A qualitative evaluation of the ‘Trailblazers’ teaching the teachers programme in mental health

© 2003 Blackwell Publishing Ltd.

Learning in Health and Social Care

,

2

, 2, 74–82

Original article

Blackwell Publishing Ltd.

A qualitative evaluation of the ‘Trailblazers’ teaching the teachers programme in mental health

Celia A.

Brown

BSocSc PGCert (RM)

,

1

Sarah E.

Wakefield

BA MA PGCert (RM)

,

2

Alison D.

Bullock

BA PhD PGCE

3

&

Steve J.

Field

MBChB DRCOG MMEd ILTM

FRCGP

4

*

1

Research Fellow, School of Education, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK

2

Research Fellow, School of Education, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK

3

Senior Research Fellow, School of Education, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK

4

University of Warwick and Regional Postgraduate Medical Dean, West Midlands Deanery, PO Box 9771, Birmingham Research Park, 97 Vincent Drive, Birmingham, B15 2XE, UK

Abstract

This article aims to provide an evaluation of the ‘Trailblazers’ programme, and seeks

to identify the factors affecting the impact of the programme. ‘Trailblazers’ is a learner-

centred ‘Teaching the Teachers’ programme in primary care mental health. In the first

programme to be run in the West Midlands, seven pairs of participants attended three

residential modules and developed an action plan that was cascaded to local colleagues.

A primarily qualitative investigation, exploring the experiences of the first cohort of 14

Trailblazers in the West Midlands, demonstrated that the modules were well received

and over 200 other professionals benefited from education sessions delivered by the

participants. Most delegates were keen to be involved in future programmes and

regional policy-making. The Trailblazers programme demonstrated short-term

effectiveness in terms of participant reaction, knowledge and changes in professional

practice.

Keywords

education and training,

mental health, primary

care, primary healthcare

team

*Corresponding author. Tel. +44 121 414 6890; fax +44 121 414 3155; e-mail [email protected]

Introduction

The prevalence of mental health problems in the

UK should not be underestimated. The National Ser-

vice Framework for Mental Health (NSF) suggests

that ‘mental ill health is so common that at any one

time around one in six people of working age have

a mental health problem, most often anxiety or

depression’ (Department of Health 1999, p. 3). One

of the five key areas for national action identified in

the NSF is education and training, and a Workforce

Action Team (WAT) reported in 2001 on the needs

and priorities for human resources to ensure the

successful implementation of the NSF. The WAT

reported that there is an ‘overwhelming case’ for

education and training programmes in primary

Qualitative evaluation of the ‘Trailblazers’ programme 75



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care mental health to be strengthened and further

developed (Workforce Action Team 2001, p. 9).

Any educational programme in primary care

mental health must seek to address a number of bar-

riers and learning needs before it can be effective.

First, there is a lack of recognition of mental health

problems in primary care. The WAT Primary Care

report (Workforce Action Team 2001, p. 6) states that:

… Up to 40% of patients attending their GP for any reason will have a mental health problem. However, between 30 and 50% of presentations of depression are undetected by GPs.

Low detection rates could be the result of profes-

sional ‘apathy’. Second, some GPs hold misconcep-

tions about the effectiveness of antidepressants, and

this may be one reason why GPs are reluctant to pre-

scribe these drugs. Third, there is a need to look

holistically at mental and physical health, as patients

with physical ill-health are particularly prone to

mental health problems (Armstrong 1995). Finally,

the WAT (2001, p. 7) report states that there is

‘organizational, professional and cultural separa-

tion between primary and specialized services’

which may prevent effective mental health care.

Kendrick (2000) detailed how the promising

short-term results of a study investigating the effec-

tiveness of an educational programme for GPs in

Gotland, Sweden, were the foundation for a number

of educational initiatives for depression in the

1990s. However the short-term results were not

sustained and, moreover, the study was based on a

small sample and lacked a control group. Other

studies have subsequently failed to show a link

between GP education in mental health issues and

healthcare outcomes (Thompson

et al

. 2000). Such

findings suggest that the design of educational pro-

grammes in mental health may need to be refined. A

review of the research literature suggests that educa-

tion and training in primary mental health care can

be effectively delivered to the whole primary health-

care team (Tylee 1999); national campaigns need to

be supplemented with local and practice-based

teaching activities (Rix

et al

. 1999); educational

programmes need to be longitudinal, rather than

‘one-off events’ if knowledge is to be retained (Kelly

1998); and trainers can use their own educational

experiences to train others (Gask

et al

. 1987).

