Redesigning mental health services: lessons on user involvement from the Mental Health Collaborative

Barriers and facilitators of meaningful patient participation at the collective level in healthcare organizations: A systematic review

INTRODUCTION

Collective patient participation, such as patient participation in policy making, has become increasingly important to achieve high-quality care. However, there is little knowledge on how to let patients participate in a meaningful manner at this level. The aim of this systematic literature review was to provide an overview of barriers, facilitators, and associated impact of collective patient participation.

METHODS

PubMed and EMBASE were searched until May 2023 for studies that evaluated collective patient participation. Study characteristics, methods for patient participation, barriers and facilitators, and impact (if measured) of patient participation were extracted from the articles.

RESULTS

We included 59 articles. Identified barriers and facilitators of collective patient participation were grouped into five categories: (1) preconditions for patient participation, (2) strategy for patient participation, (3) preparation of patients and staff for patient participation, (4) support for patients and staff during patient participation, and (5) evaluation of patient participation. Impact of patient participation was reported in 34 included studies at three levels: quality of care and research, the team and organization, and the participants themselves. Only three studies reported quantitative outcomes.

CONCLUSION

Interestingly, similar challenges were experienced during a period of twenty years, indicating that little progress has been made in structuring patient participation. Our overview of barriers and facilitators will therefore help to improve and structure collective patient participation.

Evaluating quality improvement at scale: A pilot study on routine reporting for executive board governance in a UK National Health Service organisation

BACKGROUND

Quality improvement (QI) in healthcare is a cultural transformation process. We explored how routine reporting could be developed to aid visibility of the process for QI governance.

METHOD

A retrospective evaluation of QI projects in a large healthcare organisation was conducted. We used an online survey so that the data accrual process resembled routine reporting to help identify implementation challenges. A purposive sample of QI projects was targeted to maximise contrast between projects that were or were not successful as determined by the resident QI team. To hone strategic focus in what should be reported, we also compared factors that might affect project outcomes.

RESULTS

Out of 52 QI projects, 10 led to a change in routine practice ('adoption'). Details of project outcomes were limited. Project team outcomes, indicative of capacity building, were not systematically documented. Service user involvement, quality of measurement plan, fidelity of plan-do-study-act (PDSA) cycles had a major impact on adoption.

CONCLUSION

Designing a routine reporting framework requires an iterative process to navigate data accrual demands. A retrospective evaluation, as in this study, can yield empirical insights to support development of QI governance, thereby honing the implementation science of QI in a healthcare organisation.

Consumers' and health providers' views and perceptions of partnering to improve health services design, delivery and evaluation: a co-produced qualitative evidence synthesis

BACKGROUND

Partnering with consumers in the planning, delivery and evaluation of health services is an essential component of person-centred care. There are many ways to partner with consumers to improve health services, including formal group partnerships (such as committees, boards or steering groups). However, consumers' and health providers' views and experiences of formal group partnerships remain unclear. In this qualitative evidence synthesis (QES), we focus specifically on formal group partnerships where health providers and consumers share decision-making about planning, delivering and/or evaluating health services. Formal group partnerships were selected because they are widely used throughout the world to improve person-centred care. For the purposes of this QES, the term 'consumer' refers to a person who is a patient, carer or community member who brings their perspective to health service partnerships. 'Health provider' refers to a person with a health policy, management, administrative or clinical role who participates in formal partnerships in an advisory or representative capacity. This QES was co-produced with a Stakeholder Panel of consumers and health providers. The QES was undertaken concurrently with a Cochrane intervention review entitled Effects of consumers and health providers working in partnership on health services planning, delivery and evaluation.

OBJECTIVES

1. To synthesise the views and experiences of consumers and health providers of formal partnership approaches that aimed to improve planning, delivery or evaluation of health services. 2. To identify best practice principles for formal partnership approaches in health services by understanding consumers' and health providers' views and experiences.

