Tag Archives: course design

Mental health care needn’t be complicated

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Training room.jpgI used to think that mental health care would be really complicated. So I looked for complicated theories to underpin everything I did. For many years I studied and tried hard to negotiate my way through the complex world of mental disorder. And because I looked for complicated answers, complicated answers were all I found. That was a great mistake.

The more I studied, the more I realised that good quality mental health care doesn’t need to be complicated. It may not always be easy to deliver but that doesn’t mean it should be hard to understand. Often the simplest solutons are the most effective.

Eventually I realised that there are some straightforward, basic principles that we need to follow. Everything else flows from there. These are the simple ideas that make the difference between good care and bad, between illness and recovery.

If only someone had distilled those principles for me when I first began. My early career would have been so much easier and more effective. But nobody did that in those days. That’s a great shame.

So I’ve done it myself. I’ve boiled down the basic ideas into usable, teachable concepts that every care worker can quickly understand and apply. These are the fundamental principles that underpin every Mind The Care Training course and seminar. Subscribe to this page and come back often to find out more.

Course design 15: Don’t milk it

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I’ll keep this section brief.

Don’t take more time than is necessary to get your point across.

I’ll give you two little ‘scenarios’ to illustrate this simple point.

When I took my nurses’ ‘teaching and assessing’ course I remember finishing work one afternoon and driving for 90 minutes to Carlisle to attend a class. I then sat for two hours while the lecturer explained (time and again) that there is no point wasting time telling people what they already know.

Two hours later I took my mounting sense of irony back home in time to go to sleep ready for the following day’s ‘early shift’ on the ward.

That was a complete waste of time.

Now another brief tale.

A man goes to the dentist complaining of toothache.

The dentist extracts the tooth in just a few minutes and then presents him with a bill for £100.

“£100!” Exclaimed the man. “But it only took you 5 minutes.”

Wryly the dentist replied..

“Next time I promise to make it last as long as you like.”

Don’t waste your time and your participants’ time repeating the same point over and over again. If you’ve said it (and they’ve understood it), you’ve said it.

 

Course design 13: Take the time to tell the tale

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The following is the text of an article I first wrote for ‘Local government Lawyer’ magazine. You can find it online here:

http://localgovernmentlawyer.co.uk/index.php?option=com_content&view=article&id=7057%3Alessons-in-law&catid=52%3Aadult-social-services-articles&q=&Itemid=20

Lessons in law meme“Lessons in law      

Thursday, 23 June 2011

The right approach to training in health and social care law can make a world of difference, writes Stuart Sorensen.

The abuse of vulnerable adults at Winterbourne View Hospital was extreme, dramatic and horrific. That’s presumably why Panorama chose to investigate it and why it has received so much attention from both press and public. Many bloggers have jumped on the scandal to make a point, some moral and some procedural. I have done as much myself. Several of us have taken the opportunity to write about specific legal issues from the Mental Capacity Act and the Deprivation of Liberty Safeguards to the Mental Health Act and the European Convention on Human Rights. It’s always helpful to have a topical ‘angle’ to focus upon when discussing law.

Unfortunately though this sort of blogging often becomes an exercise in futility. Those people who are interested in matters of law will most likely already be familiar with the principles discussed, or at least know how to find out about them. Those who are not, who simply want to know more about the human drama unfolding as a result of the programme will simply ignore the legal stuff in favour of more lurid pieces. For many the very thought of trying to understand legal concepts conjures up images of dusty textbooks and overly complicated jargon that might as well be written in a foreign language. There’s a perception of inaccessibility that discourages many people from even trying to understand. That’s where I come in.

I’m not a lawyer – I’m a nurse. A mental health nurse to be exact. I’m also a trainer. Oh yes – and I’m a bit of a geek with a passion for law. Well, everybody needs a hobby.

So it’s not too surprising that I regularly find myself training nurses, care workers, social workers, doctors and even police officers on health and social care law related issues. I must have trained tens of thousands of people over the years on topics such as the Mental Capacity Act, the Deprivation of Liberty Safeguards, the Safeguarding Vulnerable Groups Act and its Scottish equivalents the Protection of Vulnerable Groups (Scotland) Act and the Adult Support and Protection (Scotland) Act. Does that make me an international trainer? I doubt it but a nurse can dream.

