Service user involvement in teaching and learning: student nurse perspectives

Abstract

Background

Service user involvement in educating healthcare professionals in higher education can help student nurses develop a compassionate approach to care practice. This article explains one university’s initiative, the Patient as Coach Team (PaCT), and presents evaluation results from phase 1. The PaCT strategy involved a service user-led session with student nurses, in small groups, sharing experiences of care from a service user perspective.

Aim

Our aim was to evaluate nursing students’ views of the PaCT session, involving service users in their teaching and learning.

Design

Survey.

Method

Structured questionnaires with a free-text box were completed by student nurses (n = 321). Structured question responses were analysed manually and free-text data thematically. Data collection took place from June 2016 to June 2017.

Results

There were very positive responses to the survey questions, with students perceiving a positive impact on their learning. Five themes emerged from the students’ free-text responses: ‘Usefulness of the session’, ‘Seeing patients’ perspectives’, ‘Inspiring and motivating session’, ‘Good discussions with patient coach’ and ‘Overall views about the PaCT session’.

Conclusion

The PaCT session provides a valid learning strategy, utilising coaching as a technique to enable student nurses to learn from service users’ experiences and perspectives of care. In addition, it contributes to students’ reflective practice about their individual professional practice in care settings.

Keywords

education evaluation patient as coach team service user involvement student nurse

Introduction

Service user involvement (SUI) has been regarded as important across health programmes in Higher Education (HE) (Higher Education Academy, 2013; Nursing and Midwifery Council, 2010, 2016), with recognition of the contribution service users can make to the education of health professionals (Irvin et al., 2015). SUI is now mandated as a main requirement by government and professional bodies (Department of Health 2012; Rhodes, 2012).

The SUI initiative allows people who have experienced health and social care services to be involved in HE degree programmes (Scammel et al., 2015). There is a clear rationale within SUI policy of ‘doing with’ patients (Department of Health, 2015). This has occurred as a result of service users’ concerns regarding the importance for healthcare professionals to understand service users’ needs. Hence, there have been various research studies exploring the principles and process of SUI in student nurse education (O’Donnell and Gormley, 2013; Terry, 2013; Tremayne et al., 2014). These policies and previous research drove the development of the Patient as Coach Team (PaCT) strategy as a core part of the nursing education programme at the University of Bolton.

Given the importance of SUI initiatives to enact long-term change in the delivery of health and social care in the UK, it is mandatory for educators to embed SUI in the teaching and learning curriculum. In turn, it is important that there is an understanding of what students learn through interactions with service users, in an educational setting, and how such learning contributes to their professional development.

The PaCT initiative was developed to create critical learning for student nurses, from real-life experiences of service users (Bramley and Matiti, 2014). The Patient Coach (PC) approach to student learning was based on the premise that real-life experiences of service users can facilitate learning for student nurses. Ranjan (1992) suggested that experience is a form of knowledge, thus reflecting on service users’ experiences will help students to be more aware of their practice during their practice placements and prepare them for future practice.

The PaCT session was developed around the 6Cs of nursing (Department of Health, 2012), which are identified as care, compassion, competence, courage, commitment and communication (see Table 1). Two PaCT sessions are embedded per academic year of the 3-year adult nursing degree. In stage 1 of the PaCT session, service users are invited to lead a workshop session. The six themes provide a focus of discussion during the workshops as well as continuity of learning during their academic studies. In stage 2, student nurses are required to complete a reflective learning worksheet to be included as part of their personal development portfolios (PDP). The reflective learning worksheets have not been evaluated as part of the research presented here.

Table 1.

The six themes that make up the Patient as Coach Team sessions.

