Power shift promotes partnership

Mental Health Nursing,  May 2005  by Breeze, Jayne,  Bryant, Hazel,  Bryant, Laurie,  Davidson, Bill,  Et al

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This paper by Jayne Breeze et al, describes the process underpinning the design and delivery of a post basic module degree at the University of Sheffield and focuses on working with mental health service users and carers. The module was a collaboration between service users, carers and academics whose aim was to work in partnership. Partnership cannot be achieved without a shift in the balance of power. This paper argues that issues relating to: remuneration, roles, representativeness and control need to be addressed before partnership can be realised

In 2004 the Department of Mental Health and Learning Disability at the University of Sheffield included, for the first time, a module entitled 'Working with service users and significant others' within its post basic provision. The module formed part of the 'BMedSci Mental Health Practice' degree but could be accessed by all post basic students, Delivery of the module was the result of the collaboration between service users, carers and academics. The following paper describes the process of this collaboration and identifies ways of working that enables shifts in the balance of power.

The importance of involving service users and carers in all aspects of health care has been firmly ensconced in health policy since the 1990s. Recent legislation has confirmed this principle. see, for example, Patient and Public Involvement in the New NHS (DOH 1999); The Expert Patient (DOH 2001) and the different National Service Frameworks. This has resulted in the development of structures for service user and carer involvement within services, research and education. In nurse education there is a requirement for educational institutions to involve service users and carers when designing and delivering training programmes (ENB, 1996).

In response to policy requirements for healthcare education, educational institutions and workforce confederations have been developing guidelines for involving service users and carers in education and training. The Northern Centre for Mental Health, funded by NIMHE (National Institute for Mental Health England), produced a tool to help workforce development confederations to audit user and carer involvement in higher education and inform the commissioning of post-qualification mental health education programmes (NCMH 2003). An integral part of the tool is the adaptation of the 'ladder of participation' offered by Goss and Miller (1995). This : comprises five levels ranging from: 'no involvement' at level one; through 'passive involvement' (e.g. consultation with users via a third party); 'token involvement' (e.g. consultation with users through non decision-making forums); 'collaboration' (e.g. users' views form basis of decisions); to level five 'partnership1 whereby 'educationalists and users work together systematically, strategically, and with full support, reimbursement structures and with education and training opportunities available. Users are involved at all stages of the planning, delivery and management processes. Decisions are made jointly' (NCMH, 2003 pg 34).

To involve service users at this level will essentially mean a shift in the balance of power (Repper and Perkins, 2003). Some in the user movement believe that power is so entrenched in mental health that working in partnership may never be possible in the practice areas (Coleman and Harding, 2004).

Resistance to changing this balance of power has also been found in nurse education (Felton and Stickley, 2004).

The remainder of this paper offers an example of how these power imbalances can be overcome in order to work together in partnership. Following the initial idea of developing a 20 credit post basic module (degree level) entitled 'working with service users and significant others', the lecturer (JB) met with both the Impact service user group and a carer group for an initial consultation. The Impact team had already developed a national reputation for both training and monitoring but had not been involved in developing and delivering a module of study before. The carer group was organised and convened by two carer trainers (AM and LW) who were already involved in delivering sessions within the pre-registration mental health courses. This consultation formed the design of the module and underpinned the application for validation.

In order to progress to working in partnership, however, potential barriers to involvement needed to be addressed, which are: preparation, remuneration and representation.

Preparation and Remuneration

A lack of, or limited, preparation prior to participating in education can result in service users feeling uncertain about their involvement, not understanding the purpose, and feeling that they lack expertise (Spencer et al, 1999; Turner et al, 2000; Masters et al, 2002). Not surprisingly, therefore, preparation is considered to be an important part of the process (Curran, 1997). This can include structured training on teaching and assessing (Hanson and Mitchell, 2001). The service users and carers involved in this module were all experienced trainers and therefore did not require this level of preparation. In addition they had control over the learning content of the module from the outset as well as full participation in the proposed learning outcomes and teaching delivery and so were always in a position whereby they understood what was expected of them. The planning meetings with the accompanying lecturer support were considered by the service users and carers to be appropriate preparation.