Involving people with lived experience in physiotherapy education – Research report

In September 2014, the physiotherapy regulator for England and Wales (Health and Care Professions Council) introduced an education and training standard requiring service user and carer involvement in all approved programmes (HCPC 2018) including physiotherapy. Despite this, a scoping literature search on the involvement of people with lived experience in physiotherapy education and training returned only two results (Thomson and Hilton 2011, 2013), both of which pre-date the regulatory requirement. This means that there is no documented scientific literature on a client's lived experience involvement in a physiotherapy course since the introduction of this standard.


Introduction
In this series of reports, we present three research reports critically reflecting on the involvement of people with lived experience in a UK based physiotherapy degree programme.Each report is written from the distinct perspectives of the co-authors and includes an introduction to set the scene, reflections from the co-authors and a discussion and conclusion (see reports two and three).
In September 2014, the physiotherapy regulator for England and Wales (Health and Care Professions Council) introduced an education and training standard requiring service user and carer involvement in all approved programmes (HCPC 2018) including physiotherapy.Despite this, a scoping literature search on the involvement of people with lived experience in physiotherapy education and training returned only two results (Thomson andHilton 2011, 2013), both of which pre-date the regulatory requirement.This means that there is no documented scientific literature on a client's lived experience involvement in a physiotherapy course since the introduction of this standard.Prior to this, Thomson and Hilton report from both the student (2011) and the service user (2013) perspective on the involvement in a physiotherapy programme.They identify clear impacts on students' process as a result of 'becoming ' a physiotherapist (2011:47) and benefits to the service user of participating (2013).Impacts on students included enhancing communication, challenging assumptions and offering students a halfway house between the classroom and clinical practice (Thomson and Hilton 2011).Further evidence of the impact of public involvement in physiotherapy education is distinctly lacking.Whether this is due to a lack of activity; a lack of reporting; or a lack of value placed on public involvement in physiotherapy education remains unclear.What it does suggest is the absence of a well-developed culture and framework for high quality, evidenced informed public involvement activity in physiotherapy education in the UK, which needs to be addressed.
As a public involvement in education and research partnership based in a Faculty of Health and Social Science in England, this lack of published evidence led us to acknowledge that despite extensive embedding of lived experience expertise in our physiotherapy programme, we had not reported or published this work outside of our faculty.This paper is part of a series of three case studies where we report on different activities to showcase approaches to public involvement in physiotherapy education (see also part two: Harnessing the expertise of people with lived experience (Easterbrook, Blackman, Collins and Hughes 2022); and part three: Developing equal partnerships (Buckley, Fazakarley and Hughes 2022)).
In keeping with our partnership approach of bringing people with lived experience and academics together to work as equal partners, each of the case studies has been codesigned and co-authored.Our primary goal is to establish an empirical evidence base for public involvement in physiotherapy education and to encourage other educators to follow suit.
In part one, we critically reflect on the challenges and enablers for effective involvement; and consider the impact on all participants in the learning process.We focus on the collaboration between Rachel (person with lived experience) and Vikram (physiotherapy lecturer) in the design and delivery of a physiotherapy teaching session on abdominal surgery.Specifically, we discuss the importance of collaboration and shared critical reflection when developing content and improving its delivery year by year.In his seminal work in 1983 on reflection both in and on action, Schon outlined the process of professionals reflecting both during and following an event.He argued that the benefits of reflecting on action (after the event) include being able to generate ideas on what to change in the future (Schon 1983(Schon , 1987)).The process of reflecting together on an unexpected experience (what Schon describes as backtalk or dealing with surprises) enabled Rachel and Vikram to make changes to the design and delivery of their session which enhanced the learning experience for subsequent students.

Report
My name is Rachel and I am a PIER (Public Involvement in Education and Research) Partnership member at Bournemouth University.I have taken part in many sessions where I have shared my experience of being a patient and highlighted different aspects of my care relating to the audience.Before Covid hit I took part in a few sessions on campus where I shared my health journey with 1 st year physiotherapy students and discussed my physiotherapy involvement.I am an ex-Health Care Professional who had to leave my career due to my bladder and bowel failing at the age of 21 due to autonomic neuropathy.Subsequently, I have had my bladder removed and a urostomy formed as well as my large bowel diverted, and an ileostomy formed.My adversity has led to a deeper acceptance of myself and a purpose to help share my experiences for students and healthcare professionals to learn from.
