Health Education East Midlands Governing Body

Paper Q

Health Education East Midlands Governing Body Executive Summary: Embedding the principles of prevention in the education HEEM invests in Purpose of this paper In 2013 HEEM commissioned research by the University of Northampton and Coventry University to examine the education available to ensure the readiness of students and medical trainees in the East Midlands ESTMENT to help them PLAN improve people’s health and welling being. This paper provides the Executive Summary outlining the outcomes of that research

M Multi-Professional Education and Training INVESTMENT It is(MPET) acknowledged that the NHS must put PLAN significantly more effort into prevention as it seeks Why is it important?

to improve the health and wellbeing of the population. The initiative ‘Making Every Contact Count’ (MECC) was introduced to spearhead a change. This research examines how well the education we invest this in is equipping our future workforce to be able to create the right relationships with those they care for to continue this work.

U Multi-Professional Education and Training (MPET) INVESTMENT PLAN

l-Profess Education and Training (MPET) OneINVESTMENT of our strategic prioritiesPLAN in 2013/14 was MEEC hence this research was commissioned How it links to our strategic priorities

What are the implications/options/possibilities/risks/consequences/impacts? This Executive Summary and its full report provide the evidence to answer the question as to how well our learners are prepared to tackle their future role in preventing ill health. It suggests there is considerable room for improvement and this needs to addressed What action/output/come is required? The HEEM project group that has overseen this work is preparing an action plan in response to this research the action plan will be completed in December. Suggested resolution The Governing Body are requested to receive the Executive Summary for information.

Authors: Jane Johnson, Deputy Director of Workforce, Education and Quality Trish Knight, Director of Workforce Education and Quality Date: November 2014

Embedding the principles of prevention in all the education HEEM invest in Executive Summary Faculty of Health and Life Sciences Coventry University Prior Street Coventry CV1 5FB 024 7688 3808

Institute of Health & Wellbeing The University of Northampton Boughton Green Road Northampton NN2 7AL (01604) 893559

June 2014

This project was commissioned by the East Midlands NHS Local Education and Training Board (LETB), and jointly undertaken by the University of Northampton and Coventry University. Project Lead: Dr Jacqueline Parkes, Associate Professor in the Institute of Health and Wellbeing, School of Health, University of Northampton. Co-Investigator: Dr Colin Wisely, Research Fellow, Department of Nursing, Coventry University. Co-Investigator: Dr Anne Coufopoulos, Senior Lecturer in Public Health, Faculty of Health and Life Sciences, Coventry University. Co-Investigator: Ms Alison Ewing, Lead for Learning and Teaching, School of Health, University of Northampton. Co-Investigator: Dr Matthew Callender, Researcher in the Institute of Health and Wellbeing, School of Health, University of Northampton. Research Assistant: Natasha Bayes, Research Assistant in the Institute of Health and Wellbeing, School of Health, University of Northampton. Researcher:

Dr Rosie Kneafsey, Associate Head Academic (Paramedic Science,

Midwifery and ODP) in the Faculty of Health and Social Care, Coventry University. Research Assistant: Dr Alex Toft, Research Assistant, Coventry University. Data Collector: Prof Annie Turner, Emeritus Professor in the School of Health, University of Northampton.

Institute of Health and Wellbeing, the University of Northampton The Institute of Health and Wellbeing (formerly the Centre for Health and Wellbeing Research) is an inter-disciplinary and inter professional centre of excellence in health and wellbeing working with health and social care providers, commissioners and other partners to support research, enterprise and innovation relevant to the health and wellbeing of the population. The Institute is fully resourced to undertake evidence review and primary data collection using both quantitative and qualitative evaluation methods (e.g. large questionnaire surveys, social surveys, one-to-one interviews, SPSS analysis, focus groups, in-depth discussion groups, semi-structured and open interviews, and tape transcriptions). All members of project teams have extensive experience of research and evaluation projects.

Faculty of Health and Life Sciences, Coventry University The principal areas of activity in the Faculty of Health and Life Sciences at Coventry University are higher education and applied research. The Faculty is a multi-professional faculty and has an excellent teaching and applied research profile. It has a strong track record of research and evaluation work in which we have successfully utilised a variety of research methodologies and approaches. The Faculty of Health and Life Sciences at Coventry University has a good record of working successfully in partnership with Strategic Health Authorities, NHS Trusts and other health and social care providers in the delivery of high quality healthcare education in an extensive range of nursing, clinical psychology and allied health professional programmes.

3 © Institute of Health and Wellbeing 2014 commercial and in confidence

Contents 1

Introduction................................................................................................................. 5

2

Aims and Objectives ............................................................................................... 7

3

Literature Review..................................................................................................... 9

4

Service User Focus Group.................................................................................. 12 4.1

Methods ........................................................................................................................ 12

4.2

Results .......................................................................................................................... 12

5

Programme Lead Survey .................................................................................... 13 5.1

Methods ........................................................................................................................ 13

5.2

Results .......................................................................................................................... 13

6

Programme Lead Interviews/Focus Groups ............................................. 16 6.1

Methods ........................................................................................................................ 16

6.2

Results .......................................................................................................................... 16

7

Student Survey....................................................................................................... 21 7.1

Methods ........................................................................................................................ 21

7.2

Results .......................................................................................................................... 22

8

Student Interviews/Focus Groups ................................................................ 25 8.1

Methods ........................................................................................................................ 25

8.2

Results .......................................................................................................................... 25

9

University Deans/NHS Board level staff telephone interviews ........ 35 9.1

Methods ........................................................................................................................ 35

9.2

Results .......................................................................................................................... 36

10

Conclusions and Recommendations.............................................................. 41

11

References................................................................................................................. 45


1 Introduction Prevention, Wellbeing and Health Inequalities are the key national priorities highlighted by Fair Society, Healthy Lives (Marmot, 2008). Professor Steve Field Chair of The NHS Future Forum report of January 2012 noted that continuing health inequalities in England and Wales are driven by “people continuing to make unhealthy choices: choosing to smoke, drink excessively, eat poorly or not take enough exercise” (2012: 5) The report states that it is the responsibility of every healthcare worker to intervene with physical and mental health and wellbeing in mind ‘whatever their speciality or the purpose of the contact’ (2012: 17). Key actions included:a. Professional bodies ensuring members take full responsibility for such interventions b. A senior level adoption of the national programme c. The full commitment of the NHS Leadership Academy The importance of ensuring these competencies in the future NHS workforce is therefore crucial particularly to all professional training. The role of Educational Institutions is crucial in relation to achieving the workforce requirement, and hence the commissioning of undergraduate, postgraduate and professional development of NHS staff must emphasise the preventive role of all staff. There is a rich literature regarding behaviour change in terms of consumer intentions, enhancing motivational change and maintaining change behaviour following on from the original work of Prochaska and DiClementi (1984) that has inspired the Making Every Contact Count programme (Johnston and Richardson, 2010: 5). These core components include:a. Persuasive Communications b. Motivational Interviewing c. Recovery and Asset Focused Approaches Many of the major diseases that cause mortality in the United Kingdom are related to lifestyle, where we have considerable evidence of what works. The governments Behavioural Insight team also provide interesting insights into behaviour change and persuasive communications. The diseases that is associated with unhealthy lifestyles 5 © Institute of Health and Wellbeing 2014 commercial and in confidence

are therefore a significant contributor to health inequalities in the United Kingdom. The NHS Future Forum (2012) has emphasised the need to maximise the impact of health prevention viewing all clientele contacts as an opportunity to raise these issues. The key objective for all registered NHS workforce is that they are:a) Skilled in raising and dealing with sensitive personal discussions b) Know how to promote health in a persuasive style c) Are skilled in raising questions with individuals around health and lifestyle in an appropriate and timely manner d) Are aware of how to respond to the patient’s response whether positive or negative and are comfortable with dealing with resistance. The East Midlands Local Education Training Board (LETB), part of Health Education England (HEE), commissioned the University of Northampton (UoN) and Coventry University to work in collaboration to conduct research to review the education and training provision available to the future healthcare workforce which helps them to create effective therapeutic relationships to enhance health and wellbeing of the individual and those that care about them. This report provides an overview of the methods utilised as well as a summary of the results for each phase of data collection. A full and comprehensive final report will be produced and disseminated to the commissioners in July 2014.


2 Aims and Objectives Aim: The study aims to review the current readiness of Health Education East Midlands Higher Education Institutions who provide healthcare programmes for Health Education East Midlands (HEEM) to deliver training which supports the development of therapeutic relationships between health professionals and patients to enhance health and wellbeing. Objectives: 1. Review

of

current

education

provision

on

creating

effective

therapeutic

relationships to enhance the health and wellbeing of the individual and those who care about them in the East Midlands. 2. Identify students and medical trainees’ perceptions of their responsibility in learning to create these relationships. 3. Identify educators’ perceptions of their responsibility in helping learners create these relationships. 4. Identify at organisation board level the education provider perception of their role in: -

Providing the environment where students and medical trainees can really practice their skills and demonstrate empathy.

-

Providing a culture which enables these relationships to flourish.

5. Identify

service

user

perceptions

of

the

strengths

and

weaknesses

of

implementing health initiatives to influence behaviour change to enhance health and wellbeing. In order to meet the aims and objectives of this project, a mixed methods approach was employed by collecting data through quantitative and qualitative methods, and range of participant samples were included. This was broken down as follows:Quantitative (online surveys): Two online surveys were conducted between early October 2013 and early December 2013 with Programme Leads and students from a variety of health courses at Higher 7 © Institute of Health and Wellbeing 2014 commercial and in confidence

Education Institutions (HEIs) in the East Midlands and surrounding areas were invited to take part in the survey. Qualitative (face-to-face/telephone interviews/focus groups): A series of interviews/focus groups were conducted between December 2013 and March 2014: 

Focus group with Service Users from a range of health contexts; 



Focus groups/interviews with Programme Leads from Higher Education Institutions;

 



Focus groups/interviews with Students from Higher Education Institutions; 



Telephone interviews with Board level staff from NHS Trusts and Deans from Higher Education Institutions. 