The West Midlands ‘Trailblazers’ programme

The West Midlands ‘Trailblazers’ programme was

developed against this background of educational

need and research evidence within primary mental

health care. The design of the programme drew on

the experience of ‘Teaching the Teachers’ courses

that began in 1996 under the leadership of Professor

Andre Tylee of the Institute of Psychiatry on behalf

of the Royal College of General Practitioners (Tylee

1999).

The West Midlands programme was designed by

a steering group of the West Midlands Primary Care

Network, specifically to meet the needs of the par-

ticipants. The steering group was responsible for

organization of the course and selection of the par-

ticipants. The course followed a learner-centred

curriculum, facilitated by four mental health leads

with particular specialisms: Professor Andre Tylee

(Psychiatry); Dr Helen Lester (General Practice and

Education); Dr Jonas Miller (General Practice and

Education); and Professor Peter Nolan (Nursing).

The tutors also made themselves available to pro-

vide support and mentoring to participants between

modules.

The course was described on the advertising flyer

as an ‘Innovative “teaching the teachers” course in

primary mental healthcare’, an ‘integrated primary

care training programme’ that will ‘explore innova-

tive ways of using education and training to develop

more integrated working between primary care,

community and mental health professionals and

agencies to provide benefits for patients at a local

level’. (West Midlands Deanery 2001)

The design of the programme is not exclusive to a

mental health curriculum. The ideology of the pro-

gramme supports three tiers of change:

• personal change in the participants through atten-

dance at three residential modules;

• change in local mental health teams (and their

patients) through the implementation of participants’

76 C.A. Brown

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action plans developed as part of the programme;

and

• change in regional and national mental health

policy through participants’

trailblazing

activities.

The aims of the course can be derived from the

flyer and from the first steering group meeting. It

was expected that:

1

leadership would be developed;

2

learning would be cascaded to local colleagues;

3

participants in the first cohort would contribute

to subsequent courses;

4

integration between medical and mental health

professionals would be improved; and

5

patients’ needs would be more effectively addressed.

The focus of the activity on the course was the

identification by participants of local training needs

and ways to meet them. The content of the course

was divided into three 1.5-day residential modules,

each with its own focus. In the first module the par-

ticipants established their own learning needs and

developed action plans to carry through the entire

course. The second module, held 3 months later,

involved reflective feedback from the participants,

although the main thrust of the module was provi-

sion of teaching sessions to meet participants’ iden-

tified learning needs. In the final module, after a

further 3 months, participants were given time to

reflect and report back on their progress, and to

develop their plans for the future.

While the course enabled participants to work on

an action plan in pairs, the course organizer consid-

ered that this was not actually the key to the curric-

ulum. In an interview, the course organizer stated:

That [the action plans] was just a way for them to really start thinking about how things can change and a way of facilitating the pairs to work together. But I don’t think the action plans were the important bit, I think it was to do with the personal self-confidence, with swapping ideas about mental health.

According to participants’ stated needs, other

specialists were brought in for specific sessions. The

first cohort of Trailblazers requested a session on

managing change, which was delivered in the second

module by a specialist from the University of Bath.

The programme was run as a residential programme,

with all modules held at The University of Birming-

ham’s Wasthills conference site. The steering group

considered that it was important for the course to be

residential, because of the socializing, continued

learning and networking that could occur ‘after

hours’. Other physical resources employed for the

course included a number of videos, books and

other learning resources that were made available

for participants to consult during the modules. The

participants themselves added to these resources on

the second and third modules.

Participants

The Trailblazers course brought together seven mul-

tiprofessional pairs of colleagues in each cohort, one

from primary care and one from mental health. This

is in line with the Government commitment that,

‘wherever practical, learning should be shared by

different staff groups and professions’ (Department

of Health 2001, p. 6).