SEARCH METHODS

We searched MEDLINE, Embase, PsycINFO and CINAHL for studies published between January 2000 and October 2018. We also searched grey literature sources including websites of relevant research and policy organisations involved in promoting person-centred care.

SELECTION CRITERIA

We included qualitative studies that explored consumers' and health providers' perceptions and experiences of partnering in formal group formats to improve the planning, delivery or evaluation of health services.

DATA COLLECTION AND ANALYSIS

Following completion of abstract and full-text screening, we used purposive sampling to select a sample of eligible studies that covered a range of pre-defined criteria, including rich data, range of countries and country income level, settings, participants, and types of partnership activities. A Framework Synthesis approach was used to synthesise the findings of the sample. We appraised the quality of each study using the CASP (Critical Appraisal Skill Program) tool. We assessed our confidence in the findings using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach. The Stakeholder Panel was involved in each stage of the review from development of the protocol to development of the best practice principles.

MAIN RESULTS

We found 182 studies that were eligible for inclusion. From this group, we selected 33 studies to include in the final synthesis. These studies came from a wide range of countries including 28 from high-income countries and five from low- or middle-income countries (LMICs). Each of the studies included the experiences and views of consumers and/or health providers of partnering in formal group formats. The results were divided into the following categories. Contextual factors influencing partnerships: government policy, policy implementation processes and funding, as well as the organisational context of the health service, could facilitate or impede partnering (moderate level of confidence). Consumer recruitment: consumer recruitment occurred in different ways and consumers managed the recruitment process in a minority of studies only (high level of confidence). Recruiting a range of consumers who were reflective of the clinic's demographic population was considered desirable, particularly by health providers (high level of confidence). Some health providers perceived that individual consumers' experiences were not generalisable to the broader population whereas consumers perceived it could be problematic to aim to represent a broad range of community views (high level of confidence). Partnership dynamics and processes: positive interpersonal dynamics between health providers and consumers facilitated partnerships (high level of confidence). However, formal meeting formats and lack of clarity about the consumer role could constrain consumers' involvement (high level of confidence). Health providers' professional status, technical knowledge and use of jargon were intimidating for some consumers (high level of confidence) and consumers could feel their experiential knowledge was not valued (moderate level of confidence). Consumers could also become frustrated when health providers dominated the meeting agenda (moderate level of confidence) and when they experienced token involvement, such as a lack of decision-making power (high level of confidence) Perceived impacts on partnership participants: partnering could affect health provider and consumer participants in both positive and negative ways (high level of confidence). Perceived impacts on health service planning, delivery and evaluation: partnering was perceived to improve the person-centredness of health service culture (high level of confidence), improve the built environment of the health service (high level of confidence), improve health service design and delivery e.g. facilitate 'out of hours' services or treatment closer to home (high level of confidence), enhance community ownership of health services, particularly in LMICs (moderate level of confidence), and improve consumer involvement in strategic decision-making, under certain conditions (moderate level of confidence). There was limited evidence suggesting partnering may improve health service evaluation (very low level of confidence). Best practice principles for formal partnering to promote person-centred care were developed from these findings. The principles were developed collaboratively with the Stakeholder Panel and included leadership and health service culture; diversity; equity; mutual respect; shared vision and regular communication; shared agendas and decision-making; influence and sustainability.

AUTHORS' CONCLUSIONS

Successful formal group partnerships with consumers require health providers to continually reflect and address power imbalances that may constrain consumers' participation. Such imbalances may be particularly acute in recruitment procedures, meeting structure and content and decision-making processes. Formal group partnerships were perceived to improve the physical environment of health services, the person-centredness of health service culture and health service design and delivery. Implementing the best practice principles may help to address power imbalances, strengthen formal partnering, improve the experiences of consumers and health providers and positively affect partnership outcomes.