The mixed method data collection approach combined with multiple participant samples resulted in this project summary report being broken down into several sections: 

Literature review; 



Service User focus group; 



Programme Lead survey; 



Programme Lead interviews/focus groups; 



Student survey; 



Student interviews/focus groups; 



NHS Board/Dean telephone interviews. 

     

Each section provides an overview of the methods utilised as well as the results for that phase of data collection.

© Institute of Health and Wellbeing 2014 commercial and in confidence

3 Literature Review Introduction Prevention, Wellbeing and Health Inequalities are the key national priorities highlighted by Fair Society, Healthy Lives (Marmot, 2008). Professor Steve Field, Chair of The NHS Future Forum reported in January 2012 that continuing health inequalities in England and Wales are driven by: “People continuing to make unhealthy choices: choosing to smoke, drink excessively, eat poorly or not take enough exercise” (2012: 5) The report states that it is the responsibility of every healthcare worker to intervene with physical and mental health and wellbeing in mind ‘whatever their speciality or the purpose of the contact’ (2012: 17). The General Medical Council described medical students as “tomorrow’s doctors” (2009: 14). This statement can be applied across all students that are preparing to contribute to the health professions. Burns et al. (2012) stated that educational programmes increase students ‘readiness to practice’ by preparing students for their inevitable transition to practice. It has been reported that brief intervention training leads to an increase in the delivery of brief interventions by healthcare professionals (Lancaster and Fowler, 2008), and that training increases health professionals’ confidence to use brief interventions as a behaviour change tool (West and Saffin, 2008). A recent ChaMPs Public Health Network report (2012) highlighted that students and educators are in favour of introducing brief intervention training into health professional courses. Delivering Brief Intervention training. Brief intervention training appears to exist in a variety of formats. Some brief intervention training is face-to-face (Stop Smoking Wales, 2013), whilst others were conducted online (Burrow et al., 2009). Most published training that have been evaluated are generally tailored to specific health behaviours such as smoking cessation (Stop Smoking Wales, 2013; Rice & Stead, 2004), alcohol reduction (Burrows et al., 2009) and sexual health promotion (Hopkins and Phillips-Howard, 2010), physical activity (Dunn et al., 2001) rather than providing generic brief intervention training to enable health professionals to provide brief interventions about a range of health behaviours. This suggests that brief intervention training can be versatile and has the potential to reach a variety of health professional audiences. The provision of relevant 9 © Institute of Health and Wellbeing 2014 commercial and in confidence

training to health professionals is therefore crucial to the successful delivery of brief interventions (Roche et al., 1997). Brief interventions are not designed for people with severe problems where frequently those individuals will need a more intensive intervention (NICE, 2007; Taylor et al., 2006). It is important that trainers understand this principle to avoid the potential of counterproductive consequences to interventions. The context where the intervention is delivered is, from a practical and ethical perspective, crucial to training. Given that much of what has gone on as training in brief advice and intervention includes such training we must be concerned about the quality of existing training if stages of change are the main element of the training. Taylor et al (2006) also recommend that the use of the Health Belief Model (HBM; focuses on motivating people to engage in positive health behaviours in order to avoid negative health consequences) be dropped in place of the Theory of Planned behaviour and the transtheoretical method (also known as ‘Stages of Change’; where there are several discrete phases to behaviour change (precontemplation, contemplation, preparation, action and maintenance)). The recent emergence of discussions concerning ethics in Public Health raises the potential that such interventions could prove unethical if issues regarding anonymity, confidentiality and informed consent are not taken into account during the planning of screening programmes (Peterson and Lupton, 1995; Lupton, 2012; Callahan and Jennings, 2002; Carter et al., 2012). At worst such interventions could backfire, engendering the typical response of the increased defensiveness of patients, particularly where potential implications of empowering an entire workforce to open up discussions about sensitive matters. Without recourse to the context of those discussions we may be causing harm, for example where reception areas do not provide any opportunity for discretion or where staff are not conscious of their potential to discriminate against certain patient groups particularly those that are visibly overweight, hence antioppressive practice is also important in training for brief interventions. Issues of confidentiality, anonymity and informed consent must also be included in the training of all staff. The foundations for improving therapeutic rapport are clear: nurses, midwives and general practitioners are clearly indicated. There is evidence of various training techniques that are available. The importance of the content of training is less clear. The evidence base for good quality training indicates that we should cease teaching stages of change alone and that we must move on from the Health Belief Model. The key content of the training of key staff should include locus of control, self-efficacy and reflective listening. 10 © Institute of Health and Wellbeing 2014 commercial and in confidence

The universal brief intervention approach with alcohol is considered by Drummond (2012) who concludes that whilst targeted approaches are more successful, population wide approaches can reveal new individuals who would otherwise never have received an intervention. In his study the importance of embedding a single question in the routine assessment of an Accident and Emergency department that led on to the FAST assessment procedure was important in revealing many new individuals. The evidence around targeted approaches at certain points in the life-course is strong and

this

indicates

that

particular

professional

groups

have

many

appropriate

opportunities to intervene. There is clear evidence that the ability to identify the locus of control and ability to enhance self-efficacy are backed by the strongest evidence. Many healthcare professionals struggle with resistance from patients concerning lifestyle issues and there is some tentative evidence that the techniques of motivational interviewing, particularly reflective listening can also help to deal with ambivalence (Taylor et al., 2006; Gaume et al., 2010). These are the three key features that have the greatest impact in developing therapeutic rapport with our patients. Training programmes that include these elements will enable competent practice in brief interventions. The Delivery of Making Every Contact Count Training There are however common key concepts that are utilised in all training and interventions that have been successfully evaluated. The Making Every Contact Count (MECC) competencies identified by Johnston and Richardson (2010: 5) acknowledges the importance of the transtheoretical model as the main component of competence whereas other NICE (Taylor et al., 2006) finds the supporting evidence tentative. NICE (Taylor et al., 2006) indicate that the most robust evidence base for brief interventions is to be found with the Theory of Planned Behaviour (Azden, 1991; 2001). The key elements of training should therefore contain both locus of control and self-efficacy and ambivalence as core components. NICE (2007) Behaviour Change Guidance states:“Significant events or transition points in people's lives present an important opportunity for intervening at some or all of the levels, because it is then that people often review their own behaviour and contact services. Typical transition points include: leaving school, entering the workforce, becoming a parent, becoming unemployed, retirement and bereavement”. To date, many MECC training programmes, of varying quality have been delivered to health professionals at both local and national levels; however, there needs to be greater 11 © Institute of Health and Wellbeing 2014 commercial and in confidence

evaluation of the quality and benefits of these programmes in developing competent practitioners who can deliver enhanced patient care.

4 Service User Focus Group This section provides an overview of the methods and results for the service user focus group.

4.1

Methods

Service users from a range of healthcare contexts were recruited were accessed from the Health and Social Care Service Users and Carers group established by the University of Northampton to take part in a focus group. The focus group was semi-structured, with several questions prepared and asked during the focus group. A total of 6 participants took part in the focus group.

4.2

Results

It is apparent from the findings that all participants in this phase of the project were generally in favour of being offered brief interventions. However, brief interventions need to be provided at a time that is appropriate to the individual circumstances of the recipient:“just reflecting on people’s personalities and how you deliver any sort of news or advice or to even infringe on somebody’s personal, you know, I wasn’t asking that question and here I am coming forth and giving you all, you know, so it’s how that person perceives what they’re receiving and I think it’s about getting to know your patient, being treated as an individual, how I would take information, whether I pick up a leaflet and that’s the way I want to absorb information and make a change or whether I make an appointment and I think everybody’s different and I think that needs to be factored into how people want to change, how they make those first steps to change”. In general, however, the intervention needs to be: 



Led by the client; 



Delivered by a practitioner that has a positive relationship with the client; 



Overtly introduced during a routine medical visit; 


  



Conducted in a private place; 



Clearly and accurately documented; 



Followed-up on a subsequent visit; 



Provided by trained professional or by a supervised student practitioner. 

5 Programme Lead Survey This section provides an overview of the methods and results for the Programme Lead survey. A Programme Lead is a senior member of staff that is responsible for the development, organisation and management of a specific programme offered at Higher Education Institutions (HEIs).

5.1

Methods

An online survey was conducted using the Bristol Online Survey tool from early October 2013 to late November 2013. Programme Leads from a range of Medical and Health HEIs in the East Midlands and surrounding areas were invited to take part in the survey. A total of 26 Programme Leads from 11 different HE Institutions took part in the survey. Courses Lead by these Programme Leads were Diagnostic and Therapeutic Radiography, Medicine,

Midwifery,

Nursing

(all

strands),

Occupational

Therapy,

Pharmacy,

Physiotherapy, Podiatry, and Speech and Language Therapy.

5.2

Results

Programme leads were asked to identify whether they include training on brief interventions and MECC within their programme, and if so, how this training is delivered, to which year group(s) and what content is included in the training. Brief interventions are interventions focused on changing behaviour that are usually limited by time - often a few minutes per session. MECC is an intervention that encourages the health workforce to deliver health advice during consultations in order to encourage the public to make positive health decisions and/or changes. Therefore, brief interventions are the vehicles through which MECC is delivered. Brief Interventions and Making Every Contact Count (MECC) 

Over half of the programme leads highlighted that they include brief intervention (58%) and MECC (60%) training within their programme. 




The majority of programme leads that include brief interventions and MECC training within their programme do so by embedding this training within one or multiple modules (BI=93%, MECC=92%). 

 

Brief intervention and MECC training are provided most frequently delivered to second

(BI=47%,

MECC=42%)

and

third

(BI=47%,

MECC=58%)

year

undergraduate students.   

Training on brief interventions focuses largely on ethics/confidentiality/informed consent (73%), motivational interviewing (73%), and behaviour change models such as the stages of change (67%) and health belief (60%) models. Training on MECC focuses on ethics/confidentiality/informed consent (83%), and behaviour change models such as the stages of change (100%) and health belief (83%) models. 