Forty-seven applications for the 14 places in the

first cohort were received. The predominant profes-

sional groups within the applicants were community

psychiatric nurses (CPNs) (

n

= 20) and GPs (

n

= 14).

The steering group decided that pre-existing pairs

would be preferred to singletons in the first cohort,

with singletons given the opportunity to form pairs

and apply to take part in subsequent cohorts. The

selection group therefore considered the 14 pairs

who had applied, and rejected one pair of CPNs as

the pairing was not multidisciplinary. The remain-

ing pairs were assessed using a short-listing form

that scored applicants out of 100 in nine key areas:

1

identified as one of a pair;

2

professional background;

3

organizational support (participants were required

to gain the support of their organization, e.g. their

Trust or Primary Care Group (PCG), for allowing

time to attend the modules, time for project work

between modules and consideration of resource

implications of educational cascades);

4

geographical background (no score but used to

ensure a mix of participants to work in their local

areas);




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2

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5

leadership potential;

6

personal statement: integrated working;

7

personal statement: innovative working;

8

track record as a local champion; and

9

‘passion’.

The pairs who were unsuccessful for the first

cohort were offered a place on the second cohort,

provided that their circumstances did not change in

the interim.

The study described below provides an independ-

ent evaluation of the first Trailblazers programme in

the West Midlands. The focus of the evaluation was

to assess the impact of the programme in each of the

three tiers of change, and to identify the factors

affecting the impact of the programme.

Method

This evaluation focused on the experiences of the

first cohort of 14 Trailblazers in the West Midlands,

who participated in three residential modules

between April and September 2001. Each module

lasted for 1.5 days and was observed by a member of

the research team.

Data for the evaluation were also gathered from a

number of sources (postcourse questionnaires after

each module; semi-structured interviews with 13 of

the 14 participants and the course organizer; written

and oral presentations of participants’ action plans;

module and ‘celebration’ observation; course docu-

mentation; and case studies) discussed below.

Postcourse questionnaires after each module

Questionnaires were sent to all participants approxi-

mately 1 month after each module and were returned

directly to the evaluation team. The questionnaires

were designed to identify the strengths and weak-

nesses of each module and the programme as a

whole; and also to assess the impact of the pro-

gramme on both the participants themselves and

their action plans. As such, the questionnaires inclu-

ded both closed and open-ended questions. Closed

questions were entered into an Excel database,

while open-ended questions were coded for ana-

lysis. Participants were happy to give their names

on the questionnaires, although all results in this

evaluation remain anonymous. Response rates of

100% were achieved for the questionnaires follow-

ing the first and second modules. After the third

module, 10 participants returned their question-

naires, representing a response rate of 71%.

Semi-structured interviews with 13 of the 14 participants and the course organizer

Thirteen of the 14 participants were interviewed

using a semistructured interview schedule. One

participant was on long-term sick leave and unavail-

able for interview. Interviews were transcribed and

coded for analysis. The course organizer, who was

one of the facilitators, was also interviewed. The inter-

view was semistructured and designed to provide

some context for the course, as well as the opinion of

the facilitator on the success or otherwise of the

course. This interview was transcribed and content-

analysed.

Written and oral presentations of participants’ action plans

Most participant pairs produced a report of their

action plans and achievements that was circulated at

a ‘Celebration Event’. These documents provided

detail on the philosophies and actions of each pair

in their localities and beyond.

Module and ‘Celebration’ observation

Each module was observed by a member of the evalu-

ation team. Data on participants’ learning needs and

action plans were gathered as the course progressed.

In addition, the Trailblazers hosted a ‘Celebration’

event in December 2001 to which a number of key

stakeholders and participants’ employers were invited.

The celebration event gave the pairs a chance to

present their project achievements, and this was also

attended by a member of the evaluation team.

Course documentation

Information from the course flyer and minutes of

steering group meetings was taken to provide back-

ground on the course and its aims.

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Case studies

A range of data were used to produce descriptive

case studies of the seven pairs of participants in the

first cohort of Trailblazers. Same-sex pseudonyms

were used to protect the identities of the particip-

ants. The case studies include the following details:

participants’ professional background; reasons for

participating; stated learning needs; project action

plans; and future plans.