Spreading a Strategy to Prevent Suicide After Psychiatric Hospitalization: Results of a Quality Improvement Spread Initiative

BACKGROUND

Suicide after psychiatric hospitalization is a major concern. Poor treatment engagement may contribute to risk. The World Health Organization Brief Intervention and Contact (BIC) Program is an evidence-based practice shown to prevent suicide after psychiatric discharge in international trials. There have been no efforts to implement BIC into routine practice in US populations.

METHODS

The authors conducted a 12-month quality improvement (QI) collaborative at six US Department of Veterans Affairs (VA) medical centers serving a large rural population. Sites had low to moderate performance on a VA quality measure of mental health postdischarge care; a measure assessing the proportion of discharged patients who achieve the required number of visits ≤ 30 days. Sites received programmatic support to implement BIC locally. Implementation was assessed using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework.

RESULTS

Overall, teams had high participation in programmatic activities and enrolled 85% of eligible patients that they approached. Among 70 enrolled patients, 81.4% achieved the VA quality measure of mental health postdischarge care, suggesting good treatment engagement. On average, patients rated BIC as excellent. Team members agreed that BIC was easy to use, implementable, possible, and doable. Factors facilitating implementation included standardized operating procedures to standardize processes. Barriers included insufficient staffing and loss to follow-up. Most sites plan to continue to enroll patients and to expand BIC to other areas.

CONCLUSION

A QI collaborative can facilitate implementation of BIC in six VA facilities that provide inpatient psychiatric treatment. BIC may appeal to patients and providers and may improve treatment engagement.

How can we describe impact of adult patient participation in health-service development? A scoping review

OBJECTIVE

Patient participation represents a worldwide policy, but its impact lacks research. This study investigates impact of patient participation in health-service development by providing a comprehensive overview of how the literature describes it.

METHOD

A scoping review with a broad search strategy was conducted. The literature was examined for study characteristics, purpose for, approaches to and impact of patient participation. The data were analyzed using a thematic analysis.

RESULTS

The 34 included primary studies reported impacts of patient participation that were interpreted to constitute two categories: 1. The participatory process´ impact on involved patient representatives and health professionals, and the organization´s patient participation practice itself. 2. The participatory service development´s impact on the design and delivery of services regarding patients and health professionals, and the organization.

CONCLUSION

The literature describes a broad variation of impacts from health-service development, relevant for health professionals and patient representatives when initiating or participating in such processes. Our review provides an overview and discussion of these types of impact.

PRACTICE IMPLICATIONS

The findings can be of practical relevance to those aiming to develop services, quality indicators regarding effects of patient participation, or to further investigate aspects of participatory service development.

Consumer input into health care: Time for a new active and comprehensive model of consumer involvement

Background

To ensure the provision of patient‐centred health care, it is essential that consumers are actively involved in the process of determining and implementing health‐care quality improvements. However, common strategies used to involve consumers in quality improvements, such as consumer membership on committees and collection of patient feedback via surveys, are ineffective and have a number of limitations, including: limited representativeness; tokenism; a lack of reliable and valid patient feedback data; infrequent assessment of patient feedback; delays in acquiring feedback; and how collected feedback is used to drive health‐care improvements.

Objectives

We propose a new active model of consumer engagement that aims to overcome these limitations. This model involves the following: (i) the development of a new measure of consumer perceptions; (ii) low cost and frequent electronic data collection of patient views of quality improvements; (iii) efficient feedback to the health‐care decision makers; and (iv) active involvement of consumers that fosters power to influence health system changes.

Patients' involvement in improvement initiatives: a qualitative systematic review

BACKGROUND

Over the last 20 years, quality improvement in health has become an important strategy in health services in many countries. With the emphasis on quality health care, there has been a shift in social paradigms towards including service users in their own health on different levels. There is growing evidence in literature on the positive impact on health outcomes where patients are active participants in their personal care. There is however less information available on the broader influence of users on improvement in systems.

OBJECTIVES

The objective of this review was to identify the barriers and enablers to patients being involved in quality improvement efforts directed towards their own health care.

