Preparing for collaborative working in mental health: an interprofessional education project with clinical psychology trainees and nursing

students
Helena Priest, Paula Roberts, Helen Dent, Tom Hunt, Dale Weston, Amy Chell, Christine Blincoe and Christine Armstrong

Helena Priest and Helen Dent are based at the Shropshire and Staffordshire Clinical Psychology Training Programme, Faculty of Sciences, Staffordshire University, Stoke-on-Trent, UK. Paula Roberts and Christine Armstrong are based at the School of Nursing and Midwifery, Keele University, Stoke-on-Trent, UK. Tom Hunt is based at Psychology and Mental Health, Faculty of Sciences, Staffordshire University, Stoke-on-Trent, UK. Dale Weston and Amy Chell were formerly based at the School of Psychology, Keele University, Stoke-on-Trent, UK. Christine Blincoe is based at Densy Psychological Services, Stoke-on-Trent, UK.

Abstract Purpose Effective interprofessional working is widely claimed to enhance service delivery, user satisfaction, and most importantly, clinical outcomes. Achieving this position is proving difcult. Research suggests that strategies to enhance interprofessional collaboration should begin at the earliest possible opportunity to prevent negative stereotypes from developing. This project was an attempt to develop effective interprofessional education (IPE) across staff groups who work in the mental health arena (mental health nursing students and clinical psychology trainees). Design/methodology/approach Participants were whole cohorts of undergraduate mental health nursing students ( n 11) in their second year of training (at the commencement of their branch programme), and trainees on the doctorate in clinical psychology ( n 10) at the start of their rst year of training. IPE sessions were facilitated by mental health nursing and clinical psychology academic staff and clinicians. Activities included creative group work and problem-based learning. Seven sessions were delivered across over a 2 year period. Findings Qualitative and quantitative data from this two year project showed an increase in positive attitudes towards professionals from each profession over a two year period, though no overall improvement. Qualitative analysis of participant comments provided more encouraging support for improvement in attitudes, within the theme areas of teamwork and collaboration, professional identity, and roles and responsibilities. Overall, the project provided important information on building positive attitudes within the mental health workforce, while identifying challenges that need to be anticipated and addressed. Originality/value Few studies have explored IPE in mental health contexts, especially in the pre-qualication arena. Keywords Professional education, Mental health services, Psychology, Attitudes Paper type Research paper

Introduction
Interprofessional education (IPE) is said to occur when two or more [healthcare] professions learn with, from, and about each other to improve collaboration and the quality of care (Freeth et al. 2005, p. 11). IPE differs from multi-professional education, as in the latter, people from different professions learn alongside one another but do not collaborate in shared tasks.

Why IPE?
Effective healthcare communication has been linked to service user satisfaction, with many complaints investigated by the Parliamentary and Health Service Ombudsman

DOI 10.1108/17556221111136161 VOL. 6 NO. 1 2011, pp. 47-57, Q Emerald Group Publishing Limited, ISSN 1755-6228

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(www.ombudsman.org.uk/about-us/publications/annual-reports) identifying serious communication and information-sharing lapses. IPE is one way of preparing a workforce to work effectively and collaboratively in practice, as recommended by the Department of Health (DH) (2004) which has produced an outline of the essential capabilities required to achieve best practice for education and training of all staff who work in mental health services. Indeed, many professional bodies now require IPE to be in place within educational curricula. Professional training programmes are increasingly seeking to identify relevant theoretical perspectives, and to deliver and evaluate useful and practical programmes (Colyer et al., 2005; Freeth et al., 2005). There are many advantages to interprofessional healthcare education. It encourages the development of close relationships between different health care professionals, which is essential for effective care delivery (Finch, 2000). It can increase professionals intentions to work well together in the future, by helping to change negative attitudes and discover common ground (Barr et al., 1999). It can also contribute to the sharing of knowledge, theories and terminology and enhance job satisfaction. Increased collaboration via IPE may also reinforce clinical competencies (Barr et al., 2000) and improve patient outcomes (Zwarenstein and Bryant, 2002), though these are more difcult to demonstrate from evaluations of IPE.