 

Several ‘other’ responses were provided in relation to how BI and MECC training is delivered, to which year group(s) and what content is included in the training. These responses highlighted that MECC and BI training are integrated at all levels of the programme, though the training is not always explicitly recognised specifically as MECC or BI training. 

Programme responsibility in supporting students to create therapeutic relationships Programme leads were asked to identify how strongly they think it is the responsibility of their educational programme to support students to create therapeutic relationships. 

The majority of programme leads (N=23, 88%) strongly agreed that it was their programmes

responsibility

to

support

students

to

create

therapeutic

relationships, with the remaining programme leads (N=3) agreeing with this statement. No participants disagreed with this statement.  Confidence in supporting students to create therapeutic relationships Programme leads were asked to identify how confident they feel about supporting students to create therapeutic relationships. 

Most of the programme leads had some level of confidence in supporting students, with over a quarter of programme leads feeling very confident (N=7, 27%), more than a third feeling confident (N=10, 38%), and almost a third 


feeling a little confident (N=8, 31%). Only one programme lead felt unconfident about supporting students to create therapeutic relationships. Barriers in supporting students to create therapeutic relationships Programme Leads identified a number of barriers in supporting students to create effective therapeutic relationships. Key themes were as follows: 

Culture/environment: Having staff that were supportive in allowing students to nurture a therapeutic relationship with their patients was identified, as well as the environment of the clinical placement. 

 

Student’s own insight/awareness: Staff identified that it was important for students to be aware of their own interpersonal skills and self-awareness of how they communicated with patients. 

 

Embedded within the University curriculum: Staff identified that the university curriculum was a vehicle for supporting the development of effective therapeutic relationships and that is needed to be incorporated into the curriculum. Furthermore it was identified that if staff teaching students valued and demonstrated an effective therapeutic approach then it would likely be emulated by students. 

 

Time: Time in the clinical environment being important for the development of clinical skills was also identified in the responses. 

Facilitators in supporting students to create therapeutic relationships Programme Leads identified a number of facilitators in supporting students to create effective therapeutic relationships. Key themes were as follows: 

Communication style of tutors: Responses here focussed upon the need to reflect upon the different styles of communication used by tutors (academic & clinical) in their teaching and opportunities for staff to develop skills in techniques such as motivational interviewing. 

 

Role models: It was identified in the responses that the tutors’ own styles of communication were important for students and that tutors themselves should act as positive role models in their teaching and practice. 




Theoretical understanding: A good understanding of the theoretical underpinnings of communication was identified as an area that was important for students to understand, in order to embed their own practice. 

6 Programme Lead Interviews/Focus Groups This section provides an overview of the methods and results for the Programme Lead interviews/focus groups.

6.1

Methods

The interviews/focus groups conducted were semi-structured, with several questions designed prior to the interviews/focus groups being conducted but with the flexibility to probe participants with additional questions where appropriate. Programme Leads from a range of Medical and Health Higher Education (HE) Institutions in the East Midlands and surrounding areas were invited to take part. The interviews/focus groups were carried out between early January 2014 and late March 2014. One focus group (N=3) and seven one to one interviews (eight data collection sessions) were conducted, therefore a total of 10 programme leads from five different HE Institutions took part in this phase of the research. Courses Lead by these Programme Leads were Midwifery, Nursing, Operating Department Practitioner, Physiotherapy, Podiatry, and Therapeutic Radiography.

6.2

Results

Following thematic analysis of the data, the following themes emerged. Terminology Several

of

the

programme

leads

found

the

terminology

associated

with

Brief

Interventions and the MECC agenda, to be very indeterminate and vague. Some found that terminology which had a specific meaning in one context might have a different meaning in another. Several examples were provided by the participants:-


“Certainly. Our encounters are brief, they could be a matter of minutes before a patient goes to sleep or they could be with us for an hour or so afterwards in recovery, so…” “I even looked up what you meant by therapeutic relationship because it is not a term we tend to use in midwifery because, as I say, it’s just when we’re focussed, its family focussed.” “It is every time, it comes back to Every Contact Counts, it’s really about, if somebody walks into the ward, even if you’re busy, about smiling, seen to be approachable and also being open and honest with people as to why [inaudible] labour the discharge(?) so the parents aren’t getting agitated.” “I’ve not heard of that and I’ve only heard of MECC from you, I’ve not really heard of it in any other way, although, you know, a lot of my teaching is around things like chronic disability and, you know, ageing.“ Skills and Core tasks Despite the lack of precise understanding of the technical terms, the programme leads appeared to have some understanding of the core tasks and skills necessary with delivering a brief intervention in a practice environment:“in the first three weeks they’re with us before they go to practice and we do a lot on communication skills, the theories behind patient anxiety for instance, if that’s going to be an intervention, professional skills about communicating with patients but then when we, and they get some role play, some, little bit of experience of those sort of things, you know, it could be simply like, “Here’s a little check list so you can ask questions of the patient,” student role plays the patient and they have a go at that and just break that ice really.” However, for four of the participants, they acknowledged that they felt these skills were not being taught to the student practitioners who would be using these skills following successful registration. There also seemed to be lack of clarity about what could be taught and assessed, although it was suggested by one participant that the assessment skills that are taught could be modified to incorporate a brief intervention type approach:“But they will also get the student to reflect on the event that they’ve had, [inaudible] cared for a patient under a local anaesthetic, you’ve sat there, you’ve held their hand, you’ve reassured them, you need to reflect on that and, you know. And then, you know, and then the formative stuff with the initial, intermediate, final discussions, certainly the 17 © Institute of Health and Wellbeing 2014 commercial and in confidence

final we have a sort of professional summary for that thing so the assessment is not one thing, it’s a camera, 360 thing, try and get a picture of everything that’s going on and that may include several mentors to do that.” Dealing with Stigma Some programme leads expressed concern about the potential difficulties associated with perceived stigmatising conditions, particularly where the stigma was visible such as the case of obesity:“Absolutely, you know, and I think we have examples of people, of students who’ve looked at patients who are morbidly obese and looked at how they’ve had to adapt their treatment which they’ve done and reasoned kind of well. But sometimes still the bit that’s missing is that kind of judgement over it’s your own fault that you’re in this sort of state.” Knowing when to push and when to hold back with patients was a topic that many of the respondents, both students and programme leads found tricky:“Yes, and the fact I go and see students out on placement and I’m a bit of the old school, I still like to see them actually with patients because I think you can tell so much, you know, from looking at a student’s interactions with patients but we do see patients at various, in various episodes of their lives and there just are types of people or people at different stages in their lives with the conditions that they’re presenting with, where it isn’t appropriate, the timing’s not right or the patient’s personality’s not right or they’re, you know, the sort of psychological state at that time is not the right time to be doing the Brief Interventions.” Context and Environment For respondents there was also a perception that national advice was subject to change and was influenced by changing NHS ideology:“Yeah, and I think also from my, I just take my, mine’s a very, very small, specific area, if I take my area, the advice about alcohol consumption for example has varied in the last five years, you should, you should take that, actually we’ve found that a glass of wine actually helps you, actually no, [inaudible] about pregnancy… “ For some of the respondents there was a clear link between Making Every Contact Count and the skills necessary in the post-Francis Report era:-


“It’s not really about the message that you’re actually passing, you know, that you’re putting over to the patient, it’s actually stop and take the time to talk to the patient, is that patient in the right place” The potential for the spread of responsibilities for behaviour advice beyond professionals was an observation made by one respondent:“I wonder whether getting the cleaners and the receptionists to tell someone that they’re overweight and need to eat less is going to make any difference, so I sort of wonder whether the way we do it, you know, is there a better way of doing it.” For some of the respondents the ethical dimensions of giving lifestyle advice was uncomfortable. For one particular respondent the attempt to provide lifestyle advice was potentially a minefield:“You know, and I think it comes down to, and I think that’s a really valuable point, is how many times do you say it, oh there was also about them being adults and able to make their own decisions and it’s the big brother being, you’re repeatedly told you mustn’t drink this and you shouldn’t eat that and you cannot do this and you cannot do that to the point where, it’s kind of what can I do with my life, if I can’t do any of the things that, maybe they enjoy, so it’s a balance and probably the way in which that’s approached and I think that sometimes, it’s time…” One of the key concerns for most of the participants, was that time was the enemy. Increasing workload and patient numbers worked against the requirement of a moment to discuss a very sensitive topic:“But in real life we don’t have the luxury of spending a 20 minute conversation with a patient because the list is just being held up, it’s got to be very fast, adaptable skills, and effective, it has to be effective.” “I wonder sometimes if the reality of that is that we all end up, because of time and the amount of people that we’re having, they’re having to see in clinical practice and the pressures into silo working, this is really all I can deal with, this is really all I know, I don’t have time for referrals, I don’t, I’m just trying to get through those 14 people waiting out there who have been waiting more than four hours and I’m trying to hit targets… “ Person, Place, Moment


The lack of understanding of social determinants of health was absent for some people in the objective of changing lifestyle:“The context is crucial, yeah, so we need to be able to adapt it to, say, 85 year old Fred who smoked 40 a day, you know, has been working in the pit and, you know, now he’s got a grandchild who he’s been told not to smoke around, so it has to be contextualised to their speciality, so I mean, and we do a lot of work on them understanding the determinants of those behaviours and how they can influence health within their context, and, you know, provide hope, hope of change”. For at least one respondent making a brief lifestyle intervention actually constituted a personal risk within a managerial risk adverse culture. For another respondent, the personal experience of an alcohol brief intervention had produced a contradictory response where the respondent had scored a few points too high on an assessment and was automatically referred for assessment. For others, in order to tackle potential insensitivity, the need to train future healthcare workers required core counselling skills:“I would say developing relationships with clients that are based on the core conditions for therapeutic relationships, which is, you know, Roger’s work around warmth and empathy, genuineness, unconditional positive regard underpins both the pre-registration curriculum and the programme that I’m most involved in, which is the Specialist Community Public Health Nursing programme.” Overcoming Resistance For several of the respondents, it was felt that the difficulties associated with dealing with resistant behaviour could lead to the practitioner feeling frustrated, particularly where there was a clear link between a particular behaviour and disease:“the answer is all about your rapport with the patient and for you to be able to put, for example, physiotherapy students get very frustrated when they’re working with someone with a chronic chest condition and they still smoke and they just don’t get it, “Well, why don’t they just not smoke?” And as young people, you know, they’re very black and white about things and, you know, I would perhaps suggest to them, you know, imagine them being in hospital in a very stressful situation and all their life they’ve, so trying to get the students to put themselves in the patient’s situation so that they can sort of feel it from that way and perhaps be a bit more understanding that you can’t just stop smoking like that when it’s something that you’ve leant on all your life” 20 © Institute of Health and Wellbeing 2014 commercial and in confidence

However, the solution that was advocated by some was to evoke and roll with the resistance, as ultimately it could result in a lifestyle change:“I could see, if it wasn’t the right time for the right person, I could certainly see that that would, you know, possibly spoil a rapport and could have a negative effect, yeah. And I think could make them resistant not only just to the Brief Intervention but then resistant to the therapeutic sort of intervention that we would be trying to engage in at that time.”

