The impact of expert by experience involvement in teaching in a DClinPsych programme; for trainees and experts by experience

Abstract Introduction There is a growing acknowledgement of the value of creating partnerships between those delivering and those accessing health services. Less is known about this in the context of clinical psychology doctoral training programmes. This study explores the models of involvement of experts by experience (EbEs) in teaching on a DClinPsych course in England; the impact of this both for EbEs and trainee clinical psychologists and whether improvements are required to better meet their needs. Methods An audit of current involvement was conducted by reviewing course records. Two survey questionnaires designed around commonly used frameworks of participation and reflective learning were completed by EbEs and trainees. Thematic Analysis was used to evaluate the written feedback from the surveys. Results Records of current EbE involvement were found to be lacking in detail and sometimes missing. Key themes extrapolated from the surveys highlighted the importance of EbE involvement in supporting the wellbeing of EbEs and the learning experiences of trainees. Conclusions Recommendations with regard to the processes for future involvement of EbEs in teaching are put forward. Patient or Public Contribution A carer of a service user was consulted about the design of the participant information sheet, consent form and the survey questionnaire which was sent to the EbEs. A trainee clinical psychologist was also consulted to provide a trainee perspective on the above forms and the survey questionnaire that was sent to trainees. Further to this, the first author's supervisor identifies as a user of physical and mental health services and provided continued supervision and support regarding the direction of the study including the research questions, design, methodology and interpretation of results.


| INTRODUCTION
Experts by experience (EbEs) are people with lived experience of using or caring for someone who uses health or social care services. 1 EbEs are thought to bring invaluable insights and perspectives, via their personal expertise, to the training of health practitioners. 2 The importance of encouraging patient participation and co-production has been emphasised in statutory guidance, 3 and there is growing recognition of the value of EbE involvement in NHS training programmes such as the Doctorate in Clinical Psychology (DClinPsych).

| Impact of involvement for EbEs
Closer partnerships between EbEs and organisations involved in their care can bring about a sense of empowerment, confidence and wellbeing for EbEs. 4,5 This is thought to in part be due to a breaking down of stigmatising power differentials through greater contact between EbEs and professionals, in the context of equal status. 6,7 The redistribution of power hierarchies is central to the Ladder of Participation 8 ; an eight-step model that provides a benchmark for understanding different levels of involvement, ranging from 'manipulation' to 'citizen control' (Figure 1). 8 It measures the extent to which EbEs are provided with opportunities to exert influence and power in the health system and their own care, 9 taking account of their personal 'choice' over the position they wish to hold. 10 Despite national guidelines, research studies show that there can be a gap between what is recommended and what is delivered with regard to EbE involvement in healthcare training settings. 11,12 Therefore, there is an ongoing need to evaluate the level of EbE involvement in clinical psychology training, to ensure that it remains beneficial and meaningful, rather than tokenistic, for those involved. 13 1.2 | The impact of involvement for students Studies show that students, including clinical psychology doctorate trainees, feel that EbE involvement in their education, can improve their clinical practice by helping them reflect on their therapeutic relationships. 14,15 The process of learning is promoted by experiences of reflection that occur within a social context. 16,17 In line with Kolb's reflective cycle (Figure 2), EbE involvement in teaching may offer greater opportunities for learning by reaching students on an emotional level and supporting the transformation of experience into learning and new behaviour. 17, 18 Kolb's reflective cycle has been used to conceptualise the process by which EbE involvement in social work training can promote trainee learning by building greater reflective awareness that can then be taken into their practice. 19 As yet, this model has not been used to evaluate the impact of EbE involvement in the training of trainee clinical psychologists.
In line with ongoing plans to increase EbE involvement in a UK DClinPsych course and move towards a position of co-production

| Design
The study employed a qualitative survey design that was approved as a service improvement project by the local NHS Trust. It was guided by the Model for improvement and aimed to gather the information required to generate change ideas and recommendations for EbE involvement in teaching on a DClinPsych course. 20 The survey approach was chosen to allow for a broader range of perspectives to be collected, compared to an interview approach which may not reach as many participants.

| Procedure
An initial audit of the record of EbE involvement in teaching was conducted by requesting information by email from 13 course teaching leads regarding the number of teaching sessions that included EbEs, and details of the format of involvement.
The online survey platform, Qualtrics, was used to create and store answers from two separate survey questionnaires that were provided to the PEG and trainees respectively. Each survey began with an initial participant information sheet and consent form that participants were required to complete before progressing to the full survey.
The PEG survey included a demographics questionnaire which was followed by 15 questions that were underpinned by the Ladder of Participation. 21 Therefore, questions targeted the broad themes of 'level of involvement' (e.g., 'what kind of way were you involved in teaching?'), 'impact' (e.g., 'How might PEG involvement in teaching impact PEG members?') and 'improvement' (e.g., 'how would you like PEG involvement in teaching to change?') (Appendix B).
The trainee survey included 10 questions that were underpinned by Kolb's Learning Cycle. 17 In this way, the questions targeted the