The use of qualitative techniques is important, as

many of the planned outcomes are intangibles and

cannot be measured quantitatively. The impact of

the programme, for each of the three tiers, is assessed

using an adaptation of Kirkpatrick’s hierarchy of

outcomes (Kirkpatrick 1967). The hierarchy is based

on five levels of evaluation:

1

participation in the educational intervention;

2

participants’ reactions to the intervention;

3

effects on participants’ knowledge;

4

impact on participants’ practice; and

5

impact on patient outcomes.

In theory, higher levels of the hierarchy are harder

to attain than lower levels.

Results

Tier 1: impact of the modules

All 14 participants in their seven pairs completed the

Trailblazers programme. The professional groups

represented on the course were: GPs (

n

= 4), practice

nurses (

n

= 1), community psychiatric nurses (

n

= 5),

clinical psychologists (

n

= 1), health visitors (

n

= 2)

and mental health service management (

n

= 1).

The postcourse questionnaires asked participants

to rate their ‘reaction’ to the modules (in terms of

module structure, content delivery and enjoyment),

the amount of new learning (knowledge) and the

extent of change in their professional practice. Rat-

ings were sought on a six-point Likert scale, with

one being very poor and six excellent. Mean scores

across the three modules were highest for enjoy-

ment (5.6) and delivery (5.3). The lowest scores, as

perhaps would be expected, with higher levels of the

Kirkpatrick hierarchy harder to attain, were for new

learning (4.1) and change in practice (3.7).

The ratings for course content were varied, and this

led to an interview question regarding the curriculum

of the modules. The learner-centred approach to the

curriculum appears to have been both positive (with

a session on ‘Managing Change’ requested by the

participants very highly regarded) and negative (one

participant stated that they had spent an entire module

‘just looking at what everyone was doing’). While the

participants generally spoke highly of the modules,

some were not clear about what learning outcomes

had been achieved, as the following quote illustrates:

… But you couldn’t say to anybody this is what we discussed, this is what we learned.

Participants were asked in their interviews to

identify the most important thing they had learned

from the programme. Responses to this question

were quite varied, but focused on

Trailblazing

issues

such as networking and influencing skills, awareness

of wider agendas, accessing resources and organiza-

tions, and the different yet complementary roles of

a number of professional groups. These issues are

reflective of the ‘teaching the teacher’ approach to

the programme.

At interview, less than half of the participants (46%)

were able to identify areas where their practice had

changed. This may be a result of the nature of the

programme, with participants encouraged to change

the practice of others. Two quotes illustrate the different

levels of effect on participants’ professional practice:

I find myself spending more time with depressed patients … my surgeries always over-run … it is true that once I’ve got into the system and I’m using it well, I’m quicker at referring them on to the right service.

Probably not because I saw myself as quite forward thinking anyway.

With respect to healthcare outcomes, most partici-

pants considered that it was too early to determine

whether there had been any effects on their patients.

Several participants (who did not have a background




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in mental health) commented that they had more

confidence to deal with mental health issues and

that a positive effect on their patients should ensue.

Tier 2: impact of action plans

By December 2001, the seven pairs of participants

had involved over 200 health professionals, from a

wide range of professional groups, in a range of

educational activities. Other educational activities

were still under development, and other activities,

such as the development of protocols for the

treatment of depression, were also taking place. The

educational activities undertaken include a series of

clinical supervisions on mental health, a survey of

learning needs, work-shadowing opportunities and

a training package/CD-ROM in psychosis.

Reaction to the implementation of action plans

appears to have been mixed. Comments from the

participants at the course modules suggested that

allied health professionals (AHPs) were being more

receptive to the educational sessions than GPs. One

participant, who had organized educational sessions

for AHPs, spoke of the difficulties of getting GPs on

board:

[My partner] and I had all these plans, and I was going to come back here and say in the practice meeting ‘I’ve been on this course on mental health and we ought to think about doing this, that and the other’ and the doctors sort of go ‘oh mental health, do we have to?’

It is difficult to determine the effects of the

educational sessions run by the Trailblazers on

participants’ knowledge, as the results of planned

evaluations (by two of the pairs) are not available.