Summary In conclusion, the findings illustrate that not all programme leaders are confident about their knowledge and understanding of brief interventions and the MECC agenda. Some suggested that it was not always taught or assessed in the curriculum specifically, but did suggest that the skills associated with these techniques were introduced to students in other parts of the training. Concern was expressed that there was a particular focus on interventions such as this at the current time due to the political agenda focussing on public health issues. It was, however, argued that if introduced in the right way, at the right time, and by skilled practitioners, the use of brief interventions could result in positive lifestyle transformations.

7 Student Survey This section provides an overview of the methods and results for the student survey.

7.1

Methods

An online survey was conducted using the Bristol Online Survey tool from late October 2013 to early December 2013. Undergraduate and postgraduate students from a range of health courses at Higher Education Institutions (HEIs) in the East Midlands and surrounding areas were invited to take part in the survey. A total of 157 students from 9 different HE Institutions took part in the survey. The majority of participants were studying full time at pre-registration/undergraduate level. Undergraduate courses typically last three years, however some courses are four, five and even six years in length. Additionally, courses typically start in September, however some courses may also start in January or March. The majority of students were in the second or third year of their course, although there were students ranging from year one to year five of their course. 21 © Institute of Health and Wellbeing 2014 commercial and in confidence

Courses studied by these students were Diagnostic and Therapeutic Radiography, Dietetics, Medicine, Midwifery, Nursing (all strands), Occupational Therapy, Pharmacy, Physiotherapy, and Speech and Language Therapy. Unfortunately students from Clinical Psychology, Dental Hygiene Therapy, Operating Department Practitioner, Paramedic Science and Podiatry courses did not take part in the survey.

7.2

Results

Brief Interventions and Making Every Contact Count (MECC) Students were asked to identify whether their programme of study includes training on brief interventions and MECC, and if so, how this training is delivered. Students were also asked if they are given the opportunity to implement MECC/brief Interventions in the clinical environment. 

Almost half of the students stated that they were unsure about whether their course includes training on brief interventions (45%) and MECC (47%). Less than a quarter of students highlighted that their programme of study includes training on brief interventions (25%) and MECC (22%). 

 

Brief intervention and MECC training is largely delivered by embedding this training within one or multiple modules (BI=78%, MECC=100%), and a few students suggested that brief intervention and MECC training is a compulsory component of their course (BI=28%, MECC 13%). 

 

The

majority

of

students

highlighted

that

they

either

often

(BI=33%,

MECC=42%) or at least sometimes (BI=55%, MECC=29%) had the opportunity to implement brief interventions/MECC in the clinical environment.  Confidence in practising core therapeutic relationship skills Students were asked to identify how confident they feel about practising therapeutic relationships skills in clinical practice with patients/service users. Core therapeutic rapport skills: 

The majority of students either strongly agreed or agreed that they were confident in practising therapeutic relationship skills in the clinical environment,



particularly:  -

“opening up conversations about health” (SA=22%, A=63%); 


-

“using a client centred approach” (SA=27%, A=46%).

More than half of the students were confident in:

-

“addressing resistance to change” (SA=5%, A=52%);

-

“using the skills of persuasive communication in clinical practice” (SA=14%, A=52%).

However, almost a third of students that felt unsure about their confidence in: -

“addressing resistance to change” (U=31%); “using the skills of persuasive communication” (U=25%).

Specific health issues: 

Although the majority of students felt confident in practising therapeutic relationship skills in the clinical environment, when students were asked how confident they feel in giving advice about specific health issues (e.g. smoking cessation, healthy eating), their responses were more varied. Many students strongly agreed or agreed that they are confident in giving advice about: 



-

healthy eating (SA=27%, A=55%);

-

physical activity (SA=27%, A=54%);

-

stopping smoking (SA=24%, A=50%);

-

alcohol (SA=19%), A=50%).

Some students were confident in giving advice about sexual health (SA=8%, A=36%) and mental health (SA=8%, A=29%), however more students felt that they were not confident in giving advice about these health issues (sexual health: D=29%; mental health: D=36%). Factors that may hamper giving advice about specific health issues 

The main reasons provided about why giving advice about specific health issues may be difficult are due to the clinical area of these health issues being outside the student’s area of knowledge/expertise, and lack of confidence in giving advice about health issues. To a lesser degree, ‘timing is not right to offer advice’ was a reason provided about why giving health advice may be difficult, and very few students felt that their ‘own lifestyle’ would make giving advice difficult. 

 

Despite the many reasons why giving health advice may be challenging, approximately half of the students felt that nothing would hamper them giving advice about: 

 -

physical activity(52%);

-

healthy eating (47%);


-

stopping smoking (45%);

-

alcohol (41%).

However, giving advice about mental health and sexual health seems more challenging to students as only a small proportion of students felt that nothing would hamper them giving advice about sexual health (20%) and mental health (12%). 

A number of ‘other’ responses were provided in relation to why giving health advice may be challenging. Within that, the most prominent response provided was ‘lack of knowledge/experience/expertise of the health issue’; this was cited several times across all the health issues, but particularly for ‘mental health’ (N=16). ‘Lack of training/qualifications’ was also mentioned at least once across all the health issues. These responses relate to ‘clinical area’, in that a certain level of knowledge/experience/training within a specific clinical area is required in order to effectively offer advice about a particular health issue. 

 A small number of students (N=4) suggested that ‘relational difficulties with practice mentors’ could make giving health advice to patients challenging. One student suggested that ‘practice location’ could at times hinder giving advice about specific health issues, as different services are offered at different localities. 

 Finally, a small number of students (N=3) suggested that behaviour change such as increasing physical activity and stopping smoking is most effective when ‘patients specifically request the advice’ rather than the advice giving being instigated by the health professional.  Factors that would help the development of therapeutic relationships Students identified a number of factors that would help the development of therapeutic relationships. Key themes were as follows: 

Confidence building: Students identified that it was important for them to be given opportunities both within the University and clinical placement setting to practice their skills in brief interventions with ‘real life’ patients as opposed to other students. 

 

Placement environment: Similar to the programme leads survey findings the actual environment (both physical and staff) was important for students in terms of developing their skills. 




Time: This was something reflected in the programme leads survey also of having adequate time to be able to develop therapeutic relationships with patients and is somewhat connected to the previous theme of the placement environment. 

 

Real life settings: The importance of students being able to have the opportunity to develop their skills even further in clinical practice, once on placement was also identified. 

8 Student Interviews/Focus Groups This section provides an overview of the methods and results for the student interviews/focus groups.

8.1

Methods

The interviews/focus groups conducted were semi-structured, with several questions designed prior to the interviews/focus groups being conducted but with the flexibility to probe participants with additional questions where appropriate. Undergraduate and postgraduate students from a range of health courses at Higher Education Institutions (HEIs) in the East Midlands and surrounding areas were invited to take part. The interviews/focus groups were carried out between early January 2014 and late March 2014. One focus group (N=3) and three one to one interviews (four data collection sessions) were conducted, therefore a total of six students leads from three different HEIs took part in this phase of the research. Courses studied by these students were Midwifery, Nursing, Occupational Therapy, and Physiotherapy.

8.2

Results

Following thematic analysis of the data, the following themes emerged. Knowledge and understanding of Brief Interventions/MECC Whilst all students were very much aware of the importance of health promotion, their knowledge and understanding of MECC was limited. None of the students had received specific training on brief interventions or MECC. One student had been introduced to MECC in the workplace in a paid employment role, rather than through a University


course. After explanation, some students stated that such an incentive would be useful:-

“Yeah, definitely, definitely, yeah, I mean we’ve had lectures on health promotion and kind of using, I mean I know a topic that’s been kind of really, not popular, that’s not the right word, but kind of high interest at the moment is obesity, you know, using, especially kind of earlier appointments as well, stop smoking, stop drinking, substance abuse, just promoting a healthier lifestyle…” In general the respondents had some insight into what was meant by the phrase ‘brief intervention’, but they did not have a clear understanding of the technical terminology associated with lifestyle advice and hence there was a requirement to clarify terms such as brief interventions, therapeutic rapport and Making Every Contact Count:“Not the specific term brief Interventions, I don't think so, I think it’s something that I’ve heard maybe when I’ve been in the workplace but not something that I’ve heard directly through my course or through my placements.” “It rings a bell, Brief Interventions, it rings a bell but I couldn’t tell you (laughs) in any detail what it meant.” One respondent however understood the concept and gave a definition:“Brief intervention as in like, brief opportunistic advice to give a small chunk of information…” One student had heard the term brief intervention, but assumed it was a mental health intervention; whilst others assumed Making Every Contact Count to be related to the Francis Report, referring to need for compassion in all brief contacts. Once clarified, there was some understanding of the objectives and methods from associated learning in other areas. One student referred to these as ‘micro-interventions’:“if you’re seeing a client over a long period of time, to use a micro intervention just to kind of, start, almost to see it as a tester, in like, testing the water to see if they’re likely to be interested in then, the Brief Intervention that you can kind of do the next session, so then you can write down I’ll give advice on physical activity, obesity, whatever…” Personal experiences with MECC and brief interventions As the majority of the respondents were unable to define what brief interventions were, it is unsurprising that most were unable to provide any personal examples. However, there was a feeling that in times of austerity brief interventions could be useful: © Institute of Health and Wellbeing 2014 commercial and in confidence

