Academic Staff Perspective of the Perceived Impact of Patient and Public Involvement in Nursing and Social Work Education

In the last three decades, the United Kingdom (UK) has witnessed a surge in patient and public involvement in health and social care education, research, and practice. However, little is known about its perceived impact on academic staff. This paper explored the perceived impact of patient and public involvement on academic staff using a descriptive phenomenology approach from a tripartite perspective of the three main stakeholders in Higher Education which are: patients/public, academic staff, and students. A total of 38 participants took part. Semi-structured interview was used to gather information and subsequently analyzed thematically. Two main themes emergedbeneficial outcomes to academic staff both personally and professionally as well as concerns about patient and public involvement in a university environment. It is hoped that recognition of the impact of patient and public involvement to academic staff can help to optimize its effectiveness in higher education institutions.


Introduction
Patients and members of the public have become active partners in the development, planning, designing and implementation of health and social care education, research, and services globally and in the United Kingdom (UK) [1,2]. Academic staff members have been recognised as one of the main stakeholder groups of patients and public involvement in health and social care degree programmes in Higher Education Institutions (HEIs) [3][4][5]. However, there are few studies that have explored the perceived impact of patients and public involvement on academic staff in Nursing and Social work Education within a HEI context, particularly, the perceived impact on their skills, attitude, behaviour and professional role.
In this study, "patient and public involvement" (hereafter known as 'involvement') is referred to as meaningful participation or integration of patients and members of the public in one or more educational activities. "Patients" are defined as the end-recipient of health and social care services due to their ongoing social care problems and/or their long-term health conditions. They are sometimes referred to as "service users". We define "Public" as family members or loved ones who look after patients in an unpaid capacity and they are sometimes referred to as "carers". It should be noted that the term patients and service users can be used interchangeably. Also public and carers can be used interchangeably.
Traditionally, academic staff members are viewed as 'givers' or 'holders' of knowledge and expertise transferred to students [6]. Moreover, they are 'gatekeepers' that determine the extent of development and sustainability of patient and public involvement in students' education [7]. The advent of involvement in students education implies that academic staff members are no longer perceived as sole 'giver' or 'holder' of knowledge, rather they are now co-experts alongside patients and the public [6,7]. This explains why they are often portrayed in literature as being resistant to involvement in students' education [7,8].
Moreover, it has been stated that concerns associated with involvement further makes academic staff resist it within students' education [7]. Some of the documented concerns raised by staff include: individualised and not representative experiences of patients/public, lack of expertise, lack of clarity of the description and definition of patients/public; questioning and downplaying academic staff wisdom; shift in power to patients/public [2,6,7].
It has equally been highlighted that academic staff members perceive patients and public involvement as positively enhancing students' education [9,10]. Currently, there is drought of evidence about the perceived impact of involvement on academic staff in Higher Education Institutions (HEIs), particularly, involvement which takes place within the university environment to support students learning. This paper reports a facet of a doctoral study which explored the impact of patients and public involvement in Adult Nursing and Social Work pre-registration programmes within a Faculty of Health in the UK. The perceived impact is explored from the different reported viewpoints of the three main stakeholders (students, patients/public, and academic staff) in order to provide a rounded understanding of these impacts on academic staff. This paper explored the perceived impact of patients and public involvement on academic staff members. It focused on involvement occurring within the university environment to support students learning. This study provides insight into the perceived impact of involvement on academic staff members' professional role as well as their skills, attitude and behaviour. Hence, the research question is: how does exposure to patients and public involvement influence Adult Nursing and Social Work academic staff?

