World J Surg DOI 10.1007/s00268-014-2635-7
Essential Pain Management: An Educational Program for Health Care Workers C. Roger Goucke • Tracy Jackson Wayne Morriss • Jane Royle
•
Socie´te´ Internationale de Chirurgie 2014
Abstract Background Education for health care workers on painrelated topics is not always readily available, and this is especially so in low and middle income countries (LMICs). The Essential Pain Management program (EPM) has been developed to offer a simple interactive educational opportunity for health care workers in LMICs. Methods Following a needs analysis in Papua New Guinea, an 8 h educational program with the aims of improving pain knowledge and providing a simple pain management framework was developed. An evaluation of the program using the Kirkpatrick model is being used. The program has a ‘‘teach the teachers’’ component to encourage sustainability. Results The program has been run in 30 countries, delivered to 1,600 participants, and 340 instructors have been trained. Feedback has been positive, pre post testing in 27 sites showed a mean pre score of 65.89 % rising to 75.23 % (n = 581 respondents). A subanalysis demonstrates doctors and nurses improving by similar degrees. When local instructors have delivered the program after attending
On behalf of the Alliance for Surgical and Anesthesia Presence. C. R. Goucke Sir Charles Gairdner Hospital, University of Western Australia, Perth, WA 6009, Australia C. R. Goucke (&) J. Royle Department of Pain Management, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA 6009, Western Australia e-mail: [email protected] T. Jackson Vanderbilt University, Nashville, TN, USA W. Morriss Christchurch Hospital, Christchurch, New Zealand
the trainer’s session the participant test results were comparable to the results seen when the overseas instructors taught the course. Discussion The widespread adoption of the EPM program suggests there is a need for pain education in LMICs. The teach the teachers component of the program and the comparable results from their teaching should contribute to sustainability. Further support and mentoring using electronic systems such as Facebook, text messaging, and a website may also contribute to sustainability.
Introduction Incidence and prevalence studies relating to pain vary widely depending on the interview technique and content of the survey. Published data from high-income countries suggest up to 35 % of these populations have chronic pain, defined as continuous pain lasting more than three months [1]. Prevalence studies are scarce in low- and middleincome countries (LMICs), but a recent survey from Ghana reports a prevalence of 20 % following a face-to-face rural community study (M Notrica, personal communication). When one considers cancer-related pain, up to 75 % of patients with cancer can experience clinically significant pain and on average 43 % receive inappropriate pain care. In many parts of the world, despite significant efforts by a number of organizations, cancer pain remains poorly treated or untreated [2]. With the advent of surgical approaches to management of disease in LMICs, the incidence of acute postsurgical pain and chronic postoperative pain is likely to rise [3]. Effective pain management can improve quality of life [4, 5] and result in shorter hospital stays, reduced complication
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rates, and better patient satisfaction when programs like Fast Track or Enhanced Recovery After Surgery (ERAS) have been implemented [6]. Specific education related to pain is rarely included in the training of health care providers, even in developed countries, and attitudes regarding the necessity or feasibility of pain relief vary widely among cultures [7]. Even though the WHO provides guidelines for treatment [3, 8] and an essential medicines list (EML) [9] health care providers and patients continue to have misconceptions about drug therapies [10]. Pain is often considered only a symptom of a larger problem like cancer or HIV; even if the symptom is more debilitating than the associated disease, management may be marginalized when patients in poverty must continue to work despite pain in order to survive. When patients do attempt to seek treatment, access is often limited [11]. The International Association for the Study of Pain (IASP) states that education on pain management should be incorporated into the curricula of health care students, as well as in the continuing education of health care providers [11]. This education is meant to aid in the assessment and management of pain, as well as highlight the inequity in treatment among certain groups[12–14]. Improvement of pain management programs must take into account which methods of education work best for a particular area or group of people. Pain education should be accessible and relevant. Recent efforts employ websites like YouTube, Twitter, and Facebook, as well as web-based educational modules[15– 19]. The International Pain Policy Fellowships of the IASP have used a trainee-as-trainer approach to implement pain management education in the respective countries of the chosen fellows [11, 16]. For example, IASP fellows in Sierra Leone, Colombia, and Serbia have been successful in increasing the availability of morphine through collaboration with their respective governments and stakeholders [20].