1. Compassion and empathy

2. Dignity and confidentiality

3. Trust and honesty

4. Collaboration and communication

5. Courage and commitment

6. Competence and expressing emotion

Literature review

Literature evidence suggests that there is an increased implementation of SUI in HE (Blackhall et al., 2012; Terry, 2013; Tew et al., 2004). This is reflected in the Nursing and Midwifery Council (NMC) guidance on both maintaining the impetus of SUI in nursing education (NMC 2010, 2016) and requiring evidence in courses (NMC, 2011). As service users are regarded as experts through experience (Muir and Laxton, 2012), their involvement can assist in helping students develop skills that will contribute to quality of patient care (Tremayne, et al., 2014)

The purpose of SUI in education, according to Tew et al. (2004), is to be involved across all spectrums of involvement, from consulting to partnership. This would mean involving service users in recruitment of students, as well as curriculum design, delivery and assessment. Having this type of full involvement in education demonstrates further the need to understand the impact of SUI.

According to Scammell et al.’s (2015) systematic review of SUI in pre-registration nursing programmes, several research studies have focused on the perceptions of participants, asking what benefits they have gained. The authors suggested that further research exploring the impact SUI has on student learning is needed.

There has been a focus of what constitutes SUI in education (Rhodes, 2012). Following the inquiry into the Mid-Staffordshire NHS Trust, the Francis report highlighted the impetus for SUI in student learning as it reinforced the importance of patient-centred care (Francis, 2013). The report called for nurse education to focus on the 6Cs in order to encourage the development of values from initial education.

According to Tobbell et al. (2018), the pedagogy of SUI can be explained in terms of a learning theory, that is, the socio-cultural theory. This type of learning is said to emerge as a result of the interactions about a person within a context (Skilton, 2011). Such learning could be facilitated through mentoring and coaching (Brockbank and McGill, 2006), where student interactions with people who have personal experience of care services can help students construct a well-rounded view of their professional practice when caring for service users. Creating such interactions in a class setting and not only in practice placement areas establishes the importance of linking theory and practice. According to Brockbank and McGill (2006), coaching as a learning style fosters critical reflection in such a way that students can aspire to a desired behaviour (Tobbell et al., 2018).

This study explored nursing students’ perceptions of SUI through the use of PaCT during nursing education, with the key focus being coaching style of learning. Creating a learning environment, where social meanings across the 6Cs are discussed in an open and honest format, could facilitate a form of reflective learning for transformation (Brockbank and McGill, 2006). This could enable students to develop a competent and well-integrated professional identity (Le Var, 2002), as compassionate carers in practice.

Methodology

Aim

This study aimed to evaluate nursing students’ views of the PaCT session, through which service users were involved in their teaching and learning experience.

Design

The study design was a survey, using a structured questionnaire with a free-text comment box.

Participants

The study involved adult nursing and nursing associate students studying at the University of Bolton, UK. All 321 students who took part in the 10 PaCT sessions between June 2016 and June 2017 completed an individual questionnaire. This was a positive response rate from the students, which could have been as a result of adopting a convenience sampling strategy, as the service users invited their groups of students to complete the questionnaire following the session.

Methods

Following the PaCT workshop, a structured questionnaire (see Supplementary material) was distributed to the students to evaluate the usefulness of the session. The questionnaire (Table 2) included 10 close-ended questions, using 5 category responses: (1) non-applicable, (2) strongly disagree, (3) disagree, (4) agree and (5) strongly agree. In addition, a free-text box was used to further ascertain students’ views of their learning.

Members from the service user group reviewed the questionnaire to ensure that the questions would capture students’ opinions. The questionnaire responses were manually collated.

Of the 321 completed questionnaires, 170 (53%) students wrote comments in the free-text box. This was low in comparison to the 100% response rate from the questionnaire. This outcome may be as a result of the questionnaire format, which also captured individual opinions.

The free-text comments were analysed thematically (Braun and Clarke, 2006). Themes were identified by the first author and then examined by the second author to verify the meanings ascribed. The themes offer transparency, as they allowed participants’ voices to be heard through the direct quotes reported.

Results

It is clear from the results (Table 2) that students found the service user sessions a positive learning experience, with few negative feedbacks. The free-text comments were also overwhelmingly positive. Following the thematic analysis, the comments were grouped into five themes (see Table 3).

Table 2.

Student responses to the structured questions.