IPE in mental health contexts

Since the 1990s, interprofessional working has been promoted to improve mental health care in the UK (Care Services Improvement Partnership, 2005). For example, integrated community mental health teams involving health and social care professionals are now in place nationally (DH, 2002), and IPE lends itself well to supporting such developments. Despite this, few studies have explored IPE in mental health contexts, especially in the pre-qualication arena. Studies undertaken in the post-qualication arena have produced limited or disappointing results. For example, Reeves and Freeth (2006) reviewed an in-service IPE programme within community mental health teams and concluded that although participants responded well to the programme, it was difcult to identify wider impact. Barnes et al. (2000) also found that within community mental health teams, interprofessional stereotypes and perceived status differences persisted, despite a one-year programme of IPE. Furthermore, this teams longitudinal work (Carpenter et al., 2006), which followed students undertaking a programme designed to help multiprofessional teams to deliver mental health interventions in the community such as psychosocial interventions, showed that professional stereotyping was resistant to change and participant stress levels and attrition increased during the training (Barnes et al., 2006). Reeves (2001) systematic review also highlighted allegiances to professional cultures, and conicts around different approaches to care delivery, leadership and responsibility as particular barriers. The pilot study described by Priest et al. (2008) focused on the pre-qualication arena, bringing together clinical psychology and mental health nursing students in IPE. This study identied major challenges in integrating participants from different universities, with different timetables, studying at different academic levels, and with different expectations and experience. However, the study did yield some promising results in terms of positive changes in attitudes to teamwork and collaboration, and to views on roles and responsibilities. This promising start led directly to the project described in this paper, and a desire to resolve some of the inherent challenges.

The IPE in mental health project

Building directly upon the pilot study (Priest et al., 2008), the full project aimed to add to the knowledge base around IPE in mental health by bringing together two professional groups who often work together in mental health contexts. The project was longitudinal (two years), addressing many criticisms of snapshot evaluations of IPE, and its aims were to explore any changes in interprofessional attitudes arising from shared learning amongst mental health professionals in training, and potential impact on interprofessional working.

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Method
Participants Participants were whole cohorts of undergraduate mental health nursing students (n 11) in their second year of training (at the commencement of their branch programme), and trainees on the doctorate in clinical psychology (n 10) at the start of their rst year of training. Procedure IPE sessions were facilitated by mental health nursing and clinical psychology lecturers and practising clinicians. Session aims were directly linked to the respective student groups programme learning outcomes, and activities included creative group work and clinical vignette problem-based learning. Seven sessions were delivered across the two-year period. Tools A participant information sheet and consent form were designed to outline the purpose of the study and how it would be implemented and evaluated. The information sheet also detailed the methods of data storage, use and dissemination. An oral presentation was also provided. An evaluation questionnaire was designed and administered at the beginning of the rst session and immediately following four of the subsequent six IPE sessions (Priest et al., 2008). The tool gathered demographic data; free text responses to open ended questions; and scores from an adapted scale (RIPLS; Parsell and Bligh, 1999). This scale comprises three major constructs: collaboration and teamwork, professional identity, and roles and responsibilities. Ethical issues NHS Research Ethics Committee approval and NHS Research Governance approval was gained from the NHS Trusts employing the clinical psychology trainees. Permission was also obtained from the respective academic schools of both participant groups, and all participants gave written consent. All data were kept condential to the research team, with data being separate from personally identiable information, via code numbers, and anonymity was preserved in published reports. The RIPLS was adapted and used with kind permission of the publishers.

Quantitative data analysis: ndings[1]

Attendance at sessions Attendance was variable (Figure 1), with total numbers at each measurement point being 19, 15, 16, 12 and 18 (out of a maximum of 21). There were consistently more mental health nurses at each session, with the exception of time 4 (T4). While participation was compulsory, and there were similar numbers of participants at each of the ve sessions, it was apparent from registers taken that there were many absences, and that (some) different participants attended different sessions. Only six people attended every session. The fall in attendance by clinical psychology trainees at T3 was due to an administrative error. In fact, no clinical psychology students actually attended this session, because they had not been informed of the date, but ve chose to complete the associated questionnaire nonetheless. Preparation for IPE Participants were asked if they had received adequate preparation for the IPE sessions. Participants were generally happy with the preparation received, and particularly so by the nal session.