Essential pain management (EPM) With this background, we developed a program called Essential Pain Management (EPM) for health workers in LMICs. The program was piloted in Papua New Guinea in 2010 and has now been taught in over 30 countries around the world (Table 1). The aims of EPM are: • • •
To improve pain knowledge To provide a simple framework for managing pain To address pain management barriers
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Table 1 List of essential pain management (EPM) countries
Fiji Vanuatu Tonga Samoa Solomon Islands Papua New Guinea Tuvalu Micronesia Cook Islands Myanmar Malaysia Thailand Indonesia Mongolia Mexico Vietnam India Bangladesh Nepal Tanzania Kenya Uganda Panama Dominican Republic South Africa Rwanda Honduras Paraguay New Zealand Australia
The program is designed to improve management of pain of all types, e.g., traumatic and post-surgical pain, cancer pain, and chronic non-cancer pain. Essential Pain Management was developed after a needs assessment in Papua New Guinea. The program is flexible to allow for differences in health care and educational resources, and it can be taught to a range of health care workers, from hospice volunteers to nursing students to consultant physicians. The EPM program promotes early handover of teaching to local instructors, to encourage educational sustainability and the development of local solutions for local problems. Program structure and content The EPM program has two parts—the EPM One-Day Workshop and the EPM Instructor Workshop. The OneDay Workshop runs for 8 h and usually involves three to four instructors and 25 participants. The workshop is
World J Surg
highly interactive, and comprises a series of short lectures, brainstorming sessions, and case discussions. Like Advanced Trauma Life Support (ATLS), EPM offers a system for managing patients in pain. Instead of ABC (Airway, Breathing, Circulation), we use RAT (Recognize, Assess, Treat). The Essential Pain Management ‘‘RAT’’ has proved to be a very popular educational tool with course participants and instructors, and it can be used to discuss the management of a variety of pain presentations. The RAT approach highlights some important differences between traditional teaching of pain management and EPM. First, the importance of recognizing pain is highlighted. As summarized above, pain is often not recognized for a variety of social and systemic reasons. The importance of asking the patient is emphasized, along with the concept of pain as the ‘‘fifth vital sign’’ [21]. Second, assessment is simplified to a relatively small number of questions and answers required to guide treatment and monitoring: How severe is the pain? What is the pain diagnosis? Are there other physical or psychological factors? The pain diagnosis depends on the duration (acute or chronic), cause (cancer or non-cancer), and mechanism (nociceptive or neuropathic) of the pain. For example, a patient with a simple fracture has acute, non-cancer, nociceptive pain, while a patient with long-standing diabetic foot pain has chronic, non-cancer, neuropathic pain. Third, treatment emphasizes both non-drug and drug therapy. We have observed that, in a multidisciplinary group, non-physician participants tend to emphasize nondrug treatments and physician participants emphasize drug treatments. It is important to use both approaches in the treatment of many types of pain [22], and particularly so in resource-poor settings where some treatments may not be available. The availability (or lack of availability) of medicines on the WHO’s EML is a topic that often comes up during the brainstorming session on pain management barriers. Case discussions are a very important part of the workshop. The cases are discussed in small groups (around six participants) and cover a variety of pain types—acute nociceptive pain, chronic cancer pain, and chronic noncancer pain. The discussions give participants the opportunity to put ‘‘RAT’’ into practice and to devise management plans based on local resource constraints. The depth of discussion depends on the makeup of the group. Course participants use a brainstorming session to identify pain management barriers in their own environment. These barriers are sorted into four categories: patient factors, drug issues, health worker barriers, and system issues. At the end of the day, groups spend 30–45 min identifying potential solutions to these barriers in their particular environment.
The EPM program is targeted at all health care workers, from undergraduate nurses and medical students to senior surgical and anesthesia consultants. It can be easily ‘‘fine tuned’’ to include case discussions on specific local conditions; for example, in Uganda, the EPM RAT is used to discuss the management of severe pain due to sickle cell disease. Similarly, the course can be modified to take into account the availability or non-availability of treatments. Morphine is unavailable in many environments, and such alternatives as tramadol may be discussed instead. Evidence for the use of non-pharmacologic treatment strategies is emphasized, and may include education, explanation, and empathy, with rest, ice, compression, and elevation (RICE), followed by exercise programs for early and late rehabilitation [22]. A series of slides and a workbook are available and were developed in English with awareness that English is the second or even third language for the majority of the likely participants. Participants are then encouraged to become instructors themselves in order to promote exponential dissemination of this information. The half-day Instructor Course is a 5 h ‘‘Train the Trainer’’ type program that covers the essentials of adult learning and reinforces the teaching techniques used in EPM. Participants practice using the prepared slides in a lecture situation and receive feedback from their peers regarding their delivery style. A similar process is used for running group discussion programs, such as the case presentations. The full EPM program consists of the day 1 workshop for up to 25 participants, followed on day 2 by up to 12 of those participants taking the 5 h instructor workshop. On day three the new instructors teach the 8 h EPM workshop to a new group of participants with some supervision from the external instructors. The local instructors are encouraged to teach the program in their national language. EPM roll-out and development The EPM program has now been taught in 30 countries around the world—in the Pacific region, Asia, Africa, and Latin America. The course has been translated into a number of languages, including Spanish, Indonesian, Vietnamese, and Mongolian. In most cases, EPM has been offered to countries following personal contact between the program providers and members of the local anaesthesia or pain societies. A local in-country coordinator is identified, and he or she recruits participants for the courses. We encourage multidisciplinary participation (doctors, nurses, and other health workers) because, in our experience, this leads to improved group discussions and emphasizes the importance of teamwork in pain management.