During these sessions one theme is almost constant. People come into the training expecting to be bored. They also expect to be confused by a topic that they will not be able to relate to and that has little or nothing to do with their everyday experience. Not the best starting place for a jobbing trainer like me.

The problem is that many legal trainers have never taken the time to understand how health and social care workers learn. We’re different from lawyers – at least I think we are. There are many ways to think about learning styles and personality types and generalisations can be misleading but here goes anyway. In my experience health and social care staff from support workers to social workers tend to be more or less ‘top down’ learners. If the training was a jigsaw they’d like to see the picture on the box before they even start to look at the individual pieces.

Introducing care professionals to the minutiae of doctrine has its place but not until they understand the broad picture – the background and purpose of the particular act and how it relates to their work on a day to day basis. These people are not lawyers, they don’t generally think like lawyers and very often they don’t even start with the basic point that the law can help and protect them.

There is a culture of resentment in health and social care, especially regarding mental capacity, rights and safeguarding legislation. It’s not because people would prefer to be abusive – it’s because they don’t understand the law well enough to realise how positive it can be. So we begin with the basics, the purpose, the background and the scope. And we do it through story. This allows us to pull out the basic principles that we will rely upon and return to throughout the rest of the training. It sets up a basic foundation, the ‘picture on the box’ and gives participants the confidence to engage without fear of looking ‘stupid’.

Care workers tend to be ‘hands on’ people. We don’t usually ‘do’ abstract nearly so well as we ‘do’ tangible. That’s not to suggest that we’re not capable, far from it. But tangible is the ‘default’. As a rule we work with people and we get involved in the narrative of their lives. That’s what we do. It’s also how we learn.

So for Safeguarding we begin with Soham and with Miss X. For the Mental Capacity Act we tell the Bournewood story and from this month DoLS training will start with Hillingdon and the ‘Neary case’. By using narrative right from the start we draw people into a world that they’re already familiar with. By asking questions throughout the stories we begin to relate legal constructs to everyday scenarios:

What should the social worker have done?

How should the care worker react?

Is this good practice? If not, why not?

Before they realise it the participants have gone from work to law without a hiccup. This is the value of narrative. From stories and case studies to participants’ own experiences and even newspaper headlines, stories work. Stories are memorable, stories are accessible and stories help people to ‘grock’, to assimilate the true meaning of the law.

That may seem obvious. Indeed it is obvious but it’s also depressingly uncommon. I genuinely have lost count of the number of people who’ve told me how much easier to understand they found social care law after narrative based training. I won’t bore readers with their reports of previous, ‘chapter and verse’ style training but I’m sure you can imagine.

So if you’re a lawyer, a trainer or a social worker with the responsibility for delivering health and social care law training to care workers remember the rule of ‘T’:

Take The Time To Tell The Tale”

 

Course design 12: Write handout titles and trainers notes first – then write handouts and activities

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From this point on the course should be fairly straightforward to put together. You have a plan to follow and you know how to make your training inclusive and engaging. Now all you need to do is write the materials.

This is the point when I leave my low tech index cards behind and go to my word processor. I type up the list of topics in the order already identified and then copy and paste it immediately below. I now have two copies of the same list.

The first copy stays on the first page for reference.

The second copy is reformatted in bold and each entry becomes the heading for a separate handout or exercise. The links to the various, pre-identified themes become the first of the preparatory notes for each handout or exercise.

But that’s all you do with these handouts for now.

Next you write the trainers’ notes (even if nobody else will deliver it). These are the notes accompanying each handout that clearly define what each handout will aim to achieve and what anecdotes you will tell. These notes are also the place where exercises are identified and where you can list the particular learning points and questions you want to introduce to the group at each stage.

Only then, when you’ve identified all these ingredients should you write the actual handouts that you are going to use.

By the time you’ve finished the trainers notes and handouts you should have a single document (part pack) that anyone could use to deliver your training provided they understand the topic. This doesn’t mean that others necessarily will gain access to your materials – simply that the very process of creating trainers notes alongside the course materials themselves keeps you on track and helps ensure that the original training plan is reflected in the finished product.