		Strongly disagree n (%)	Disagree n (%)	Agree n (%)	Strongly agree n (%)
1	The discussions were relevant			66 (21%)	254 (79%)
2	I was encouraged to participate	1 (0.3%)	1 (0.3%)	56 (17%)	263 (82%)
3	The service user was helpful		2 (1%)	48 (15%)	270 (84%)
4	The session assisted me in learning		9 (3%)	64 (20%)	248 (77%)
5	The session length was appropriate	1 (0.3%)	4 (1.3%)	71 (22%)	243 (76%)
6	The service user created a comfortable learning environment		1 (0.3%)	46 (14%)	274 (85.4%)
7	The service user displayed confidence in the subject matter		1 (0.3%)	41 (13%)	279 (87%)
8	The service user promoted critical thinking and self-directed learning		1 (0.3%)	68 (21%)	252 (79%)
9	I will apply what I have learnt to my future practice		3 (1%)	47 (15%)	271 (84%)
10	Overall, I was satisfied with the PaCT session		2 (1%)	48 (15%)	271 (84%)

Table 3.

Five themes from free-text comments box.

Usefulness of session

Seeing the patient’s perspective

Inspiring and motivating session

Good discussions with Patient Coach

Overall views about the PaCT session

Themes

Usefulness of session

In response to the first structured question, ‘the discussions were relevant’, students who completed a free-text comment expressed how useful the PaCT session was. Students commented:

extremely helpful; enjoyed; interesting!

The most useful session yet!

I find the session very educative, … interactive.

The students felt that the sessions helped them to reflect on their student nurse education and contemplate their future practice. Commonly expressed comments were:

relevant for my student journey

I am able to take what I have learnt into future placements.

It has given me a lot to reflect upon and has really helped me inform my practise.

Personally, I feel this experience has been essential as a student nurse and has enabled me to think differently about the care I give to my patients.

It enables you to think about your approach to nursing and what you can do to make a difference … all this knowledge has a positive effect on caring for patients.

The students also appreciated having the time to listen to the service users, the time to ask questions and also receiving feedback from the service users.

I found it useful to listen to other people’s experiences. It will help me in future practice.

It will help in future practice, when out in practice, good getting feedback off others.

Learning from the service user point of view is very relevant to my studies.

There was a clear recognition among participants that the PaCT session was more than just a taught academic session. It was a session that aided their anticipation of their future career in nursing practice.

Seeing the patient’s perspective

The students felt that the sessions helped them to empathise with the patients and to see the patients’ perspectives. This reinforced their power of reflection, in putting themselves in the patient’s place, as they listened to the unique perspectives of the service users. This emerged strongly from students:

really makes you see things from a patient’s perspective

interesting to listen to a service user perspective

very informational, looking at situations from other point of view

Excellent patient coach experience, fantastic seeing things from another perspective.

Eye opening to see from other person’s views and experiences.

The students could perceive the value of SUI in their nursing education. This direct focus on patients’ experience provided students with first-hand insights into a patient’s care journey. They were able to embrace the patient’s perspective, as explained by these student comments:

how it feels to be a patient

opened my eyes and given a good insight into understanding people better and colleagues

beneficial to learn people’s different experience as both staff and patients and the different views on how to handle a situation

I enjoy listening to others point of views and reflecting. Listening to the patient coaches and their experiences makes you see their side.

Inspiring and motivating session

Many of the students found that the PaCT session had a stimulating impact on their learning. This strong impression was brought about by the open and honest shared patient experiences that the student nurses had the opportunity of discussing with the service users.

It was really uplifting.

The service users were helpful to encourage us to be open and honest about placement areas experiences …

very thought provoking, inspiring, interesting subject matter

Very inspirational … on patient experiences and building up relationships.

Of particular interest were student comments that demonstrated that the PaCT session had positively stirred their learning and practice ambition and will impact their direct behaviour in future efforts in care settings. There was this perceived determination to achieve a goal that will drive their professional development and improvement when in placement or work situations that could be perceived as challenging to student nurses. Students commented:

I have gained even more courage plus commitment through the interesting discussions that have taken place.

This session helped me tremendously, felt as though I had received courage raise concerns.

gave the confidence to do what we do

The session built up my confidence in regard to compassion.