INCLUSION CRITERIA

This review considered studies that included adults and children of any age experiencing any health problem.The review considered studies that explored patient or user participation in quality improvement and the factors enabling and hindering this processThe qualitative component of this review considered studies that focused on qualitative data, including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research. Other texts such as opinion papers and reports were also considered.

SEARCH STRATEGY

The search strategy aimed to find both published and unpublished studies. A three-step search strategy was utilized in this review. The searches using all identified keywords and index terms included the databases PubMed, PsycINFO, Medline, Scopus, EBSCOhost and CINAHL.Qualitative, text and opinion papers were considered for inclusion in this review.Closely related concepts like community involvement, family involvement, patients' involvement in their own care (for example, in the case of shared decision making), and patient centeredness in the context of a consultation were excluded.

METHODOLOGICAL QUALITY

Qualitative and textual papers selected for retrieval were assessed by two independent reviewers for authenticity prior to inclusion in the review using the standardized critical appraisal instruments from the Joanna Briggs Institute.

DATA EXTRACTION

Qualitative and textual data were extracted from papers included in the review using the standardized data extraction tool from the Joanna Briggs Institute.

DATA SYNTHESIS

The above findings were pooled and through the identification of categories, a final meta-synthesis was formulated.

RESULTS

Two synthesized findings were created from the included papers. Firstly, there are barriers to patients' participation in quality improvement in health and in spite of policy support for user involvement in quality improvement, it is a difficult strategy to implement. The second synthesized finding was that there are enablers to patients' involvement in quality improvement: when patients are involved in quality improvement efforts in health care, there are innovative, often unexpected, outcomes at different levels of the process, and sustaining these efforts is possible with ongoing individual or group support.Five categories which supported the synthesized findings were created through the meta-aggregative process.

CONCLUSIONS

There are enablers and barriers to involving patients in quality improvement in health care that need to be considered when planning such interventions.Relationships and roles will need to be very clear from the outset. A developmental approach needs to be considered where support and training is part of the project. Where patients are truly engaged in service improvement, unexpected innovation occurs.There are many more reports and opinion papers published regarding this topic than there are rigorous research studies. This leaves the field open to the development of good methodological studies related to quality improvement and in particular to the participation of patients.

Encouraging user involvement in mental health services

This article summarises the current research evidence base on user involvement in mental health services from both policy and practical perspectives. We begin by examining the many meanings of the term ‘mental health service user’ and the policy imperatives for user involvement, to provide a context for later examples of good practice. We then discuss what is meant by ‘involvement’ and the reasons why user involvement is particularly important in mental health services. Finally, we describe some of the traditional barriers to involvement and a number of examples of positive practice across a range of different aspects of mental health service development and delivery.

Participation in mental healthcare: a qualitative meta-synthesis

Background

Facilitation of service user participation in the co-production of mental healthcare planning and service delivery is an integral component of contemporary mental health policy and clinical guidelines. However, many service users continue to experience exclusion from the planning of their care. This review synthesizes qualitative research about participation in mental healthcare and articulates essential processes that enable service user participation in mental health care.

Methods

Electronic databases were systematically searched. Studies were included if they were peer reviewed qualitative studies, published between 2000 and 2015, examining participation in mental health care. The Critical Appraisal Skills Program checklist was used to assess the quality of each included study. Constant comparison was used to identify similar constructs across several studies, which were then abstracted into thematic constructs.

Results

The synthesis resulted in the identification of six principal themes, which articulate key processes that facilitate service user participation in mental healthcare. These themes included: exercising influence; tokenism; sharing knowledge; lacking capacity; respect; and empathy.

Conclusions

This meta-synthesis demonstrates that service user participation in mental healthcare remains a policy aspiration, which generally has not been translated into clinical practice. The continued lack of impact on policy on the delivery of mental healthcare suggests that change may have to be community driven. Systemic service user advocacy groups could contribute critically to promoting authentic service user participation in the co-production of mental health services.