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The workshop manual and slides are covered by a Creative Commons copyright licence, which stipulates that the material cannot be used for commercial purposes. In most countries, participation in an EPM workshop is free, although some countries have used a nominal registration fee to cover printing and/or catering costs. In one country, participants received a per diem ($1 per day) to attend the workshop; this was to compensate them for loss of income while they were at the workshop. In many countries, the local anaesthesia or pain society has contributed to course costs, reinforcing the concept that EPM is being run as a partnership between the overseas providers and the local society. Overseas workshop providers are not remunerated but are able to claim airfare and accommodation costs from donor agencies. In the first three years of the program following a pilot series of courses, there have been minimal changes to the teaching materials; however, a review of the workshop manual and slide set is underway. To date, we have used a standardized set of true/false questions to assess knowledge acquisition. A multiple choice question-and-answer test is being piloted. Evaluation The ultimate purpose of improving pain education is to change behavior that has a positive impact on individual patients and society as a whole. Our program evaluations have included the number of courses delivered, the number of participants in the one-day workshops, and the number of instructors taught. We have also used the four levels of Kirkpatrick’s revised model of program evaluation to more formally assess the programs to date: www.kirkpa trickpartners.com/ Level 1 reaction The programs have been evaluated from standard participant program evaluation forms. The forms list several items that, once completed, were evaluated with standard rating and Likert scales to assess usefulness of the content; completion of stated objectives; overall satisfaction; self-assessed changes in knowledge, attitudes, and skill/behaviors; and suggestions for improvement (qualitative). Level 2 learning To measure whether the program resulted in changes in knowledge, attitudes, behavior, or intent, participants’ preand post-course knowledge was assessed with a 25-item true/false assessment test administered both at the beginning and the end of the one-day workshop. Pre- and post-
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course scores were compared, but only participants who had completed both tests were included in our analysis. Level 3 transfer To assess effective transfer and dissemination of this information by trainers who were previously trainees, the scores of the participants trained by the new trainers have been compared with those of the participants taught by the developers of the module. Pre- and post-course test differences have also been compared between different countries. We are continuing to develop Level 3 evaluation. Patterns and barriers to transfer of information will be assessed. Durability of improvements in knowledge, attitudes, behaviors, and intent will be followed with periodic longitudinal testing of previous course participants. Change in behavior and ability in the workplace over the medium term is being recorded in a logbook and will be monitored. Level 4 results To measure impact and patient outcomes we will monitor changes in patterns of pharmacologic and non-pharmacologic modalities for pain management. We anticipate this can be done by ‘‘snapshot surveys’’ of prescribing and dispensing patterns in surgical wards and emergency departments. Patient surveys of pain, quality of life, and satisfaction are forthcoming and will be collected over the next few years.
Results In the 30 countries where EPM has been run it has been delivered to 1,600 participants, and 340 instructors have been trained. A Kirkpatrick Level 1 assessment of reaction to the teaching module has been assessed from feedback. Responses for usefulness of the content, completion of stated objectives, overall satisfaction, self-assessed changes in knowledge, attitudes, and skill/behaviors all scored 4 or 5 out of 5 on the 6 point scale (0–5) (data not shown). Examples of Kirkpatrick Level 2 assessment of learning are shown in Fig. 1 and 2 from Myanmar, Fiji, and across a number of participating countries. An initial analysis of data from a 25-item true/false assessment test administered before and after the EPM program in 27 sites showed a mean pre-score of 65.9 % answers correct and a mean postscore of 75.2 % (n = 581 respondents). This reflects an average improvement of 9.34 % (paired t-test, p \ 0.001). The individual range in improvement in scores from Myanmar is shown in Fig. 1. A sub-analysis comparing the results between doctors and nurses in Fiji shows a similar
World J Surg Myanmar 17 March 2013 Percent improvement
30% 25% 20% 15% 10% 5% 0% -5% 18 19 1
8 25 2 10 17 23 6 11 15 22 27 3
5
7
9 12 20 26 29 4 14 28 13 24 16 21
-10% -15%
Respondent number (N=29)
Fig. 1 Improvement in scores by respondent–Myanmar
Mean pre and post scores Suva 31 Mar 2011 Correct answers (N=25)
25 22 19
18
20 16 15 10
5 0
Pre
Discussion
Post Nurses
Doctors
Fig. 2 Changes in the 25-item true/false pre- and post-test scores between doctors and nurses Number of correct answers (N=25)
A Kirkpatrick Level 3 measure compares the improvement of scores between day 1 (taught in English by overseas instructors) and day 3 (taught in English or the local language by local instructors). This showed no difference in improvement between the groups taught by the different instructors (2 sample t-test, p [ 0.05), suggesting that information transfer during the instructors teaching course has occurred successfully (Fig. 3).
Mean scores pre and post testing 25 21 20
17
21
20 17
16
20 17
15 10 5 0 Suva 29 March Suva 31 March 2011 2011 Mean Pre
Suva 1 April 2011
Lautoka 1 April 2011
Mean Post
Fig. 3 The 25-item pre- and post-test scores with different instructors teaching. Suva 29 March was taught by overseas instructors; the other dates were all taught by local instructors
improvement between groups (Fig. 2); however, this analysis could not be translated across all countries either due to lack of collected data or to widely varying groups of attendees (ranging from volunteers to physiotherapists, social workers, and occupational therapists).
