Co-producing Psychiatric Education with Service User Educators: a Collective Autobiographical Case Study of the Meaning, Ethics, and Importance of Payment

"We're back in control of the story and we're not letting anyone take that away from us": patient teacher programs as means for patient emancipation

While patient engagement in healthcare professions education (HPE) has significantly increased in the past decades, a theoretical gap remains. What are the varied reasons as to why patients get involved with HPE programs? With a focus on understanding what drives patient involvement with HPE programs, this study examined how a patient as teacher (PAT) program was experienced by medical students, patient teachers, and faculty within a medical school. Through a phenomenographic approach, this study captures and describes the different ways our study participants experienced a PAT program (the 'phenomenon'). 24 semi-structured interviews were conducted in total, comprised of interviews with patient teachers (N = 10), medical students (N = 10) and program facilitators (N = 4) who participated in a PAT program. Our focus was on participants' description of the program and was grounded in their experiences of as well as their beliefs about it. Our findings captured 4 layers representing the qualitatively different (yet interrelated) ways in which participants experienced/perceived and conceptualized the various aspects of their experience with the PAT program: (1) A productive disruption of the learning space (2) A re-humanization within healthcare (3) A means of empowerment and agency (4) A catalyst for change and emancipation. Our outcome space results can be visually illustrated by a nesting "Matryoshka" doll, representing the four layers and depicting the process of uncovering the less conscious layers of sense-making within this phenomenon. HPE programs that are co-produced with patients and actively involve patients as teachers have the potential, but not guarantee, to be emancipatory. To engage in PAT programs that exhibit an emancipatory potential, we need to consider transformative paradigms of education, which are aligned with social change, and disrupt the traditional teacher-learner hierarchy.

A balancing act: navigating the nuances of co-production in mental health research

BACKGROUND

In the context of mental health research, co-production involves people with lived expertise, those with professional or academic expertise, and people with both of these perspectives collaborating to design and actualize research initiatives. In the literature, two dominant perspectives on co-production emerge. The first is in support of co-production, pointing to the transformative value of co-production for those involved, the quality of services developed through this process, as well as to broader system-level impacts (e.g. influencing changes in health system decision making, care practices, government policies, etc.). The second stance expresses scepticism about the capacity of co-production to engender genuine collaboration given the deeply ingrained power imbalances in the systems in which we operate. While some scholars have explored the intersections of these two perspectives, this body of literature remains limited.

MAIN TEXT

This paper contributes to the literature base by exploring the nuances of co-production in health research. Using our mental health participatory action research project as a case example, we explore the nuances of co-production through four key values that we embraced: 1. Navigating power relations together 2. Multi-directional learning 3. Slow and steady wins the race 4. Connecting through vulnerability CONCLUSIONS: By sharing these values and associated principles and practices, we invite readers to consider the complexities of co-production and explore how our experiences may inform their practice of co-production. Despite the inherent complexity of co-production, we contend that pursuing authentic and equitable collaborations is integral to shaping a more just and inclusive future in mental health research and the mental health system at large.

Power to the people? A co-produced critical review of service user involvement in mental health professions education

Meaningful service user involvement in health professions education requires integrating knowledge held by "lay" people affected by health challenges into professional theories and practices. Involving service users redefines whose knowledge "counts" and implies a shift in power. Such a shift is especially significant in the mental health field, where power imbalances between health professionals and service users are magnified. However, reviews of the literature on service user involvement in mental health professional education do little to explore how power manifests in this work. Meanwhile critical and Mad studies scholars have highlighted that without real shifts in power, inclusion practices can lead to harmful consequences. We conducted a critical review to explore how power is addressed in the literature that describes service user involvement in mental health professions education. Our team used a co-produced approach and critical theories to identify how power implicitly and explicitly operates in this work to unearth the inequities and power structures that service user involvement may inadvertently perpetuate. We demonstrate that power permeates service user involvement in mental health professional education but is rarely made visible. We also argue that by missing the opportunity to locate power, the literature contributes to a series of epistemic injustices that reveal the contours of legitimate knowledge in mental health professions education and its neoliberal underpinnings. Ultimately, we call for a critical turn that foregrounds power relations to unlock the social justice-oriented transformative potential of service user involvement in mental health professions education and health professions education more broadly.

Collaborating With Service Users to Select Psychiatry Residents Committed to Health Equity and Social Justice

PROBLEM

Advocates have called for health services to be delivered equitably to all. Academic psychiatry must play a role in this work, given its history of creating and perpetuating the marginalization of people experiencing mental health issues. While medical educators have started teaching concepts such as structural competency and cultural safety, careful consideration of who enters the medical workforce and what values they bring is also important.

