Kragelj A, Pahor M, Zaletel-Kragelj L, Makivić I. Learning needs assessment among professional workers in community mental health centres in Slovenia: Study protocol (Original research). SEEJPH 2022, posted: 21 May 2022. DOI: 10.11576/seejph-5478 P a g e 1 | 11 ORIGINAL RESEARCH Learning needs assessment among professional workers in community mental health centres in Slovenia: Study protocol Anja Kragelj1, Majda Pahor2, Lijana Zaletel-Kragelj1,3, Irena Makivic1 1 National Institute of Public Health, Ljubljana, Slovenia 2 Faculty of Health Sciences, University of Ljubljana, Ljubljana, Slovenia (retired) 3 Chair of Public Health, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia Corresponding author: Lijana Zaletel-Kragelj Faculty of Medicine, University of Ljubljana Chair of Public Health Zaloska 4, 1000 Ljubljana, Slovenia Phone: + 386 1 543 75 40; Fax: + 386 1 543 75 41 E-mail: lijana.zaletel-kragelj@mf.uni-lj.si Kragelj A, Pahor M, Zaletel-Kragelj L, Makivić I. Learning needs assessment among professional workers in community mental health centres in Slovenia: Study protocol (Original research). SEEJPH 2022, posted: 21 May 2022. DOI: 10.11576/seejph-5478 P a g e 2 | 11 Abstract Aim: This article aims to present a study protocol that represents a tool developed for a learning needs assessment. With a pilot study, based on the presented concept of a model study, we will be able to assess what mental health learning content is not yet part of formal higher education for professionals working in community mental health centres, but has been identified as necessary for inclusion. The presented tool is transferable with appropriate modifications. The goal is to conduct multiple research with the same basic tool at all levels of the educational system and in continuing professional education for all professionals who work with people. Methods: The learning needs assessment study protocol presented uses both quantitative and qualitative research approaches. It is expected that the research will be conducted in several interrelated phases that holistically cover the needs assessment process. Results: The pilot study will provide insight into the advantages and disadvantages of the prepared learning needs assessment tool. Through the research study, the learning needs of professionals working in community mental health centres, will be identified. Conclusion: Professional mental health care workers must be equipped with the necessary knowledge, skills, attitudes, and values to perform their work with quality. By implementing appropriate mental health learning content in educational processes from pre-school education to higher education and further to continuing professional education, we can impact the mental health of the entire population. Since this can lead to acquiring the competencies necessary to care of one’s own mental health and that of others, it can be considered an important public health intervention. Keywords: Needs assessment, mental health, educational programmes Source of funding None declared Acknowledgements The authors gratefully acknowledge Maja Dizdarevic, Vera Grebenc, Kaja Krajc, Vesna Svab, Matej Vinko and Nika Vuksa Jurejevcic for their invaluable contribution when creating the methodological document. Conflict of interest None declared. Kragelj A, Pahor M, Zaletel-Kragelj L, Makivić I. Learning needs assessment among professional workers in community mental health centres in Slovenia: Study protocol (Original research). SEEJPH 2022, posted: 21 May 2022. DOI: 10.11576/seejph-5478 P a g e 3 | 11 Introduction Mental disorders are one of the major public health problems. According to the World Health Organization (WHO), Regional Office for Europe, they are one of the major public health challenges in the WHO European Region (1). The WHO data for 2015 showed that mental disorders are the leading cause in terms of disability (Years Lived with Disability - YLDs) and the third leading cause in terms of premature mortality and disability (Disability Adjusted Life Years - DALYs) (1). A similar picture is shown by the Global Burden of Disease Study (GBDS) database for the year 2019 as well (second leading cause in terms of YLDs, and fourth leading cause in terms of DALYs) (2,3), even excluding substance use disorders and self- harm (4). Moreover, the classification of Alzheimer's disease, which is considered a neurological disorder in available databases, is also blurred. Due to its expression in terms of mental changes, it can also be considered as a mental disorder (5-7). Also, historically dementia was treated within psychiatric services because of its mental manifestations (6). Therefore, the burden of disease (BoD) of this group of health phenomena is often underestimated (4). In Slovenia, the BoD of mental disorders is highest in terms of YLDs (12.3%), and it is even much higher when substance use disorders, self-harm, Alzheimer disease and other dementias are included (17.5% of the total BoD) (8). In 2018, Slovenia adopted the Resolution on the National Mental Health Programme 2018-2028 (RNPDZ), a document that defines the strategy for action in the field of mental health (9). One of the priority areas is “Education, research, monitoring and evaluation” (9). An important goal of this priority area is to provide learning content about mental health in educational programmes (EPs) at different levels of the educational system and in continuing professional education for all professionals who work with people (health care, social and family care, education, justice and law enforcement) (9). In order to optimally integrate learning content into educational processes, it is first necessary to assess the needs in this area. To achieve this goal, a methodological document was prepared with the design of multiple research to assess the needs for the inclusion of learning content on mental health (in short, learning needs) at different levels of the educational system and in the field of continuing professional education (10). The need reflects the gap between the current situation regarding the inclusion of learning content in educational