The rapid dissemination of EPM since its inception in 2010 suggests there is a need for education in pain management in many LMICs. While education in its own right does not equate to change of practice, our evaluation suggests that the program is useful and valued as measured by the end of program feedback, and that there is at least short-term improvement of knowledge as measured by the differences in pre- and post-course testing across multiple cultures. Evaluation aimed at behavior change will be available when enough log books have been collected from course participants. As an aid to encourage return of these data from the field, we anticipate awarding a certificate called EPM Plus to participants who return ten cases in the six months immediately following their participation in the program. There was a worsening of test scores for some individuals. The cause of this is not clear, but it is important to note that, in many countries, English is the participants’ second (or third) language and the level of English proficiency varies considerably. Lack of English comprehension may have contributed to some poor test scores. In general, doctors usually have better English than nurses and other health workers. These language issues underline the importance of early handover to local instructors, using translators to explain concepts, and translate course materials into the local language. We have encouraged multidisciplinary groups of doctors and nurses; some groups also
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included allied health medical workers, students, and nurse aides. The varied background and initial knowledge level is also likely to be reflected in the pre- and post-course test result variation. Pre-testing also allows a measure of starting core knowledge, which is likely to be different between doctors and nurses. Making the pre- and postcourse tests easier or more difficult is likely to affect the degree of change in the scores. We anticipate exploring these concepts over the next few years as more data are collected. While we have delivered EPM to 1,600 participants, we report here only the results from those participants for whom we were able to collect both pre- and posttest scores. Incomplete paired test results had many causes, e.g., late participant arrivals, early departures, lack of paper or photocopying, not writing names on the test papers, and local organizers wishing to keep the results for local audit and feedback, among others. Our data show that participant knowledge also improved when the workshop was delivered by newly trained local instructors. This is encouraging because it suggests that local health workers can be rapidly trained to successfully deliver the workshop. During a typical three-day series of courses, the instructors run the workshop with minimal support on the third day. This rapid handover to local instructors is an important factor in developing sustainability of the program. We are yet to formulate a definition for significant improvement following the introduction of EPM, as conditions in terms of culture, language, funding sources, and health care delivery systems vary so much between countries. However, we believe that using repeatable measures such as those described and the structure outlined by Kirkpatrick have demonstrated positive change. Further development for EPM is underway and includes a condensed 4 h workshop called EPM Lite. This course is designed for medical students and is being pioneered at Auckland University, New Zealand. This workshop may be a useful educational tool for universities in LMICs. We are also developing a mobile phone application that can be used both as a bedside clinical tool and a log book. Ongoing support for participants and instructors of EPM will be provided through our website (www.essentialpain management.org) and Facebook page (www.facebook. com/EssentialPainManagement). Acknowledgments Financial and in-kind support has been provided by the Australian and New Zealand College of Anaesthetists, The Australian Society of Anaesthetists, AusAid through the Pacific Islands Project and The Royal Australasian College of Surgeons, International Association for the Study of Pain, The World Federation of Societies of Anaesthesiologists, and the Ronald Geoffrey Arnott Foundation through Perpetual Trustees. Conflicts of interest the authors.
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No conflicts or potential conflicts are known to
References 1. Blyth FM, March LM, Brnabic AJ et al (2001) Chronic pain in Australia: a prevalence study. Pain 89:127–134 2. Portenoy RK (2011) Treatment of cancer pain. Lancet 377:2236–2247 3. WHO Emergency and essential surgical care (2013). http://www. who.int/surgery/en/. Accessed 15 May 2014 4. Katz N (2002) The impact of pain management on quality of life. J Pain Symptom Manage 24:S38–S47 5. McCarberg BH, Nicholson BD, Todd KH et al (2008) The impact of pain on quality of life and the unmet needs of pain management: results from pain sufferers and physicians participating in an Internet survey. Am J Ther 15:312–320 6. Spanjersberg WR, Reurings J, Keus F, et al (2011) Fast track surgery versus conventional recovery strategies for colorectal surgery. In: The Cochrane database of systematic reviews CD007635. Cochrane Library, Split 7. Size M, Soyannwo OA, Justins DM (2007) Pain management in developing countries. Anaesthesia 62(Suppl 1):38–43 8. WHO Normative guidelines on pain management: report of a Delphi study to determine the need for guidelines and to identify the number and topics of guidelines that should be developed by WHO 9. WHO (2013) Model lists of essential medicines. 