However, there is some evidence of the positive

effects of the educational sessions, as the following

quote illustrates:

A few of them went away and said ‘I’m really looking forward to someone who’s got anxiety now – I know what to say and I know what to do!’

Most Trailblazers thought that it was not really

possible to suggest whether others had changed their

professional practice as a result of their educational

initiatives. While this is true, other Trailblazers high-

lighted changes they had seen in the practice of others,

such as more evidence of joint working and better refer-

rals. Potential benefits for the future involve breaking

down the barriers between primary and secondary

care, and the involvement of all staff within a practice

(including receptionists and cleaners) in the identi-

fication of patients with mental health problems.

Given the difficulties of assessing healthcare out-

comes and a lack of evaluation of the educational

interventions, our interpretations of participants’

responses are speculative. Most Trailblazers thought

their educational interventions would have an effect

on patients in the long term, but that it was not pos-

sible to identify such benefits at this stage.

Tier 3: impact of the programme on Trailblazing

All participants interviewed expressed a desire to

continue with their Trailblazers Action Plans and

initiate further activity. It is encouraging that one

pair had aspirations of rolling-out educational sessions

over 3 years. Many suggested in their interviews that

they would be happy to be involved with subsequent

cohorts of Trailblazers, perhaps in a mentoring role.

A small number of participants identified areas

of involvement in mental health that they would

attribute to their participation on Trailblazers.

Examples mentioned by participants include:

I did a talk yesterday. I would never of dreamed of putting myself in that position a few months ago.

Applying for a position on the (Mental Health) Professional Executive Committee within the Trust.

If I can get political support and financial support … I am hoping to spend half a day a week … on mental health issues for my area.

Joined the ‘Good Practice in Mental Health’ forum.

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A number of participants suggested that they

would be constrained from further participation in

Trailblazing activity owing to a lack of time. One

CPN had been forced to cut short her secondment

(granted to work on her Trailblazers Action Plan)

as a result of clinical staff shortages. Also, not all

participants were keen to take part in this type of

activity. One participant commented in their inter-

view that:

I think it’s getting a bit more political … I think well I’m not particularly interested in that – I just want to improve the mental health of my patients here. I don’t want to get involved in regional things or anything.

Participants’ reaction to longer-term Trailblazing

can be measured through their motivation towards

the mental healthcare agenda. Each postcourse ques-

tionnaire asked participants to rate their current

motivation on a scale of one (very low) to six (very

high). The mean score across all respondents was

never below 5.4 across the three modules, and the

lowest score given was 4.0. These results suggest

that the participants are highly motivated towards

bringing about change to mental healthcare services.

However, it cannot be determined from these

responses whether the programme itself contributed

to participants’ motivation.

The participants considered that they acquired

knowledge which would help them to undertake

effective Trailblazing action in the future. The

course included a session on teaching and learning,

to provide healthcare practitioners with an insight

into educational philosophies. The teaching style of

the Trailblazers course itself proved useful for the

participants in planning their own educational

sessions:

It gave me a lot of confidence about what I was doing in the education initiative: that I’m following a similar style to the Trailblazers and this feels good for me, hopefully this is a good experience then for people on the receiving end of my facilitations.

In the ‘Trailblazing’ context, the impact of the

course can be assessed by changes in participants’

professional practice that affect the way in which

they trailblaze themselves. These changes resulted

from the knowledge gains, described above, being

put into practice by the participants. Some partici-

pants commented on their questionnaires about

how their professional trailblazing practice had been

changed as a result of the course, specifically:

1

confidence to deliver a talk on depression to

colleagues;

2

challenging others more; and

3

let the ‘walking dead’ rest.

Effecting change in healthcare outcomes is a long-

term process, and longer still when policy has to

change first, or when participants are cascading their

knowledge and skills to others. At this stage it is

impossible to tell whether healthcare outcomes for

the mentally ill in the West Midlands (or nationally)

will improve as a result of this initiative. However, it

is anticipated that if the participants continue and

expand their trailblazing activity, that some gains in

healthcare outcomes will result in the future.

