JOURNAL ISSUE 11
Towards the meaningful involvement of people using services and
carers in social work education:
Developing strategies for good practice.
School of Social, Community and Health Studies
University of Hertfordshire, UK
The requirements of social work training (DoH, 2002) include people using services as an essential component of stakeholders in all areas of the social work qualifying programmes, including the design, delivery of teaching, selecting new students, assessment, and review. This is a relatively new concept for the providers of social work education, for while there has been a requirement for programmes to develop systems promoting the involvement of people using services in their provision throughout the 1990s (GSCC/SCIE, 2004), until recently this has developed in a piecemeal way across the UK—the main focus of involvement of service users being the providing of one or two teaching sessions about their experiences. However, new strategies are now being developed in which the emphasis on the perspectives of people using services is becoming well established (Waterson and Morris, 2005). To be effective, involving people using services and their careers/caregivers? requires significant changes in the traditional approach to learning and teaching and the challenge for higher education is to find new and meaningful ways of doing this. While some good examples of involvement are evident, there is relatively little empirical research on the active involvement of people using services on social work qualifying programmes (Hastings, 2000 in Waterson and Masters, 2005).
In the light of these developments, this paper will consider some good practice issues that may help to promote meaningful partnerships between people using services and teaching staff in the delivery of social work education. Firstly, the background to user involvement in the delivery and provision of services in the UK will be explored briefly, identifying some of the positive aspects and also some of the barriers that can impact the development of initiatives for social work education. The paper will highlight what people using services themselves have identified as desirable learning outcomes for students on social work education programmes. The importance of involving people using services themselves in promoting these messages will be explored focusing on the model that is currently being developed at the University of Hertfordshire (UH).
Background to the involvement of people using services and carers
The importance of involving people using services and carers has been a central theme in the Government’s modernisation agenda in health and social care developments (DoH, 2001, 2002a/b). In recent years, health and social care services have been increasingly working towards involving people using services more fully in all areas of service provision, including in the delivery of social care, assessment and individual care plans, planning of services, and in the development of more user-led initiatives (Morris, 1997; Smale and Tucson, 1993; Beresford and Trevillion, 1995).
The emphasis on the individual as a consumer of a social service, with the same rights as a consumer of any other commercial service including choice, quality, value for money, exit and complaints procedures, has moved the focus from the professional to the person using the services as the “expert” in their own needs. There is now an emphasis on evidence-based policy and practice that stresses the importance of basing public services on a strong knowledge base (Beresford, 2005; Molyneux and Irvine, 2004). Research and publications involving the perspectives of people using services and their carers are now well established (Barnes and Wistow, 1992). The emphasis on values such as empowerment, self-determination, and anti oppressive practice has also set the agenda for working in partnership with users of services (GSCC, 2002). Professional codes of ethics make clear reference to involving service users in practice and policy development (BASW, 2002)
Positives to the involvement of people using services
Barnes and Wistow (1992) identified two broad purposes to the involvement of people using services: firstly, a desire to improve the quality of services to make them more sensitive to the needs and preferences of the individuals who use them, and, secondly, to develop a strategy to extend the capacity of users to participate in decisions about the design, management and review of services.
Involving those who use the services in decision making about how services are delivered increases the choice and control that people have over their lives, and provides flexibility by responding to particular needs at particular times (Morris, 1994). People using services working in this way can gain a sense of unity and identification with each other that strengthens their voice. They can provide a valuable perspective shaped by their knowledge and experience of health and social care issues, introducing a fresh approach that brings new thoughts and ideas. People using services may also be able to help with the wording of documentation, reports and other material to ensure that they are understandable to service users, carers and members of the public. The positives identified here were very evident in the development of strategies for user involvement at the University of Hertfordshire (UH), as were the barriers identified in the following section.
Barriers to achieving involvement:
Despite involving people using services being a major theme in current policy and practice, difficulties and barriers arise that impede progress towards this in social work services and organisations including educational settings.