My name is Vikram and I am a lecturer in physiotherapy.In 2019, I was presented with a great opportunity of teaching abdominal surgery and the importance of physiotherapy management.Teaching this content was my first-time teaching in this unit.The learning objective of that week was to understand the anatomy, physiology and clinical presentation with physiotherapy management for abdominal surgery.One of the unit objectives was for students to understand the concepts of humanisation of care (Sidani & Fox, 2014;Todres et al., 2009).For this, I requested the involvement of a physiotherapy service user from the PIER partnership and was paired with Rachel who had been involved in this session previously.For the first session we delivered together, Rachel presented her entire clinical, surgical history and management to the students with a PowerPoint presentation.The students actively engaged by discussing the content and asking questions to Rachel.I know that Rachel however did not feel that the session had been as well received as in previous years.
Rachel (PIER member): I have done this quite a few times and each session has been different.The first time the students were engaged.I started off asking what their first assumptions of me were.Then I showed a picture of my stoma bags highlighting invisible illnesses and not to judge a book by its cover.They seemed to listen and asked questions.When repeating this session for Vikram and a different cohort, they were not really engaged, and I felt they missed the point of my session.Instead of understanding my lived experience holistically they were only interested in physiotherapy involvement.I guess I felt a bit disheartened afterwards but then I reflected on how I could change the way I delivered my session to get the engagement.
Vikram (physiotherapy lecturer): Being a tutor, to develop reflective practice, I critically reflected on Rachel's session by incorporating my personal beliefs about teaching and learning (Larrivee, 2000).My feeling is that Rachel played a key role in actively facilitating the session through lived experience as a patient-teacher to enhance student learning (Jha et al., 2009).In this session, the students understood the clinical nature of the condition as they were able to reproduce the clinical and surgical picture of the clinical condition.On reflection however, I identified that the students felt there was not much discussed or presented about the importance of physiotherapy even though the discussion following the presentation went well.I also reflected that I could have done this session better by incorporating the role of the Multi-Disciplinary Team (MDT) along with Physiotherapy management to the students.This is something that my programme lead identified as a good focus when involving service users in a session.I realised that informing Rachel of the learning objective and content ahead of the session would have led to a better student learning experience.I realised that I could collaborate with Rachel as a co-facilitator in teaching as she lives with the experience and has this expertise.
Rachel (PIER member): Roll on a year and I was asked to deliver the same session again on Zoom due to the covid restrictions but this time with more focus on my surgery.Vikram contacted me and this time we had a session before hand where we worked out exactly what points I would mention.I discussed my concerns from the session before and surprisingly I was quite nervous to deliver this again and part of me thought to decline.However, I felt reassured after the preparation session with Vikram, and the Zoom seminar was booked.
On the day, there were a few technical problems my end and I was slightly flustered, but the session went very well.The students were very engaged, full of questions and, with my guidance, tried to put themselves in my shoes.I made my presentation more relatable to the topic of abdominal surgery instead of previously delivering points that I wanted to get across.I tried to view what the student group wanted and needed.This felt completely different from the previous sessions.I was surprised because being on Zoom I did think it wouldn't work so well.I believe looking at the way I delivered my sessions and working closely with Vikram I was able to tweak what I did for the audience and still get certain points across that I wanted to such as how the little things are the big things and to see the patient as a whole and not just their intervention.I imagine there was a lot of learning on all fronts.There were no suggestions from students in their feedback to change the way we delivered it, which was a good bonus.