processes and the state we want to achieve (Figure 1). Figure 1 also represents the targeted state, which is determined when content that is important for implementation is recognized. The methodological document presents in more detail the design of the model study, which is, after further development of the concept, presented further on. A pilot study will be conducted to test and complement currently existing phases, steps and procedures within the prepared tool. In the model study, the learning needs of professionals working in community mental health centres (CMHCs) will be assessed, based on the competencies (referring to their components such as knowledge, skills, values and attitudes (11)) they need to perform high-quality work. CMHCs are special units that address population mental health at the primary level of the health care system. Their establishment has begun with the RNPDZ implementation (9). CMHCs for children and adolescents provide treatment for the population aged 0-19 years, while CMHCs for adults provide care for those over 19 years of age (9). CMHC for adults consists of two teams, the regional outpatient treatment team and the regional community psychiatric treatment team (9). Table 1 shows the structure of professional staff working in CMHCs (12). Kragelj A, Pahor M, Zaletel-Kragelj L, Makivić I. Learning needs assessment among professional workers in community mental health centres in Slovenia: Study protocol (Original research). SEEJPH 2022, posted: 21 May 2022. DOI: 10.11576/seejph-5478 P a g e 4 | 11 Figure 1. Relationship between need, current state, desired state and targeted state in relation to the inclusion of mental health learning content in educational processes. Table 1. Profiles of professionals in community mental health centres (CMHCs) in Slovenia (12). CMHC FOR CHILDREN AND ADOLESCENTS CMHC FOR ADULTS The regional outpatient team The regional community psychiatric treatment team  Physician, Specialist in child and adolescent psychiatry  Psychologist, Specialist in clinical psychology  Psychologist  Special pedagogue  Speech-language pathologist  Speech-language pathologist, Specialist in clinical speech- language pathology  Occupational therapist  Social worker  Registered nurse  Physician, Specialist in psychiatry  Psychologist, Specialist in clinical psychology  Psychologist  Social worker  Registered nurse  Physician, Specialist in psychiatry  Psychologist, Specialist in clinical psychology  Occupational therapist  Social worker  Registered nurse Design and methods Research framework and design Purpose and objectives The purpose of the model study is to find out if there exist a need to include learning content, identified as missing, from the field of mental health in EPs for professionals working in CMHCs. The objectives of the model study are: a) to review already conducted research and findings on the topic that will be investigated; b) to assess the current state and analyse what mental health learning content already exists in formal EPs for professionals working in CMHCs, to assess the desired state considering the perspective of users and professionals, and afterwards to identify the learning needs by comparing the current and desired state; c) to explore examples of good practices from Slovenia or abroad, and d) through the consensus process based on the identified learning needs and the examples of good practice, to identify the target state - the state, that needs to be achieved. The phases and steps to achieve the listed objectives are described below. Research design Both quantitative and qualitative research approaches will be used. The research will be conducted in several interrelated phases, as shown in Figure 2. Kragelj A, Pahor M, Zaletel-Kragelj L, Makivić I. Learning needs assessment among professional workers in community mental health centres in Slovenia: Study protocol (Original research). SEEJPH 2022, posted: 21 May 2022. DOI: 10.11576/seejph-5478 P a g e 5 | 11 Figure 2. Schematic representation of the phases of the model study that focuses on learning needs assessment among professional workers in community mental health centres in Slovenia. Methods by phases Phase 1 In the first phase of the model study, we will conduct a scoping review. We are interested in research and findings that focus on assessing the learning needs of mental health professionals who are also part of CMHC teams. Phase 2 The identification of learning needs or the analysis of the gap between the current state and the desired state will take place in three segments (analysis of the current state, desired state and comparison between them), and within this in several steps. A) Analysis of the current state: In order to assess what competencies professionals in CMHCs can acquire before they start working, we will first review the formal higher EPs intended for educating these professionals. We will review first cycle (bachelor’s), second cycle (master’s), second cycle integrated master’s degree programmes and educational programmes within specializations. Through document analysis, we will identify courses with mental health content and corresponding credit points. This will be followed by a detailed review of the content of the identified courses and an analysis of the learning outcomes, objectives, and competencies expected and described in the syllabus. In the second step, we will explore the experience of recent graduate students with the content identified in the first step. We will explore their experiences using a questionnaire with closed and open-ended questions. If there will be a need for an in- depth assessment of the current situation based on the experiences of graduates, additional interviews or focus groups will be conducted. B) Analysis of the desired state: Kragelj A, Pahor M, Zaletel-Kragelj L, Makivić I. Learning needs assessment among professional workers in community mental health centres in Slovenia: Study protocol (Original research). SEEJPH 2022, posted: 21 May 2022. DOI: 10.11576/seejph-5478 P a g e 6 | 11 In the first part of the first step, we will learn the perspective of professionals, who