Firstly, it is important to avoid “tokenism.” This, for example may involve one or two service users who may not represent the views of the wider service user group being invited on to a management or planning committee of a social work agency or organisation (Ager et. al, 2005; Tew et. al, 2004; SIESWE, 2004). This may allow social care organisations to “tick the box” but does not represent meaningful involvement. This raises the question of how to widen participation to involve people who may be hard to reach.
The attitudes of the professionals may also be a barrier to participation of people using services, with traditional power imbalances playing an important role here. They may be reluctant to share the power of decision making, and feel a need to still be in control, particularly with regard to resources, and be concerned that consulting service users may “open the floodgates,” deluging them with suggestions or requests that they cannot meet. Similarly in social work education, teaching staff need to review current practices, respond positively to challenges to the traditional approach to teaching, and be aware of power issues (Tew et. al, 2004; Molyneux and Irvine, 2004; Ager et. al, 2005).
People using services have traditionally been a disempowered group and may see themselves as under the control of the “experts”—the psychiatrists, doctors, nurses, social workers, and other professionals. They may internalise the negative attitudes of wider society (Thompson, 1997), including those of the professionals—creating barriers to involvement, believing that they are unable to participate due to a lack of power, knowledge, and understanding, or due to their personal circumstances such as illness, age, or disability. People using services and their carers need training and support to overcome this barrier with service user groups given the necessary autonomy and power to make their voices heard in partnership process.
Organisational structures can be exclusionary and institutional practices including those of educational establishments can make power sharing difficult (GSCC/SCIE, 2004). Power issues have been cited as underlying the majority of identified difficulties with effective user led change (Carr 2004), and a continual awareness of the context of power relations and the framework in which they are being conducted is required in order to achieve successful outcomes.
Resources and time constraints are also a major barrier. The process of involvement needs proper resourcing in order to meet service users’ needs (Shaping out Live,s 2003a; Waterson and Morris, 2005; Tew et. al, 2004). Particular support may be necessary, including environmental requirements, replacement care costs to allow for the involvement of carers, transport, and payment of people using services for the work done. At UH, this includes attendance at meetings, teaching, interviewing, and assessment sessions for which people using services are paid part time lecturer rates. This presented difficulties when the work was first undertaken at the University, reflecting the barriers inherent in institutional structures and practices identified earlier. However, supportive management played a valuable role in enabling the process of payment to take place, including reimbursement for replacement care and transport costs.
Although government policy actively promotes user involvement, the social security benefit system in the UK disadvantages those who earn over a certain sum, by reducing or terminating their benefits. This has had a direct impact on some of the people using services working at UH; the fear of losing their benefits limited the volume of work that they could undertake at the University. Beresford (2004) states that it is important to address the conflict between government pressure for user involvement and payment, and failure of the benefits system to support this. The independent consultants who provide support for the people using services at UH are actively engaged in trying to address this problem at a national level.
Members of minority ethnic groups who are already marginalized in the population may have other barriers such as culture and language issues that need to be addressed before they can participate in a consultation process.
Has the participation of people using services made a difference?
Recent research on the effectiveness of user involvement in the planning, provision and delivery of services they use has found that efforts to involve people using services are taking place across the UK. However, the impact of participation on the change and improvement of social care services is yet to be properly monitored and evaluated (Carr, 2004). Much progress has been made in establishing the principle of service user participation and developing ways of doing this, however traditional modes of thinking and operating need to be challenged and organisational structures, systems, and practice need to change in order to respond more effectively to creating ways of working with people who have been oppressed and marginalized. There is a need for a range of models of involvement, which should make clear what service users may or may not be able to change. User-led awareness training is necessary to promote this process (Carr, 2004).
People using services themselves are very sceptical about current practices around user involvement, considering these to be patchy and tokenistic. Studies undertaken to ascertain service users perspectives on services by the Shaping Our Lives Project (2003a), have found that users felt services continued to show a lack of respect concerning their views, and that the value of their own outcomes was not acknowledged or valued, reflecting the barrier identified earlier concerning professional attitudes. People using services found it very difficult to get service providers to prioritise the support that they identified as important to them, emphasising the necessity of meeting together to strengthen their own voice in order to achieve the outcomes they wished for.
