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

In 2004 the Royal College of Psychiatrists made it clear that it was committed to increasing the involvement of service users and carers throughout psychiatric education. This has been mandatory since June 2005 and it has been a compulsory aspect of psychiatric training for schemes to demonstrate a

In 2004 the Royal College of Psychiatrists made it clear that it was committed to increasing the involvement of service users and carers throughout psychiatric education. This has been mandatory since June 2005 and it has been a compulsory aspect of psychiatric training for schemes to demonstrate a meaningful involvement 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 in the NHS, in particular, service development and evaluation, has been central to national health policy (Department of Health, 1991, 2000, 2001. Moreover, the Postgraduate Medical Education Board (PMETB) is likely to require the involvement of users and carers in postgraduate training and endorses the use of lay 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 involvement of patients in training psychiatrists. The new curriculum in line with the Modernising Medical Careers (MMC) involves workplacebased assessments, one of which is 'patient satisfaction questionnaires'. These allow evidence to be gathered from patients, carers and others on aspects of trainees' performance such as politeness and responding to questions.
The inclusion of service users as teachers has been a slower process but it is becoming increasingly recognised and valued by health professionals. Direct contact with patients can be seen to play a crucial role in the development of clinical reasoning, communication skills, professional attitudes and empathy (Spencer et al, 2000). The value of involving patients in an active teaching role, where learners can benefit from patients' experience and expertise, is being recognised and it has been found that the experience of being taught by a trained patient can increase confidence, reduce anxiety and generate new insights (Wykurz & Kelly, 2002). There are issues that need to be considered by those involved in psychiatric training who will be implementing the new guidance and there is also the need to address any anxieties that trainees may have (Fadden et al, 2005).
The survey described here was designed to obtain an insight into the views of both specialist registrars (SpRs) and senior house officers (SHOs) and into what they perceive as benefits, any anxieties they may have and the form of training they would like to receive from service users/carers. This involved all SHOs on the Solent and all SpRs on the Wessex rotation schemes (south of England).

Method
We developed an anonymous questionnaire that was sent to 52 SHOs and 38 SpRs in the Solent and Wessex rotations respectively. The names of trainees were obtained from the postgraduate department at the Royal South Hants Hospital, Southampton. The questionnaires were sent to the trainees by internal post with a self-addressed envelope for return of the completed questionnaires. To increase the response rate, reminders were sent after a period of 3 weeks. Those on maternity leave were excluded. The trainees worked in a variety of areas such as adult mental health, old age psychiatry, rehabilitation psychiatry, substance misuse, forensic psychiatry, psychotherapy, child and adolescent psychiatry and learning disabilities and had varying levels of experience (between 1 and 4 years at SHO level and 1 and 5 years at SpR level). The majority of trainees were employed by the Hampshire Partnership NHS Trust. There were trainees from six other trusts across Dorset, Southampton, Portsmouth, Avon and Wiltshire, East Hampshire and the Isle of Wight. The results were analysed using descriptive statistics with expert help from the audit department of the Hampshire Partnership NHS Trust.
The anonymous questionnaire was piloted on a small number of trainees before the final version was agreed and distributed among participants. The questionnaire comprised leading questions, open-ended questions, questions requiring a 'Yes' or 'No' answer, and questions on a five-point Likert scale.

Results
Out of the 90 questionnaires sent out 77 were completed and returned -an 85% response rate. Out of the 77 questionnaires, SHOs completed 42 and SpRs completed 35 (Table 1).
There were 36 out of 77 trainees (47%) who were aware of the College requirement for psychiatric trainees to receive training directly from service users and carers and 53% (n=41) had had a chance to hear a service user/ carer's perspective as part of formal training in the previous year. Situations in which 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, a video and a play by a service user.
The majority of trainees (77%) agreed that the experience of involving service users or carers in training was worthwhile, and argued that it is important to get an idea of the service user perspective as it helps to understand mental illness in a 'human context'. The trainees who felt otherwise (15% were unsure and 8% did not think it was worthwhile) commented that they were unsure how it can be put into practice, and that there could be confidentiality issues. There were 23 trainees who had had no involvement of service users/carers in their training 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% did not feel that it would be beneficial and 10% were unsure. Those who disagreed thought that service users and carers might be too emotionally involved and have irrational expectations. Some trainees worried that the service users/carers might not be able to provide training in a structured way.
A vast majority of trainees thought that service users' and carers' involvement would probably make them better psychiatrists (84%); 38% of trainees expressed anxieties about the involvement of service users/carers in their training and education; 46%, however, had no anxieties; 14% were unsure. The main concerns were with regard to potential 'conflicts of 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 confidence and dilution of their authority. Other concerns included issues of appropriate training and standards, service users' objectivity and communication skills, confidentiality issues and effect on users' health.
We also asked trainees whether they saw it as being different from other aspects of their training; 49% thought it was and 32% thought it was not and that it was an integral part of training to be a psychiatrist. Box 1 shows trainees' views on how they considered service users and carers should be involved in training.
Most trainees were opposed to having service users as assessors or observers in their examinations; less than a quarter were in favour. Overall 22% thought it was a good idea to have users/carers as observers in examinations and 16% thought that it would be useful to have them as assessors. A majority of trainees expressed concerns with regard to issues of validity and reliability of such user roles and many felt this would only provoke further unnecessary anxiety in an already stressful situation. Some felt there was a need to ensure consistency and standardisation through proper training. Trainees also felt that they would be 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 service users and carers in their education. Feedback from service users and carers on the trainees' interviewing skills, their views on the quality of services and most of all their experience of mental illness were seen as useful aspects of training.