You can never overestimate the value of a good set of trainers’ notes – even if you never look at them again.

 

Course design 11: Planning

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So far we’ve considered a few of the elements that need to be considered when putting together a training course. But that’s all we’ve done.

It’s one thing to understand that we need to identify the ‘jigsaw pieces’ and the themes that will bind them together but it’s another thing to know how best to do it.

It’s one thing to know that we need to incorporate a range of exercises, case studies and anecdotes alongside ‘information giving’ but it’s another to know how best to do it.

It’s one thing to know that people have different ‘modalities’ to take into account but it’s another to know how best to do it.

There are many ways to plan a course and every trainer is different so if you have your own system that works for you then please continue to use it. The system I’m about to outline is the one that works for me but realistically, so long as you have a method that works for you it doesn’t really matter what system you use. But this is how I do it.

First I do a little research to update myself. My field is so fast moving that even subjects that I was absolutely up to date with 6 months ago may well need updating today. So I check for recent developments that I might need to incorporate.

This can be anything from recent research to new theories – even political debates around service provision may need to be included (depending upon the client and the trainees).

Then I define the points that I need to make. I do this in one of two ways:

  1. Mind map the whole topic;
  2. Write everything that may be necessary to include on a separate index card with references as necessary.

Then I arrange that information into a logical sequence (this is the beauty of index cards – they’re easy to shuffle around.

Once I’ve done that I check my original notes to ensure that I’m still on track with the client’s requirements.

Is this still the content they were looking for?

Is it at the right level of complexity?

Is everything relevant?

Once I’m satisfied that I’ve got the right content in the right order I make a quick note of the order in which to present the information logically.

Finally I rearrange the index cards into themes which can be used to give the course structure and consistency. Don’t underestimate the importance of this stage. These themes are vital to the success of the training that you will deliver.

In the end I will have a list of subtopics (and handouts) in the order that I intend to present them and a note alongside each that serves to remind me of the themes that each relates to. This is exactly the sort of list we identified in part 8 when we discussed training on deliberate self-harm:

“The themes I’d use for this particular jigsaw are….

  1. Deliberate self harm is a coping strategy.
  2. We’re all the same.
  3. Care workers are not the focus of people’s problems – it’s not about us.

The ‘jigsaw pieces’ most commonly included in a one day self harm awareness day are:

  • Self harm is not about us (theme 3);
  • Self harm isn’t suicide – but people who harm themselves are at higher risk of suicide (theme 3);
  • Self harm is about coping (theme 1);
  • Most self harm is done in private and kept secret (theme 3);
  • When coping fails people behave in more and more extreme ways (theme 2);
  • We all use particular coping strategies to feel better when distressed (theme 2);
  • The most effective coping strategies change brain/body chemistry (endorphins) (themes 1, 2 & 3);
  • Deliberate self harm stimulates endorphins (themes 1 & 3);
  • People generally use the best coping strategies they know (theme 2);
  • Our job is to enhance coping strategies – not to remove the only effective coping strategy a person has. (themes 1 & 3);
  • Developing alternative coping strategies (themes 1,2 and 3);
  • Looking after ourselves (theme 2).

The jigsaw pieces follow a logical pattern and the use of themes allows participants to see how it all hang together. This is important if the participants are to create a ‘schema’ which will be the focus of tomorrow’s instalment.

This list and the thematic notes alongside it form the backbone of the finished course. In the next instalment we’ll consider some of the tips and tricks that help us to make sense of the many strands that will need to be pulled together to construct a really effective training session.

 

Course design 9: Schema (build on what they know)

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According to Wikipedia a schema can be described as…

  • An organized pattern of thought or behavior.
  • A structured cluster of pre-conceived ideas.
  • A mental structure that represents some aspect of the world.
  • A specific knowledge structure or cognitive representation of the self.
  • A mental framework centering on a specific theme that helps us to organize social information.
  • Structures that organize our knowledge and assumptions about something and are used for interpreting and processing information.

http://en.wikipedia.org/wiki/Schema_(psychology)

This is one of the reasons for the importance of themes and the sequential structure of topics that are introduced in a logical order throughout the training day. It helps participants to maintain a cohesive schema. But there’s more to it than that.