The impact of patient advisors on healthcare outcomes: a systematic review

BACKGROUND

Patient advisory councils are a way for healthcare organizations to promote patient engagement. Despite mandates to implement patient advisory councils through programs like the Patient-Centered Medical Home (PCMH), there is a paucity of data measuring the impact of patients functioning in advisory roles. Our objective is to investigate whether patient engagement in patient advisory councils is linked to improvements in clinical quality, patient safety or patient satisfaction.

METHODS

We searched PubMed, SCOPUS, CINAHL and Google Scholar for English language publications between November 2002 to August 2015, using a combination of "patient advisor" and "care outcomes" search terms. Article selection utilized dual screening facilitated by DistillerSR software, with group discussion to resolve discordance. Observational studies, randomized controlled trials, and case studies were included that described patients serving in an advisory role where primary outcomes were mentioned. Reference lists of included studies and grey literature searches were conducted. Qualitative thematic analysis was performed to synthesize results.

RESULTS

Database searching yielded 639 articles total after removing duplicates, with 129 articles meeting full text inclusion criteria. 32 articles were identified for final review, 16 of which were case studies. Advisory roles included patient advisory councils, ad-hoc patient committees, community advisory councils, experience-based co-design, and other. Four practice-based studies from one research group, involving community advisors in the design of public health interventions, found improved clinical outcomes. No prospective experimental studies assessed the impact of patient advisors on patient safety or patient satisfaction. One cluster-randomized RCT showed that patient advisors helped health care planning efforts identify priorities more aligned with the PCMH. Ten case studies reported anecdotal benefit to individual patient advisors.

CONCLUSION

Five included studies demonstrate promising methods for evaluating patient engagement in healthcare delivery and describe impacts on clinical outcomes and priority setting. Based on the case studies found, patient advisors tend to contribute to patient-facing services that may affect clinical care but are not easily evaluated. As clinics and hospitals implement patient advisory councils, rigorous evaluation of their programs is needed to support the expansion of system-level patient engagement.

TRIAL REGISTRATION

This systematic review was registered in the PROSPERO database of the University of York Centre for Reviews and Dissemination (ID: 2015: CRD42015030020 ).

Whose voices? Patient and public involvement in clinical commissioning

Aim

This paper aims to explore patient and public representation in a NHS clinical commissioning group and how this is experienced by staff and lay members involved.

Background

Patient and public involvement is believed to foster greater public representativeness in the development and delivery of health care services. However, there is widespread debate about what representation is or what it should be. Questions arise about the different constructions of representation and the representativeness of patients and the public in decision‐making structures and processes.

Design

Ethnographic, two‐phase study involving twenty‐four observations across two types of clinical commissioning group meetings with patient and public involvement, fourteen follow‐up interviews with NHS staff and lay members, and a focus group with five lay members.

Results

Perceptions of what constitutes legitimate representativeness varied between respondents, ranging from representing an individual patient experience to reaching large numbers of people. Consistent with previous studies, there was a lack of clarity about the role of lay members in the work of the clinical commissioning group.

Conclusions

Unlike previous studies, it was lay members, not staff, who raised concerns about their representativeness and legitimacy. Although the clinical commissioning group provides resources to support patient and public involvement, there continues to be a lack of clarity about roles and scope for impact. Lay members are still some way from constituting a powerful voice at the table.

"Very much evolving": a qualitative study of the views of psychiatrists about peer support workers

BACKGROUND

Mental health services continue to develop service user involvement, including a growth in employment of peer support workers (PSWs). Despite the importance of the views and attitudes expressed by psychiatrists, this topic has not previously been studied.

AIMS

To gain insight into the views and attitudes psychiatrists have about PSWs.

METHODS

A qualitative study based on semi-structured interviews with 11 psychiatrists in the East of England.