“But in terms of making, trying to make interventions a bit more cost-effective we were really encouraged to have brief focussed interventions is what they were called in my workplace in my Trust, and so to offer a set number of sessions that would likely be under six to try and get the intervention taking place with your client rather than it going on for a long period of time…” Experiences of MECC were dependent upon the course upon which the student was enrolled. The two physiotherapy students, for example, were more knowledgeable about MECC and the areas upon which it focussed. This seemed to be due to their direct contact with service users and the relationship between injury and likely causes such as smoking or obesity. “And as I say, when you highlight kind of, on the subjective history, yes they’re a smoker, yes they have high alcohol intake, yes they’re obese, whatever, from that point then you can start to think well, and ask them, you have to be confident to ask the question, “Have you thought about your weight recently?” or, “Have you thought about looking at it?” and then trying to hit home with that so…” In general, there was an overall impression from students that health professionals would implement MECC on the basis of their common sense and experience, rather than on the basis of a structured theoretical knowledge base. “So it’s very much, we’re taking on these approaches, probably independently implementing them within our own practice, without really having a, you know, a structural theoretical background to that.” Learning in Relation to Health Promotion Although students’ specific knowledge relating to brief interventions and MECC was not well developed, students identified that health promotion topics and discussions were covered within all of the courses referred to, though in a somewhat subtle manner:“Well at the moment the way they’re delivered is probably, mainly via lectures, I mean it’s probably done more subtly actually in the practice placement. I think it’s probably more focused on in lectures to be honest, they do it out of there, but I think maybe it’s not kind of emphasised on…” One participant noted that through discussion with mentors whilst on placement, students were able to learn more about how to ask service users questions about their health:-


“…your kind of mentors that you work with on placement, they help you with that more and you know, “This is how I say it, because I find that that’s how, you know, people react to it better.” I think it’s easier to learn that whilst you’re actually doing it, again it depends which mentors you’re working with, you see different people ask things in different ways.” The student respondents identified specific example of where teaching and learning occurred in relation to health promotion in their courses. Though this content was not often specifically entitled brief intervention or MECC, respondents discussed issues such as raising difficult topics and how they would learn this with their mentors in practice. “And it was something that you had to talk about with her every day really, because she’d make suicide attempts at every opportunity, she was on one-to-one observations all of the time so even when you were with her for a short period of time, there was always another member of staff who was on the one-to-one obs with her. And I wasn't given any specific training but through supervision, with my educator, that was something that we discussed quite a lot, and the difficulties that I had, kind of, you know, communicating with her, talking about personal things when you’ve got somebody else, sitting in the room, you know…” The general feeling from the interviewees was that their communication skills were most fully developed within the clinical setting when working alongside their mentors. One individual seemed to be suggesting a need for greater opportunity to develop communication skills within the university settings:“I think it’s something that’s talked about, you can read about it, but I don't know that there are enough opportunities outside of placements to really practice that skill…” Rapport/relationship building During the interviews, students spent a significant amount of time discussing the skills involved in questioning service users about their health, particularly with regards to asking difficult questions and building relationships with patients. Building rapport with service users was identified as an important precursor to broaching potentially difficult topics, rather than immediately honing in on sensitive health issues. Students talked about the need to rehearse communication skills and practise them whilst on placement. This was particularly in relation to asking questions about difficult subjects:-


“And I think the same with this is, it’s just you’ve got to get used to asking the questions that aren’t nice about obesity. Like have you thought about your weight? Have you thought about your physical activity? Have you thought about stopping smoking and reducing your alcohol intake?...it feels kind of cringeworthy to start off with…” Respondents identified that service users were routinely asked about smoking and alcohol intake, although they perceived that levels were more likely to be under-reported unless a trusting relationship existed with the health professional. Promoting a healthy diet and physical activity was also viewed as difficult, particularly in a situation where the practitioner smoked or was overweight. Several students and staff raised the dilemma of overweight NHS employees:“if you see someone who may be overweight and you want to bring it up, that might be more difficult as a practitioner if you’re overweight, which can happen a lot. Like, I’ve seen physios which are overweight, even, almost, technically was like, dieticians, which are going up to be overweight, and that’s going to cause problems, ‘cause they might not want to bring it up as much, ‘cause they might feel uncomfortable with the situation, but also maybe the patient wouldn’t trust them as well, wouldn’t listen to everything, they’re not practising what they’re preaching, so…” The common theme across most of the interviews with students was their feelings of discomfort and concern about jeopardising the relationship with the patients when tackling sensitive subjects. Embarrassment and fear of appearing rude or judgemental was a common reason identified for not raising sensitive topics:“I think it’s just difficult for being like, not being, feeling rude, almost. I just feel that’s a big thing...you’re trying to gain that rapport all the time, ‘cause a lot of it you can have so much intimate sessions, you’ve got legs in the air and all sorts of things, you don’t want them to feel uncomfortable with you, and that’s why you feel more sensitive what you’re saying.....(and later) I agree signposting is great, but I think that the problem with that is it’s, if you’re telling somebody what they should do, like, really being quite, almost that, like you said, the vertical line kind of looking down on them as such, or their habits…” In contrast, the physiotherapy student below appeared to feel it was within role to offer ‘expert’ advice in the capacity as a health professional. The same individual identified that

health

professionals

who

did

not

possess

motivational

and

persuasive

communication skills were falling short in their professional skill set.


“I think, as part of the NHS, as a healthcare professional and when the patient comes to see you, you do have that kind of, expert role, I think that is the perfect opportunity to give the advice that they need to have…” The personal nature of lifestyle interventions and the potential for a negative response present students with a very new type of relationship to develop with patients. The nonexpert role of the practitioner when discussing alcohol, weight, exercise and smoking places students in a difficult position where they feel they have little or no training and are certainly out of their comfort zone. The ability to quickly develop rapport and the confidence to raise a sensitive topic and to know how to respond if the answer is negative appeared to be the most important area of discussion. One student identified a case conference where a patient suffering from chronic complaints associated with morbid obesity was being discussed. The student reported that none of the staff at the case conference had ever raised the question of weight. Another reason given for not carrying out lifestyle discussion was a perception that the student lacked skills:“So if someone’s got a severely arthritic knee and they’re really overweight, then without doubt you’ve got to mention that your pain is hugely linked with the amount of weight that you’ve putting onto it, whereas if it was more subtle and they was less overweight or something, that’s where I might feel like I’m not mention it as much, ‘cause it’s not so specifically like, going to tie in with what I’m doing”. In particular students found the topic of stigma affected their confidence in raising lifestyle issues. The potential for these interventions to lead to feelings of vulnerability on the part of the student was a common theme:“I think it’s something people skip over a bit isn’t it, a bit offended, worried about offending someone, you know, you don’t want to pry whether they’re smoking or they’re drinking or they’re, you know, and I think again with obesity, it’s really, and with mental health as well, there’s a big stigma isn’t there.” Due to the stigmatised nature of the behaviours that were discussed, one student found that it took more than one contact to develop rapport with his patient. The opportunity for repeated options for interventions and the development of deeper relationships was a factor that students raised:“it’s worth spending that extra five seconds to say, “What does that mean? Is that two pints on a Saturday? Is that actually,” we had one patient and it ended up being 60 30 © Institute of Health and Wellbeing 2014 commercial and in confidence

pints in a week, when they said, “Oh, I just have a few in the week,” and it’s just like, you go into it a bit more, and you’re just like, 60 pints in a week, Jesus.” Challenges Identified in relation to the Implementation of MECC Although all participants were clear regarding the importance of promoting health, all students identified some concerns and factors to consider before embarking on brief interventions. For example, one student found the idea of training people in how to Make Every Contact Count problematic and argued that since people are inherently complex, the approach of MECC may not be appropriate:“…the Making Every Contact Count, if you’re going to be really true to that and brief interventions, they don't really tally that well together because it’s, a person’s very complex and, you know, especially with health issues and you might just be going in because somebody’s broken their leg or something but that has so many other impacts on their mental health, on their family, on you know, their general wellbeing, on the types of things they can do.” This respondent also argued that in practice, developing meaningful relationships with service users could take time, rather than being something that occurred immediately. Similarly, the respondent below was unsure that the formal approach of MECC was beneficial and felt that it could be restrictive, insincere and too much like a tick-box exercise:“And it’s these really kind of, not forced situations, but it was very much not, “This is an opportunity for Making Every Contact Count,” this is a, “Let’s do this ‘cause this is what I’ve done for years, and I see the benefit of it.” Rather than saying, “Let’s talk about alcohol, let’s talk about smoking, let’s talk about obesity,” it was a, “let’s give some general lifestyle advice to these people who are in here because of their lifestyle choices already.” Another respondent identified practical reasons for not engaging in MECC, such as during pregnancy: “I think obesity is probably again the one where, you know, it’s difficult because you’re not meant to, a pregnant lady’s not meant to diet but just kind of encouraging a healthier lifestyle, obviously it’s not a good time to start heavy exercise and, you know, strict dieting…”