Methods
Qualitative methodology was used in this study because it allowed the perceived impact of patients and public involvement to be explored from the lived experience of the three main stakeholders that have experienced it within Higher Education setting [11].
This study took place at a Faculty of Health in a University located in the Midlands of UK. Data collection took place over a period of 8 months as part of a doctoral study. The population for this study was drawn from the three main stakeholders-patients and public, students, and academic staff. A total of 38 participants took part in this study 15 academic staff (10 adult nursing. 5 social work), 15 students (11 adult nursing, 4 social work) and 8 patients/ public.
Purposive sampling was employed in this study in order to deliberately select individuals for this study. Patients/public was recruited from the patients and public involvement group within the university. The patients/public were included if they had volunteered for more than one academic year and actively participated in at least two educational activities. Reported educational activities with patients and public involvement within the university include, student recruitment, designing and implementing educational activities, evaluation of students' performance, teaching, research, governance, and quality assurance management as well as planning educational initiatives.
The students and academic staff recruited for this study were from the field of Adult Nursing and Social Work. These two degrees were selected because they share similar structure and function. For instance, both degrees values and core principles are care, compassion, respect, person-centeredness and dignity [12,13]. Moreover, the two degrees involves classroom-based and practice learning (also referred to as placement). Also, involvement in student education is a regulatory requirement by the Professional Regulatory and Statutory Bodies (PRSBs) of both degrees. Besides, studies about involvement in both degrees have demanded that evaluation of its impact be carried out [14][15][16].
The student sample was drawn from final year undergraduate level. This was because in line with their course curriculum they must have had at least one module where they had been exposed to patients and public involvement in at least one classroom-based session. Furthermore, the final year undergraduate will have had more opportunity to reflect on their experiences and put into practice what has been learnt in the classroom while on clinical placements. Thus, the students recruited must be in their final year and have had at least one exposure with patients/public in a classroom-based session. The academic staff who participated in this study should engaged patients/public in at least one form of educational activities in one module in the last in the last 12 months.
The patient and public involvement co-ordinator was the key gatekeeper to access patients/public. The Lead researcher contacted this individual and it was agreed that a talk should be giving during one of the bi-monthly meeting to raise awareness and recruit potential participants. Permission to access students and academic staff members was granted by the Dean of the faculty. Student and staff were recruited via email and having a talk to raise awareness about the study.
An Advisory group was recruited from a patients and public involvement hub group of the university, which is a team of academic heads, academic staff, the co-ordinator, students, and patients/public. The hub group meet quarterly to evaluate Volume 4; Issue 7 Int J Nurs Health Care Res, an open access journal ISSN: 2688-9501 patients and public involvement in students' education across the university. The role of the advisory group in this study was to jointly make decisions throughout the research process [17]. Also, their involvement in this study is in line with the ethos of this study to strengthen and promote patients/public voices [18].
The combination of various stakeholders within the Advisory group was an advantage as it helped to triangulated viewpoints, thus enhancing the trustworthiness of the study. 13 individuals (1 academic head, 3 academic staff, 1 patient and public involvement co-ordinator, 1 administrator, 2 students, 5 patients/public) agreed to participate.
Data were gathered using a semi-structured interview to elicit participants' views and perceptions of the impact of involvement on academic staff. Data collection tools were developed following appraisal of literature, consultation with patients/public and other key stakeholders, and a pilot interview. Interviews were conducted face-to-face and lasted around 30-60 min. It was audio-recorded, and the recordings were transcribed in a typed form in preparation for data analysis.
The resultant qualitative data were thematically analysed inductively using Colaizzi [19], analysis procedures. This choice is based on its ability to give a systematic process of data analysis. Additionally, its last stage requires validation of the findings by returning to the participants. This is in line with the ethos of involvement which is the focus of this study. Validation of emerging themes and sub-themes was carried out by the advisory group.
Data collection and analysis were carried out by the lead researcher. Nevertheless, themes and subthemes were agreed on by consensus with co-authors. This further helped interpretation of the data and ensured rigour in the data analysis process. Themes and subthemes identified from the data were represented using thematic maps. NVIVO v10 software was used to help manage and organise the data.
Lincoln and Guba [20], criteria was used to ensure trustworthiness and rigour. To ensure credibility is achieved, the lead researcher carried out member checking by validating the findings (The emergent themes, sub-themes, and quotes) with the advisory group. Confirmability was attained by making sure that the interpretations and findings are from the themes and subthemes derived from the data and this is supported by quotes. Transferability was achieved by providing a detailed description of the research so it can be easily applied in another context. Dependability was achieved by clearly documenting the research process.
Ethical approval was sought and obtained prior to conducting this study from the University's ethics committee. Participant letter, information sheet and consent forms were circulated to potential participants prior to date scheduled for interviews. On the stipulated day, the purpose of the study was recounted to participants and both verbal and written consent was obtained before data collection proceeded. Participation in this study was optional and no participant was coerced. They were informed that they could withdraw at any time without giving any reason.
Caution was taken around issues of confidentiality and anonymity and the process of informed consent. Codes were assigned to participants and these assigned codes were used during interviews. Named individual, places and hospitals mentioned during interview were changed to codes during transcription. Disseminated findings were devoid of any identifiable information of participants.