It is important for teaching institutions to be aware of the above in order not to reproduce the barriers that people using services experience in certain service areas where people may be marginalized, patronised and ignored (Tew et. al, 2004).
What do service users want from the services they use and from social workers?
People using services have themselves clearly identified what they expect the learning outcomes to be from social work education programmes (SIESWE 2004, GSCC/SCIE 2004). Research projects and consultation exercises in the UK, including the consultation exercise undertaken at the University of Hertfordshire, have reached similar conclusions concerning what people using services want from services and their social workers (Barnes et al 2000: Waterson and Morris, 2005: Beresford, 2005: Shaping our Lives, 2003b: Byers and Belcher, 2003). The personal and “human” qualities of warmth, empathy, honesty, respect, and competence, are rated highly; knowledge of and respect for different cultures and lifestyles is considered important, but above all, people using services want to be listened to and heard. Barnes (2000) identifies that service users want to be treated with understanding, have differences acknowledged, and be able to share perspectives enabling effective negotiation and working together (Shaping Our Lives, 2003a). The importance of good communication and writing skills that use clear language, avoid jargon, and are understandable, readable, and accessible to different groups of people using services is given a high priority (Ager et. al 2005; SIESWE 2004). Values such as respecting confidentiality, challenging where appropriate, being aware of power issues, and showing a personal interest were also identified (Tew et. al, 2004; Crawford, 2003).
Two particular potential outcomes for social work education emerge from these consultations (Crawford 2003): first, the need for social workers to understand and be sensitive to the everyday life experiences of a person using services and not to make assumptions and judgements about wants or needs, and second, recognising the importance of the quality of the relationship that the social worker has with the person using the service. This was confirmed by “Creating Links,” the people-using services group involved in social work programmes at UH, and reflected in the wording of their mission statement:
Aim of the group: to improve services for us and the people we look after
How? To use our experience to give social work students and others an understanding of what life is really like for people who use services and their carers. To help them understand that they need to respect people as individuals. (Creating Links, 2005)
People using services are enthusiastic about involvement in the area of practice learning, and initiatives are being developed about how this could be achieved (Tew et. Al, 2004; Crawford, 2003). However this is an area for further detailed discussion and not encompassed in this paper.
From this evidence two themes emerge that are of a high priority for people using services and therefore of particular importance to social work educators. Firstly, the centrality of good communication and effective personal skills and secondly, the importance of social workers having the knowledge and information about services and systems that enable them to find practical ways of helping people using services (Barnes, 2002).
As Beresford (2005) points out, the challenge for social work education is developing an effective system that will put such qualities and skills into operation so that they are the everyday experience of people using services.
Towards good practice in the involvement of people using services and carers in social work education
It is important to take forward these messages at an early stage in social work training, particularly when students are preparing to go out on practice learning placements so that right from the start of their professional career they have an inbuilt respect and understanding of the importance of involving people using services at all stages of service provision and planning. Social work students need to be aware of and have access to the perspectives of people using services and be able to work in partnership in a meaningful way (GSCC/SCIE, 2004). In order to address this, values need to be promoted that will enable students to integrate partnership working with people using services into their everyday practice.
There is a need to take the direct experience of people using services seriously as a source of knowledge and understanding, and recognise that their viewpoints and contributions are of equal value to academic and professional perspectives (Tew et. al 2004). Fundamental to the success of the involvement of people using services is the recognition of the value and importance of promoting the knowledge, conceptual theories and models that service users hold which has developed from their own “lived experience” (Beresford and Croft, 2001: GSCC/SCIE, 2004). This knowledge base can provide a theoretical framework for underpinning students’ learning and informing their practice. This may be at variance with views held by professionals, making direct face-to-face teaching approaches that encourage dialogue particularly useful (Waterson and Morris, 2005). While this might be challenging for teaching staff, this approach signals to students a positive approach to engaging with people using services and offers the opportunity to share learning about situations where things go wrong (GSCC/SCIE, 2004).