Vikram (physiotherapy lecturer): As Rachel explains, we met approximately a month before the session through Zoom to plan the content together and this time, I explained about the learning objective of the session.In this discussion, I suggested that Rachel focus on one aspect of her history.We agreed that she would share and present one surgical condition with a focus on the care received in the Intensive Care Unit (ICU) and in the ward along with the role of Multi-Disciplinary Team (MDT) and physiotherapy.I was thinking this more focused action plan for the session would improve the students' understanding of the condition.In preparation for the week, I prepared a short podcast related to abdominal surgery and this was posted on the online learning platform along with the indications of surgery.A week before the session, the students were given a short introduction regarding Rachel's medical and surgical history in a word document and students were requested to have one or two questions to discuss with Rachel on the day.
Rachel (PIER member): I felt the session had a lot of impact not just for the students but with myself.The students seemed very engaged, and I felt happy and relieved when there were questions at the end.What really was beautiful was a student sharing their own experience of surgery and relating to some of the things I had felt, like isolation and feeling scared.This identification seemed to keep engagement and it worked very well to have another story back up my experience.
Vikram (physiotherapy lecturer): The session was well received by the students on the day, and this was further reflected in the mid unit student evaluation.Students responded well to the session and reported feeling more positive and confident afterwards regarding abdominal surgery.I too felt that the session had gone well by achieving the learning objective of the week.Students understood the humanisation principle, the role of the MDT and physiotherapy.The short podcast and the short introduction also helped the students in understanding the condition.Having these initial preliminary meetings with Rachel prior to the session really assisted me in terms of organising the ideas and mapping the learning outcome for the session.The preparation session was both informative and thought provoking.I learned that it is important to think of every teaching activity and how that activity is going to serve the students and meet our learning objectives.I also learned how to facilitate the student and service user session more successfully by maintaining a broader perspective of the content and considering the students' needs first and foremost.Perhaps, teaching this content taught me how to facilitate and organise a service user session by being more collaborative and drawing on the expertise of the service user from the planning stage.
I am now planning for similar activities for other clinical scenarios for the unit as this will enhance students' learning and understanding.I believe, by having patient teachers for teaching physiotherapy courses, we are regarding them as partners in student education (McKinlay et al., 2009).
Rachel (PIER member): It is an honour to be a PIER member and to have a purpose again knowing that my adversity and experience can impact and help mould future healthcare professionals.What means a lot to me is that sessions are co-produced before delivering.It enables me to work out what is needed from my input and to discuss different avenues with the lecturers.

Discussion and conclusions
Rachel (PIER member) and Vikram's (physiotherapy lecturer) accounts illustrate a process of reflecting on action that led to improved outcomes for students.It was also a more satisfying experience for Rachel and Vikram who both identify improvement to their own teaching as a result.In their paper focusing on service user perspectives of involvement in physiotherapy education, Thompson and Hilton (2013) identified service user motivations for involvement as including the wish to foster a sense of partnership, to communicate 'what it was like on the other side', to cut across theory and to challenge perceptions of disability (2013:155-6).These were all reflected in Rachel's account and the outcomes identified by students and by Vikram.As a public involvement in education and research partnership, we coordinate over 1,000 direct contact hours between people with lived experience, academics and students each year.In our experience, co-designed, delivered and evaluated sessions which value professional, academic and lived experience expertise have the most impact on student learning.Had Rachel not had the confidence to share her views on the initial session not being as well received, or if Vikram and Rachel had not met to explore why this was and what could be done differently, it is likely that the experience would have been repeated and the opportunity to improve would have been missed.As Rachel identifies, she would most likely have declined to take part again.The benefits of reflective practice including collective and shared reflective processes are well documented.Fook (2015) identifies the benefits of group reflection as leading to a better sense of connection between colleagues and finding new strategies for dealing with dilemmas.Bringing together academics and people with lived experience to co-design, deliver and evaluate sessions, ensures that this process is informed by different perspectives and areas of expertise.It role models partnership working in professional practice.The nature of partnership working and professional relationships between academics and people with lived experience is explored in the third of the case studies in this series (Buckley, Fazakarley and Hughes 2022).In case study two (Easterbrook, Blackman, Collins and Hughes 2022), we explore the opportunities for students to draw on the expertise of people with lived experience by gaining feedback, support, and guidance on their continuing professional development and practice.