18th Edn. WHO, New York 10. Pargeon KL, Hailey BJ (1999) Barriers to effective cancer pain management: a review of the literature. J Pain Symptom Manage 18:358–368 11. Kopf A, Patel NB (eds) (2010) Guide to pain management in lowresource settings. Pub IASP. http://www.iasp-pain.org/files/Con tent/ContentFolders/Publications2/FreeBooks/Guide_to_Pain_Man agement_in_Low-Resource_Settings.pdf. Accessed 15 May 2014 12. Fillingim RB, King CD, Ribeiro-Dasilva MC et al (2009) Sex, gender, and pain: a review of recent clinical and experimental findings. J Pain 10:447–485 13. Goldfrank LR, Knopp RK (2000) Racially and ethnically selective oligoanalgesia: is this racism? Ann Emerg Med 35:79–82 14. Committee on Advancing Pain Care, Institute of Medicine (2011) Relieving pain in America: a blueprint for transforming prevention, care, education, and research. National Academies Press, Washington 15. Online course: pain and policy studies group: increasing patient access to pain medicines around the world: a framework to improve national policies that govern drug distribution. http:// www.painpolicy.wisc.edu/online-course. Accessed 15 May 2014 16. Joranson DE, Ryan KM, Maurer MA (2010) Opioid policy, availability, and access in developing and nonindustrialized countries. In: Bonica’s Management of Pain. 4th Edn. Lippincott Williams & Wilkins, Baltimore, p 194–208 17. IASP YouTube: IASP Secretariat. https://www.youtube.com/ user/IASPSecretariat 18. IASP Facebook: IASP. https://www.facebook.com/IASP.pain 19. https://twitter.com/AmericanPainSoc 20. Bosnjak S, Maurer MA, Ryan KM et al (2011) Improving the availability and accessibility of opioids for the treatment of pain: the international pain policy fellowship. Support Care Cancer 19:1239–1247 21. Flaherty JH (2001) Who’s taking your 5th vital sign? J Gerontol Ser A, Biol Sci Med Sci 56:M397–M399 22. Macintyre PE, Scott DA, Schug, SA, et al (2010) APM:SE working group of the Australian and New Zealand College of anaesthetists and faculty of pain medicine (2010). In: Acute Pain Management:Scientific Evidence. 3rd (Edn.) ANZCA & FPM, Melbourne
Essential Pain Management: An Educational Program for Health Care Workers C. Roger Goucke • Tracy Jackson Wayne Morriss • Jane Royle
•
Socie´te´ Internationale de Chirurgie 2014
Abstract Background Education for health care workers on painrelated topics is not always readily available, and this is especially so in low and middle income countries (LMICs). The Essential Pain Management program (EPM) has been developed to offer a simple interactive educational opportunity for health care workers in LMICs. Methods Following a needs analysis in Papua New Guinea, an 8 h educational program with the aims of improving pain knowledge and providing a simple pain management framework was developed. An evaluation of the program using the Kirkpatrick model is being used. The program has a ‘‘teach the teachers’’ component to encourage sustainability. Results The program has been run in 30 countries, delivered to 1,600 participants, and 340 instructors have been trained. Feedback has been positive, pre post testing in 27 sites showed a mean pre score of 65.89 % rising to 75.23 % (n = 581 respondents). A subanalysis demonstrates doctors and nurses improving by similar degrees. When local instructors have delivered the program after attending
On behalf of the Alliance for Surgical and Anesthesia Presence. C. R. Goucke Sir Charles Gairdner Hospital, University of Western Australia, Perth, WA 6009, Australia C. R. Goucke (&) J. Royle Department of Pain Management, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA 6009, Western Australia e-mail: [email protected] T. Jackson Vanderbilt University, Nashville, TN, USA W. Morriss Christchurch Hospital, Christchurch, New Zealand
the trainer’s session the participant test results were comparable to the results seen when the overseas instructors taught the course. Discussion The widespread adoption of the EPM program suggests there is a need for pain education in LMICs. The teach the teachers component of the program and the comparable results from their teaching should contribute to sustainability. Further support and mentoring using electronic systems such as Facebook, text messaging, and a website may also contribute to sustainability.
Introduction Incidence and prevalence studies relating to pain vary widely depending on the interview technique and content of the survey. Published data from high-income countries suggest up to 35 % of these populations have chronic pain, defined as continuous pain lasting more than three months [1]. Prevalence studies are scarce in low- and middleincome countries (LMICs), but a recent survey from Ghana reports a prevalence of 20 % following a face-to-face rural community study (M Notrica, personal communication). When one considers cancer-related pain, up to 75 % of patients with cancer can experience clinically significant pain and on average 43 % receive inappropriate pain care. In many parts of the world, despite significant efforts by a number of organizations, cancer pain remains poorly treated or untreated [2]. With the advent of surgical approaches to management of disease in LMICs, the incidence of acute postsurgical pain and chronic postoperative pain is likely to rise [3]. Effective pain management can improve quality of life [4, 5] and result in shorter hospital stays, reduced complication
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rates, and better patient satisfaction when programs like Fast Track or Enhanced Recovery After Surgery (ERAS) have been implemented [6]. Specific education related to pain is rarely included in the training of health care providers, even in developed countries, and attitudes regarding the necessity or feasibility of pain relief vary widely among cultures [7]. Even though the WHO provides guidelines for treatment [3, 8] and an essential medicines list (EML) [9] health care providers and patients continue to have misconceptions about drug therapies [10]. Pain is often considered only a symptom of a larger problem like cancer or HIV; even if the symptom is more debilitating than the associated disease, management may be marginalized when patients in poverty must continue to work despite pain in order to survive. When patients do attempt to seek treatment, access is often limited [11]. The International Association for the Study of Pain (IASP) states that education on pain management should be incorporated into the curricula of health care students, as well as in the continuing education of health care providers [11]. This education is meant to aid in the assessment and management of pain, as well as highlight the inequity in treatment among certain groups[12–14]. Improvement of pain management programs must take into account which methods of education work best for a particular area or group of people. Pain education should be accessible and relevant. Recent efforts employ websites like YouTube, Twitter, and Facebook, as well as web-based educational modules[15– 19]. The International Pain Policy Fellowships of the IASP have used a trainee-as-trainer approach to implement pain management education in the respective countries of the chosen fellows [11, 16]. For example, IASP fellows in Sierra Leone, Colombia, and Serbia have been successful in increasing the availability of morphine through collaboration with their respective governments and stakeholders [20].