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Figure 1 Number of participants at each session

20 18 16 14 12 10 8 6 4 2 0 Time 1 Time 2 Time 3 Session Time 4 Time 5

No of participants

Clinical psychologist Mental health nurse Total

Feedback on participation Participants were asked if they had received clear and constructive feedback on their participation in the shared learning sessions. Participants were largely happy with the feedback received, apart from at T3 when virtually all participants were unhappy. Reasons for this have already been alluded to, and will be considered further in the discussion section. Previous experience of IPE Participants were asked whether they had any previous experience of IPE, as this might have had a confounding effect on their experience and evaluation. The number of participants who reported previous experience of IPE was similar to the number who did not. While it might have been expected that, after session 1, most if not all participants would respond yes at each subsequent time point, it is possible that those answering no were referring to experiences prior to the study commencing. Variation could be explained by different participants attending different sessions. Opportunity to work together in clinical practice Participants were asked if they had had opportunity to work together with the other professional group during clinical placements. There was a steady rise in participants working together in practice over the two year life of the project, which could perhaps therefore indicate an improvement in attitudes towards the other professional group and interprofessional working generally over time. Helpfulness of IPE sessions Participants indicated how helpful they found the sessions, by marking a position on a visual analogue scale from 0 very unhelpful to 10 very helpful (Figure 2). This graph shows that initially, all participants viewed the IPE sessions as helpful to their learning, but this dropped signicantly for both professional groups at T3 and T4, and after a rise, fell again for DClinPsy trainees at T5. The nurses, however, perceived the sessions to be slightly more helpful at the end than at the beginning. Attitudes towards IPE Functions of, and attitudes towards, IPE were further explored by means of the Parsell and Bligh (1999) scale. Although this scale was designed to assess readiness for IPE, it was adapted, with permission, for use in this study by repeated administration to detect any changes in attitudes towards interprofessional learning over time, as a result of participation in IPE activities. Because there were unequal time periods between the administration of each questionnaire, a trend analysis was conducted to correct for any resulting anomalies. This took the form of

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Figure 2 Perceived helpfulness of IPE sessions by professional group

80.00

Mean perceived_ helpfulness

70.00

60.00

50.00 Professional group DClinPsych Nursing 2 3 Admin 4 5

40.00

exploring simple linear trends, general non-linear trends, and quadratic trends for each group separately and for all participants. Results are illustrated in line graphs (Figures 3-5). As can be seen from Figures 3-5, no simple linear trend in attitude change was present, as evidenced by the u-shaped graphs. To explore the impact of lack of consistency in session attendance, a mini case study analysis was conducted on the data for the six students who attended every session. No signicant results were found for this subsample, although this could be a product of the small sample size. In summary, there was no evidence of change Figure 3 Change in attitudes towards IPE, mental health nurses
Mental_health_nursing

4.20

Mean

4.00

3.80

3.60 Admin_1 Admin_2 Admin_3 Admin_4 Admin_5

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Figure 4 Changes in attitudes to IPE, clincial psychology trainees

DClinPsych 3.80

3.70

Mean

3.60

3.50

3.40 Admin_1 Admin_2 Admin_3 Admin_4 Admin_5

Figure 5 Changes in attitude towards IPE, all students

4.10 4.00 3.90 Mean 3.80 3.70 3.60 3.50 Admin_1 Admin_2 Admin_3 Admin_4 Admin_5

over time in attitudes towards IPE or perceptions of interprofessional roles either for the group as a whole or for the subset.

Qualitative data analysis: ndings

Given these disappointing results, written answers to specic questions were thematically analysed (using the procedure described by Newell and Burnard (2006)) to shed further light on attitudes towards IPE. Qualitative data responses were organised into three key themes as per the subscales identied by Parsell and Bligh (1999). Quotes are included as evidence of the themes and issues and are attributed by professional group and time of questionnaire completion. However, it should be noted that the nature of the data provided (generally brief comments) does not allow a condent demarcation of themes into professional identity and roles and responsibilities. What follows is an attempt at best t.

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Theme 1: teamwork and collaboration Parsell and Bligh (1999) comment that interprofessional learning is relevant to teamwork and collaboration and point to the importance of positive relationships, effective teamworking, and contributing professional knowledge within a multi disciplinary team. This theme emerged strongly, particularly the need for greater interprofessional co-operation in practice, and can be seen in responses to questions about how the shared learning sessions enhanced participants understanding of the other professional group:
[I] feel this session in particular has been important in establishing a positive relationship between professions more of an understanding of how we are working on commonalities and our shared/cross over roles [. . .] (Nurse, T2).

