning from users, with themselves as the most receptive group. This indicates that the trainees would expect their educational supervisors to also learn from an expert patient programme.
Finally, less than half the trainees had read any patient involvement strategies and few were involved in any type of service planning or development. This is perhaps not surprising as it is at the specialist registrar stage that trainee psychiatrists have been encouraged to be more involved in managerial decision-making.

Conclusions
We would suggest that one way forward with regard to any potential changes in Membership examinations is for the College to ensure that patient/user ratings are transparent to the candidates and objective. However, participation in user-led teaching sessions may allay some trainees' fears.
We suggest that users should be involved in teaching sessions as experts rather than demonstrators of symptoms. With a relaxation of the College's requirement for patient presentations and journal clubs within local academic programmes, a user/carer-centred teaching session could be substituted for a patient 'presentation' or journal club so that all grades of doctors can learn.

Declaration of interest
None.