| Data analysis
The thematic analysis procedure described by Braun and Clarke 22 was used to manually code and analyse key themes in survey responses. The PEG and trainee surveys were analysed separately.
The free text for each survey was read and reread to ensure familiarisation. Key words or phrases were highlighted, and the 'comment' function in Word was used to develop initial codes alongside the text data. These codes were then organised into categories of repeated patterns, or themes. An inductive approach to analysis was taken, to ensure that the themes would closely reflect participants' experiences rather than be driven by specific research questions. Provisional themes were reviewed to check that they (a) reflected the codes, and (b) reflected the semantic content of the data set as a whole. Interpretations and conclusions were reviewed and discussed in meetings with the research team. The research team was made up of a trainee, PEG member and course tutor. It was therefore important for them each to reflect on their own positions in relation to the topic and how this might influence their interpretation of the data. Where possible, the words used by participants were included in the theme title. Quantitative data derived from the two surveys were summarised by descriptive statistics.

| RESULTS
The initial audit of EbE involvement in teaching revealed that 9 out of the Overall, the audit demonstrated that there was no current centralised or agreed upon method for recording data about EbE involvement, and the level and detail of data recorded varied across teaching.

| PEG survey
Of the 14 PEG members who were provided information about the study, 12 (83%) consented to complete the survey. Two of these 12 did not continue past the initial consent stage, leaving 10 participants who completed the survey in full. The majority were female (60%), aged 36+ (90%) and identified as white (80%). Seven had been PEG members for 1-2 years and three for 10 years. Eight considered themselves to have a mental health difficulty, seven a physical health difficulty and three stated they were caring for someone with a mental health difficulty. Five had completed a bachelor's degree and one a doctorate degree. Four were retired, three were working part-time, one was self-employed and one was a student. The majority identified with a religion (six Christianity, two Islam) and five of these were actively practising.
The initial questions on the survey asked about their level of involvement in teaching in the 2020 academic year. Seven PEG members stated that they had been directly involved in teaching, with the majority having heard about involvement through a course email or PEG meeting.
They identified types of involvement as 'talking about lived experience in large or small groups', 'co-presenting' and 'leading small group discussions'. Three PEG members stated that they had not been made aware of the opportunities available for involvement.

| Informing change
Eight (80%) of the PEG members surveyed, commented on a motivation to bring about change in themselves, the trainees, and future clients. Two EbEs also named specific clinical areas in which they hoped to influence through involvement.

| Flexible opportunities
Several PEG members felt that further training in teaching delivery, including training in using 'Zoom', would support them and their future careers.
Getting more training and certificates that may help us getting into employment or education in the future.
(EbE 10) The ability to join teaching sessions online was also thought to be an important factor for increasing access, for one PEG member: Virtual access has enabled me to be involved, without concern about accessibility issues and travel. (EbE 6)

| Keeping EbEs informed
Three PEG members commented on the importance of having information about the teaching session beforehand and a space to debrief afterwards.
It is helpful to always have a pre-meeting to meet the tutor and discuss and plan how you are going to be involved. (EbE 4)

| Potential for distress or discomfort
All PEG members felt there was potential for discomfort or distress for the EbEs involved in teaching, due to the nature of the content or the questions asked. It has made me more appreciative of people's journeys before they come to see psychology, for example have they got a child with a learning disability, did they go through a mental health crisis in a different country, have they had a life changing injury? (T21)

| Permission to be curious
Trainees valued the opportunity to speak more informally with EbEs in small groups and have permission to ask questions.
They are so powerful and insightful and it's such a privilege to hear people's narratives and be able to ask

| Emotional learning
Eight trainees talked about the role of emotional learning in promoting their ability to remember and act on teaching that had involved EbEs.
It is often an emotional interaction to hear from EbEs.
It has been difficult to listen to some of them, but they are the teaching sessions that stand out in my mind as

| Support for trainees
Six trainees wrote about finding some EbE teaching sessions emotionally challenging to 'sit with'. One trainee suggested a need to support trainees following these sessions, and another felt it was helpful when lecturers prepared them for emotional content and gave them time to process it following lectures.
…I think sometimes stories can be harrowing, and it's really useful for the session leader to name this, and make sure we take time out for ourselves after meeting them (i.e. by putting the stories just before lunch, etc). (T9) While being exposed to these feelings of distress was felt to be crucial by one trainee, they also recognised the limits of online teaching in ensuring trainees connect with these experiences.
… it can be hard to sit with that emotion on Zoom vs in the room, although I think it is important for us as trainees to be exposed to these discussions early in training. (T15)

| Integrating EbEs into teaching
There was an overarching theme of trainees (70%) considering the process in which EbEs were involved in teaching sessions.