The respondents also noted the importance of the appearance of the physiotherapists (in this example). Again, the issue of obesity proved most problematic, with the suggestion that an overweight physiotherapist might find discussing this topic difficult. “Like, I’ve seen physios which are overweight, even, almost, technically was like, dieticians, which are going up to be overweight, and that’s going to cause problems, ‘cause they might not want to bring it up as much, ‘cause they might feel uncomfortable with the situation, but also maybe the patient wouldn’t trust them as well, wouldn’t listen to everything, they’re not practising what they’re preaching, so…” However, a second respondent at the focus group countered this by suggesting that an overweight professional might be empathic and be able to use personal experience to engage with the patient. One of the key dimensions for students was where to conduct an intervention, with whom and what moment. Some students were aware of the ethical dimensions of talking with people about lifestyle whilst others did not perceive these potential hurdles. In particular one respondent spoke of the sensitivities of opening up conversations in a stressful scenario:“if you was on a vascular ward and you’d had someone who has just has a below-knee amputation and then you start going on, “Stop smoking, stop smoking,” yes, obviously that’s what they need to do, but that’s not what they are focussed on right now. They’ve got everything else going on, and that’s why it would be more difficult than to think, well, this is not my issue. They don’t want to go down that road.” One of the crucial areas for students was in identifying the right moment and the right context to open up conversations around change. Some of the students recognized that this was a potentially difficult task with the possibility that mistakes could be made. Questions around confidentiality, anonymity and informed consent were implicit in many of the scenarios that students outlined. Knowing when to make an intervention without breaching a patient’s right to anonymity and confidentiality was a confusing issue where students had understood that they could do a MECC intervention at any time. Context was therefore considered significant with concern about willingness to conduct interventions in public space raised as a general issue. In particular the silo based delivery of NHS services appeared to militate against broader holistic tasks. One student identified mental health residential environments as a key problem area:“Everyone was overweight there, largely due to the medication, obviously, ‘cause of the mental health, how they are and they’re just not getting around as much, but then that © Institute of Health and Wellbeing 2014 commercial and in confidence

reflected in, we had a large amount of back pain patients, which indirectly is going to be linked to their obesity again.” Skills Students identified the skills required to conduct an accurate assessment of lifestyle and behavioural interventions, often requiring relatives and others to check that information was accurate:“Yeah, so, this was on a stroke setting. He’d had a large haemorrhagic stroke, so he, it was indicated that it might be alcohol-related to start off with, so when he, it was actually I think his, him and his wife both together giving the alcohol intake. When he said, “A couple of units a week” or, “A couple of pints a week,” I think his wife kind of, shook her head out of the corner of my eye, and so then that kind of, prompted you to delve a little bit deeper.” The ability to quickly develop rapport and to open up a conversation around stigmatised behaviours appeared to be much more challenging, with the potential for a hostile response a potential. The common sense nature of the objective of losing weight, giving up smoking, reducing alcohol consumption seemed to be opposed by the reception that such interventions met with, often resulting in an unwillingness to tread ion uncertain emotional ground. One of the common reasons given for not conducting lifestyle interventions was time:“I think it’s just difficult, although I think if you asked a lot of people, they know what they need to say, what they need to do. I think it’s just when you get into the wards and, like you said, you’ve got the time pressures, you’ve got everything else, and you’ve got a focus, that’s where things start to slip a little bit, in terms of Making Every Contact Count, in terms of their health.” For others, there was scepticism about the effectiveness of such approaches. Was it the traditional business of medicine and related professions? The need to ‘buy into’ the concept of behaviour change was also identified as a potential issue:“I think you’ve got to buy into it, I think as any health professional you’ve got to buy into it, into something. If you don’t see the value of it as an individual you are not going to implement that, however good or altruistic the motives are from a higher power. If you don’t buy into it, then you’re not going to, and then you will find barriers like time, and relevance and opportunity, to kind of, explain away your kind of, lack of compliance, or adherence, to it, so…” 33 © Institute of Health and Wellbeing 2014 commercial and in confidence

Students felt strongly that there was need to increase the amount of practical skills in order to overcome feelings of their own inadequacy:“I don’t see it as a focus, really, within our training at all. But quite a lot of things, mention passing the buck, a lot of our experience and professional training is promised to us on placement, so in a university setting quite often they’ll say, “Oh, we don’t need to discuss this, because you’ll learn all about this on placement,” and then quite often…” The two kinds of skills most commonly raised were how to evoke a change conversation with patients and how to respond if they resisted the idea of change:“I sometimes think it’s quite, it’s done quite kind of matter of factly and, we’ll just ask these questions because we have to. I don’t know, maybe just taking a more, you know, open approach on it. I don’t know, I feel sometimes when you say to a lady, oh I’ve got to ask these questions, they feel oh well, I’ll answer them the way you want me to then…” For some students the answer to resistance was an assertive response:“‘Cause when we was talking about resistance I, every patient you have got, we are always trying to push them to the next level, so even if there’s someone who, first day post-surgery don’t want to get out of bed, we get them up.” The role of mentors and the lack of priority on placements was also raised:“I think it’s probably more focused on in lectures to be honest, they do it out of there, but I think maybe it’s not kind of emphasised on, it’s not, you know, I’m doing this, obviously, when you’re doing a booking you’re asking about smoking, you’re asking about drinking and from that you’re, you know, you kind of try and do the health promotion there, but I think that it’s kind of more emphasised on, definitely, in university.” Summary Conclusion These findings from the student interviews highlighted a general willingness from students to engage in MECC and brief interventions. However, there was a sense that formal teaching around this was somewhat limited. What was clear however was that students had learnt a great deal about effective communication strategies both in University and placement and recognised their importance in developing positive relationships with service users.


The findings from the student interviews highlighted their overriding concerns about when, where, and when to initiate a brief intervention without breaching confidentiality, or anonymity. The nature of the environment in which the intervention takes place is highly significant, both in terms of privacy and in not causing embarrassment to both the recipient of the intervention and the practitioner. Learning how to deal with potentially uncomfortable, challenging, or resistive behaviours was also of major importance to this study group. The students identified the range of assessment skills and positive rapport building skills required to support this type of intervention. Learning to develop conversations quickly that develop rapidly into a supportive relationship, and learning to respond effectively to resistive individuals seemed to be clearly identified skills by the students. The positive support of knowledgeable mentors was also considered to be critical to the development of BI skills in the student. Some students expressed some scepticism about the success of BI, but most felt such approaches could be helpful in facilitating lifestyle change.

9 University Deans/NHS Board level staff telephone interviews This section provides an overview of the methods and results for the NHS Trust Board level staff and University Dean telephone interviews.

9.1

Methods

The NHS Trust Board level staff and University Dean telephone interviews were structured interviews, with several questions designed prior to the telephone interviews being conducted. Board level staff from NHS Trusts within the East Midlands as well as University Deans responsible for a range of health courses at Higher Education Institutions in the East Midlands were invited to take part in the telephone interviews. Additionally. Telephone interviews were carried out from early February 2014 until midMarch 2014 and took approximately 30 minutes to complete. A total of 26 one to one telephone interviews and one multi-person telephone interviews (N=2) were carried out, therefore a total of 28 Trust Board level staff/University Dean’s took part over 27 data collection session. Within that, 18 telephone interviews were carried out with Trust Board level Staff, broken down as follows:




5 telephone interviews across 4 NHS Trusts in Derbyshire (N=5); 



6 telephone interviews across 2 NHS Trusts in Leicestershire (N=6). 



2 telephone interviews across 2 NHS Trusts in Lincolnshire (N=2); 



1 telephone interview across 1 NHS Trust in Northamptonshire (N=1); 



4 interviews across 3 NHS Trusts in Nottinghamshire (N=5; 1 interview was a 2

    

participant interview);  9 telephone interviews were carried out with University Deans from 9 different HE Institutions.

9.2

Results

People: Practices and Relationships This section provides an overview of the practices and relationships between different people identified by University Deans and Trust Board level staff in shaping the teaching and learning of therapeutic relationships. Three groups of people were suggested within data to be directly involved in teaching and learning of therapeutic relationships: students; lecturers and practice mentors. The self-perceived roles of University Deans and Trust Board level staff were also suggested within the data. Direct Teaching and Learning Practices and Relationships: 

Disciplinary identities (e.g. nursing, physiotherapy, occupational therapy etc.) were viewed as shaping the extent to which students engaged with the teaching and learning of therapeutic relationships; 

 

Lecturers and trainers were required to be knowledgeable, enthusiastic and energetic whilst teaching using an assortment of approaches and methods; 

 

The openness and encouragement of practice mentors and staff to receive feedback from students was identified as a chief facilitative factor in enabling students to develop critical analysis skills; 

 

Qualified healthcare professionals understood the delivery of brief interventions and/or MECC as the responsibility of the student to put into action; 




It was suggested that more could be done to increase the awareness of students to the diversity of situations and health professionals working within communitybased settings; 

 

The ability of practice mentors to act as positive role models and demonstrate skills and abilities associated with therapeutic relationships was viewed as the decisive factor determining the quality of placements for students. Nevertheless, while some mentors demonstrated the attributes of a quality mentor (leadership, communication, good behavioural practices etc.), others found stances by professional bodies to be problematic as some staff were viewed as not having the right skills to foster and enable therapeutic relationships to develop; 

 

The culture within practice settings was viewed as a key determinant influencing the comfort of students when completing placements; 

 

The agenda and establishment of brief interventions via therapeutic relationships was described as being in transition and not fully realised within the broader healthcare system. 

Roles of University Deans: 

University Deans viewed themselves as being involved in the design and provision of courses but tended not to be directly involved in the delivery of training and teaching; 

 

Policy relating to MECC and/or brief interventions was central to the institutional strategic direction and was being used to set expectations for students with regard to the nature of the courses; 

 

The importance of acting as role models for staff in order to ‘set-the-tone’ within the institution to enliven strategies and policies was emphasised by University Deans; 

 

It was recognised that more development was required in terms of establishing a culture that enables therapeutic relationships to flourish. 

Roles of Trust Board level staff: 

Provision was required in terms of support, training, resources, time and reflective practice in order to galvanise staff to meet expectations and implement brief interventions and MECC policy; 




The empowerment of staff was viewed as critical to the delivery of quality teaching and learning opportunities within Trusts; 

 

Distilling key messages from national policy drivers and then communicating these points to Trust staff in order for them to put these messages into practice was a key role of Trust Board level staff; 

 

A principal challenge facing Trust Board level staff was overseeing long-term cultural change while simultaneously managing short-term crises. 

