Saturday, 8 July 2017

Co-delivered #meded with technology - a joint blog with @TrevorKet

There is a drive in healthcare education to use technology and involve patients and service users in teaching sessions. Combining these two important agendas, I collaborated with a healthcare sciences lecturer, Trevor Kettle (@TrevorKet). to co-deliver two teaching sessions using the Meetoo app (and Skype). This a blog of two halves, with my reflections and Trevor's reflections (so do make sure you read both bits!)

These were students on two different courses at the Faculty of Health Sciences at Southampton University – both post-graduate, qualified health and social care professionals. The sessions were both 1.5 hours, and the first was co-delivered in person, while the second was co-delivered with Trevor Kettle in the room, and me Skyping in. 

The Meetoo App is a platform for real-time polling and discussion that allows students to share their thoughts and reflections, opinions and ask questions.

This blog is a collection of reflections on these experiences. These are twofold:
-       the process of using technology and collaborative teaching as a process to educate
-       the content of the conversation we had with the students.

Underpinning all of this was a strong equal partnership to co-produce the teaching sessions, the content and process between Trevor Kettle and myself – for which I am very grateful. Far from being onerous, this collaboration to coproduce the two teaching sessions required only a preliminary Skype meeting of about an hour and one or two iterations of the PowerPoint slides being shared via email. We had a short reflective debrief afterwards. Trevor’s perspective on it all in included below...

N.B. This isn’t formal research, so the data from the polls isn’t definitive but interesting none the less!

Establishing an understanding

Both sessions started with open-ended questions about the students thoughts and understanding of patient and public involvement. Whilst there was empathy with what patients, service users and carers might experience when receiving care, the majority of responses showed that their thinking on this subject was limited to people being involved directly in the care that the professionals were providing, rather than people influencing care provision at strategic level. When professionals were wearing their ‘care provider’ hat, involvement seemed to come naturally to them, but it wasn’t initially transferable to when the professionals were wearing their ‘leadership or management or strategic’ hats. A&E was the example raised in both sessions that highlighted this. In an emergency setting, a patients’ involvement in their own care is clearly limited, but people who have used A&E can be involved in planning patient pathways through A&E for example, which is at a strategic level.

This is reflected in two polls that were done in the first teaching session:

Who had heard of PPI before?
16.67% Yes, I am really familiar with it
53.33% Yes, I think so but don’t really know much about it
30% No, not heard of it before

Who sees involving and engaging patients and carers in partnerships as part of their role?
Yes, certainly, 54.57%
Yes to a degree, 46.43%
No 0%

And a third poll, in the second session:
How important do you think PPI is for research and service improvement?
Very important
Somewhat important
Not really important
Not important at all

This suggests that in these sessions, there was a basic concept and understanding of the importance of involving people, but a degree of confusion or lack of confidence about what that means in practice. This was clear through some of the very enlightening questions that were later asked through MeeToo.

Questions and points of discussion

The MeeToo app allowed for questions that were very honest and quite hard-hitting, and allowed exploration of some of the most sensitive aspects of PPI.

The issue of motivation and bias was raised multiple times, as it feels like something the students are concerned about. Understandably, these are issues that important for their professional regulation.

What are the intentions of those involved in [PPI]? it always positive? Constructive?

[Their] agenda clouded by previous treatments?

Whilst I believe that patient/public interaction is important, there is the risk that there is a strong bias based upon experience and belief that may have the 'stronger voice'.  Obviously, there may be the same bias amongst the 'professionals'. However, those professionals may have a better ability to see the other view based upon their own academic learning and previous research experiences.

Does paying participates not create bias as well? Participating only to get paid?

The intentions of individuals getting involved can be very important in determining how they find the experience of involvement. Good recruitment, role explanation and expectation management can help with this. The payment question was interesting, as clinicians are often paid for additional roles, and the payment is actually very low in real terms, as the work is very sporadic. Again, recruitment processes can clarify this. It did prove a good opportunity to emphasize the importance of meaningfully valuing contributions from patients, carers and service users through different models of reciprocity. The bias of previous experiences was fascinating, as using previous experiences is what clinicians do as they become more senior to inform their practice. The key difference was that patients and carers might not have the academic and professional rigor to balance that. This is where ongoing support and debriefing from sessions and meetings can be important for patients involved, so they can reflect on their own processing of experiences. The conversations that people have when they are involved are often at a more general level of service improvement, research or education, and should be suitably facilitated so this doesn’t become an issue.

I’d feel awkward if not able to meet their requirements… Promise the world, not delivering it!

Faith that the organisation will support the input and feedback and allow involvement....I don't believe this exists therefore difficult to fully engage in PPI as feels a little fraudulent if cant act with best intentions

PPI can be difficult on the front line due to lack of resources and time. We want to do it!

These were both positive remarks, showing that the students appreciated how important the experience for the individual involved is, but highlights lack of confidence and support they receive in order to deliver that.

We have strategic knowledge which aids decision-making, service users do not. They may have great ideas for change management but financially and realistically we cannot provide.

Representatives aren't necessarily representative

No discussion on PPI would be complete without the representation debate, where we want people to be representative of an average patient, but bemoan their lack of greater understanding of the NHS. Many patients and carers and service users are interested in getting involved in PPI because they have a capacity for strategic thinking. Even if that isn’t obvious, the fresh perspective they bring can greatly aid decision making too. Part of the conversation is for the professionals at the table to be open and honest about the boundaries so there is shared understanding.  One student described this well on an post:
“Sometimes patient expectations can be unrealistic. The partnership should encourage a common understanding on both sides of the spectrum. I think only then we can create real solutions.”