Good discussions with PC

The discussions the students had with the service users showed that they were on an experiential learning journey with the service users. It was evident that the discussions between service users and the students came into their own, in a relaxed atmosphere but considering various unique experiences of care, creating new insights for the students. The students found this helpful:

evoked some good discussions

an engaging friendly session, in-depth discussions, assists in developing skills

Very enlightening, enjoyed … self-awareness talk.

Service user wonderful, really pleasant and easy to talk to, felt at ease.

The small group sizes for the session were also identified as an aid to the good discussions that ensued and the students’ learning experience:

I found it enjoyable discussing our experiences in a small group.

Different way of learning, felt comfortable talking, given the chance to talk.

Students also appreciated the opportunity to learn from their peers’ experience in placement, gaining added understanding and deeper learning from their peers:

a good opportunity for us to discuss with one another

I learnt a lot of things from each other

A student’s comment that particularly summed up the status of the PaCT sessions as a beneficial initiative to nursing education was summed up below as:

I feel that it was an enjoyable session. Getting to know other people’s experiences as well as talk about your own was a positive experience. I would enjoy participating in a session like this again.

Overall views about the PaCT session

Students found the PaCT session a valuable way of learning that provided them with new insights into SUI in nursing education. Comments included:

An invaluable … amazing experience

Amazing session … should be incorporated in every nursing course. Learnt a lot!

It was also very clear that there is no substitute for hearing first hand from the direct patient experience and perspective of care. It enhanced student learning, as stated by some students:

Transferable to real life situations, like the role play, should be done more frequently.

I enjoyed the session and it helped me to reflect.

This is the most integrating and interesting session ever had.

necessary for nursing

I feel like this has been one of my favourite experiences ever. More than satisfied.

Students recognised the PaCT session as a very powerful educational initiative that helped them develop greater insight and understanding that will be beneficial throughout their nursing education. To highlight its worth, students expressed that:

Session needs to be longer.

I think the session could have been a bit longer.

Discussion

Overall, the introduction of the PaCT session was perceived very positively by students, who considered it had made a valuable contribution to their learning. Previous studies have also found that students evaluate SUI in education positively (Blackhall et al., 2012; Morgan and Jones, 2009; O’Donnell and Gormley, 2013; Repper and Breeze, 2007).

It is important to note that the students felt comfortable with service users and appreciated that they were encouraged to participate in open discussions about real experiences between students and service users, thus supporting previous work (Repper and Breeze, 2007). This key factor highlights the value of conversational learning. According to Alred et al.’s (1998) research on learning in conversation, falling into a conversation with a stranger could facilitate a more expansive talk than when in a familiar context. A familiar learning style, as referred to by Alred et al. (1998), is the ‘one-linear learning’ environment, such as a conversation in a classroom led by the teacher, passing knowledge or information to students.

The PC session arranged in an informal, conversational style of shared experiences between students and service users improved profoundly the way the students engaged with the discussions during the session. The experiential style of teaching and learning that the PCs held in conversations with the students made learning something ‘personal’ to the students, peculiar to them as individuals (Laurillard, 2002). The students were learning from the same PC, on the same subject; however, they personalised their learning experience, arriving at an individual positive experience of how their learning will contribute to their future practice.

The inspiration and motivation that the students achieved from the PC sessions suggested that the students were directly touched with the realities that the PC shared, adding to their knowledge on the various topics considered. According to Tate (1992), this direct encounter with the realities of service users’ lived experience of care ignited in the students a means to a greater goal, that of developing their professional practice, during their nursing education. Through the service users’ experiences, students could perceive the real-world implications (Perrin, 2014) of the topics discussed. This allowed them to self-reflect about real life professional practice and values on various aspects of patient care. This, according to Clouder (2009), is associated with empowerment, resulting in an increased desire to keep learning.

According to Law (2013), positive psychology is underpinned by coaching as a technique and learning theory. The coaching format of the PC initiative allowed the students to ‘see’ the service user. It was concerned about the person, rather than the mechanical process of care. Thus, the dialogue that ensued between the PC and the students fostered a relationship that highlighted the importance of key qualities in caring such as compassion (Baughan and Smith, 2013).