Results
Most of the academic staff teach 4-6 modules and have engaged patients/public in at least one module. The staff had mostly involved engage patients/public in teaching and student recruitment. Two main themes emerged (beneficial outcomes and academic staff concerns). Quotes derived from the semi-structured interviews were used to represent view and each assigned a code. Each interviewee has a participant number in chronological order (1-38), the relevant course (Social Work-SW or Nursing-N) and which stakeholder group they represent.

Beneficial Outcomes
This study identified two main beneficial outcomes. These are the influence on academic staff members: professional role; and personally, on their skills, attitude, and behaviour. Nearly all the academics were taken aback when asked how involvement had benefited them personally and/or professionally. In fact, many of the academic staff participants admitted that had never thought about the beneficial outcomes to themselves, rather they had only considered and reflected on the benefits to students. This often led to staff requesting more time to reflect before providing answers.

Influence on Professional Role
All three main stakeholders acknowledged that involvement positively influences academic staff by complementing their professional role. For instance, all patients/public, some students, and staff indicated that involvement makes academic staff teaching holistic by complementing the theoretical teachings delivered by academic staff with experiential knowledge from patients/public. In particular, three academic staff explained that being in the academic environment had made them somewhat detached from what is currently going on in practice/clinical areas and the experiential knowledge from patients/public makes their teaching session real and powerful, thereby bridging the gap between theory and practice.
"From a personal point of view, I also quite like it (patients and public involvement) because I am not practicing as before, only occasionally…So I think having them involved in students learning stops it from being just theoretical, it makes the teaching holistic and puts true meaning to what we are trying to achieve for students"-P27Academicstaff.
More than half of the staff and nearly all patients/public indicated that involvement keeps academic staff informed of current opinions and practices about health problems and services. These staff admitted that involvement makes students education current and relevant. One staff gave an example of involvement updated his knowledge.

"Well I learn, I learn from them, if I sit in on their presentation I learn about what is current, like what the current treatments are for instance, I may be out of touch with some of the current treatments whereas if I hear it from people who are currently being treated then that improves my own knowledge"-P10Academicstaff
Nearly all staff expressed that involvement improves their teaching style and this positively impact on students learning. One staff member concluded it that makes teaching session refreshing and aids better understanding.

"Having patients or service users or public member offers a different type of learning style and allows the student to synthesize, evaluate, you know some of the question, also ask questions as well about what their concerns or issues are direct to the patient and not directly to an academic staff member who is there as an academic. Well directly to a service user and this gives them that insight and it's refreshing in that way"-P11Academicstaff.
This view is also supported by nearly all students with one nursing student strongly affirming that this style of teaching is more enjoyable and aids better understanding of health and social problems.
"I mean you can ask me about a lecture from last week in a normal classroom and I wouldn't know but I can still remember the patient that came in that day and that was about a year ago, so easily you draw it in a lot more and its more focused and interesting"-P35Student.

Influence on Skills, Attitude and Behaviour
Only academic staff could explicitly express the influence of involvement on their skills attitude and behaviour. The students and patients/public were vague in their responses and could not clearly indicate how or what skills and behavioural acquisition or modification takes place by virtue of involvement.
Half of the academic staff participants indicated that patients and public involvement help to improve and role model good interpersonal skills. These staff identified interpersonal skills such as: listening, communication and empathy.