| Support for EbEs
Eight trainees considered ways of supporting EbEs to ensure they had a helpful experience of teaching. They recognised the possibility of EbEs feeling uncomfortable when asked certain questions, and therefore the importance of trainees and EbEs agreeing on how to navigate challenging questions.
…it was always helpful to navigate this discussion with some 'ground rules' (e.g. saying that they can simply choose not to answer any questions that feel too personal/uncomfortable). (T15) One trainee felt that EbEs needed further support with online tech support during teaching sessions. The initial audit revealed that records of involvement varied in quality across teaching, with some gaps in evidence regarding whether EbEs were involved at all in some teaching areas. The lack of consistent record keeping meant that it was not possible to report on the number of lectures that involved EbEs, however, nine of the 13 teaching streams were found to involve EbEs in some way. Levels of involvement varied, with some EbEs choosing to talk about their personal experiences, and others co-presenting teaching material or being more actively involved in the design and production of a lecture. At the same time, some EbEs reported to have not been made aware of their options for involvement. Therefore, the degree to which power was shared, and therefore the level of participation, 8 appeared to vary across teaching and EbE.
The PEG survey showed that involvement such as sharing personal experiences or answering trainee questions promoted selfconfidence and a sense of purpose from creating positive change for others. The PEG survey also highlighted the need for EbEs to be fully informed and supported in teaching, through the provision of information, debrief meetings and further training where appropriate. Therefore, while these findings are consistent with other studies showing that service user involvement in mental health systems has therapeutic benefits for EbEs, 23 there is also a need to ensure they are properly supported to ensure their involvement lands higher on the ladder of participation. 8  for EbE sessions, and incorporating more time for reflection. In line with the audit, trainees felt there was some disparity in level of involvement from different patient groups across teaching, and felt this was an area for improvement, to move closer to co-production.

| Limitations
The survey methodology, while chosen purposely to allow access to a greater number of participants, was limited with regard to the level of exploration afforded around each question. Additionally, recruitment of EbEs through the PEG is likely to have reduced the heterogeneity of the sample, as many of them were highly educated and interested in research. There is therefore scope for future research to incorporate wider recruitment strategies and utilise interview methods to enhance the current findings.
The analysis and interpretation of the results are likely to have been influenced by the positions and perspectives of the researchers.
The team worked closely to ensure that the codes and themes closely matched the extracts to ensure that important aspects of the data were not overlooked. 26

| Clinical implications and future directions
The lack of recorded data with regard to EbE involvement in teaching,

CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.

ETHICS STATEMENT
According to the HRA decision tool, this project falls into the category of service evaluation/audit. Therefore, NHS approval was not required. Service evaluation approval will be sought before commencing the project. Design and embedding Improving

ORCID
Maintaining and continue move towards co-production The PEG aims to develop a selection process for new membership, with the aim of increasing diversity and experience within the group. The course will run an open day for interested parties to hear more about the role. An information sheet and role specification will be developed and shared with interested parties. Following this, a one-to-one meeting will be held and if it's felt by both parties that joining the PEG would be of benefit, a 3-year term of office will begin. This includes an induction training session and induction pack. New members will be allocated a mentor (who will initially be a course staff member but as the PEG is further established, experienced PEG members will be mentors). The PEG will meet quarterly and will comprise: -Approximately 8 people with personal experiences -2 course staff one trainee from each year (minimum) There will be PEG representation in all streams.
Academic (co-facilitating teaching), clinical (attendance at the practice and placement committee) and research (attendance at PAS, consulting on trainee research projects and attendance at the research committee). A PEG member will be represented on each course committee (including admissions) and will feedback to the PEG group quarterly. A PEG member will also attend GTiCP.
The second year of the PEG implementation will focus on building on the initial progress from year one. This includes: Research PEG members with an interest and/or experience in research will act as collaborators/co-supervisors (as appropriate) for trainee research projects. This will include training for PEG members interested. The PEG will have greater involvement with trainee research through informal lunches following PEG meetings. Trainees can join the lunch to discuss their project and research ideas in a less formal setting with members, to share ideas and promote collaboration. Academic A PEG member will be linked in with each stream lead to provide input when reviewing the content of teaching for the following year, and to review trainee's feedback on teaching for each stream.

Admissions
The aim by this stage is to include a PEG member in the video task design and production. In addition, we plan to have a PEG member available each day at interviews to welcome applicants and to be involved in invigilating the video task.
Further aims for the final phase include an increase in PEG presence for admissions, with a PEG member on each panel for clinical interviews and a member working with the video task team. PEG members will also sit on interview panels for new course staff. In addition, the formation of a young person's PEG will begin. The aim is to establish a small (3-4 person) group who meet biannually comprising young people and young carers. The remit of this group will be much smaller than the original PEG. By this phase the aim is to recognise and measure the impact of the existing PEG group through a PEG annual report and research project. PEG members who were recruited in 2020 will be reaching the end of their term of office and future recruitment and signposting will be considered. Finally, future aims will include a PEG conference and publication of any research projects. PEG members will be paid for their time in accordance with Oxford Health FT guidelines.