All of your training ‘victims’ will have their own schemata (worldviews) already. They bring them into training with them and good training acknowledges that.

If the materials you present appear to conflict with their pre-established worldview then you will have great difficulty in maintaining their interest, their engagement and your own credibility. So it’s important to start the ‘journey’ they will take through the training with what they already understand. To put it another way…

Meet them where they are

In the previous instalment I used the example of a deliberate self harm course for a reason. It’s because it provides us with an excellent illustration of how to use participants’ pre-existing schemata to gain engagement and then lead them on to new discoveries and more sophisticated understanding. Let me explain….

Many people believe that deliberate self harm is all about us. They think (because for years care professionals have told them) that deliberate self harm is all about attention seeking and manipulation. The reality is that this is not true but to begin with this blunt statement would meet signficant resistance that the trainer may never really overcome.

So before we can lead people to this realisation we need to do two things…

First we need to give the participants a reason to change their minds – they must make their own decision. As Rudyard Kipling once wrote

“A man convinced against his will

Is of the same opinion still”

Secondly we need to ‘soften the blow’ by incorporating as much of their pre-existing knowledge into the new belief system as we possibly can.

In deliberate self harm training I usually do this by exploring coping in general and by asking the group about their own coping skills. Once we have developed a long enough list of coping skills we highlight the ones that induce chemical changes in the central nervous system. At this point we have not directly mentioned self harm, just general coping skills.

In this way we tap into the participants’ existing schema about coping and then added a small piece of information (that doesn’t contradict their original view) which is that they are manipulating brain chemistry to feel better.

Only once they have clearly understood the chemical aspect of coping skills such as exercise, alcohol and substance use, arguing, making love, relaxing/meditating, comfort-eating etc do we make the point that physical trauma also stimulates endorphins in the central nervous system in exactly the same way.

We have begun with what they already understand about their own coping, added a piece of information that is non-threatening and then introduced the same information to demonstrate that deliberate self harm is just another version of what we all do.

This is working with the participants’ schemata. It also remains consistent with the general themes of the training…

  • Deliberate self harm is a coping strategy.
  • We’re all the same.
  • Care workers are not the focus of people’s problems – it’s not about us.

By taking the time to work with peoples’ schemata we can introduce some quite sophisticated concepts over the course of a day without difficulty. It isn’t uncommon for participants to report a completely changed point of view by the end of the day without having to overcome any significant resistance during the training. This lack of resistance is a sign that attention has been given to step by step development of their existing schemata rather than trying to go straight into what may be contentious, unfamiliar or otherwise uncomfortable for them.

 

Course design 7: A few major points and supporting info/exercises

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If your training is to succeed you will need to know much more about the topic than you will ever be able to include in the course itself. It’s not enough to just ‘wing it’ and try to stay ‘one step ahead’ of your participants. Trainers who don’t understand their topic enough to answer the variety of questions that crop up will quickly lose credibility – the kiss of death for any training course. So you really do need to have an in depth understanding of the topic you’re delivering training around.

But this creates a problem of its own. Since you can’t include all that you know you’ll need to decide not only what to include in your course materials but also what to leave out. I would argue that this issue of what to leave out is more important than deciding what to include. Any fool can heap fact after fact into their course outline but this will only overload your ‘victims’ and cause them to switch off as they fail to grasp the flood of detail that overwhelms them.

I use the analogy of a jigsaw when preparing training. The idea is that the course is a jigsaw containing a number of jigsaw pieces (important, fundamental points to be made). In a full day training around 10-12 jigsaw pieces is enough. These should be arranged in a logical, sequential order, each one leading to the next and they should be arranged in themes so that participants can continue to build upon the information received throughout. We’ll look more at this in a later instalment on ‘themes’.

For today it’s enough to understand that the structure of training needs to hang around a relatively small number of fundamental points. Everything else, from exercises to anecdotes are there to support those fundamentals, to make them memorable or to help participants to understand how they fit together.

For example, in Mental Capacity Act training for Local Authority care workers or those who deliver services in voluntary sector care homes I won’t usually introduce the rules relating to research involving people who lack the capacity to consent to it. I need to know about it in case I’m asked but most care providers don’t need to understand that stuff. Nor will I go into great detail about the processes involved in taking cases to the court of Protection. It’s enough for carers to understand that this could happen. Should they ever be involved in court of Protection cases they’ll be briefed by specialist lawyers anyway so they don’t need me to overload them in training about care delivery.