Essential pain management (EPM) With this background, we developed a program called Essential Pain Management (EPM) for health workers in LMICs. The program was piloted in Papua New Guinea in 2010 and has now been taught in over 30 countries around the world (Table 1). The aims of EPM are: • • •
To improve pain knowledge To provide a simple framework for managing pain To address pain management barriers
123
Table 1 List of essential pain management (EPM) countries
Fiji Vanuatu Tonga Samoa Solomon Islands Papua New Guinea Tuvalu Micronesia Cook Islands Myanmar Malaysia Thailand Indonesia Mongolia Mexico Vietnam India Bangladesh Nepal Tanzania Kenya Uganda Panama Dominican Republic South Africa Rwanda Honduras Paraguay New Zealand Australia
The program is designed to improve management of pain of all types, e.g., traumatic and post-surgical pain, cancer pain, and chronic non-cancer pain. Essential Pain Management was developed after a needs assessment in Papua New Guinea. The program is flexible to allow for differences in health care and educational resources, and it can be taught to a range of health care workers, from hospice volunteers to nursing students to consultant physicians. The EPM program promotes early handover of teaching to local instructors, to encourage educational sustainability and the development of local solutions for local problems. Program structure and content The EPM program has two parts—the EPM One-Day Workshop and the EPM Instructor Workshop. The OneDay Workshop runs for 8 h and usually involves three to four instructors and 25 participants. The workshop is
World J Surg
highly interactive, and comprises a series of short lectures, brainstorming sessions, and case discussions. Like Advanced Trauma Life Support (ATLS), EPM offers a system for managing patients in pain. Instead of ABC (Airway, Breathing, Circulation), we use RAT (Recognize, Assess, Treat). The Essential Pain Management ‘‘RAT’’ has proved to be a very popular educational tool with course participants and instructors, and it can be used to discuss the management of a variety of pain presentations. The RAT approach highlights some important differences between traditional teaching of pain management and EPM. First, the importance of recognizing pain is highlighted. As summarized above, pain is often not recognized for a variety of social and systemic reasons. The importance of asking the patient is emphasized, along with the concept of pain as the ‘‘fifth vital sign’’ [21]. Second, assessment is simplified to a relatively small number of questions and answers required to guide treatment and monitoring: How severe is the pain? What is the pain diagnosis? Are there other physical or psychological factors? The pain diagnosis depends on the duration (acute or chronic), cause (cancer or non-cancer), and mechanism (nociceptive or neuropathic) of the pain. For example, a patient with a simple fracture has acute, non-cancer, nociceptive pain, while a patient with long-standing diabetic foot pain has chronic, non-cancer, neuropathic pain. Third, treatment emphasizes both non-drug and drug therapy. We have observed that, in a multidisciplinary group, non-physician participants tend to emphasize nondrug treatments and physician participants emphasize drug treatments. It is important to use both approaches in the treatment of many types of pain [22], and particularly so in resource-poor settings where some treatments may not be available. The availability (or lack of availability) of medicines on the WHO’s EML is a topic that often comes up during the brainstorming session on pain management barriers. Case discussions are a very important part of the workshop. The cases are discussed in small groups (around six participants) and cover a variety of pain types—acute nociceptive pain, chronic cancer pain, and chronic noncancer pain. The discussions give participants the opportunity to put ‘‘RAT’’ into practice and to devise management plans based on local resource constraints. The depth of discussion depends on the makeup of the group. Course participants use a brainstorming session to identify pain management barriers in their own environment. These barriers are sorted into four categories: patient factors, drug issues, health worker barriers, and system issues. At the end of the day, groups spend 30–45 min identifying potential solutions to these barriers in their particular environment.