Learning Environments This section provides analysis of data relating to the ‘learning environments’ in which the ‘People: Practices and Relationships’ are set. As such, while University Deans and Trust Board level staff, module leads and mentors, and the students themselves shape the learning environment, this section focusses on the spaces and places in which brief interventions are learned. Three types of ‘learning environment’ were described by participants: organisational/institutional (i.e. University/Trust settings), practice (i.e. medical and community settings) and virtual (i.e. online spaces). Rather than being separate spaces of learning, these different environments should be understood as overlapping and interacting. Institutional/Organisational Learning Environments: 

The importance of spaces to simulate the environments that students will be located in practice was seen as paramount to the development of students to deliver and practise therapeutic relationships; 

 

Environments that offered adaptable learning spaces were seen as best facilitating students to develop skills associated with therapeutic relationships; 

 

A significant amount of focus and investment was/is being made into simulated community/residential and formalised healthcare spaces that allow students to practise their skills; 

 

Balancing an increase in student recruitment with a ‘blended learning’ approach which requires smaller and more intimate spaces was a core challenge in relation to timetabling and building layouts. 

Practice Learning Environments:




It was suggested that in some cases students were required to ‘fit-into’ the practice environment which speaks to the organisational commitment to teaching and learning; 

 

There was a degree of uncertainty whether every practice opportunity provided the optimal learning environment for students; 

 

University Deans saw themselves as being able to influence and set expectations regarding spaces for formal examinations but were to a degree powerless to affect the practice environment. 

Virtual Learning Environments: 

It was indicated that creating a virtual learning environment, though seen as beneficial to the learning experiences of students, was not within the ‘remit’ of some Trusts at present. 

 

Having a fast, pacey and dynamic virtual learning environment was seen as a critical component of the overall learning environment by University Deans and Trust Board level staff; 

 

University Deans tended to discuss a deeper integration of IT equipment within institutional spaces whereas Trust Board level staff suggested a more discrete and separate virtual learning environment from the Trust environment; 

 

Pace, functionality and intuition of virtual learning environments were emphasised as being critical to provide a richer environment for students to develop therapeutic relationships. 

Organisational/Institutional Policy and Strategy This section provides analysis of data relating to institutional/organisational policy and strategy, influencing both people in terms of practices and relationships and the provision/nature of learning environments. The section provides an overview of analytical themes relating to institutional/organisational values, strategy and policy, followed by an outline of comments concerning the review and progress of the therapeutic relationships agenda by University Deans and Trust Board level staff. Values, Strategy and Policy: 

Organisations/Institutions were in a state of transition and were redefining themselves in response to macro-level NHS shifts; 




While brief interventions and/or MECC were seen as influencing institutional values, strategy and policy, these agendas were positioned alongside other drivers which may reduce their capacity as policy to effect wholesale change in order to deliver, teach or foster therapeutic relationships; 

 

It was stressed that core values should be explicit, identifiable and embedded but that closing the gap between the strategic level of an institution and staff ‘on-thefrontline’ was described as a challenge; 

 

An important role of Trust Board level staff and University Deans was to align strategic direction with national drivers and ensure that the learning spaces within the respective institution allowed lecturers/trainers to teach and students to learn skills that reflect identified values. 

 

While therapeutic relationships are included within organisational/institutional values, strategy and policy, the agenda and focus upon this agenda loses and gains momentum in response to other and emergent priorities. 

Review and Progress: 

Brief interventions and/or MECC policy was seen as ‘woolly’ and not having robustness in terms of measuring performance; 

 

While institutional/organisational staff ‘sign-up’ and endorse different values systems, the capacity of senior management teams to witness and measure brief interventions in action was suggested to be very limited. 

 

Triangulated ‘metrics and audits’ were seen as tenuous in their ability to measure the quality and appropriateness of teaching that prepares students to deliver brief interventions and/or MECC; 

 

Mechanisms to measure and assess the teaching and learning of therapeutic relationships were especially reliant on the feedback of practice mentors; 

 

The response to reports and feedback of poor performance in relation to brief interventions was consciously managed in relation to the cultures of practice so as to foster the empowerment of students and staff. 


10 Conclusions and Recommendations The following conclusions summarise the key findings from the data from the perspective of each of the participant groups.

The PPI perspective From a service user perspective, brief interventions need to be delivered by trained practitioners with whom they have a positive, long-standing relationship or a trainee practitioner under direct supervision. Recommendation 1: The delivery of a brief intervention needs to be conducted in private, clearly and accurately documented, and be sensitive to context and personal circumstances. The programme lead perspective

The responses from the programme leads survey highlighted that brief interventions and/or MECC training is woven throughout all levels of educational programme, but more commonly in years 2 and 3, and is therefore not easily recognised explicitly as BI or MECC training. Some suggested that BI/MECC was not always taught or assessed specifically in the curriculum, but did suggest that the skills associated with these techniques are introduced to students in other parts of the training. The majority of programme leads (N=23, 88%) strongly agreed that they felt it was the responsibility

of

their

programmes

to

support

students

to

create

therapeutic

relationships. However, not all programme leads felt confident about their knowledge and understanding of brief interventions and the MECC agenda. Concern was expressed techniques such as these were being focused on at the current time, due to the political agenda being focused on public health issues; however, it was argued that if introduced in the right way, at the right time, and by skilled practitioners, the use of brief interventions could result in positive lifestyle transformations. Recommendation 2: Brief interventions should be clearly taught and assessed as a separate discrete element in the curriculum of all professional programmes. 41 © Institute of Health and Wellbeing 2014 commercial and in confidence

Recommendation 3: Programme leaders responsible for developing programmes which incorporate training on brief interventions should be knowledgeable and confident to support the delivery of training in these approaches. The student perspective

Almost half of the students stated that they were unsure about whether their course includes training on brief interventions (45%) and MECC (47%). Less than a quarter of students highlighted that their programme of study includes training on brief interventions (25%) and MECC (22%). Brief intervention and MECC training is largely delivered by embedding this training within one or multiple modules (BI=78%, MECC=100%), and a few students suggested that brief intervention and MECC training is a compulsory component of their course (BI=28%, MECC 13%). The majority of students highlighted that they either often (BI=33%, MECC=42%) or at least sometimes (BI=55%, MECC=29%) had the opportunity to implement brief interventions/MECC in the clinical environment. The findings from the student interviews highlighted a willingness from students to engage in MECC and brief interventions, but there was a sense that formal teaching around this was somewhat limited. However, students had learnt a great deal about effective communication strategies both in University and placement and recognised their importance in developing positive relationships with service users. The interviews highlighted students’ overriding concerns about when, where, and when to initiate a brief intervention without breaching confidentiality, or anonymity. Learning how to deal with potentially uncomfortable, challenging, or resistive behaviours was also of major importance to this study group. The students identified the range of assessment skills and positive rapport building skills required to support this type of intervention. Learning to develop conversations quickly that develop rapidly into a supportive relationship and learning to respond effectively to resistive individuals seemed to be clearly identified skills by the students. The positive support of knowledgeable mentors was also considered to be critical to the development of BI skills in the student. Some students expressed some scepticism about 42 © Institute of Health and Wellbeing 2014 commercial and in confidence

the success of BI, but most felt such approaches could be helpful in facilitating lifestyle change. Recommendation 4: Students should be introduced to the concepts associated with BI in their first year and have an opportunity to practice the skills associated with this approach in a safe environment i.e. simulation. Recommendation 5: Students in years 2 and 3 of training should have access to knowledgeable mentors who can competently supervise students who which to develop the skills associated with BI. Recommendation 6: Students should be taught about specific health issues (e.g. healthy eating, physical activity, sexual health) in order to increase their confidence to deliver brief interventions. The Trust Board level/University Dean perspective

A critical aspect of the agenda is understanding the context for the Brief Intervention encounter and/or training opportunity. An emergent theme from the data related to a synergy between different people, processes and environment; if a synergy is created that cuts through the different levels of the big diagram, BI is achievable, but if ruptures exist at different levels, it is not deliverable. A related point is the nature and type of relationship that exists both between student and mentor and well as peer relationships between healthcare professionals in developing therapeutic relationships within healthcare. The tension central to this issue is the extent to which lines of responsibility to deliver the Brief interventions/MECC agenda is an individual or collective endeavour. Indeed, expanding discussion above, data suggest that many students, who are seen as being placed to put-into-action these agendas implicitly learn that when they qualify such aspects become less of a priority with the void being filled by the next cohort or generation of students. More positive comments were made towards therapeutic relationships when the actions and attitudes reflected the sense of ‘togetherness’, with the key point being both student and mentor learning and developing the skills through shared encounters and practice experiences. The positions of participants should be noted as influencing the type of account provided. For instance, one participant discussed how it was relatively easy to ‘take the stance’ 43 © Institute of Health and Wellbeing 2014 commercial and in confidence

that would be defensive of the work and qualities of students while being cynical about an ‘uncaring NHS’. While noting this issue, the majority of participants were critical about the extent to which brief interventions and health promotion were implemented in practice. The need to empower champions of this agenda within the NHS to drive this agenda forwards and maintain its priority within departments is a critical theme that emerges from within the data. Students in many ways were viewed as the one who would drive this agenda forwards and are the future leaders in the NHS – thus it is critical to empower students to feedback poor performance and Trust Board level staff/University Deans must encourage feedback and this type of reporting. There is something in this concerning the preparation students are getting for the flexible/dynamic/transdisciplinary vision for NHS. This is about the end point of the transition the NHS is currently experiencing… what will the NHS look like in 30 years. This relates to recruitment strategies employed by institutions/organisations and the skills students need to demonstrate when being interviewed by universities. Data revealed how University Deans and Trust Board level staff, while providing valuable information and views concerning a host of issues, were perhaps distant from the ‘nutsand-bolts’ driving the teaching and learning ‘engine’. There were many instances where participants identified fundamental skills to the teaching and learning of therapeutic relationships, but used more oblique language concerning the ability of students to deliver brief interventions within different modules/placements. Recommendation 7: Mentors in practice, who are supporting and assessing student practitioners should have access to training designed to enhance their knowledge, skills and competence in delivering BI. Final recommendations 

There needs to be a clarification and standardisation of language associated with the concepts and policy context associated with the delivery of brief interventions and the MECC agenda. 

 

There is a need to identify and empower champions across the health sector to liaise with all stakeholders (HEIs, Trusts and HEEM) in developing a strategy to prepare students for the effective delivering of brief interventions. 