RESULTS

Psychiatrists were broadly positive and supportive of PSWs. Interviewees not only could anticipate a range of possible benefits of employing PSWs, but also had concerns regarding their implementation and management. There was a lack of clarity and consistency between interviewees about what the exact role of a PSW might involve.

CONCLUSION

This study provides insights into how PSWs are perceived by psychiatrists. While broadly positive attitudes exist, the research highlights certain challenges, particularly role ambiguity.

Competing Paradigms

A recovery paradigm that promotes service user involvement, empowerment, and agency has been a guiding principle for the transformation of mental health services internationally. Incorporating recovery values into traditional mental health care settings, however, has been problematic due to organizational, structural, and attitudinal barriers. A new emphasis on contexts, values, and partnerships with service users requires providers to collectively redefine their roles, creating a shift in both individual and organizational identities. This conceptual article provides an in-depth exploration of the social and cultural factors involved in frontline mental health care, highlighting the nature of shared cognition in organizational learning as well as the conflicting forces that promote social stability and change. Using theory drawn from clinical, organizational, and social science literature, the article will discuss the competing ideologies in mental health care, emphasizing the need to create new learning conversations that honor the system’s capacity while creating the necessary dissonance for transformation.

The development of recovery competencies for in-patient mental health providers working with people with serious mental illness

Delivering recovery-oriented services is particularly challenging in in-patient settings. The purpose of this study was to identify the most salient recovery competencies required of in-patient providers. Established methods for the development of competencies were used. Data collection included interviews with multiple stakeholders and a literature review. Data analysis focused on understanding how characteristics of the in-patient context influence recovery-enabling service delivery and the competencies associated with addressing these issues. Eight core competencies with four to ten sub-competencies were identified based on a tension-practice-consequence model. The competency framework can serve as a tool for tailoring workforce education.

Discovery Interviews: a mechanism for user involvement

Discovery Interviews have become widely used in the UK National Health Service as a service improvement tool and patient involvement mechanism. This first paper in a series of three explores the development of Discovery Interviews in the NHS in the context of explicit central government policy of the development of patient-centred services and user involvement in shaping health service organization and delivery. It draws on the published literature on Discovery Interviews to date, including that on evaluation.

Mutual powerlessness in client participation practices in mental health care

BACKGROUND

Client participation has become a dominant policy goal in many countries including the Netherlands and is a topic much discussed in the literature. The success of client participation is usually measured in terms of the extent to which clients have a say in the participation process. Many articles have concluded that client participation is limited; professionals often still control the participation process and outcomes.

OBJECTIVE

The objective of this study is to gain insight into (i) the practice of client participation within a quality improvement collaborative in mental health care and (ii) the consequences of a Foucauldian conceptualization of power in analysing practices of client participation.

DESIGN

We used an ethnographic design consisting of observations of national events and improvement team meetings and interviews with the collaborative's team members and programme managers.

RESULTS

Contrary to many studies on client participation, we found both clients and service providers frequently felt powerless in its practice. Professionals and clients alike struggled with the contributions clients could make to the improvement processes and what functions they should fulfil. Moreover, professionals did not want to exert power upon clients, but ironically just for that reason sometimes struggled with shaping practices of client participation. This mutual powerlessness (partly) disappeared when clients helped to determine and execute specific improvement actions instead of participating in improvement teams.

CONCLUSION

Recognizing that power is inescapable might allow for a more substantive discussion concerning the consequences that power arrangements produce, rather than looking at who is exerting how much power.

Service user involvement in nurse education: a report on using online discussions with a service user to augment his digital story

Service user involvement is a key element within current pre- and post-registration nurse education in the U.K. but achieving this is challenging. Most service user involvement is through classroom visits. Digital stories, film and audio are alternatives but lack the interactivity and development of reflection that can be achieved through face-to-face contact. This report reviews the background to service user involvement in healthcare professional education then provides a reflective account of a novel initiative whereby a spinal-injured patient was involved in creating a digital story around some of his in-hospital experiences and then engaged in online discussions with post-registration nursing (degree) and practice educator (masters) students. These discussions provided a richer experience for the students enabling them to reflect more deeply on how nursing care is delivered and perceived by service users. The report concludes that digital stories can be used with repeated groups to inspire discussion and reflection. Augmenting such digital stories with online discussions with the service user whose story is told helps practitioners develop greater empathy, insight and understanding which are beneficial for improving service delivery and nursing care.

