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11 Articles in Volume 15, Issue #2
Chronic Headache Management: Outpatient Strategies
Magnesium Sulfate Helpful in Treatment of Acute Migraines
New Guide to Migraine Rx Garners Mixed Reviews
Pain Education Across VA Clinics
12 Classes Offered at VA Pain School
Practical Guide to the Safe Use of Methadone
Chronic Pain Patients Who Fail Standard Treatment
Balancing State Opioid Policies With Need for Access to Pain Therapies
New Mexico’s Approach to Improving Pain and Addiction Management
Editor's Memo: Prescription Opioid Abuse is Declining
Ask the Expert: Lupus and Suicidal Ideation

Pain Education Across VA Clinics

First study to examine provider satisfaction of a health education program catered to patients who suffer from chronic, non-cancer pain.

Multidisciplinary disease management programs increasingly are bringing together health professionals with different skill sets and expertise to improve patient outcomes. Previous literature has warned of major barriers associated with these large interprofessional systems, and at times, they have resulted in poor patient care.1

One solution that has been proposed to improve patient outcomes in patients treated in such multidisciplinary programs is enhancing teamwork among the various health professionals that are part of the team.2 Teamwork among providers is critically important to patient care and program outcomes. Teams can be bounded (clearly defined workgroups)1,2 or unbounded (workgroups with shifting members). Currently, large workgroups of unbounded professionals are brought together to manage complex patient cases.1,2

The goal interdependence theory of teamwork outlines types of interdependence in teams: negative, neutral, and positive (Figure 1). In positive interdependence, teamwork is considered an important factor for performance when tasks are highly interdependent.1 Teamwork most often is defined as behavioral processes (such as communication) that people use to accomplish interdependent work.2 According to past literature, these behavioral processes can benefit from assessment at the individual and system levels.3 Literature in the area of provider satisfaction tends to examine workload, job satisfaction, and managed care rather than on provider use of disease management programs or provider and patient levels of satisfaction with such programs.4 To address this gap in the literature, the primary objective of the present study was to define and describe provider satisfaction with a health education program.5,6

Study Design

A group of investigators at the Jesse Brown Veterans Affairs (VA) Medical Center developed working relationships with representatives from more than 20 disciplines, which resulted in a network of facilitators who teach classes in a “Pain Education School” program.5 Pain Education School is an empirically validated, health education program developed at the Jesse Brown VA Medical Center in November 2009, which caters to veterans who suffer from chronic, non-cancer pain. The goals of the program are to share basic principles of pain relief, provide education about pharmacology, introduce services offering non-pharmacological interventions, and promote self-management strategies.7 For the study, 26 providers at the medical center were polled between November 6, 2009 and January 20, 2012 about the program. Approximately 88% of the providers (n=23) completed a voluntary, anonymous satisfaction survey and their responses were analyzed (Table 1). The study protocol was reviewed and approved by the affiliated university’s institutional review board and the VA’s Research & Development office.

Intervention

Pain Education School consists of 12-weeks of 1-hour classes with an additional 1-hour introduction class during the first week (total of 13 hours). Classes are scheduled on a rotating basis, regardless of the patient’s entry point—the providers in the study rotate on a schedule, not the patients. Over the course of the program, 23 modules are presented (averaging 30 minutes each). A list of the 23 modules is included (see article). There were approximately 4 (12-week) rotations during the year of this study. The class was recommended to 1,138 patients during the year, but it was not a prerequisite for treatment. In fact, it is not recommended that patients be required to go to such classes because that could negatively affect their perspective of the material being learned. Approximately 558 patients (49%) participated in some of these classes during the year. Patients were participating in other pain treatments during the time of the education course. Instructors volunteered their time and received “encounter” credit for the classes they teach.