APPROACH

The authors report on the first 5 years (2016-2021) of a collaboration with individuals who have used mental health or addiction services or identify as having lived experiences of mental health and/or substance use issues (i.e., service users) to select residents to the general adult psychiatry residency program at the University of Toronto who are committed to working toward health equity and social justice and who bring diverse personal, academic, and community-based experiences. Starting in 2016, a working group of service users and faculty iteratively refined the selection process to add personal letter and interview day writing sample prompts centered on social justice and advocacy.

OUTCOMES

The working group, coled by service users since 2019, defined the problem (lack of attention to health equity and social justice in resident selection) and codesigned the solution by revising writing prompts used in the selection process and their assessment rubrics to emphasize these missing areas. Further, service users directly participated in the implementation by reviewing candidates' personal letters and interview day writing samples alongside faculty and residents. This work serves as an example of meaningful service user engagement in action.

NEXT STEPS

To ensure the needs of service users are prioritized, future work must aim for long-term institutional commitment to strengthen service user involvement and power sharing with service user communities in resident selection and at other points along the medical education pathway.

Co-producing research on psychosis: a scoping review on barriers, facilitators and outcomes

INTRODUCTION

Co-production is a collaborative approach to service user involvement in which users and researchers share power and responsibility in the research process. Although previous reviews have investigated co-production in mental health research, these do not typically focus on psychosis or severe mental health conditions. Meanwhile, people with psychosis may be under-represented in co-production efforts. This scoping review aims to explore the peer-reviewed literature to better understand the processes and terminology employed, as well as the barriers, facilitators, and outcomes of co-production in psychosis research.

METHODS

Three databases were searched (MEDLINE, EMBASE, PsycINFO) using terms and headings related to psychosis and co-production. All titles, abstracts and full texts were independently double-screened. Disagreements were resolved by consensus. Original research articles reporting on processes and methods of co-production involving adults with psychosis as well as barriers, facilitators, and/or outcomes of co-production were included. Data was extracted using a standardised template and synthesised narratively. Joanna Briggs Institute and the AGREE Reporting Checklist were used for quality assessment.

RESULTS

The search returned 1243 references. Fifteen studies were included: five qualitative, two cross-sectional, and eight descriptive studies. Most studies took place in the UK, and all reported user involvement in the research process; however, the amount and methods of involvement varied greatly. Although all studies were required to satisfy INVOLVE (2018) principles of co-production to be included, seven were missing several of the key features of co-production and often used different terms to describe their collaborative approaches. Commonly reported outcomes included improvements in mutual engagement as well as depth of understanding and exploration. Key barriers were power differentials between researchers and service users and stigma. Key facilitators were stakeholder buy-in and effective communication.

CONCLUSIONS

The methodology, terminology and quality of the studies varied considerably; meanwhile, over-representation of UK studies suggests there may be even more heterogeneity in the global literature not captured by our review. This study makes recommendations for encouraging co-production and improving the reporting of co-produced research, while also identifying several limitations that could be improved upon for a more comprehensive review of the literature.

"Come and share your story and make everyone cry": complicating service user educator storytelling in mental health professional education

It has become relatively common practice within health professional education to invite people who have used mental health and social care services (or service user educators) to share their stories with health professional learners and students. This paper reports on findings from a postcritical ethnographic study of the practice of service user involvement (SUI), in which we reflexively inquired into conceptualizations of service user educators' knowledge contributions to health professional education in the accounts of both service user- and health professional educators. This research was conducted in response to recent calls for greater scrutiny surrounding the risks, challenges, and complexities inherent in involving service users in health professional education spaces. 'Story/telling' was identified as a pronounced overarching construct in our analysis, which focuses on participants' reports of both the obvious and more subtle tensions and complexities they experience in relation to storytelling as a predominant tool or approach to SUI. Our findings are presented as three distinct, yet overlapping, themes related to these complexities or tensions: (a) performative expectations; (b) the invisible work of storytelling; and (c) broadening conceptualizations of service user educators' knowledge. Our findings and discussion contribute to a growing body of literature which problematizes the uncritical solicitation of service user educators' stories in health professional education and highlights the need for greater consideration of the emotional and epistemic labour expected of those who are invited to share their stories. This paper concludes with generative recommendations and reflexive prompts for health professional educators seeking to engage service user educators in health professional education through the practice of storytelling.