The impact of patient and public involvement on UK NHS health care: a systematic review

PURPOSE

Patient and public involvement (PPI) has become an integral part of health care with its emphasis on including and empowering individuals and communities in the shaping of health and social care services. The aims of this study were to identify the impact of PPI on UK National Health Service (NHS) healthcare services and to identify the economic cost. It also examined how PPI is being defined, theorized and conceptualized, and how the impact of PPI is captured or measured.

DATA SOURCES

Seventeen key online databases and websites were searched, e.g. Medline and the King's Fund.

STUDY SELECTION

UK studies from 1997 to 2009 which included service user involvement in NHS healthcare services. Date extraction Key themes were identified and a narrative analysis was undertaken.

RESULTS OF DATA SYNTHESIS

The review indicates that PPI has a range of impacts on healthcare services. There is little evidence of any economic analysis of the costs involved. A key limitation of the PPI evidence base is the poor quality of reporting impact. Few studies define PPI, there is little theoretical underpinning or conceptualization reported, there is an absence of robust measurement of impact and descriptive evidence lacked detail.

CONCLUSION

There is a need for significant development of the PPI evidence base particularly around guidance for the reporting of user activity and impact. The evidence base needs to be significantly strengthened to ensure the full impact of involving service users in NHS healthcare services is fully understood.

User involvement in hospital wards: professionals negotiating user knowledge. A qualitative study

OBJECTIVE

To investigate how health professionals in hospital wards that have voluntarily initiated user involvement negotiate user knowledge into their professional knowledge.

METHODS

Qualitative interviews were conducted with 18 health professionals from 12 hospital wards in Central Norway.

RESULTS

The main value to health professionals of initiating user involvement was gaining access to user knowledge. Two functions of user knowledge were identified--user knowledge as an alternative to professional knowledge and user knowledge as support for professional knowledge. The need for good professional practice was used as an argument for closing professional fields to user involvement. Professionals were also under scrutiny from other discourses, such as scientific-bureaucratic medicine, which had a strong impact on how user involvement was carried out.

CONCLUSION

Health professionals saw knowledge transfer as valuable, but ultimately valued professional knowledge above user knowledge.

PRACTICE IMPLICATIONS

Even health personnel who embrace user involvement limit the influence of user knowledge on their own professional work. It seems necessary that user involvement be included in health policy and practice guidelines at hospital wards, if it is desirable that user knowledge influence professional knowledge and everyday work.

Involvement in mental health and substance abuse work: conceptions of service users

Service user involvement (SUI) is a principal and a guideline in social and health care and also in mental health and substance abuse work. In practice, however, there are indicators of SUI remaining rhetoric rather than reality. The purpose of this study was to analyse and describe service users' conceptions of SUI in mental health and substance abuse work. The following study question was addressed: what are service users' conceptions of service user involvement in mental health and substance abuse work? In total, 27 users of services participated in the study, and the data was gathered by means of interviews. A phenomenographic approach was applied in order to explore the qualitative variations in participants' conceptions of SUI. As a result of the data analysis, four main categories of description representing service users' conceptions of service user involvement were formed: service users have the best expertise, opinions are not heard, systems make the rules, and courage and readiness to participate. In mental health and substance abuse work, SUI is still insufficiently achieved and there are obstacles to be taken into consideration. Nurses are in a key position to promote and encourage service user involvement.

[Patient participation in hospital wards--health personnel's experience]

BACKGROUND

Users of the Norwegian health services have a legal right to influence the services through user committees, and also to assess the treatment they are being subject to on an individual basis. The aim of this study was to investigate the experience health personnel have with patient participation in hospital wards.