Highlighting their understanding

There were some very good quotes from the students that helped us see what PPI means from their perspective…

Often organisations use [PPI] as tick box through easy methods such as patient survey.... so they look good that they appear to have done it but often find in reality feedback is ignored. Definite room for improvement!

Axe to grind people are often only around short term the true transformational patient leaders remain long term

We use [PPI] to enhance , improve and shape our services :)
It is striking that these students acknowledge imperfections in the system and the room for improvement and feel the potential in this approach, but it is challenging and they feel the pressure to do this  in a meaningful and appropriate way, while being unsupported.

The added value of the MeeToo app

Across the two sessions, there was an average of 90 posts per session, and several polls. There was a very high level of engagement with the app, and the feedback was overwhelming positive. The key points the students made about the benefits of the app in the session were:
-       Helpful if not someone who is comfortable speaking out in class
-       Interesting to hear more of what others think
-       Good for questions that might be ‘silly’
-       Gauge how others are feeling through polls
-       Useful to share links to websites and resources discussed
-       Helped the conversation stay honest
-       Anonymous comments
-       Good balance of face to face and technology

The only point for consideration in the future is about the challenge of listening to the discussion and following questions on the app. It might be that a follow-up session via the app could allow for further exploration of other questions not answered, and allow students time to process other questions while focusing on the discussion at the time in the session.

The graphs were very visual and normalized how they felt about PPI.

Being able to add polling questions enabled us to respond to the direction of conversation in the room and ask questions in a non-confrontational way to test the students approaches.

From a delivery perspective, it made the preparation easier as discussions could take care of themselves and slides needed to be simplified to just the key points of models to refer to in discussion.

PPI Co-delivery
As a non-academic ‘lay’ educator, these sessions felt very comfortable, for a range of reasons.

It was a very easy platform to use, and enable me to pick questions I felt most comfortable answering and that were the most important. This was real time ‘patient’ influence of the teaching agenda in collaboration with students!

It changed the dynamic from a lecturer knows best preaching to students to a more equal relationship of mutual interest and appreciation. This felt important as it directly models the behavior shift central to person-centred care and patient partnerships at all levels.

It enabled the student to ask questions of my experience comfortably, which meant they were acknowledging the assets I brought as a patient, and allowed me to acknowledge tier assets by hearing their experiences, again modeling an assets based approach which they might be unfamiliar with in a safe way.

Trevor’s Reflections…

I am a full time academic working in the Faculty of Health Sciences, university of Southampton. I have had the pleasure of working in partnership with Anya on a number of occasions in different ways, particular on jointly delivered teaching sessions. Anya has explained previously how we have begun to work with a new audience participation system called ‘Meetoo which has in my opinion enabled students to be connected with PPI in the lecture room to a much richer degree than has been possible up to now. Traditionally, in education we have used the tried and tested ‘raise your hand if you have a question’ format to allow students to communicate with the speaker. This can be successful in some contexts although it is easy to fall into the illusion that you are giving full opportunity to all students to ask questions and express their views. This is not so. Some students can be anxious about asking questions on such a public stage as they can perceive to be judged by their fellow students and also by the lecturer in case they are criticised for asking a ‘silly’ question. This usually results in the same few more confident students asking questions and giving comments. Meetoo (and other similar systems) offers the opportunity for ALL students to use web-based devices (Smartphones, etc) to send text questions/comments directly, in real-time, to the session presenter completely anonymously.  If a patient expert is leading the session, they will receive the questions on their own device and can choose the questions they would like to answer and comment on. All users see all questions. An added feature is the students can ‘like’ each other’s questions and the patient can order the comments in order of ‘most likes’, very useful if a large number of questions are received and there is not time to answer all. However, all comments can be downloaded after the session to be answered via text if required.

This system can be enhanced further by utilising Skype as a way of connecting patients geographically distant from the university campus. I have worked with Anya on developing this now to a fine art! In order to eliminate travel time and expense, Anya has more than once skyped her presence into the lecture room directly from her home location. By using Meetoo on her tablet device, next to her computer, she has access to all student comments as they are typed by the students. She is therefore have control over which questions to answer as explained previously.

What implications are there for PPI in healthcare education?  Combining technology in creative ways to enhance and enable a deeper level of patient involvement within a lecture environment can enhance a deeper learning within students, in my opinion. This have implications however to how academia interfaces with patients. My relationship with Anya is based on mutual trust, partnership and collaboration. I never consider myself to have a higher or more important knowledge level, even though I have a list of professional and academic qualifications. As a patient leader, I fully respect the experience and knowledge Anya brings to our projects. We are equals. I bring another kind of knowledge which includes teaching experience that enables me to construct learning environments described above that enhance and enable a deeper level of engagement between patients and learners.

Patient involvement in healthcare education is here to stay. As educators, we must move away from the model of wheeling a patient onto the lecture stage to ‘tell their story’ and be metaphorically ‘prodded’ by students. Using technology we can enhance the ability of patient leaders such as Anya to question and ask students to think about the issues that matter to patients and to take PPI into more strategic levels where real change can occur.  I want to thank Anya for her commitment to being involved with our student’s education and look forward to many more collaborations.


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