The EPM program is targeted at all health care workers, from undergraduate nurses and medical students to senior surgical and anesthesia consultants. It can be easily ‘‘fine tuned’’ to include case discussions on specific local conditions; for example, in Uganda, the EPM RAT is used to discuss the management of severe pain due to sickle cell disease. Similarly, the course can be modified to take into account the availability or non-availability of treatments. Morphine is unavailable in many environments, and such alternatives as tramadol may be discussed instead. Evidence for the use of non-pharmacologic treatment strategies is emphasized, and may include education, explanation, and empathy, with rest, ice, compression, and elevation (RICE), followed by exercise programs for early and late rehabilitation [22]. A series of slides and a workbook are available and were developed in English with awareness that English is the second or even third language for the majority of the likely participants. Participants are then encouraged to become instructors themselves in order to promote exponential dissemination of this information. The half-day Instructor Course is a 5 h ‘‘Train the Trainer’’ type program that covers the essentials of adult learning and reinforces the teaching techniques used in EPM. Participants practice using the prepared slides in a lecture situation and receive feedback from their peers regarding their delivery style. A similar process is used for running group discussion programs, such as the case presentations. The full EPM program consists of the day 1 workshop for up to 25 participants, followed on day 2 by up to 12 of those participants taking the 5 h instructor workshop. On day three the new instructors teach the 8 h EPM workshop to a new group of participants with some supervision from the external instructors. The local instructors are encouraged to teach the program in their national language. EPM roll-out and development The EPM program has now been taught in 30 countries around the world—in the Pacific region, Asia, Africa, and Latin America. The course has been translated into a number of languages, including Spanish, Indonesian, Vietnamese, and Mongolian. In most cases, EPM has been offered to countries following personal contact between the program providers and members of the local anaesthesia or pain societies. A local in-country coordinator is identified, and he or she recruits participants for the courses. We encourage multidisciplinary participation (doctors, nurses, and other health workers) because, in our experience, this leads to improved group discussions and emphasizes the importance of teamwork in pain management.
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The workshop manual and slides are covered by a Creative Commons copyright licence, which stipulates that the material cannot be used for commercial purposes. In most countries, participation in an EPM workshop is free, although some countries have used a nominal registration fee to cover printing and/or catering costs. In one country, participants received a per diem ($1 per day) to attend the workshop; this was to compensate them for loss of income while they were at the workshop. In many countries, the local anaesthesia or pain society has contributed to course costs, reinforcing the concept that EPM is being run as a partnership between the overseas providers and the local society. Overseas workshop providers are not remunerated but are able to claim airfare and accommodation costs from donor agencies. In the first three years of the program following a pilot series of courses, there have been minimal changes to the teaching materials; however, a review of the workshop manual and slide set is underway. To date, we have used a standardized set of true/false questions to assess knowledge acquisition. A multiple choice question-and-answer test is being piloted. Evaluation The ultimate purpose of improving pain education is to change behavior that has a positive impact on individual patients and society as a whole. Our program evaluations have included the number of courses delivered, the number of participants in the one-day workshops, and the number of instructors taught. We have also used the four levels of Kirkpatrick’s revised model of program evaluation to more formally assess the programs to date: www.kirkpa trickpartners.com/ Level 1 reaction The programs have been evaluated from standard participant program evaluation forms. The forms list several items that, once completed, were evaluated with standard rating and Likert scales to assess usefulness of the content; completion of stated objectives; overall satisfaction; self-assessed changes in knowledge, attitudes, and skill/behaviors; and suggestions for improvement (qualitative). Level 2 learning To measure whether the program resulted in changes in knowledge, attitudes, behavior, or intent, participants’ preand post-course knowledge was assessed with a 25-item true/false assessment test administered both at the beginning and the end of the one-day workshop. Pre- and post-
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course scores were compared, but only participants who had completed both tests were included in our analysis. Level 3 transfer To assess effective transfer and dissemination of this information by trainers who were previously trainees, the scores of the participants trained by the new trainers have been compared with those of the participants taught by the developers of the module. Pre- and post-course test differences have also been compared between different countries. We are continuing to develop Level 3 evaluation. Patterns and barriers to transfer of information will be assessed. Durability of improvements in knowledge, attitudes, behaviors, and intent will be followed with periodic longitudinal testing of previous course participants. Change in behavior and ability in the workplace over the medium term is being recorded in a logbook and will be monitored. Level 4 results To measure impact and patient outcomes we will monitor changes in patterns of pharmacologic and non-pharmacologic modalities for pain management. We anticipate this can be done by ‘‘snapshot surveys’’ of prescribing and dispensing patterns in surgical wards and emergency departments. Patient surveys of pain, quality of life, and satisfaction are forthcoming and will be collected over the next few years.