Factors affecting impact

The Trailblazers participants identified a number of

factors that affected the impact of the programme in

each of the three tiers. Factors that were considered

to increase the impact of the modules included:

multiple modules; high participant to facilitator

ratio; multiprofessional, highly regarded facilitators;

multiprofessional course; and residential modules.

Several of these elements concur with previous research

on factors making for effective education and

training in primary mental health care, which can be

extended to ‘teaching the teacher’ initiatives (Gask

et al

. 1987; Kelly 1998; Rix

et al

. 1999). Participants

who were not able to stay the night did, however, feel

somewhat alienated from the rest of the group, and

some would have preferred more formal, structured

support between the modules. The learner-centred

curriculum was considered an advantage in that

participants could set their own agenda, and a

disadvantage as participants were not always clear of

their learning needs, and many did not really know

what the programme was about when they enrolled.




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With respect to participants’ action plans and

wider Trailblazing activities, a number of factors

were identified that were considered to increase

impact: working in multiprofessional pairs (although

this could prove difficult if pairs could not find time

to get together); investing time in planning; and

being able to get time away from practice. Factors

hindering the effectiveness of action plans included:

a lack of time, resources and organizational support;

political constraints; and negative attitudes towards

mental health.

Conclusion

‘Trailblazers’ was well received by participants who

spoke highly of the programme and the facilitators.

In particular, the participants felt that the residential

and multiprofessional components of the course

were extremely important. Views regarding the

suitability of the learner-centred curriculum were

generally positive, although some participants had

reservations. Several participants suggested that the

course had resulted in positive changes to their pro-

fessional practice. Such changes suggest that for some,

the programme has provided continuing professional

development in mental health, rather than being

exclusively a ‘teaching the teachers’ course.

All participants had taken steps towards the goals

of their action plans during the course, and most

had continued their efforts after the final module.

Action plans varied, although two key elements

were the provision of educational sessions for health

professionals and the development of local care pro-

tocols. In total, over 200 health professionals were

reached during educational initiatives. Action plans

that were well planned tended to be more successful

or have the potential to do so. Participants were hin-

dered in the implementation of their action plans by

a lack of time and/or resources and lack of engage-

ment of other health professionals.

A number of the Trailblazers have taken part in

various trailblazing activities, including educational

sessions (planned by others) and consultation exer-

cises (as a group). Most participants expressed their

commitment to continue trailblazing and were keen

to be involved with subsequent cohorts of Trailblazers

in some way.

This article has summarized the impact of the

Trailblazers programme on the first cohort of par-

ticipants in the West Midlands. Programme assess-

ment was problematic, both for the individual

participants and for their action plans (particularly

in terms of healthcare outcomes), for a number of

reasons. First, the evaluation was short-term, while

the aims of the course and action plans are long-

term. Second, certain Trailblazer activity would

have been undertaken anyway, and it is hard to iden-

tify the extent to which participation has impacted

on this activity. Finally, many of the outcomes are

intangibles (such as motivation), rather than mea-

surable tangibles. The dominance of non-tangible

outcomes highlights the need for a qualitative

approach to the evaluation.

These issues highlight the need for a longer-term

evaluation of participants’ action plans (including a

synthesis of the pairs’ evaluations); an investigation

of the impact of the contribution of cohort one

participants on the effectiveness of the course for

cohort two (to determine whether impact increases

over time); and a comparison of nationwide Trail-

blazing programmes to identify common features

contributing to effectiveness.

Nevertheless, the research suggests that locally

based, multiprofessional ‘teaching the teacher’

programmes can be successful at cascading educa-

tional strategies to many other health professionals,

although motivating others in the need for mental

health training can be difficult. Educational cas-

cades require organizational support, in terms of

time and funding, in order to be successful. The

format adopted by the programme could be

applied to ‘teaching the teacher’ initiatives in other

fields.

Acknowledgements

The authors would like to thank the organisers of

Trailblazers for allowing us access to the Trailblazers

programme; and for all the information provided that

has helped in this evaluation. Express thanks to the

‘Trailblazers’ who completed questionnaires and were

interviewed for this evaluation. We would like to thank

Dr Marilyn Hammick for helpful comments on earlier

drafts of this paper.

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Documents

A qualitative evaluation of the ‘Trailblazers’ teaching the teachers programme in mental health