Measure

The Provider Satisfaction and Program Evaluation is a satisfaction measure adapted from an internal VA shared document that was completed by participating providers. Eight items assessed the providers’ perception of the impact of the program on services provided to patients (1=“strongly disagree” to 5=“strongly agree”). Three items assessed the level of use of the program by the providers (1=“never”; 2=“occasionally”; 3=“frequently”). One item assessed the provider’s perception of patient levels of satisfaction (1=“no comment” to 4=”very satisfied”). Providers were then asked an open-ended question that solicited comments and suggestions to improve the program.

Analyses of Data

Morgan’s Priority Sequence Model (1998) is a decision-making process for determining the most applicable research design for complementary combinations of quantitative and qualitative data.8 A quantitative analysis of the data was computed using the IBM SPSS Statistics program. Due to small sample size (n<30), providers’ ratings were assessed using a one-sample t-test to determine confidence intervals (CIs). A qualitative analysis of the data obtained in the surveys was used as a follow-up complementary method and provided interpretative insights.8 Braun and Clarke’s thematic analysis (2006), specifically the inductive semantic approach, supports our aim to organize the data, show patterns, and summarize and interpret the data. Additionally, the thematic analysis approach clearly outlines a sequential guiding process, is compatible with different paradigms, and gives evidence to unrecognized and underlying data.9,10

Study Results

The majority of the providers were female (58%) and identified as being Caucasian (65%). Providers found the goals and services of the program to be “clear” (mean [M], 4.48; standard deviation [SD], 0.73), perceived that the strategies used “influenced” their practice (M, 4.22; SD, 0.95), perceived that the methods of communication with the coordinators were “helpful” (M, 4.43; SD, 0.79), and perceived the program as having a “positive” impact on their service (M, 4.48; SD, 0.68) with 95% t-distribution CIs of 4.18-4.78, 3.83-4.61, 4.11-4.75, and 4.20-4.76, respectively. Additionally, providers treating patients who underwent the educational program received fewer complaints about pain medications (M, 3.77; SD, 0.92), had fewer walk-ins for pain management issues (M, 3.36; SD, 0.90), spent more time with their patients on other medical problems (M, 3.95; SD, 0.79), and felt more comfortable in managing chronic pain due to the program (M, 4.05; SD, 0.95) with 95% t-distribution CIs of 3.39-4.15, 2.99-3.73, 3.63-4.27, and 3.66-4.44, respectively (5-point Likert scale).

The results also enumerated providers’ level of use of the program, including the extent to which providers: “referred patients” for this service (M, 1.74; SD, 0.75), never referred but used it as “a resource for assistance with chronic pain management” (M, 2.07; SD, 0.80), and referred and used the service (M,1.86; SD, 0.83) with 95% t-distribution CIs of 1.43-2.05, 1.74-2.40, and 1.52-2.20, respectively (3-point Likert scale). Finally, the results indicated providers’ perception of patient levels of satisfaction (M, 1.74; SD, 0.75) with 95% t-distribution CI of 1.43-2.05 (4-point Likert scale).

Of the 23 providers, 52% provided suggestions or comments. In general, the provider participants stated there was “no change needed” (26%) or suggested improvements (16%) such as providing on-going education about the program and a possible “school” for both providers and patients. Providers who did not suggest a change for improvement noted their “own enjoyment in participating as a provider.”

Discussion

A comprehensive provider-centered approach is particularly important when determining overall satisfaction of a multidisciplinary workgroup. By using a multi-methods approach, this study provided a fuller investigation of satisfaction than often is accessible through traditional quantitative methods.10-12 A thematic map emerged from the analysis (Figure 2). The current assessment of provider satisfaction evaluated the impact of the program on services provided to patients, levels of use of the program, and levels of contentment with the program.

The impact of the program was perceived as satisfactory by the providers. These findings are consistent with past literature suggesting that effective communication among members of health care teams is imperative for overall satisfaction with care.3,13 The extracts (comments) from the qualitative analyses in the current study confirm that providers appreciate and support the program (Table 2). As evidenced by the provider extracts, the study reveals a provider population of differing levels of professional status working in sync despite the potential for professional hierarchy to contribute to teamwork failures.