A theoretical systematic review of patient involvement in health and social care education

Patient involvement in health and social care education lacks theoretical underpinning, despite increasing calls for rigour. Theories help explain how learning is advanced and offer guidance for how faculty work with patients who become involved in curriculum delivery. We conducted a systematic review to synthesise how theory shapes our understanding of patient involvement in health and social care education. Three databases were systematically searched. Studies demonstrating explicit and high-quality application of theory to patient involvement in teaching and learning or involvement within a community of health and social care educators, were included. A narrative synthesis was undertaken using Activity Theory as an analytical lens to highlight the multifaceted components of patient involvement in professional education. Seven high-quality, theoretically underpinned studies were included. Four studies applied theory to pedagogy, showing how deep learning from patient involvement occurred. Despite a growing body of studies which attempt to use theory to explain learning, many were descriptive, lacked theoretical quality and were therefore excluded. Three studies applied theory to illuminate the complexity of involving patients in the educational system, showing how patients can be supported and valued in teaching roles. This review highlights that more work is required to identify the mechanisms through which patient involvement enhances learning and, to explore what involvement within the education community means for faculty and patients. Our understandings of patient-educator partnerships for learning could be progressed by further high-quality theory driven studies, which include the patient voice.

Material and epistemic precarity: It's time to talk about labour exploitation in mental health research

The conditions under which people labour in mental health research affect how and what knowledge is produced - and who benefits or doesn't from involvement in health research systems. There has been, however, little sustained investigation of the uneven modalities of labour exploitation across what are increasingly financialised systems of mental health research. This theoretical paper advances conceptual and empirical investigations of labour in health research - outlining how material precarity and epistemic precarity often go hand in hand, and largely drawing on examples from the UK. The intertwining of labour relations and epistemic cultures can be understood by bringing together insights from two bodies of knowledge not commonly in contact with one another - survivor/service user research and critical research on universities and academic labour. The article addresses how mental health research makes significant use of the labour of (i) contract researchers (many of whom work on precarious and exploitative contracts); (ii) lay contributors (through 'patient and public involvement'); and (iii) research participants (where the conditions underpinning participation in various kinds of research increasingly blur the distinction between volunteering, and 'gig' work). Labour relations affect, and are affected by, efforts to change epistemic cultures and reduce epistemic inequalities, and epistemic and material precarity make efforts to improve research culture much more difficult. Those experiencing both material and epistemic precarity in health research systems need to be at the heart of efforts to combat both.

Developing an evaluation framework for assessing the impact of recovery colleges: protocol for a participatory stakeholder engagement process and cocreated scoping review

INTRODUCTION

Recovery colleges (RCs) are mental health centres aimed at equipping people with skills to live a meaningful life despite the presence of mental distress. Unique to them is the aspect of cocreation; RCs are designed collaboratively with people of lived experiences of mental health and addictions and care providers. Despite established benefits, there remains a lack of empirical evidence on how RCs work and on their impact.

AIMS

We aim to address this gap by designing a cocreated evaluation framework for RCs. This will be accomplished by engaging RC student/facilitators to provide perspectives on RCs/RC evaluation and cocreate a scoping review identifying evaluation gaps in the literature. Themes identified through these processes will form the evaluation framework.

METHODS AND ANALYSIS

Two methodologies will be used to explore RC evaluation: student/facilitator engagement and a scoping review of current published and grey literature on RC evaluation. Engagement will be achieved using a participatory action research approach consisting of informant interviews of ~25 RC students/facilitators across Canada, which will be thematically analysed. The scoping review will follow methodology described by Arksey and O'Malley modified to support cocreation. Concurrent conducting of the engagement process and scoping review will allow RC students and peer facilitators the opportunity to shape RC evaluations, address gaps in the literature and codesign an evaluation framework focused on recovery-oriented processes and outcomes mattering most to RCs students/facilitators.

ETHICS AND DISSEMINATION

Ethics approval was received for the RC student/facilitator engagement component from the Centre for Addictions and Mental Health Research Ethics Board (#042-2020) and Ontario Shores Centre for Mental Health Sciences (#20-013-B). Scoping review results will be copresented through national and international medical education conferences and published in open-access peer-reviewed journals. Furthermore, a dissemination strategy on evaluation for the national RC community will be created.

Virtual Education Program to Support Providers Caring for People With Intellectual and Developmental Disabilities During the COVID-19 Pandemic: Rapid Development and Evaluation Study

BACKGROUND

People with intellectual and developmental disabilities are at increased health-related risk due to the COVID-19 pandemic. Virtual training programs that support providers in caring for the physical and mental health needs of this population, as well provide psychological support to the providers themselves, are needed during the pandemic.