By T5, an increase in awareness of the complementary nature of the two roles was demonstrated, particularly evidenced by the nurses. Most participants stated that the IPE sessions were valuable in developing interprofessional relationships and in understanding how the two groups may work together in the future:
Clearer understanding of the roles and the importance of inter-professional working (C. Psychol, T5). [. . .] personal understanding of how I approach the same professionals after an initial difcult period (Nurse, T5).

Thus, it seems that a greater understanding and awareness of the complementary nature of the two professions was developed during the sessions, and the advantages of shared learning sessions for facilitating working were demonstrated. Theme 2: professional identity Parsell and Bligh (1999) comment that IPE is important in the development of professional identity the ways in which individuals dene their professional lives within the power of individual professional cultures and territories. In this study, participants identied key ways in which the professional identities of the two groups were similar, different and complementary. The most prevalent perceived similarity was the client-centred nature of the work; this was perceived consistently across the time periods:
The fact that both of our end goals is to help the client in every way possible (Nurse, T2). Focusing on needs of patient, building rapport and trusting relationship (C. Psychol, T4).

The shared focus on assessment in both professions was also highlighted:

The need for competent assessment and importance of rapport building with clients (Nurse, T3). Client-centred, importance of risk assessment, looking at issues from a wider systemic perspective as well as individually (C. Psychol, T5).

Despite these similarities, key differences concerned the different methods of working with patients, with many members of both groups commenting on perceptions of nurses as focused primarily on personal care, medication administration, and working within the Mental Health Act:
I spend more time with individual patients, nurses tend to have to problem solve on their feet (Nurse, T3). Nurses are more medication focused (Nurse, T5). They [nurses] have less time/higher caseload (C.Psychol, T4).

Theme 3: roles and responsibilities Parsell and Bligh (1999) comment that interprofessional learning is relevant to awareness of roles and responsibilities and understanding the boundaries which delineate roles in professional practice. In this study, one of the most prevalent themes was a greater understanding, by nurses, of the roles and perspectives of clinical psychologists:
Greater understanding of [clinical psychologists] professional roles, objective views and assessments of mental health (Nurse, T2).

Equally, clinical psychologists reported an increase in understanding of the general and specic roles of nurses and especially their role as therapists:

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Better understanding of the breadth of their role (C Psychol, T4).

Initially, roles were perceived to be essentially similar. However, by the later sessions there were fewer perceived similarities; this was most pronounced at T5 for the mental health nurses and could suggest a developing awareness of the other professional groups specic role:
Able to utilise their different way of working to gain a different perspective (Nurse, T5). I now know more of the clinical psychologist role (Nurse, T5).

As a result of this increasing awareness, a better understanding of the roles and approaches of the other professional group was developed, leading to greater appreciation of the similarities and differences between the two professions. From questionnaire comments, intergroup conict was an issue for both groups at various stages of the project. Mental health nurses noted difculties in working interdependently because of a perception that the clinical psychologists were dominant and interested only in their own perspective:
Psychologists take over, psychologists are overpowering sometimes, psychologists nd it difcult to understand our perspective [. . .] I dont feel they are respectful or punctual giving a bad impression (Nurse, T3).

Similarly, the clinical psychologists felt that there was conict between the two groups and perceived the nurses as not wanting to co-operate:
Conict, nurses not wanting to be involved, negative comments from nurses (C. Psychol, T3). Lack of commitment and conict made the task something to get through not a learning experience (C. Psychol, T3).