have been employed at CMHC for at least one year, on the competencies required for their work. Focus groups will be conducted. In the second part of the first step, we will learn the users’ perspective on the competencies, that professionals need for their work (focusing on the interpersonal aspect). By choosing a method of data collection through semi-structured individual interviews, we want to prevent users from refusing to participate due to withdrawal from possible stigmatisation of mental conditions. Individual interviews also reach those who do not wish to participate in the group for other reasons. Interviews will be conducted with adult patients in CMHCs (both outpatient and community psychiatric treatment), their relatives and parents or guardians of children and adolescents. In the second step, using the nominal group technique, the participating experts will reach consensus on the desired state based on the perspective of the users and the perspective of the professionals. C) By comparing the results of the analysis of the current state and desired state, we will identify the learning needs. Phase 3 In this phase, we will search for examples of good practice (from Slovenia or abroad) and review appropriate existing formal EPs for the education of mental health professionals, ideally in the form of multiple case study. We will collect data through document analysis. In the EPs, we will identify courses with mental health content and extract the learning outcomes, learning objectives and competencies related to mental health. Phase 4 Based on the identified learning needs and the analysis of good practices, starting points for the application of the Delphi method will be prepared. The Delphi method will be used to reach a consensus on the targeted state, i.e., what content (ranked in order of importance) is needed to address the identified gaps in EPs. The Delphi method involves various stakeholders who can either contribute to the implementation of the identified content in formal EPs (leaders of the EPs), are representatives of the professional staff working at CMHCs (and at this point are the users of the “services” of the educational system), or are representatives of policy or decision-makers. Ethical considerations To gain a comprehensive view of the competencies that professionals working in CMHCs need for their work, we will include different groups of participants. Based on patient participation, the protocol will be submitted to the National Medical Ethics Committee for review. Discussion The protocol presented enables the identification of the learning needs of professionals working in CMHCs. The complex design of the study enables the identification of needs based on the personal experiences of professionals working in the field. However, by comparing the experiences of professionals with those reported by users, we can also identify learning needs that professionals may not be aware of. Some of the learning needs may be outside the awareness of those for whom EPs are or will be created – so-called unperceived learning needs (13). The experiences of the users, i.e. those for whom the professionals do their work, are thus an added value. In- depth insight into the needs is only possible with a combination of quantitative and qualitative approaches, and in order to know and understand the experiences thoroughly, the protocol gives priority to the latter.The study protocol has its advantages and Kragelj A, Pahor M, Zaletel-Kragelj L, Makivić I. Learning needs assessment among professional workers in community mental health centres in Slovenia: Study protocol (Original research). SEEJPH 2022, posted: 21 May 2022. DOI: 10.11576/seejph-5478 P a g e 7 | 11 disadvantages, which can be reduced or eliminated by further developing the protocol after the pilot testing. First of all, we emphasise the fact that the protocol focuses only on formal forms of education as a source of competencies. Formal education enables to obtain formally endorsed educational results through participation in EPs (14). Formal education provides the foundation from which experts acquire the necessary competencies to successfully perform their work, so we have taken this form of education as the base from which to begin exploring their learning needs. Education is an organised, structured, systematic and goal- oriented process (15,16), but education is only one of ways in which learning can be carried out (15). Learning is any activity by which a person changes and is ongoing (17), including through incidental everyday experiences (16). Professionals acquire their competencies from various sources, including non-formal forms of education or through informal learning, which includes activities that are not planned as educational (e.g. exhibitions) but imply learning (16). Therefore, in the future it might be necessary to pay attention to other sources from which individuals draw their knowledge, skills and attitudes. Furthermore, we would like to point to the emergence of a hidden curriculum, which explains that a person involved in the educational process does not only learn what is clearly defined in the official curriculum (18). Norms, values, implicit beliefs and attitudes (19,20) can be transmitted in this hidden way. The impact of education comes from the interaction between teachers and students (18), they influence each other not only by what they do but by who they are (21). In a broader sense, life in the educational organization as a whole has its effects (18). With the phenomenon of the hidden curriculum, we could explain why changes to the official curriculum sometimes do not bring the desired results, as everyday experiences have more power than planned learning content (19). The final limitation of the study protocol presented could be that we are studying EPs that are currently in use, but some of the representatives of the professionals included in the focus groups were educated according to programmes that are no longer in use. Professional workers that will participate in the focus groups will share their experiences of working in CMHCs and