Confidence of practitioners to support self-management of pain: A multidisciplinary survey

Abstract

Background

Supported self-management is an important component of management for persistent pain according to current recommendations and guidelines. However, it is unclear whether staff from differing disciplines who may be in early contact with people with established or developing persistent pain are confident to introduce and support self-management for this patient group.

Aim

To determine the confidence of staff across professional disciplines to introduce and support self-management.

Design and Setting

Cross-sectional online survey.

Methods

Charts were constructed to represent information on professional grouping, prior training in self-management and confidence in supporting key components of self-management for persistent pain. Analysis of variance was used to test for differences between groups.

Results

Overall, 165 practitioners reported confidence to support self-management below the midpoint of a ten-point scale and 93 above. There were few differences between different professions apart from in explaining pain (f = 6.879 p < .001), managing activity levels (f = 6.340 p < .001) and supporting healthy habits (f = 4.700, p = .001) in which physiotherapists expressed higher confidence than other professional groups. There was no difference in confidence expressed between staff who had or had not received previous training in self-management (f = 1.357, p = .233).

Conclusions

Many front-line staff who might be expected to introduce and deliver self-management support for persistent pain lack the confidence and skills to do so. This is consistent with a known lack of education about pain across disciplinary boundaries in primary and community-based care. In order to meet treatment priorities for persistent pain there is an urgent need to upskill the workforce by providing access to good quality training and resources.

Introduction

Self-management support refers to activities that can be carried out by healthcare professionals to support people who live with persistent pain in the adoption and use of self-management. For some persistent painful conditions self-management is recommended as first-line treatment both nationally ¹ and internationally. ² Self-management is widely accepted as an important part of the management of various long-term conditions ³ including persistent pain.^4,5 It can be broadly understood as an active process of managing pain and its’ impact on life by engaging in a healthy and balanced range of activities.^1,2 When offered in a collaborative and patient-centred way, supported self-management meets the aim of the UK NHS long-term plan ⁶ to support people to manage their own health.

There is increasing recognition that current ‘usual care’ offered for pain may be less than ideal. A recent review ⁷ identified that routine care in both general practice and emergency departments diverges considerably from international recommendations for good practice, including an overuse of scans and opioid prescriptions and poor provision of information and advice. A study of barriers to self-management of chronic pain in primary care ⁸ found that some patients felt self-management was mentioned too late in the journey of chronic pain, and that their chronic pain could be over-medicalised. Some felt that emotional elements of their pain were dismissed which led them to feel unsupported with their pain and how to manage it. On the other hand, professionals expressed concern about introducing the self-management message too early which could lead patients to feel that their pain was being dismissed or not taken seriously (ibid.).

The task of introducing self-management is complex. A systematic review of 58 studies over a range of conditions ⁹ indicated that interventions should be individually tailored to the needs of the patient and include reference to a range of strategies along with a personalised plan and follow-up. It is also important that self-management is delivered within an open and supportive relationship within which a person feels able to be themselves and to talk with their healthcare provider about more than the medical aspects of their care. ¹⁰ Health care practitioners need to have a broad understanding of pain from a biopsychosocial perspective alongside an ability to communicate empathically and collaboratively to be able to support people to self-manage their pain condition(s). Most medical schools teach pain only as part of other courses such as pharmacology or anaesthetics ¹¹ and few have compulsory, dedicated teaching on pain. ¹² Where it is taught, assessment is usually by written examinations rather than in practice. ¹¹ Across a wide range of health disciplines, routinely accessible training was broadly found to be inadequate with regards to developing the skills, attitudes and beliefs necessary for supporting people with persistent pain.^13–15 The result of this is that many qualified practitioners from varied disciplines who might be at an early point of contact for people with pain may lack the knowledge, skills and attitudes necessary for this task. Indeed, in a survey of primary care providers in USA, only half considered that they had the required expertise to treat chronic pain. ¹⁶

Given the high prevalence of persistent pain, which is estimated to affect between a third and a half of adults in the UK, ¹⁷ and 1 in 5 in the US ¹⁸ it is crucial that the health workforce is prepared to deliver recommended and evidence-based forms of management for pain from the earliest stages. The Ten Footsteps programme ¹⁹ has been designed to offer initial training in supported self-management in order to meet this need. The Ten Footsteps programme consists of a set of free to access resources available online (www.livewellwithpain.co.uk). The aim is to help people to self-manage their pain and guide practitioners in introducing and supporting self-management by increasing their knowledge, skills and access to tools and resources. A 12-hour training programme targeted to primary care practitioners is available and has previously been demonstrated to increase their confidence in supporting self-management in their patients. ²⁰

The purpose of the current study is to report on the self-reported confidence of practitioners based in the UK and Ireland in primary care or community settings prior to this training in supporting self-management of persistent pain.