"They kind of remind you of the bits that you might forget, again to do with inter-personal skills and communication a lot of it"-P13Academicstaff
"It has taught me to listen even more than I thought I was doing"-P15Academicstaff.
Half of the staff participants also highlighted that involvement serve as both a constant reminder of the need to be person centred and ensure its importance is communicated to students. For instance, one nursing staff member indicated that involvement reinforces that patients are individuals and not bednumbers or hospital numbers.

"Having those service users/carers in the classroom reminds us that we are dealing with individuals, that we are dealing with people, not numbers, not figures, not money, you know this should be the focus for those leaders high up"-P14Academicstaff.
Nearly all staff expressed that patients and public involvement helps them to be critically reflective of their teaching practice. They used the phrase 'stop and think' to describe how involvement makes them critically reflective. These staff indicated that it makes them more thoughtful of what is important to patients and members of the public.

"I think it made me 'stop and think', so when I was developing my second year module I involved service users in a focus group and asked them what they think makes a good nursing assessment and what was their experiences of it, so they offered perspectives which I integrated into the module about what is important…So, they do make you 'stop and think'"-P12Academicstaff.
Over half of the staff also mentioned that practicing patients and public involvement have changed their perceptions, challenging their opinions, beliefs, and values about patients/ public. They also indicated that they find sessions where patients/ public are involved powerful and emotional.
"I think a lot of it is about not making assumptions or judgements about people from what you see… I think just knowing that everybody has got their own story and how important it is to hear that story"-P13Academicstaff.

Academic Staff Concerns
One main concern was raised by participants-issues during Volume 4; Issue 7 Int J Nurs Health Care Res, an open access journal ISSN: 2688-9501 delivery of patients and public involvement within the classroom. In general, the academics readily talked more about these issues than the beneficial outcomes to themselves.
Almost all patients/public and about half of the staff participants indicated that disagreement between patients/public and staff was one of the main problems that occur during patients and public involvement. These sorts of disagreement mostly occur when decisions about accepting or rejecting prospective students during recruitment are made.
Both patients/public and academic staff acknowledged that these sorts of decisions during recruitment are very weighty with strong implications. However, staff participants strongly believe that these decisions should ultimately be made by staff. One academic staff used the phrase 'carries the can' to indicate that members of staff are the ones who bear more consequences of such errors.
"I think sometimes I find working with staff challenging, not all the time, but it mostly with interview, as they (staff) are set on what they are looking for, but, we (patients/public) see deeper but, overall, we all agree in the long run-P31Patients/public "But if we (academic staff) have made an error on the recruitment of the student because the student for whatever reason you find is not right, it is the academic that 'carries the can', I think there is less consequence for the service user because it staff and not service users/carers interacting with that student in the long term" -P9Academicstaff.
Staff members went further to explain that disagreements during students' recruitment put them in a dilemma because they do not want to appear as been confrontational nor disrespectful if they challenge patients/public decision. Nevertheless, over half of the staff stated that many of the patients/public usually have the same 'gut feeling' as the staff, so decisions are jointly made by all panel members.
"I have quite often interviewed with patients/public, when you've only got a few minutes to make a decision (laughs) and you don't want to be confrontational with service users especially those who are set in some ways, you don't want to seem disrespectful. I think we do manage those things, and then come to a consensus, but they are tricky, yes" P16Acadstaff Another issue identified by less than half of staff (n=5) and students (n=4) was patients/public straying off the task originally assigned to them. These staff used the phrase 'going off a tangent' to explain this view about such inappropriate behaviour where patients/public have acted or said things out of place. Like the concern pointed out earlier about disagreement between staff and patients/public. Staff reported that it mostly occurs during students' recruitment and they feel more accountable if any complaints were made.
"All persons on the interview panel have set questions to ask and, in my experience, sometimes the service user goes a little bit outside of the questions when they are interviewing the students, I mean 'going off a tangent'. I think in terms of fairness to all the applicants, we should really ask the same questions to all the applicants. So, in that sense it is not a good thing"-P17Academicstaff.
Some students also mentioned their experience where a patient/public member was digressing from the original task in a classroom session, they felt such behaviour is inappropriate and can lead to poor students' engagement.
"I think from what I remember some other students didn't quite engage in what the patients were discussing because one gentleman did go on a while about his condition and not the topic, he also didn't allow others speak as time ran out"-P36Student.
Over half of the staff and students stated that patients/public venting negative or unhelpful personal views about their past illnesses or caring experiences while carrying out involvement was another concern that occurred while delivering involvement. The staff used the phrases "axe to grind" to express this view.
"Students have expressed concerns that on occasions, they feel that individual patients have an 'axe to grind' they have a personal experience that has impacted on them so much, that they use the session to focus on that negativity, on that negative experience"-P18Academicstaff.
However, these Students and most staff agreed that patients/public should be permitted to speak about any negative experiences but in a constructive manner that fosters learning and creates awareness of any malpractices as well as provide measures to avoid such malpractices.
"I think some patients can just have a generally negative view of professionals and services, I think when they speak they should talk from a better angle and more positive, you know not only saying what is wrong but how to learn from it"-P34Student.