Discussion
Mental health professionals need the skills, knowledge and attitudes to work effectively and collaboratively in multidisciplinary teams (Priest et al., 2008), and in principle, IPE should provide a vehicle for enhancing such collaboration. In line with other studies, however, (Barnes et al., 2000; Reeves et al., 2008), this study produced no signicant measurable effects of IPE on reported readiness for or attitudes towards interprofessional learning, although written comments were encouraging. Owing to inconsistent attendance at sessions, it was not possible to draw meaningful conclusions about the effects of previous experience of IPE, or experience of working together in practice settings, on readiness or attitudes. However, it was pleasing to note an increase in opportunities for interprofessional working as the project progressed. For both groups, there was an increase in the awareness of the other professional groups roles, and similarities between the two professional groups were unearthed in particular, the client centred nature of their approaches and methods of assessment. However, there was no clear increase in the clinical psychology trainees perceptions of role similarity over time; this could again be due to the lack of consistency in attendance at sessions. However, awareness for mental health nurses was most pronounced at the nal IPE session, which could suggest a development in their awareness of the other professional groups role. This is exemplied by the fact that both groups repeatedly noted increased role clarity as an advantage of the sessions; a nding similar to that reported by Barnes et al. (2000). Crucially, there was also a prominent theme of interprofessional working for both groups. This was particularly pronounced in mental health nurses after the nal IPE session. However, there was a decrease in emphasis on interprofessional working from clinical psychologists in the later sessions. Overall, the increase in awareness of interprofessional working was seen as a key benet of the shared learning sessions by both groups. This nding is signicant as it reafrms the positive outcomes of IPE emphasised by Barr et al. (1999) and Reeves et al. (2008) and also extends the research on IPE further in the context of mental health, a key rationale for the study (Priest et al., 2008).

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Challenges and limitations

As noted, a difculty in drawing meaningful conclusions from this study was the lack of consistency in participation at each session. Only six participants completed questionnaires from every session and so it was impossible to conduct related analyses across time points. However, even when the data from these six participants was analysed separately, in the form of a mini case study, there were still no signicant effects of IPE. Additionally, problems with scheduling and communicating led to serious consequences, with an impact on perceptions of interprofessional working as a result of intergroup conict. We have previously noted a planned session about which the clinical psychology trainees were not made aware, and a follow-on session from which many of the nurses were absent. It is true that when IPE is poorly implemented there can be serious negative consequences arising from conict (Barnes et al., 2000) and from poor structuring (Pethybridge, 2004; Reeves et al., 2008; Skjorshammer, 2001). This was certainly the case in the current research as the non-attendance by clinical psychologists at the third session and poor attendance by mental health nurses at the fourth session seriously disrupted the ow of the sessions and the coherence of the project as a whole. While this intergroup conict was identied and effectively addressed by the facilitators during the project, via some open reection and work on group dynamics, the immediate backlash as reected in the quotes above undoubtedly impacted on perceptions of IPE and working. Perhaps, with more sessions, better planning and communication, and with both groups present at all sessions, there would be less animosity this is an issue for further research. Other challenges surround bridging the gap in academic level (undergraduate and doctorate) between these participating students, and aligning requirements of different programmes to ensure appropriate content and effective scheduling. This was a small-scale study undertaken with two groups of students across two organisations, and therefore, results cannot be generalised and statistical ndings must be interpreted with caution. Nonetheless, some useful insights were gained into the preparation, delivery and impact of shared learning which concurred with other published studies.

Conclusion
Whilst there were no signicant effects found as a result of the quantitative analysis, the qualitative analysis provides encouraging support for the use of IPE in facilitating interprofessional working (Priest et al., 2008; Headrick et al., 1998; CAIPE/DH, 2007). However, the apparent ease with which interprofessional conict was triggered within this project underlines the need for further work to anticipate and address potential challenges. Learning points from both the pilot and full studies include paying particular attention to:
B B

distinct programme requirements, academic levels and group size; explaining the rationale, tasks and expectations clearly at the outset and reinforcing these frequently; group dynamics; building in ice-breakers, social activities and informal contacts to enhance inter-group working; and exibility in scheduling to allow for addressing difcult group dynamics as they arise (Priest et al., 2008).

B B

Overall, this research echoes Barr et al. (1999) and Reeves et al. (2008) by providing cautious support that IPE encourages interprofessional working. In addition, it contributes to lling the gap identied by Priest et al. (2008) in the context of mental health, and in using longitudinal measures.

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Note
1. No data are available for the two sessions that were not followed by questionnaire administration. As participants were unable to answer anything other than the RIPLS scale questions at Session1, no data are available for other parts of the questionnaire for time 1.