Methods

Data were collected from health practitioners working in primary care or community settings who had signed up to The Ten Footsteps course ²⁰ on supporting self-management for persistent pain. Survey data are available at https://doi.org/10.25405/data.ncl.23792184.v1. On registration for the training participants were sent a pre-training questionnaire by email. A reminder was sent if the survey was not filled in within 2 weeks. The questionnaire was constructed using QualtricsXM and collected information about profession, previous training and confidence in supporting various elements of pain management.

Information was then imported into Microsoft Excel for processing. Participants’ profession was categorised into the following categories: GP, Nurse, Pharmacist, Physiotherapist, Social prescriber, Health and wellbeing coach and ‘other health professions’ (which includes manager, occupational therapist, social worker, care coordinator, psychologist and not specified). Participants who specified more than 1 profession were recorded under each category, giving a total of 2 responses for the question. Data were inputted into SPSS (IBM) and tested for normality. Analysis of variance was used to determine whether confidence in elements of supporting self-management differed between professional groups and according to previous training in supported self-management approaches.

The remaining data were then categorised, and tables and charts constructed to represent a key snapshot of the confidence of practitioners to introduce and support self-management. Ratings of overall confidence in supporting self-management were supplemented by ratings of four key elements of self-management support for pain; introducing and explaining self-management, activity strategies, mood strategies and healthy habits.

Results

A total of 313 health or social care practitioners were invited to complete the survey and asked for consent to use their responses for research purposes. Data were received from 258 practitioners, representing a response rate of 82.43%. Participants represented a range of professional backgrounds as shown in Figure 1.

Figure 1.

Participants’ professions and number of participants within the professions.

Total number of participants were 258 with six participants having two professions. *Other category includes manager, occupational therapist, social worker, care coordinator, psychologist and not specified.

Eighty-six practitioners (33% of respondents) reported having had no previous training in supported self-management. The remaining 172 had some previous training either for pain (56) or other long-term conditions (116). Analysis of variance indicated no difference in overall confidence in supporting self-management between practitioners who did and did not report previous training in self-management (Mean confidence with no previous training in self-management = 4.68, SD = 2.26, n = 85, Mean confidence with previous training = 4.89, SD = 1.87, df = 6, f = 1.357, p = .233). There were, however, differences between professional groups in confidence to explain pain (f = 6.879 p < .001), manage activity levels (f = 6.340 p < .001) and support healthy habits (f = 4.700, p = .001). Inspection of mean scores indicated that the differences were the result of higher confidence expressed by physiotherapists than all other professional groups.

There were no differences between professional groups in confidence to support people with persistent pain to manage their moods (see supplementary appendix).

Reported confidence in introducing and supporting self-management overall is shown in Figure 2, on a scale from ‘not at all confident’ to ‘completely confident’. As shown practitioners endorsed a wide range of confidence. A hundred and 65 respondents reported confidence below the midpoint of the scale and 93 above.

Figure 2.

Participants’ rating of confidence in supporting a person with pain in their self-management.

In terms of different elements of self-management, participants expressed a range of confidence in each of the elements measured. There were no clear differences between overall confidence in each element of supporting self-management, as shown in Figure 3.

Figure 3.

Self-rated confidence in key elements of supporting self-management.

Discussion

The results of this survey indicate the extent towards which current health and social care practitioners in England feel confident to introduce and support self-management for persistent pain. They are important because much of the current NHS strategy ⁶ for long-term conditions, including persistent pain and for reducing harm from medications, ²¹ is likely to require the introduction and promotion of supported self-management from the earliest point of contact with health or community-based services. ²² Despite the importance of supported self-management, the confidence or ability of practitioners to work in this way has not been widely reported. The current research indicates that practitioners working in primary care or community services, where they will be responsible for service delivery for people with persistent pain, express relatively low levels of confidence in supporting self-management of pain regardless of their profession. This is in agreement with other reported research that identifies low clinician confidence in supporting this population.^14,15,23

Although 66% of participants reported having previously undertaken training in supported self-management approaches, this research demonstrates that training did not appear to improve confidence levels in supporting this population and in delivering self-management approaches.