The challenge remains for social work programmes to devise systems for the involvement of people using services that promote effective partnership and avoid the barriers and difficulties referred to earlier. At a recent conference, people using services identified what they considered to be the challenges for promoting effective partnership. These included:
How to engage the expertise of people using services;
How to start working with service users;
How to work together to develop a two way process of getting and sharing information;
How to build sustainable partnerships (GSCC/SCIE, 2004).
Current experience suggests that using a group approach to involving people using services rather than an individual approach is the preferred way of taking participation forward (Tew et. al, 2004; Beresford, 2004). Academic environments can be isolating and a group is a way of providing support to all involved including academics and practitioners. Service user and carer controlled organisations are increasingly being involved in training in social work education, and debates continue as to whether involvement is better promoted by attending as a member of a service user organisation or as an individual. Beresford (2004) suggests that organisations are in a better position to speak for people using services than individual service users if tokenism is to be avoided. However, one service user panel in Scotland consists of a mixture of both (SIESWE, 2004).
Whether a group or individual approach is adopted, it is important to recognise the need to be inclusive and widen participation to harder to reach people (SIESWE, 2004) including ethnic minorities, children, and young people and those with diverse experience including, age, gender, disability, and sexuality. A study commissioned by the Central Council for Education and Training in Social Work (CCETSW) in 2004 found limited direct input on programmes by people using children and family services (Jackson and Morris, 2004, cited in Waterson and Morris, 2005). This was also apparent in the consultation exercise undertaken at .UH. Waterson and Morris (2005) also state that the people using services most able to articulate their needs are generally the ones most likely to have the most choice. Organisations therefore need to adopt values that will promote meaningful involvement, so that all user voices have the opportunity to be heard (Ager et. al, 2005).
Any process to promote meaningful involvement should have clear timescales and outcomes so that people using services can see changes as a result of their input. Much consultation currently carried out involves the giving of time and information with little or nothing back (Carr ,2004). People using services require feedback about the impact of their participation if they are not to become disillusioned with and disinterested in the process (Shaping Our Lives, 2003a).
Taking forward the messages: the development of a model of participation at the University of Hertfordshire.
In order to develop an infrastructure for the involvement of people using services at UH that attempted to encompass the good practice issues considered in this paper, a module was devised for second year students to be delivered as a five-day block before the students went out on their level-one practice learning placements. The module was entitled “Working in Collaboration with People Using Services,” and was to be delivered almost entirely by people using services. The learning outcomes for the module reflected the themes that users of services had already identified as a priority, as outlined earlier in this paper.
Focus groups that had been involved in the initial consultation on the social work degree were revisited and given feedback on how their views had been integrated into the design of the programme. The groups were asked if they would like to be involved in the delivery of the new “Working in Collaboration” module, and a number expressed interest. A group for people using services was then set up at UH. The group quickly established its own identity and devised a name: “Creating Links.” Initially similar barriers to those identified earlier were encountered, mainly resources, time constraints, financial issues such as payment for meetings, transport costs, and replacement care costs for carers, and it was necessary to put in considerable effort to overcome these. To try to ensure that a participatory model was used, the module was not planned beforehand; the group was consulted as to what they thought should be included in the module, and what they felt comfortable presenting to the students. They quickly came up with ideas, in effect designing the sessions themselves. Training and support were offered to the group members to enable them to prepare and present their own presentations on the module. In the context of direct learning and teaching, groups can be very supportive in a number of ways (Tew et. al, 2004). Talking about personal material can be painful and stressful, and the support of the group members can be helpful, particularly when they have had time to get to know each other. While co-presenting, whether with a member or the teaching staff, a supporter or another group member demonstrates genuine collaboration and support. Group members can also help and train others. These practices were evident in the teaching strategies of the “Creating Links” group.
In the light of this large commitment, funds were approved with the support of management to engage independent consultants to support this process. The consultants had extensive experience of working with voluntary and user groups in other Universities and forums. The consultants supported the users of services in the design and presentation of their teaching sessions, and facilitated group planning meetings ensuring that the group developed in an autonomous way (Beresford, 2004), sharing power and decision making equally with the academic staff. At the present time, they are facilitating work the group is undertaking on producing an information pack for people using services who may be interested in becoming involved in the programme, students, and academic staff.