Discussion
This study highlights the perceived impact of patients and public involvement on academic staff. It explicitly identifies the beneficial impact of involvement on their professional role; and personally, on their skills, attitude, and behaviour. It is often stated that academic staff perceive involvement as positively enhancing students' learning and practices [5,7,9]. However, little or nothing is said of how it positively influences them.
The authors noticed that the way patients and public involvement influences staff and students' skills, attitude and behaviour are similar. Previous studies on the positive influence of involvement of students have documented that involvement makes students develop better interpersonal skills, critically reflective of their practices; challenge their worldview; and make them more person-centred [2,6,21]. All of these are similar with our findings. This is particularly useful as academic staff members are often perceived as being resistant to involvement. Also, due to academic staff position as 'givers' or 'holders' of knowledge, it is assumed that patients and public involvement in Higher education is carried out for the benefit of students. Nevertheless, this study has highlighted that academic staff are equally beneficiaries of patients and public involvement.
Our findings about issues during delivery of patients and public involvement are consistent with previous studies [22,23]. It can be assumed that if these issues are not address it may subsequently result in academic staff having low confidence in involving patients/public. Some studies have indicated that majority of this issue can be traced to inadequate planning, preparing, resourcing and apportioning staff time for patients and public involvement [1,24]. Hence, there is a need to allot staff time to prepare, plan and organise to enhance the positive impact of involvement to staff and students.

Conclusion
This study has revealed some new insights about the perceived impact of patients and public involvement on academic staff. This study contributes new knowledge by highlighting both the positive and negative impact of involvement on academic staff. Moreover, it also adds insight into involvement in adult nursing degree which holds little published research in comparison with other fields of health and social care, such as, mental health nursing and social work. Although, participants' views across various health and social care pre-registration degree may be the same, however, this kind of research shed more light into the context involvement is currently being practiced in Adult Nursing preregistration degree.
At the time of data collection, involvement was supported at a senior level and viewed as part of the ethos of the health and social care pre-registration courses. Therefore, the authors acknowledge that this study finding may be situationally specific and could be different if the study were conducted in setting where involvement is not viewed as important. Nevertheless, the findings of this study are offered to support others developing patient and public involvement with HEIs. We hope the findings are helpful to universities and countries where patients and public involvement has not been supported by management, government, or professional body policies.
Our recommendation for future research is to evaluate the development of patients and public involvement in HEIs and its evolving impact on academic staff as a longitudinal study to assess its impact in the long-term. We hope that the rigour applied while planning, piloting and implementing this research offers a model for others to consider.

Funding
The PhD programme was funded by grants from the Higher Education Academy (HE Academy) and University of Wolverhampton.