The actual ‘jigsaw pieces’ for a Mental Capacity Act course (for example) would vary depending upon the needs of the client but they would be likely to include:

  1. Background and purpose of the act (including the Bournewood story)
  2. Five principles
  3. The meaning of liberty
  4. Who assesses capacity?
  5. Assessing capacity
  6. Best interests
  7. Advocacy and the IMCA service
  8. Advance Decisions (AD)
  9. Lasting Power of Attorney (LPA)
  10. Appeals and court processes
  11. Links with safeguarding

For the purposes of this series it doesn’t matter whether or not readers are familiar with the Mental Capacity Act. It’s just an illustration. All you really need to know is that there are probably around 25 different ‘jigsaw pieces’ I could have chosen but 11 will be quite enough to cover in a single day.

The arrangement above allows the participants to move through the ‘journey’ of training beginning with background and first principles which can then be included in all the subsequent activities, discussions, exercises and case studies as they develop an increasing awareness of their responsibilities under the Act.

The idea is that by the end of the training the jigsaw pieces we introduced come together to recreate the ‘picture on the box’, with each piece clearly linking to (and fitting with) all the rest to form a coherent ‘whole’. This takes a bit of thought but it is far more easily understood (and far more memorable) than an unplanned collection of seemingly random points. Even these same jigsaw pieces presented out of order would confuse the participants. For example, it would be extremely difficult for participants in Mental Capacity Act training to understand when to get into ‘best interests decisions’ on behalf of service users without first going through the principles of the Act, the fact that all care workers have a role to play in assessing capacity and the assessment process itself.

So know which points to include, which to leave out and the order in which to present the ‘jigsaw pieces’ to ensure understanding and retention.

 

Course design 8: A theme runs through it

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In the last instalment we discussed the need to limit the amount of information we introduce in a single course. Rome wasn’t built in a day and there is no sense in trying to cram years of your own education into a single training day. Even in longer courses with much more delivery time we need to be realistic.

We’ve already noted that the information we do include needs to hang together but we haven’t really covered the way to ensure that it does. The basic principle here is to concentrate upon consistent and complimentary themes.

If the training consists of 10 ‘jigsaw pieces’ (see part 7) then they should be linked together by around three different themes that run through the whole training. When I was growing up I briefly took up jigsaw making as a hobby. I would spend hours completing some really rather complex jigsaws and, if I liked the finished result enough, I’d flip the jigsaw over, glue sheets of paper to the back to ‘hold’ it and then stick it in a frame to hang on my bedroom wall.

To continue with the idea of training as a jigsaw, these themes become the ‘glue’ that holds it all together. That’s why we only need a small number of themes – the same notions recur over and over, allowing participants to build upon information throughout the training and create a comprehensive ‘schema’ in their minds. We’ll cover schema specifically in the next instalment. Here’s an example of how we use themes to connect the training together.

One subject I regularly deliver training upon is ‘deliberate self harm’. The jigsaw pieces most commonly included in a one day self harm awareness day are:

  1. Self harm is not about us
  2. Self harm isn’t suicide – but people who harm themselves are at higher risk of suicide
  3. Self harm is about coping
  4. Most self harm is done in private and kept secret
  5. When coping fails people behave in more and more extreme ways
  6. We all use particular coping strategies to feel better when distressed
  7. The most effective coping strategies change brain/body chemistry (endorphins)
  8. Deliberate self harm stimulates endorphins
  9. People generally use the best coping strategies they know
  10. Our job is to enhance coping strategies – not to remove the only effective coping strategy a person has.

 

Now let’s examine how the use of themes (constantly referred to throughout) can help pull all this information together into a cohesive whole. The themes I’d use for this particular jigsaw are….

  • Deliberate self harm is a coping strategy.
  • We’re all the same.
  • Care workers are not the focus of people’s problems – it’s not about us.

Now let’s see how these themes can be used to link the training together by constantly returning to them as we move through the ‘jigsaw pieces’ in order.