The significant difference in physiotherapist confidence relating to pain education may reflect that professional groups established interest in this area and championed by well-known physiotherapists in this area (see e.g. Refs. [24] and [25]). There is growing criticism that pain education in and of itself is limited (see Ref. [26] for an example of critical discussion of this topic) which may provide some explanation regarding why physiotherapists chose to undertake the current training despite high levels of confidence in some areas. An additional element that may be important is experience in working with people with persistent pain. Physiotherapists, who were most confident in self-management skills work routinely with people who have persistent pain. For other professional groups, there may be less of a focus and less contact with this group which may have led to a difference in confidence levels.

Self-management support training needs to include a wider range of skills development beyond understanding the cause(s) of, and reasons for persistence with, pain. ³ The findings from this research support recognition that pain education alone is insufficient, and that persistent pain represents a complex phenomenon requiring a range of different approaches, as conceptualised and delivered in the 10-footsteps training, which includes pain education, and, also, identifies and addresses the wider range of challenges faced with living with pain.

Strengths of the study include the large sample size, high response rate of 82.43% and the diverse professional sample selection of practitioners who work to support people, including those with persistent pain as an early point of contact. This is a good fit to current recommendations to prioritise non-pharmacological methods of pain management throughout the treatment journey.^5,27 The main limitation is that confidence in supporting self-management was exclusively measured by self-report questionnaire and was not anchored by patient outcomes or practice observation. Although challenging to do, linking self-reported confidence to observations, patient experience and outcomes is an area of potential future study. In the current study there may, therefore, be discrepancies between how confident practitioners are in their skills and the actual implementation of these skills. However confidence remains a relevant measure and is likely to influence the likelihood of practitioners discussing self-management as an alternative to taking a more medically-focused approach to working with people with persistent pain. The survey also did not enquire about confidence in delivering medically-focused care as a point of comparison.

The confidence levels expressed by practitioners in this study are similar to those reported in the USA in response to the similar but different question of confidence in the overall management of persistent pain. ¹⁶ The minimal variation between practitioners with different professional backgrounds may reflect previous findings that training in non-pharmacological management of pain has minimal presence, if any, in undergraduate or further professional education for most health professionals.^11,13 The finding that previous training in self-management support did not appear to increase practitioners’ confidence in self-management support skills may be a reflection of the breadth of training that can be considered as relevant to self-management. Only a minority (56) of participants had attended previous training in self-management of pain. The finding is similar to that reported by Pain Concern in a paper that evaluated training in self-management support that focused on communication skills and patient-centred care. ²⁸ Although such skills and attitudes are important for the implementation of self-management support, attendees reported that training did not specifically increase their confidence to support self-management and would have preferred training that was more targeted to specific techniques. The findings of this study similarly suggest that an important element of training to provide self-management support for persistent pain is the use of targeted and actionable strategies and resources for both practitioners and patients which may not universally be provided by other training programmes.

Further research is planned to determine the impact of the Ten Footsteps programme on practitioner confidence in supporting self-management. Preliminary results ²⁹ indicates substantial improvements in self-reported confidence immediately after training which are supported by the availability of accessible resources to introduce to patients and the integration of lived experience facilitators within the training. Future research should aim to determine whether such improvements translate into changed practice and patient outcomes and whether confidence can be maintained over time. Service-related factors that can facilitate or present barriers to ongoing support for practitioners in maintaining and further developing skills and implementing supported self-management should also be the subject of additional research.

Overall, the results indicate that practitioners from multidisciplinary backgrounds who are in an important position to introduce and support self-management to people with persistent pain from a biopsychosocial perspective, lack the confidence to do so without additional training. In order to fulfil current priorities^5,6 it is therefore necessary to prioritise training in introducing and supporting self-management of persistent pain that is targeted and actionable. In order not to lose the benefit of such training, it is further important that practitioners trained in the approach are supported to apply it in their everyday work with patients so that they do not revert back to more familiar and medicalised ways of working. The aim of the Ten Footsteps Training is to ensure that training is available, through direct provision of training, ongoing opportunities for CPD to refresh and renew knowledge and freely accessible resources and supporting services to develop the infrastructure to provide their own training in self-management support.

Supplemental Material

Supplemental Material - Confidence of practitioners to support self-management of pain: A multidisciplinary survey

Confidence of practitioners to support self-management of pain: A multidisciplinary survey by Penlington Chris, Pattramon Pornsukjantra, Paul Chazot, Frances Cole and Diarmuid Denneny in British Journal of Pain