Kolb’s (1984) learning (e.g. coaching) process is grounded in experience, when learners and coach interact. The PC shared experiences created a reflective learning environment for the students. Thus, students were able to realise the importance of their professional training as a nurse and they had a greater appreciation of learning from experience. This confirms Law’s (2013) view that self-development ensues as a natural outcome of being coached in a way such that it influences the personal learning and helps individual learners perceive future possibilities of further learning.

Overall, students appreciated the value of being coached by service users to learn, and in a meaningful way (McCutcheon and Gormley, 2014). This supports the research aim to evaluate nursing students’ views of the PaCT initiative, to evidence the perceived benefits and to find out how it has impacted on nursing students' learning. In this case the majority of students viewed the PaCT session positively and as an initiative that should be fully embedded as part of their course.

Limitations of the study

We recognise that the research reported here represents only students’ initial views. Therefore, further research exploring the views of service users about the PaCT strategy is necessary in order for a further comprehensive evaluative research to explore the process currently being adopted within the PaCT initiative. This is being planned as a second stage of the evaluation. However, the positive feedback gathered from this evaluation has to some extent identified that the coaching learning style adopted as the driver of the PaCT strategy directly influences valuable learning experiences for students.

The six themes that make up the PaCT sessions are generic topics. Therefore, service users’ perceptions as shared within discussions with students might only have been particular to them as individuals and not similar to those of all other service users elsewhere. However, they still provided a valuable opportunity for the students to have the open and honest discussion. The results showed that the learning was overall beneficial to the students.

The reflective learning worksheet, mentioned in the introduction, completed by the students as part of their PDP, could have been analysed for further evidence of how the coaching initiative has helped to individually influence the students’ independent and self-reflective learning for future practice. This requires further investigation to explore the impact of completing the reflective worksheet in relation to students’ personal development around professional practice.

Conclusions

The PaCT sessions can be employed as a learning strategy to enable students to develop individual reflective practice through lessons learnt from the real experiences and perspectives of care shared by service users, for their individual professional practice in care settings. Evaluative plans can be adapted, depending on the learning setting, to examine students’ perceptions of SUI in their learning.

Continuous evaluation of SUI in education will help develop insightful ways of adopting and further embedding coaching as a learning process that facilitates positive self-reflective learning in the education of student nurses.

Key points for policy, practice and/or research

Service users have the valuable potential to coach and impact student nurses’ professional practice.

SUI should be considered across all aspects of nursing education.

There needs to be continuing research with student nurses about their experience of learning through conversations with service users.

Future studies could examine how SUI initiatives meet the learning needs of students in an integrated way, linking theory with practice.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethics

The faculty’s chair for ethics was consulted about the publication of the data, and as all data were anonymised such that none of the students or service users can be identified, ethical approval was not required. The PC sessions are attached to modules. On completion of the module, a university module evaluation is to be completed. Similarly, the PC evaluation mirrored the university’s module-evaluation form, which the students completed in confidence and in a completely anonymised format. Students were fully aware of the module-evaluation process and that the PC questionnaire was a voluntary exercise.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Bimpe Kuti (BSc, MPH, FHEA) is a Senior Lecturer in Health, teaching both undergraduate and postgraduate programmes, and is the Service User Involvement Lead. At present, Bimpe is completing her PhD, which explores the dynamics of service user participation in healthcare. She has also held the position as a Clinical Services Development Manager working closely with GP practices and a local CCG in developing patient engagement. Her research interests include health service improvement, embedding service user involvement in their local healthcare services, public health, and student learning and experience.

Trish Houghton (EN, RN, BA, PGCE, MSc, SFHEA, PhD) qualiﬁed as a registered nurse. Her current role is Head of School of Nursing and Midwifery at Bolton. She has worked in partnership with National Health Service Trust colleagues in order to meet workforce needs. In 2015 she developed and implemented the first non-commissioned nursing programme in England. It is from this that she has attained a PhD in Professional Practice in 2017. Her research interests are nurse education, mentorship, supporting learning and assessment in practice, work-based learning and evidenced-based practice.

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