Results In the 30 countries where EPM has been run it has been delivered to 1,600 participants, and 340 instructors have been trained. A Kirkpatrick Level 1 assessment of reaction to the teaching module has been assessed from feedback. Responses for usefulness of the content, completion of stated objectives, overall satisfaction, self-assessed changes in knowledge, attitudes, and skill/behaviors all scored 4 or 5 out of 5 on the 6 point scale (0–5) (data not shown). Examples of Kirkpatrick Level 2 assessment of learning are shown in Fig. 1 and 2 from Myanmar, Fiji, and across a number of participating countries. An initial analysis of data from a 25-item true/false assessment test administered before and after the EPM program in 27 sites showed a mean pre-score of 65.9 % answers correct and a mean postscore of 75.2 % (n = 581 respondents). This reflects an average improvement of 9.34 % (paired t-test, p \ 0.001). The individual range in improvement in scores from Myanmar is shown in Fig. 1. A sub-analysis comparing the results between doctors and nurses in Fiji shows a similar
World J Surg Myanmar 17 March 2013 Percent improvement
30% 25% 20% 15% 10% 5% 0% -5% 18 19 1
8 25 2 10 17 23 6 11 15 22 27 3
5
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Respondent number (N=29)
Fig. 1 Improvement in scores by respondent–Myanmar
Mean pre and post scores Suva 31 Mar 2011 Correct answers (N=25)
25 22 19
18
20 16 15 10
5 0
Pre
Discussion
Post Nurses
Doctors
Fig. 2 Changes in the 25-item true/false pre- and post-test scores between doctors and nurses Number of correct answers (N=25)
A Kirkpatrick Level 3 measure compares the improvement of scores between day 1 (taught in English by overseas instructors) and day 3 (taught in English or the local language by local instructors). This showed no difference in improvement between the groups taught by the different instructors (2 sample t-test, p [ 0.05), suggesting that information transfer during the instructors teaching course has occurred successfully (Fig. 3).
Mean scores pre and post testing 25 21 20
17
21
20 17
16
20 17
15 10 5 0 Suva 29 March Suva 31 March 2011 2011 Mean Pre
Suva 1 April 2011
Lautoka 1 April 2011
Mean Post
Fig. 3 The 25-item pre- and post-test scores with different instructors teaching. Suva 29 March was taught by overseas instructors; the other dates were all taught by local instructors
improvement between groups (Fig. 2); however, this analysis could not be translated across all countries either due to lack of collected data or to widely varying groups of attendees (ranging from volunteers to physiotherapists, social workers, and occupational therapists).
The rapid dissemination of EPM since its inception in 2010 suggests there is a need for education in pain management in many LMICs. While education in its own right does not equate to change of practice, our evaluation suggests that the program is useful and valued as measured by the end of program feedback, and that there is at least short-term improvement of knowledge as measured by the differences in pre- and post-course testing across multiple cultures. Evaluation aimed at behavior change will be available when enough log books have been collected from course participants. As an aid to encourage return of these data from the field, we anticipate awarding a certificate called EPM Plus to participants who return ten cases in the six months immediately following their participation in the program. There was a worsening of test scores for some individuals. The cause of this is not clear, but it is important to note that, in many countries, English is the participants’ second (or third) language and the level of English proficiency varies considerably. Lack of English comprehension may have contributed to some poor test scores. In general, doctors usually have better English than nurses and other health workers. These language issues underline the importance of early handover to local instructors, using translators to explain concepts, and translate course materials into the local language. We have encouraged multidisciplinary groups of doctors and nurses; some groups also
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included allied health medical workers, students, and nurse aides. The varied background and initial knowledge level is also likely to be reflected in the pre- and post-course test result variation. Pre-testing also allows a measure of starting core knowledge, which is likely to be different between doctors and nurses. Making the pre- and postcourse tests easier or more difficult is likely to affect the degree of change in the scores. We anticipate exploring these concepts over the next few years as more data are collected. While we have delivered EPM to 1,600 participants, we report here only the results from those participants for whom we were able to collect both pre- and posttest scores. Incomplete paired test results had many causes, e.g., late participant arrivals, early departures, lack of paper or photocopying, not writing names on the test papers, and local organizers wishing to keep the results for local audit and feedback, among others. Our data show that participant knowledge also improved when the workshop was delivered by newly trained local instructors. This is encouraging because it suggests that local health workers can be rapidly trained to successfully deliver the workshop. During a typical three-day series of courses, the instructors run the workshop with minimal support on the third day. This rapid handover to local instructors is an important factor in developing sustainability of the program. We are yet to formulate a definition for significant improvement following the introduction of EPM, as conditions in terms of culture, language, funding sources, and health care delivery systems vary so much between countries. However, we believe that using repeatable measures such as those described and the structure outlined by Kirkpatrick have demonstrated positive change. Further development for EPM is underway and includes a condensed 4 h workshop called EPM Lite. This course is designed for medical students and is being pioneered at Auckland University, New Zealand. This workshop may be a useful educational tool for universities in LMICs. We are also developing a mobile phone application that can be used both as a bedside clinical tool and a log book. Ongoing support for participants and instructors of EPM will be provided through our website (www.essentialpain management.org) and Facebook page (www.facebook. com/EssentialPainManagement). Acknowledgments Financial and in-kind support has been provided by the Australian and New Zealand College of Anaesthetists, The Australian Society of Anaesthetists, AusAid through the Pacific Islands Project and The Royal Australasian College of Surgeons, International Association for the Study of Pain, The World Federation of Societies of Anaesthesiologists, and the Ronald Geoffrey Arnott Foundation through Perpetual Trustees. Conflicts of interest the authors.
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No conflicts or potential conflicts are known to
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