their opinions about existing or lacking competencies - they will express what they need to do quality work, but they will not be expected to pass judgement on EP that they have participated in the past. Since we can only upgrade EPs that are currently in use, we will compare their perspective (and users' perspective) with the learning content in the current programmes. This protocol also has important strengths. Firstly, with it, Slovenia has prepared a plan for the implementation of an important national survey that can be undertaken as soon as the funds are available for its implementation. Secondly, experts from different fields came together to draft the protocol. This multi-professional approach ensures a high degree of coherence between the different professional fields involved in the protection of the mental health of the population. In addition, various stakeholders who are in some way connected with the education of professionals will be involved in the research. In this context, we would like to highlight the involvement of users. The importance of involving health and social service users in research is internationally recognized (22). This is because users know what it is like to be in their shoes (23) and can contribute with their views from a perspective that is different from that of the researchers. This has been found to be a positive contribution to both the research and the researchers, as well as to the users involved in the research (22,23). Therefore, users should also be involved in planning and Kragelj A, Pahor M, Zaletel-Kragelj L, Makivić I. Learning needs assessment among professional workers in community mental health centres in Slovenia: Study protocol (Original research). SEEJPH 2022, posted: 21 May 2022. DOI: 10.11576/seejph-5478 P a g e 8 | 11 conducting the research and in interpreting the results (23-25). In addition, the prepared protocol provides a basic research tool that can be transferred and used (with appropriate adaptations) in the design of research assessing learning needs at all levels of the educational system (from pre-school education through basic education and upper secondary education to higher and short- cycle higher vocational education) and in other forms of education (e.g. non-formal education). In this way, it will be possible to find out in a methodologically harmonised way where we currently stand in terms of the inclusion of mental health content in different educational settings and what we are missing to achieve the identified and necessary goals. The ultimate goal is a person equipped with adequate competencies not only to do professional work in the field of mental health care but also to take care of their own mental health and that of fellow human beings in the community in which they live. Given that most countries in South Eastern Europe region have historically had similar foundations in health and educational systems, the protocol may also be relevant and very helpful in planning a similar study to the one planned in Slovenia. It could also serve many European countries that are facing similar mental health issues or are in the process of reforming the mental health system similar to Slovenia. The final outcome of the model study will be the list of learning content, identified by consensus of different stakeholders as important to be covered in the education of professionals working in CMHCs. The wish is that the content will be implemented according to the priority list, but the latter will no longer be the subject of research, but the effort will be in the hands of those who will lead the implementation (either at policy level or at university and faculty level). The aim is to include missing content in already existing formal EPs. At the same time, we are aware that despite the efforts of those in charge, changing the programmes is not an easy process and will take time. Achieving this goal will be urgent in the event of a large discrepancy between the learning outcomes that are the result of current educational processes and the competencies that are actually needed by professionals in the labour market. The necessary changes can be made in a shorter time by implementing content in formal or non-formal in-service training for professionals in CMHCs. The design of the model study presented is only the first step of a large scale-up process. Conducting a pilot study based on a model study protocol will provide insight into the advantages and disadvantages of the tool used to assess learning needs. The ultimate goal is to conduct multiple research with the same basic tool at all levels of the educational system and in continuing professional education for all professional groups working with people. We see the educational system and its upgrading through the inclusion of appropriate mental health learning content in educational processes as an important factor that can impact the mental health of the whole population. Therefore, we see the implementation of these multiple research, the concepts of which are presented in the methodological document (10), as a kind of public health intervention that can lead to acquiring the necessary competencies for taking care of the mental health of oneself and others, and thus influencing the mental health of individuals and, ultimately, of society. The role of public health professionals in the communication processes between different stakeholders that can enable the implementation of the necessary learning content will be pivotal (26). Conclusion We presented a study protocol to assess what mental health learning content is not yet part Kragelj A, Pahor M, Zaletel-Kragelj L, Makivić I. Learning needs assessment among professional workers in community mental health centres in Slovenia: Study protocol (Original research). SEEJPH 2022, posted: 21 May 2022. 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South East Eur J Public Health 2021;17 (Spec.Vol No.3):4684. doi:10.11576/seejph- 4684. ________________________________________________________________ © 2022 , Zaletel-Kragelj et al.; This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.