Welcome to a bumper blog in which I attempt to write on two papers resulting from one research study – ‘Enhancing the quality of user-involved care planning in mental health services’ or EQUIP for short (appropriately). The EQUIP study is a randomised controlled trial of the clinical and cost effectiveness of a co-delivered care planning training programme for community mental health practitioners. You only have to take a cursory glance through the Mental Elf and Social Care Elf blogs from the past few years to find out that the quality of user and carer involvement in care planning needs to be enhanced, to say the least.
A while ago I looked at the COCAPP study on personalised, recovery-focused care planning and co-ordination (aside: note to researchers, if you want to get top funding, get a top acronym), which found that services users didn’t think care plans were relevant to them and rarely used them, while practitioners rarely discussed risk with them when planning care and support. Not good. What is good though, is to see this research into training on service user and carer involvement in care planning for those practitioners, and training that is co-delivered by service users and carers to boot.
The two papers published from the larger EQUIP study discussed here focus on:
- the evaluation of the acceptability of the two-day, co-delivered training package to practitioners (Grundy et al, 2017)
- the evaluation of the training the trainers programme for service users and carers co-delivering the training (Fraser et al, 2017)
The study was conducted by UK researchers at the universities of Manchester and Nottingham.
For the acceptability evaluation of the training package, 310 out of 350 community mental health practitioner trainees completed the Training Acceptability Rating Scale (TARS) post-training. TARS yielded both quantitative and qualitative data, with 15 Likert-scale type questions and 3 open-ended free-text questions. The data was analysed using descriptive statistics and content analysis.
The EQUIP training course lasted for two days and was co-delivered by an academic with a clinical background with one or two service users and where possible, a carer. The service users and carers facilitated group work and discussed good and poor care planning practice with trainees.
In preparation, the six service users and three carers due to co-deliver the EQUIP training attended a four day ‘train the trainers’ course, which included teaching practice and theory as well as specific training on EQUIP course delivery. The ‘train the trainers’ course was delivered by two senior academic clinicians with an academic colleague. The acceptability, effectiveness and suitability of this preparatory training was evaluated using semi-structured interviews with the nine attendees. Inductive thematic analysis was used to analyse the interview transcripts.
Evaluation of co-delivered EQUIP training to practitioners
The majority of practitioners undertaking the co-delivered EQUIP training ‘strongly agreed’ that it was ‘generally acceptable’ (61.2%), effective/beneficial (58.6%), appropriate (64.7%) and consistent with good practice (73.9%). The majority also ‘strongly agreed’ that the training would not harm service users and/or carers (74.9%) and approved of the training (58.3%).
The majority of EQUIP trainees also answered ‘a great deal’ to how competent the course leaders were (79.6%); their satisfaction with the training (54.5%); how well the training covered the intended topic (57.1%); how course leaders related to the trainees (81.9%); how motivating the course leaders were (74.4%).
‘Quite a lot’ was the most frequent response to questions about training improving understanding (45.5%), helping to develop skills (44.6%), increasing confidence (42.9%), and would be used in the future (41.8%).
Six main themes resulted from the analysis of the open-ended questions in the TARS:
- The value of the co-production model for training
- Time and space to reflect on care planning practice
- Training delivery preferences for group discussion
- Comprehensiveness of content
- Need to consider organisational context/culture in which practitioners have to operate and make decisions
- Emotional responses to training ranging from ‘negative’ and ‘patronising’ to ‘inspirational’ and ‘motivating’.
The authors conclude that: “the overall TARS scores demonstrated high levels of satisfaction with the training generally and with the acceptability and impact of the training for mental health professionals”.
Evaluation of ‘train the trainers’ course for service users and carers co-delivering EQUIP training
The analysis of the interview transcripts resulted in a number of key themes as follows:
- Motivation to take part: Skills development; Getting involved and making a difference
- Participant support needs and experiences: Enthusiasm vs anxious anticipation; Assessing individual support needs
- Training reflections on ‘train the trainers’: An overly theoretical approach at the expense of practical skills development; Intensity of sessions; Open, respectful learning environment; Knowledge acquisition and confidence
- Training reflections on co-delivering EQUIP training intervention: Clarity on co-trainer selection process and managing expectations; Unexpected encounters with former care co-ordinators; Hostile encounters and unguarded reflections from practitioners; The need for supervision and peer support; Personal impact of delivering training.