Discussion
The survey provides a useful insight into the views of both SHOs and SpRs and their feelings and anxieties about the involvement of service users/carers in their education.
The questions were open-ended rather than MCQ-type, which helped trainees express their own views. Furthermore we were able to compare the views of SHOs with that of SpRs. Although trainees were generally welcoming of this concept (over 80% thought that this would be beneficial and would help them to be a better psychiatrist), a majority of trainees had anxieties pertaining to the involvement of users/carers in examinations. Whereas Vijayakrishnan et al (2006) found that over 60% of trainees were in favour of user involvement in MRCPsych examinations, our trainees were less keen. We found that only a very small percentage were in agreement with it, 22% being in favour of a user and/or carer being an observer and 16% being in favour of a user and/or carer being an assessor. The reason for such a difference could be the limited exposure to such a modality of training.
Trainees felt that it would be intimidating and/or undermining of doctors' knowledge and would raise the stress and anxiety of the examination situation. Some felt that users/carers may be biased and may place too much emphasis on what is important from their perspective. A few trainees were of the opinion that it would be difficult for a user/carer to assess the level of knowledge of candidates. The trainees who were in favour of user/carer involvement in exams were of the opinion that they need to be trained for this purpose. This echoes the view of Livingston & Cooper (2004) that there is a need to improve the training of service users and carers as educators and to evaluate their teaching in line with that of other health service educators.
Trainees generally felt that service user/carer involvement would be beneficial to their education, as long as they were carefully screened and issues of confidentiality and 'over-involvement' were carefully considered. Our survey found that trainees see this form of training as a deviation from traditional teaching methods, and less structured, but nevertheless an important, interesting and holistic approach. However, in previous studies trainees have reported that carers were insensitive to their emotional needs and had their own agendas (Ikkos, 2003). Therefore prior discussions with service users/carers regarding this would be a helpful step. It is important to make sure that the patients give a balanced view of the service, their positive as well as negative experiences. It would be vital to ensure that they do not come across as antidoctor and alienate the audience, but at the same time they should be able to point out the inadequacies of services so that they can be improved. Otherwise it will defeat its very aim of increasing understanding between users and doctors.

Conclusion
The involvement of service users and carers in the education of psychiatric trainees is an important aspect of modern medical training both at undergraduate and postgraduate levels. This is especially so with MMC and the new curriculum which is coming into place. It is important to recognise that it is our humanity and our professionalism that makes us good doctors and, more importantly, good psychiatrists. With the competencybased curriculum of the MMC, the involvement of users/ carers would help to instil these values at a very early stage of training.
Our survey found that only a quarter of SHOs (26%) were aware of the College's mandatory requirement and less than half of them (36%) had had the opportunity to hear a user's and/or carer's perspective over the previous year. This may suggest that still more work needs to be done by training schemes, whose future accreditation would depend on implementation of this requirement. The results of this survey, however, represent the views of trainees in a particular area of south England only. It would be useful and informative to survey other regions to obtain a national perspective on this subject.
Although the majority of trainees embrace this concept, many have expressed anxieties that need to be addressed if they are to have confidence in the role of users/carers as educators. One way to allay trainees' anxieties would be to incorporate structured sessions by service users/carers in in-house academic programmes, which has already been initiated in some training schemes. However, formal training of service users/carers would be vital, before their involvement as observers or assessors. So far, there has not been any reported harm linked with this approach, and therefore with careful . Experience of the service from an individual from a minority ethnic group . Expectations of service users, for example on treatment goals . Views on the service . Experience of being detained under the Mental Health Act . Experience of illness . Communication/interview skills, for example empathy, dealing with sensitive issues . Issues affecting users and carers, for example impact of illness . Impact of illness on children of people with mental illness . Demonstration of symptoms/signs of illness . A voluntary organisation's perspective preparation and continued evaluation in the form of audits, this could prove to be an extremely useful tool in psychiatric training.

Declaration of interest
None.