Involving people using services in assessment is possibly the most difficult “traditional” teaching area in which to share power. There is evidence that some social work education programmes are making progress in this area, but generally this is still at an early stage of development (Tew et. al, 2004; Molyneux and Irvine, 2004).
The involvement of people using services in the assessment of the assignment for the ‘Working in Collaboration with People Using Services’ module was a significant learning experience not only for the students, but also for academic staff. The assessment criteria addressed the themes that people using services had identified; the importance of good communication, effective personal skills, and knowledge and information about services and systems. It was also important to identify whether the students had grasped the concepts and values of working in partnership. The “Creating Links” group were actively involved in devising the assessment criteria and marking schedules that corresponded to the emerging themes. They were also involved in marking the assignments and allocating a percentage of the final grade. The “Creating Links” group, which included one person with a learning disability, were offered a training session and were supported in the marking of the assignment by academic staff and the independent consultants, reflecting good practice (Tew et. al, 2004). This represented a considerable shift of power from the traditional academic roles, thereby demonstrating to students genuine collaboration and the sharing of power, and acknowledging that the knowledge of people using services is valid and of equal value to academic perspectives. For academic staff, it demonstrated the ability to respond positively to challenges to the traditional approach (Tew et. al, 2004; Beresford and Croft 2001; GSCC/SCIE 2004).
The response from the students to people using services marking their assignments to some extent mirrored the attitudes of professionals outlined earlier. While some students welcomed this, recognising the importance of ensuring that their work was understandable and acceptable to people using services and met their learning outcomes, others who had been very enthusiastic in their evaluation of the “Working in Collaboration” module became very anxious about the involvement of users of services in marking their work. A few considered that their work should only be marked by academic staff, and questioned how service users, in particular someone with a learning disability, could do this task, clearly demonstrating that the values that underpin working in collaboration with people using services will need to be addressed in more depth for next years’ module. Making students aware of how users will be involved in assessment (Tew et. al, 2004), and the rationale for this, together with changes suggested by the “Creating Links” group as part of their evaluation will be incorporated into next year’s module
Benefits to students and people using services
Student feedback from the Working in Collaboration module was overwhelmingly positive. Some students went as far as to say that it was the best learning experience they had had on the social work course. For the students, the main benefits were an increased understanding of the concepts of working in partnership with people using services. It is hoped that this module will encourage students to re-revaluate preconceptions (Waterson and Morris, 2005) and value learning gained from the experiences and knowledge of people using services. The module and its assessment demonstrated power-sharing between the people using services and academic staff, which it is hoped would influence the students in their professional roles. Awareness of the importance of good written communication and clear information was given a high priority, and evidence that this had been understood by the students was visible in “thank you” cards for the people presenting on the module in a form that took account of their particular communication needs.
Meaningful involvement of this nature is a way of validating and valuing users experience and perspectives (Waterson and Morris, 2005), and the “Creating Links” group benefited from new skills, increased confidence, and a sense of group identity as a result.
Further evaluation at a national level is needed on how initiatives to involve people using services and carers are working out for social work education (Beresford, 2004), and learning from programmes that are further ahead in the process would create a source of knowledge that could inform practice. Research exploring the views of people using services on how they would like to be involved in social work programmes could make it easier to engage hard to reach people and widen participation.
It is hoped that the initiative developed at UH will contribute to student social workers’ understanding and awareness of how to work in partnership with people using services at every stage of service provision and planning, enabling participatory work and power sharing to take place which both increases the quality of people’s lives and promotes their rights.
While there are limitations and barriers to user involvement, there are many opportunities opening up for this work. There needs to be motivation and change in the attitudes of academic staff and teaching institutions in order to facilitate the meaningful involvement of people using services and carers in social work programmes. As Waterson and Morris (2005) have stated, the involvement of people using services in social work education is a time consuming and costly process, but it is also very valuable, leading to user empowerment, and securing better services in the long term, making the necessary investment worthwhile.
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