The authors conclude that:
Mental health nurses should use co-production models of continuing professional development training that involve service users and carers as co-facilitators.
And, in order for this to be successful:
When training service users and carers to deliver training to mental health professionals, it is important that service users are equipped to deal with resistance from staff…Training for service users and carers must be offered alongside ongoing support and supervision.
Strengths and limitations
Both these evaluations are part of a larger study about the impact and effectiveness of the training for improving practice that is yet to report, so readers can’t place the findings in the overall research context. In this sense it’s a little like only having half the story, and you’re left wondering what the ending is; will this training be implemented and will involvement and co-production in care planning improve as a result in the longer term? [We’ll be sure to blog about the main RCT study findings when they are published, hopefully later in 2018].
However, in themselves the two papers provide helpful insights into practitioner experience of training co-delivered by service users and carers, and an approach that explicitly aims to move beyond the tokenistic (and some might say, exploitative) personal story telling model of service user and carer participation. Of particular interest to those like me who keep tabs on evidence about service user and carer involvement and co-production are the findings from the ‘train the trainers’ evaluation. The researchers reported the challenges that need to be addressed and planned for in service user and carer co-trainer preparation, as well as the positives.
The authors themselves recognise some of the key limitations by highighting the lack of demographic and professional background data for TARS questionnaire participants and the small cohort of service users and carers in the ‘train the trainers’ evaluation.
These papers provide a useful evaluation of a co-delivered training package from both the practitioner trainee and service user and carer trainer point of view. By demonstrating co-delivery in the classroom, with service user and carer trainers taking a lead in facilitating sessions and not just for illustrative personal narratives, the EQUIP training appears to model service user and carer involvement for care planning as an integral part of delivery.
Predictably, I’ve delved into the papers to see if the EQUIP training programme itself was co-produced as well as being co-delivered. It’s not entirely clear, although ‘consultation’ with service users and carers is mentioned, which according to most folks who know about such things is not co-production. It’d be helpful to have more detail on how the training course was developed as well as delivered to be able to assess if it really is an example of ‘co-production’, as claimed.
Despite this, the findings are consistent with existing evidence about conflict or tensions between actors being part of progressing transformative co-production in mental health, and the papers provide further evidence about the preparation required for co-production and service user and carer participation. In this case, the authors focus on preparing service users and carers:
encountering resistance from staff in training was a previously unidentified challenge to service user and carers’ experience of delivering training in practice…it is important that service users [and carers] are equipped to deal with resistance from staff.
Finally, perhaps we need to bear in mind the authors’ note that ‘no psychiatrists or senior management attended training’, and think about what that says in itself. Then what are the implications for improving service user and carer involvement in care planning, given the messages from research and policy about the importance of managers and leaders engaging with and understanding person-centred ways of working that require attitudinal, organisational and cultural change? Without the explicit engagement of senior management and clinicians, will frontline staff feel confident or supported to work co-productively with service users and carers in care planning? Will they be able to renegotiate role boundaries and be willing to take positive risks if leaders don’t create the right working culture and environment? We await the main EQUIP study findings with interest…
Grundy AC, Walker L, Meade O, Fraser C, Cree L, Bee P, Lovell K, Callaghan P. (2017) ‘Evaluation of a co-delivered training package for community mental health professionals on service user- and carer-involved care planning’ Journal of Psychiatric and Mental Health Nursing. DOI: 10.1111/jpm.12378 [Open Access]
Fraser C, Grundy A, Meade O, Callaghan P, Lovell K. (2017) ‘EQUIP training the trainers: an evaluation of a training programme for service users and carers involved in training mental health professionals in user-involved care planning’ Journal of Psychiatric and Mental Health Nursing. DOI: 10.1111/jpm.12361 [Open Access]
Carr S. (2016) Empowering, personalised and recovery-focused care planning and co-ordination: When will we ever learn? The Mental Elf, 25 May 2016.
Practical Guide: Progressing transformative co-production in mental health (PDF). National Development Team for Inclusion.