MATERIAL AND METHODS

Qualitative interview study with 18 health workers from 12 hospital wards in Central Norway Regional Health Authority.

RESULTS

Health personnel stated that they took the initiative to patient participation in the hospital ward. User representatives were either appointed by the user committee or chosen because of personal characteristics that suited the ward's needs. Health personnel were positively surprised by the user representatives' qualifications. It was still a challenge to achieve equality between health personnel and user representatives. Health personnel limited patient participation, especially regarding medical issues.

INTERPRETATION

Patient participation in hospital wards seems to be regulated by health personnel, who initiate and limit such participation.

Children's and Young People's Involvement and Participation in Mental Health Care

Accountability to service users and the wider public has become a guiding principle for the NHS and a central theme of consecutive pieces of policy that place participation and involvement at the centre of clinical practice and service provision. This paper will look at the background and objectives of children and young people's participation in two key policy areas: their own mental health care, and the planning and delivery of child and adolescent mental health services (CAMHS). In doing so, the paper will highlight children and young people's unique contribution to clinical care and examine current knowledge and practice that encourages their involvement in clinical processes and service development.

From rhetoric to reality: including patient voices in supportive cancer care planning

OBJECTIVE

To explore the extent and manner of patient participation in the planning of regional supportive care networks throughout the province of Ontario. We consider the disconnect between the rhetoric and reality of patient involvement in network planning and co-ordination.

CONTEXT

In 1997, the Province of Ontario, Canada, established a new, regionalized cancer care system. By transferring responsibility to the regional level and to networks, the architects of the new provincial system hoped to broaden participation in decision making and to enhance the responsiveness of decisions to communities.

RESEARCH APPROACH

Through a qualitative, multiple case study approach we evaluated the processes of involving patients in network development. In-depth, semi-structured interviews and document analysis were complemented by observations of provincial meetings, regional council and network meetings.

RESULTS

The network development processes in the three case study regions reveal a significant gap between intentions to involve patients in health planning and their actual involvement. This gap can be explained by: (i) a lack of clear direction regarding networks and patient participation in these networks; (ii) the dominance of regional cancer centres in network planning activities; and, (iii) the emergence of competing provincial priorities.

DISCUSSION

These three trends expose the complexity of the notion of public participation and how it is embedded in social and political contexts. The failed attempt at involving patients in health planning efforts is the result of benign neglect of public participation intents and the social and political contexts in which public and patient participation is meant to occur.

Involving mental health service users in quality assurance

OBJECTIVE

This study compares the process and outcomes of two approaches to engaging mental health (MH) service users in the quality assurance (QA) process.

BACKGROUND

QA plays a significant role in health and care services, including those delivered in the voluntary sector. The importance of actively, rather than passively, involving service users in evaluation and service development has been increasingly recognized during the last decade.

DESIGN

This retrospective small-scale study uses document analysis to compare two QA reviews of a MH Day Centre, one that took place in 1998 as a traditional inspection-type event and one that took place in 2000 as a collaborative process with a user-led QA agenda. Setting and participants The project was undertaken with staff, volunteers and service users in a voluntary sector MH Day Centre. Intervention The study compares the management, style, evaluation tools and service user responses for the two reviews; it considers staff perspectives and discusses the implications of a collaborative, user-led QA process for service development.

RESULTS

The first traditional top-down inspection-type QA event had less ownership from service users and staff and served the main purpose of demonstrating that services met organizational standards. The second review, undertaken collaboratively with a user-led agenda focused on different priorities, evolving a new approach to seeking users' views and achieving a higher response rate.

CONCLUSIONS

Because both users and staff had participated in most aspects of the second review they were more willing to work together and action plan to improve the service. It is suggested that the process contributed to an evolving ethos of more effective quality improvement and user involvement within the organization.