References
Barnes, D., Carpenter, J. and Dickinson, C. (2000), Interprofessional education for community mental health: attitudes to community care and professional stereotypes, Social Work Education, Vol. 19 No. 6, pp. 565-83. Barr, H., Freeth, D., Hammick, M., Koppel, I. and Reeves, S. (1999), Evaluating Interprofessional Education: A United Kingdom Review for Health and Social Care, BERA/CAIPE, London. Barr, H., Freeth, D., Hammick, M., Koppel, I. and Reeves, S. (2000), Evaluations of Interprofessional Education: A United Kingdom Review for Health and Social Care, CAIPE/British Educational Research Association, London. CAIPE/DH (2007), Creating An Interprofessional Workforce An Education & Training Framework for Health and Social Care in England, Department of Health, London, available at: www.dh.gov.uk/en/ Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_078592 Care Services Improvement Partnership (2005), Everybodys Business: Integrated Mental Health Services for Older Adults: a Service Development Guide, Department of Health, London. Carpenter, D., Barnes, D., Dickinson, C. and Wooff, D. (2006), Outcomes of interprofessional education for community mental health services in England: the longitudinal evaluation of a postgraduate programme, Journal of Interprofessional Care, Vol. 20 No. 2, pp. 145-61. Colyer, H., Helme, M. and Jones, I. (2005), The theory-practice relationship in interprofessional education, Higher Education Academy Health Science and Practice Network, London. DH (2002), Mental Health Policy Implementation Guide Community Mental Health Teams, Department of Health, London. DH (2004), The 10 essential shared capabilities: a framework for the whole of the mental health workforce, available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicy AndGuidance/DH_4087169 (accessed November 22 2010). Finch, J. (2000), Interprofessional education and teamworking: a view from the education providers, British Journal of Medicine, Vol. 321, pp. 1138-40. Freeth, D., Hammick, M., Reeves, S., Koppel, I. and Barr, H. (2005), Evaluating Interprofessional education: A Self-Help Guide, Higher Education Academy Health Science and Practice Network, London. Headrick, L.A., Wilcock, P.M. and Batalden, P.B. (1998), Interprofessional working and continuing medical education, British Medical Journal, Vol. 316 No. 7133, pp. 771-4. Newell, R. and Burnard, P. (2006), Research for Evidence-based Practice, Blackwell, Oxford. Parsell, G. and Bligh, J. (1999), The development of a questionnaire to assess the readiness of health care students for interprofessional learning, Medical Education, Vol. 33, pp. 95-100. Pethybridge, J. (2004), How team working inuences discharge planning from hospital: a study of four multi-disciplinary teams in an acute hospital in England, Journal of Interprofessional Care, Vol. 18, pp. 29-41. Priest, H.M., Roberts, P., Dent, H., Blincoe, C., Lawton, D. and Armstrong, C. (2008), Interprofessional education and working in mental health: in search of the evidence base, Journal of Nursing Management, Vol. 16 No. 4, pp. 474-85. Reeves, S. (2001), A systematic review of the effects of interprofessional education on staff involved in the care of adults with mental health problems, Journal of Psychiatric and Mentalhealth Nursing, Vol. 8, pp. 533-42.

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Reeves, S. and Freeth, D. (2006), Re-examining the evaluation of interprofessional education for community mental health teams with a different lens: understanding presage, process and product factors, Journal of Psychiatric and Mental Health Nursing, Vol. 13, pp. 756-70. Reeves, S., Zwarenstein, M., Goldman, J., Barr, H., Freeth, D., Hammick, M. and Koppel, I. (2008), Interprofessional education: effects on professional practice and health care outcomes, Cochrane Database of Systematic Reviews, Vol. 1, available at: http://mrw.interscience.wiley.com/cochrane/ clsysrev/articles/CD002213/frame.html Skjorshammer, M. (2001), Co-operation and conicts in a hospital: interprofessional differences in perception and management of conicts, Journal of Interprofessional Care, Vol. 15, pp. 7-18. Zwarenstein, M. and Bryant, W. (2002), Interventions to promote collaboration between nurses and doctors (Cochrane Review), The Cochrane Library, Issue 4, Update Software, Oxford.

Further reading
Health Service Ombudsman for England (2006), HSC Annual Report 2005-2006, Health Service Ombudsman for England, London, available at: www.ombudsman.org.uk/pdfs/ar_06.pdf Priest, H. and Roberts, P. (2006), Working together and learning together, Nursing Standard, Vol. 21 No. 11, pp. 62-3.

Corresponding author
Helena Priest can be contacted at: h.m.priest@staffs.ac.uk

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