The pieces most commonly included in a one day self harm awareness day are:

    1. Self harm is not about us (theme 3)
    2. Self harm isn’t suicide – but people who harm themselves are at higher risk of suicide (theme 3)
    3. Self harm is about coping (theme 1)
    4. Most self harm is done in private and kept secret (theme 3)
  • When coping fails people behave in more and more extreme ways (theme 2)
    1. We all use particular coping strategies to feel better when distressed (theme 2)
    2. The most effective coping strategies change brain/body chemistry (endorphins) (themes 1, 2 & 3)
    3. Deliberate self harm stimulates endorphins (themes 1 & 3)
  • People generally use the best coping strategies they know (theme 2)
  1. Our job is to enhance coping strategies – not to remove the only effective coping strategy a person has. (themes 1 & 3)
  2. Developing alternative coping strategies (themes 1,2 and 3)
  3. Looking after ourselves (theme 2)

The jigsaw pieces follow a logical pattern and the use of themes allows participants to see how it all hangs together. This is important if the participants are to create a ‘schema’ which will be the focus of the next instalment.

This also demonstrates why we need to be careful about what to include and what to leave out. We can’t do everything in a time-limited training session so plan with your client to include things that are useful and that hang together coherently. Otherwise you’ll leave your participants confused and unable to relate the various elements of training to each other or to their work.

Course design 6: Do you want to inform, discuss, develop or what?

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One of the most common mistakes among new trainers is to do with their own lack of clarity. It’s not enough to introduce subjects randomly in training – we need to know what we’re trying to achieve with each section of course delivery, how it fits into the overall ‘journey’ the trainees are to take and how best to get them through each step.

Sometimes we’ll use group discussion to make sure everyone is ‘on the same page’ and to check out any areas of contention that might need a little more work.

Sometimes we’ll be asking participants ‘closed’ questions that demand only a ‘yes’ or ‘no’ answer to focus their thinking or to stimulate debate within small groups.

Sometimes we’ll use simple case studies to demonstrate how a principle might be applied in practice.

Sometimes we’ll use complex case studies to get people to stretch their thinking and understanding or to draw together several ‘threads’ we’ve already discussed.

Sometimes we want to inform.

Sometimes we want to discuss and raise awareness.

Sometimes we want to boost confidence by asking trainees questions they already know the answer to.

Sometimes we want to introduce confusion because the first stage of genuine learning is an admission that you don’t yet understand.

And sometimes we just want to give them a break – a bit of psychological downtime to assimilate the information covered so far.

Each of these different aspects of training has its place and none should be ignored. There is much more to group work, for example, than endless barrages of case studies.

So the question for today is simple….

Do you want to inform, discuss, develop or what?

 

Course design 5: Tell ‘em what they need to know – not what you know

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I was once asked to design training on ‘Mental Health awareness’ for support workers. The training was to be delivered by a fairly large group of trainers across the whole of UK. This presented its own problems in that each trainer had their own particular views on some very controversial aspects of the course.

The danger we faced as a team was that we ran the risk of becoming so bogged down in our own differences of opinion that we forgot the people we’d be delivering the training to. Let me give you an example.

One of the more contentious parts of the course involved the different ways we thought about psychiatric diagnosis. This is a specialist area and only as people become well versed in the fine detail of what’s known as ‘differential diagnosis’ do they realise just how unevidenced many of these diagnoses can be.

As a group of trainers we were all very aware of the different disputes about diagnoses such as schizophrenia or the various personality disorder diagnoses and not surprisingly we all had different opinions. It would have been really easy for us to argue about the pros and cons of schizophrenia or the meaning of recovery in mental health services but that would have been beyond the understanding of our trainees.

It took us years of experience in practice even to understand the issues, let alone form our opinions about them. It would be unrealistic, unfair and even cruel to demand that same level of discernment from support workers in a single day’s training course. It would also fill them with so much doubt that they would be unable to feel confident about the work they would still need to do the next day when they returned to the workplace.

We will never help to enhance anyone’s confidence by wasting their time on topics that don’t involve them – especially if the only reason we do so is to show them how clever we are. Trainers aren’t paid to prove how clever we are, we’re paid to help people to develop appropriate understanding and skills.

So remember the rule…

Tell ‘em what they need to know – not what you know