11 References Aalto, M., Pekuri, P. & Seppa, K. (2001) Primary health care nurses’ and physicians’ attitudes, knowledge and beliefs regarding brief intervention for heavy drinkers. Addiction. 96, 305-311. Alcohol Learning Centre. (2010) Guidelines for Commissioning Identification and Brief Advice Training. Burns, H. K., Puskar, K. R., Flaherty, M. T., Mitchell, A. M., Hagle, H., Braxter, B., Fioravanti, M., Gotham, H. J., Kane, I., Talcott, K. S., Terhorst, L. & Woomer, G. R. (2012) Addiction training for undergraduate nurses using screening, brief intervention, and referral to treatment. Journal of Nursing Education and Practice. 2 (4), 167-177. Burrows, M., Morleo, M., Cook, P. A. & Hannon, K. (2009) Lancashire: Brief intervention online training evaluation. Centre for Public Health: Liverpool John Moores University. Callaghan, D.& Jennings, B. (2002) Ethics and public health: forging a strong relationship. American Journal of Public Health, 92, 169—76 Carter, S., Kerridge, I., Sainsbury, P. & Letts, J. (2012) Public health ethics: informing better public health practice. NSW Public Health Bulletin, 23(5-6), 101—6. ChaMPs Public Health Network (2012) Brief intervention training for undergraduate nurses in Cheshire and Merseyside: a three year evaluation report 2009-2012. ChaMPs: Wirral. Drummond, C., & Deluca, P. (2012) Alcohol Screening and Brief Intervention in Emergency Departments, Institute of Psychiatry, King's College London, 2012. Gaume, J et al. (2010) Counselor motivational interviewing skills and young adult change talk articulation during brief motivational interventions. J Subst Abuse Treat. 39 (3), 272-81. General Medical Council (GMC). (2009) Tomorrow’s doctors: outcomes and standards for undergraduate medical education. London: General Medical Council. Hopkins, J. & Phillips-Howard, P. (2010) Evaluation of peer training course to implement a sexual health kitbag in Cheshire and Merseyside. Centre for Public Health: Liverpool John Moores University.


Jallinoja, P. (2002) Ethics of clinical genetics: the spirit of the profession and trials of suitability from 1970s to 2000. Critical Public Health, 12(2), 103—118. Jepson, R. (2000) The Effectiveness of Interventions to change Health-Related Behaviours: a review of reviews. Medical Research Council Social & Public Health Sciences Unit Jepson, R., Harris, F., MacGillivray, S., Kearney, N. & Rowa-Dewar, N. (2006) A Review of the effectiveness of interventions, approaches and models at individual, community and population level that are aimed at changing Health outcomes through changing knowledge, attitudes and behaviour, Cancer Care Research Centre, University of Stirling & Alliance for Self Care Research, University of Abertay Knight, K.M., McGowan, L., Dickens, C & Bundy, C. (2006) A systematic review of motivational interviewing in physical health care settings. Br J Health Psychol. 11 (Pt 2):319-32. Lancaster, T. & Fowler, G. (2008) Training health professionals in smoking cessation. Cochrane Database of Systematic Reviews. 2000 (3), 1-16. Lupton, D. (1995) The Imperative of Health: Public Health and the Regulated Body. London: Sage. Lupton, D. (2012) Fat. London: Routledge. Marmot, M. (2010) Fair Society, Healthy Lives. London: The Marmot Review Mcavoy, B.R. (1999) Alcohol education for general practitioners in the united kingdom — a window of opportunity? Oxford Journals Medicine Alcohol and Alcoholism. 35, (3), 225229. National Youth Agency. (2011) Brief interventions: training for youth support staff in Coventry [online]. Available at: http://nya.org.uk/dynamic_files/yw4h/coventry%20brief%20interventions%20flyer.pdf (Accessed 6th June 2013). NICE. (2007) Behaviour Change, National Institute for Clinical Excellence, Public Health Guidance #6 Petersen, A. & Lupton. D. (1997) The New Public Health: Health and Self in the Age of Risk. London: Sage.


Roche, A. M., Stubbs, J. M., Sanson-Fisher, R. & Saunders, J. B. (1997) A controlled trial of educational strategies to teach medical students brief interventions skills for alcohol problems. Preventive Medicine. 26, 78-85. Stop Smoking Wales. (2013) Brief Intervention for Smoking Cessation [online]. Available at: http://www.stopsmokingwales.com/brief-intervention-training. (Accessed 6th June 2013). Taylor, D., Bury, M., Campling, N., Carter, S., Garfield, S., Newbould, J., & Rennie, T., (2006) A Review of the use of the Health Belief Model (HBM), the Theory of Reasoned Action (TRA), the Theory of Planned Behaviour (TPB) and the Trans-Theoretical Model (TTM) to study and predict health related behaviour change West, D. & Saffin, K. (2008) Literature review: brief interventions and childhood obesity for the North West and London Teaching Public Health Networks. Public Health resource Unit, NHS.


Report compiled by: Institute of Health and Wellbeing © 2013 The University of Northampton Boughton Green Road Northampton NN2 7AL Tel: (01604) 892887


Appendix 1

EAST MIDLANDS LOCAL EDUCATION TRAINING BOARD

Specification to deliver a research project that reviews the education available to the East Midlands workforce developing skills to improve the health and wellbeing of individuals and the population.

Lead Manager:

Di Roffe Faculty Advisor

Responsible Officer:

Trish Knight Director of Workforce

Response date:

to

specification March 5th 2013

Address for Correspondence:

[email protected]

General information

The East Midlands Local Education and Training Board (LETB) wishes to receive quotes for the delivery of the Specification outlined in this paper. The LETB reserves the right to amend the Specification at any time and to not to accept any quote for work submitted in response to this paper at its sole discretion.

This paper has been prepared for information purposes and does not in itself constitute a contract. Whilst the paper has been prepared in good faith, the LETB does not accept liability for any loss or damage arising from information or omissions so contained.

Process time-table:

Potential providers identified

February 21st 2013

Specification sent to potential providers

February 21st 2013

Response to specification received

March 5th 2013

Successful respondent commission Commission to commence

informed

of March 8th 2013 March 11th 2013

Responses should be sent to [email protected] c.c. [email protected] Queries relating to the Specification should be made to Di Roffe [email protected] or the above address.

Introduction

The East Midlands Local Education agreed that the promotion of health priorities for the organisation. As the opportunity to consider how this can effective way.

and Training Board (LETB) have and wellbeing will be one of four LETB is created there is a unique be achieved in an innovative and

Background

Improving health and protecting the health of populations is a key role of government. The approaches used to achieve this have been well documented and shared with innovative and effective approaches coming from a range of sectors and settings. There continues to be an expectation that organisations responsible for health and wellbeing care and safety use every opportunity to impact positively on people’s health and wellbeing.

However, the challenges remain. Healthy Lives, Healthy People: our strategy for public health in England highlighted that people living in the poorest areas on average, die 7 years earlier than people living in richer areas, spend 17 more years living with poor health. Enabling adults to change their behaviour for example could reduce premature death, illness and costs to society, avoiding a substantial proportion of cancers, vascular dementias and over 30% of circulatory diseases.

Nationally the NHS Commissioning Board’s draft mandate (July 2012) includes an objective stating healthcare professionals across the service “should take all appropriate opportunities to support people to improve their health”, with a key role of the Board being the embedding of public health in commissioning. In addition a key recommendation of the NHS Future Forum is that healthcare professionals should “make every contact count” using every contact with an individual to maintain or improve their mental and physical health and wellbeing where possible.

The East Midlands LETB constituency includes organisations and individuals from all sectors who have demonstrated ongoing commitment to improving population health by developing the healthcare workforce. This includes the development and testing of guidance to support positive lifestyle change that informed the “Implementation Guide and Tool Kit for Making Every Contact Count”.

The LETB believes it will best deliver this aim by focusing on the ability of the existing and future workforce to create and sustain effective therapeutic relationships which enhance the whole health and wellbeing of the individual and those who care about them. The aim would be to ensure that the whole workforce is equipped to have the right conversation at the right time.

Specification

To support the achievement of the priority to promote health and wellbeing, the East Midlands LETB is seeking to commission a review of related education provision for the healthcare workforce. This work will be dynamic and requires a flexible response by the successful bidder in working with the agents concerned. It will involve the project planning and co-ordination for the following activities (not exclusive):

1. Review of current education provision on ‘Creating effective therapeutic relationships to enhance the health and wellbeing of the individual and those who care about them in the East Midlands’ to include:  What is provided?  How is it provided?  How are the outcomes measured?  What are the barriers and opportunities?  What are examples of good practice?  What can we build on?  What should we drop?  How does it support the development of Shared Decision making (see appendix 1) 2. Identify students and medical trainees’ perceptions on their responsibility in learning to create these relationships. 3. Identify educators’ perceptions on their responsibility in helping learners create these relationships. 4. Identify at organisation board level the Education Provider perception of their role in:  Providing the environment where students and medical trainees can really practice their skills and demonstrate empathy  Providing a culture which enables these relationships to flourish.

Report on findings to include recommendations to LETB on achieving its aim.

RESPONSE CRITERIA

The LETB is requesting an itemised response to the specification which will be judged on a best value for money basis (60% quality and capability / 40% cost).

The respondent is requested to include, as a minimum:  

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An outline of their experience, capacity and capability in undertaking the Specification outlined above An outline of the respondent’s experience in the following areas; report writing and analysis, understanding of quality assurance processes, understanding of healthcare education provision, communication and engagement Ability to engage with and present to a range of stakeholders Professional profiles of those who will undertake this work In light of the dynamic nature of the work outlined the SHA requires flexibility from the respondent in carrying out this piece of work. However, in order to adjudge the cost element of the bid respondents are requested to offer a cost based upon anticipated number of days which should not exceed 50 days plus the likely overhead expenses incurred The LETB would wish the work to commence as soon as possible after 1st March 2013 and be completed by 31 July 2013.

If you have any queries or require any additional information regarding this commission please feel free to contact the Lead Manager directly [email protected]