The current findings suggest “occasional” use of the program by providers. Providers appear to have sporadically referred patients to or used the program as a resource for their chronic pain cases. Past research has shown that few providers have adequate training to effectively treat chronic pain.14 In general, these findings suggest providers would benefit from increased education related to the program and its content.15 In fact, the provider extracts confirm they are seeking more pain education.

Past literature suggests that hospitalists play a critical role in promoting and facilitating the transition of care from inpatient discharge to follow-up care.3 According to the provider extracts, the program provides “a good, structured way for veterans to learn.” One potential solution to increase use of the program might be to develop and disseminate informational pamphlets. Another solution might be to include links to all the modalities represented in the program on one electronic recording system’s ordering screen so providers can access and prescribe them. If the distribution of resources is constrained by the practices of a given organization, scholars suggest improving how team members relate or get along in the working environment (relational climate) by building teamwork activities.1 It also might be beneficial for participating providers to remind the members of their bounded teams about the program during weekly meetings.

Providers’ perceptions of patient dissatisfaction in the current study is not corroborated by patients’ self-report of satisfaction with the program from a previous study.11 These findings are consistent with past research, which has found that patients report higher levels of satisfaction with medical care than providers.16 One potential explanation for the current finding is that the providers still work in clinics greatly impacted by chronic pain, which may at times blur experiences with similar cases. Past literature also has suggested that physicians’ ability to sense their patients’ satisfaction generally is poor; providers’ tend to be more reactive to patients’ negative affect.17 For example, one extract stated, “I hear significantly less complaints from veterans.” Other variables that might have compounded the findings include how acquainted providers were with patients and how generalized their perceptions of their patients were.18

When providers are unaware of what makes patients gratified, it might prove difficult for them to develop strategies for improvement. Recent efforts have been made to encourage more use of individualized, patient-centered approaches. Interestingly, research has found that female providers have more often used this practice style, which historically has been predictive of patient satisfaction.18 In the current study, the majority of providers polled were female. However, female providers tend not to be evaluated as highly by their patients.16 Past research has shown that patient characteristics play a key role in self-reported satisfaction,19 and that physicians’ characteristics influence patients’ adherence to medical treatment.20 Given the aforementioned findings, future studies may want to determine whether specific characteristics of providers impact patient satisfaction.

Limitations of Study

There are several noteworthy limitations that may restrict the generalizability of the current study’s findings. First, not all the providers who facilitated the modules attended the full program nor completed the satisfaction measure. Future studies might want to survey providers in clinics that often refer patients but do not facilitate in the teaching of modules.

Second, the instrument used in this study is a self-report measure that might be vulnerable to social desirability biases and/or selective attribution.1,18 Adapting an existing survey poses particular risks; it might pose some difficulty assessing the specific behavioral processes of interest.2

Third, the current sample consisted of a multidisciplinary, unbounded team of providers, making it difficult to generalize findings to bounded workgroups. Fourth, the limited demographic information collected on the providers makes it difficult to generalize the impact of these characteristics on patient satisfaction.

Summary

In spite of these limitations, the current study is the first known investigation to examine provider satisfaction of a health education program catered to patients who suffer from chronic, non-cancer pain. It differed from previous studies in that it used a mixed-methods treatment outcome design; measured satisfaction outcomes of a large, unbounded workgroup of providers; combined satisfaction, use, and perception of patients’ satisfaction as variables of study; and focused on the approval of a program catered to veteran patients with chronic, non-cancer pain. The current findings provide information that is invaluable to providers whose goal is to improve the existing program. Few studies have dealt with both patient and provider perceptions simultaneously.21 Research in the area of comprehensive participant and provider satisfaction is likely to lead to improvements in continuity of care.22

Last updated on: May 12, 2015

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