OBJECTIVE

This paper describes the design, delivery, and evaluation of a virtual educational COVID-19-focused Extension for Community Healthcare Outcomes program to support providers during the COVID-19 pandemic in caring for the mental health of people with intellectual and developmental disabilities.

METHODS

A rapid design thinking approach was used to develop a 6-session program that incorporates mindfulness practice, a wellness check, COVID-19-related research and policy updates, a didactic presentation on a combination mental health and COVID-19 related topic, and a case-based discussion to encourage practical learning. We used the first 5 outcome levels of Moore's evaluation framework-focusing on participation, satisfaction, learning, self-efficacy, and change in practice-which were rated (out of 5) by care providers from health and disability service sectors, as well as additional reflection measures about innovations to the program. Qualitative feedback from open-text responses from participants were analyzed using modified manifest content analysis.

RESULTS

A total of 104 care providers from health and disability service sectors participated in the program. High levels of engagement (81 participants per session on average) and satisfaction (overall satisfaction score: mean 4.31, SD 0.17) were observed. Self-efficacy (score improvement: 19.8%), support, and coping improved. Participants also rated the newly developed COVID-19 program and its innovative components highly. Open text feedback showed participants felt that the Extension for Community Healthcare Outcomes program expanded their knowledge and competency and created a sense of being part of a community of practice; provided value for the COVID-19 innovations; supported resource-sharing within and beyond program participants; and facilitated changes to participants' approaches to client care in practice and increased participants' confidence in supporting clients and families.

CONCLUSIONS

The Extension for Community Healthcare Outcomes program is an effective model for capacity-building programs with a shared-learning approach. Future iterations should include targeted evaluation of long-term outcomes such as staff burnout.

Patient Partners in Continuing Professional Development: Experience Developing an End-of-Life Care Program for Family Physicians

Involvement of patients in continuing professional development (CPD) is less developed than in health professional education at undergraduate or postgraduate levels. Although patients are sometimes involved in delivering CPD, they are less likely to be involved in education planning. At our institution, patients have sometimes acted as consultants in the design of CPD. The problem we address is how to engage patients as partners throughout the design process. We applied principles of authentic patient engagement and lessons learned from patient involvement in undergraduate health professional education to the design of CPD for family physicians. We created a partnership between the CPD Office and Patient and Community Partnership for Education, a unit with a history of patient involvement in the education of health professional students. Practices for meaningful involvement were identified through literature review, environmental scan, and interviewing key informants, including patients involved in health professional education at the university. These principles and practices were applied to the development of a CPD module on end-of-life care. Patient partners contributed new perspectives and some CPD providers reassessed components of their own practice as a result. Lessons learned include the need for stakeholder buy-in; mechanisms to identify those patients best able to contribute expertise; ways to facilitate involvement that work for both patients and CPD providers; the importance of feedback mechanisms to patient partners; and recognition for patient contributions. CPD offices should view integration of patient partners in program planning as an opportunity to engage in ongoing quality improvement.

"Time is a Great Teacher, but Unfortunately It Kills All Its Pupils": Insights from Psychiatric Service User Engagement

In this Foundations article, the authors reflect on the meaning of time through their past work creating novel roles for psychiatric service users to be involved in the education of health professions trainees and faculty. Inspired by music composer Hector Berlioz, the authors explore and critique the ableist, chrononormative temporalities of academia, and medical education. The authors introduce the conception of crip time from critical disability studies and use it to reflect on their experiences of the different temporalities that people bring to service user engagement and other collaborative projects. "Crip time" can help challenge notions of pace and productivity to create a more inclusive space for teachers and learners in health professions education.

"It was great to break down the walls between patient and provider": liminality in a co-produced advisory course for psychiatry residents

Although rhetoric abounds about the importance of patient-, person- and relationship-centered approaches to health care, little is known about how to address the problem of dehumanization through medical and health professions education. One promising but under-theorized strategy is to co-produce education in collaboration with health service users. To this end, we co-produced a longitudinal course in psychiatry that paired people with lived experience of mental health challenges as advisors to fourth-year psychiatry residents at the University of Toronto. The goal of this study was to examine this novel, relationship-based course in order to understand co-produced health professions education more broadly. Using qualitative interviews with residents and advisors after the first iteration of the course, we explored how participants made meaning of the course and of what learning, if any, occurred, for whom and how. We found that the anthropological theory of liminality allowed us to understand participants' complex experiences and illuminated how this type of pedagogy may work to achieve its effects. Liminality also helped us understand why some participants resisted the course, and how we could more carefully think about co-produced, humanistic education and transformative learning.