Update on the Cancer Pain Role Model Education Program

Transcription

1 292 Journal of Pain and Symptom Management Vol. 10 No. 4 May 1995 Special Article Update on the Cancer Pain Role Model Education Program David E. Weissman, MD, and June L. Dahl, PhD Division of Hematology/Oncology (D.E. W.), Medical College of Wisconsin, Milwaukee; and Department of Pharmacology (].L.D.), University of Wisconsin-Madison, Madison, Wisconsin Abstract Application of traditional educational methods has done little to improve cancer pain management in the United States. This report details the results of the first year of the expanded Wisconsin Cancer Pain Initiative Role Model Program, a novel approach to cancer pain education. One hundred and ninety-six physicians and nurse educators together with their clinical partners attended one of three role model conferences in and developed Action Plans detailing their proposed educational goals. Results indicate that participants demonstrated sign~cant improvement in cancer pain knowledge as a result of the 1-day conference. Within 12 months of the conference, 64% of Role Model teams completely or partiauy met their Action Plan goals. In total, 227 educational or clinical practice projects were completed. The Cancer Pain Role Model Program represents an excellent educational program for disseminating cancer pain information and instituting positive changes in clinical practice. J Pain Symptom Manage 1995;10: Key Words Cancer pain, medical education, nursing education, palliative care Introduction Probably the greatest obstacle to improving cancer pain management in the United States is the failure to apply existing knowledge about cancer pain in clinical practice. The barriers that inhibit this application are well documented and have served as the basis for the development of educational programs by state cancer pain initiatives.~ In 1990, the Wisconsin Cancer Pain Initiative (WCPI) introduced the Role Model Program (RMP), a novel approach Address reprint requests to: David E. Weissman, MD, John Doyne Hospital, Box 133, 8700 West Wisconsin Avenue, Mihvaukee, WI 53226, USA. Accepted for publication: November 3, to health professional education. The goal of this pilot program was to train physicians, together with their nurse and/or pharmacist clinical partners, to become role models for better pain management in their clinical practice settings. Two cohorts of physicians and their clinical partners were recruited to 1-day educational conferences in 1990 and A combination of lectures and case-based workshops were used to provide participants with factual information about cancer pain assessment and treatment, along with techniques for instituting changes in their clinical settings. At the program's conclusion, participants developed an Action Plan, a detailed list of strategies they would undertake to help change pain management practices. They were contacted U.S. Cancer Pain Relief Committee, /95/$9.50 Published by Elsevier, New ~rk, New York SSDI (95)00006-K

2 Vol. 10 No. 4 Maw 1995 Cancer Pain Ro& Model Program 293 at 6 and 12 months alter the conference to determine how much of the proposed plan they had accomplished. Participants reported an impressive number of educational activities that led to clinical practice changes in the months following the conference. 2 The success of this pilot effort led to expansion of the program with assistance from a National Cancer Institute Cancer Pain Education Grant. The grant provided funding for three Role Model Program for each of 3 years ( ) and the potential for expansion of the program to other states. This report details the results of the three RMPs conducted in the first year of NCI funding. Methods The first three NCI grant-related RMP conferences were held in Milwaukee, WI (November 92), Madison, WI (March 93), and Fargo, ND (April 93). The same faculty were used for all three RMPs and included the authors and a group of trained facilitators experienced in cancer pain management. The initial recruitment target was 25 teams of clinical pairs (50 participants), which was later expanded to a maximum of 80 participants. Recruitment in Wisconsin and North Dakota was coordinated by the respective state cancer pain initiatives, with directed mailings to physicians and nurses. Recruitment was targeted to both physicians and nurses involved in some aspect of education, such as medical or nursing school faculty, hospital-based nurse supervisors, hospice education coordinators, or physicians who supervise medical students or residents in their clinical practice setting. Each physician or nurse educator was then required to attend the conference with a clinical partner, specifically a physician, nurse, or pharmacist with whom they work. 2 The agenda for the Role Model Conference is given in Table 1. Upon arrival at the conference, participants received a binder of resource materials, including a teaching slide set, and each participant completed a demographic and attitude/knowledge survey. :~ The same 29-question attitude/knowledge survey was completed at the end of the conference (posttest). Questions include pain assessment (5), drug therapy (14), nondrug therapy (6), and attitudes (4). This instrument was tested at Table 1 Role Model Program Conference Agenda 8:00 Registration Pretest 8:30-10:30 Lectures Historical and cultural aspects of pain Pain assessment Nonopioid and opioid pharmacology 10:30-12:00 Small Group Case-Based Workshops-- Focus on attitudes Addiction, tolerance Respirato D, depression Regulatory, issues Methods to change attitudes 1:00-2:00 Lectures Adjuvant analgesics Antineoplastic/anesthetic/ behavioral treatments 2:15-3:45 Small Group Case-Based Workshops-- Focus on practical pain management issues Somatic/neuropathic pain Equianalgesic case studies Post-test 4:00-4:30 Education Workshop Educational resources Health professional education methods Role modeling 4:30-5:00 Development of Action Plan Conference Evaluation the November 92 conference, and changes made after that conference have been incorporated into what is now our standard survey instrument. Pre/posttest data presented in this report include only the later two RMPs (March and April 1993). The educational format of the conferences included both lectures and small group, casebased workshops, as previously described. 2 At the conclusion of the conference, each team developed an Action Plan, a detailed list of plans for future educational and clinical activities within their practice settings (Table 2). Follow-up surveys were mailed at 6 and 12 months to determine what portion of the Action Plan had been completed. Direct phone contact was attempted with participants who did not return the follow-up surveys by mail. Resu/ts Recruitment for each of the three conferences exceeded our goal of 50 participants. To

3 294 Weissman and Dahl Vol. 10 No. 4 May 1995 Tab~ 2 Example of an Action Plan a Action Steps 1, Obtain more patient education booklets 2. In-serxdce program to agency nursing staff 3. Develop new pain-assessment tool to be used at each nursing visit 4. Develop pain control protocol for agency 5. Develop annual nursing inservice program for inpatient staff at local hospitals Target Date Janua~,1993 Janumy1993 Janua~' 1993 March 1993 May-Sep 1993 ~q0eveloped by a physician/nurse team at the Milwaukee Role Model Conference, November Note: All the above were completed or in progress by the MD/ RN team at 12 months along with a presentation to a cancer patient support group. accommodate the demand, the maximum allowable conference size was increased to 80. Participants noted that they became aware of the program primarily from the mailed brochure or by word-of-mouth. A total of 196 participants attended the three conferences as 87 teams of physician and/or nurse educators with their clinical partners. These included 56 physicians (29%), 128 nurses (65%), and 12 pharmacists (6%). The mean age was 43 years (range, years). Physician specialties included family medicine, internal medicine, medical and radiation oncology, anesthesia, and surgery. Fifty percent of participants worked in an inpatient hospital setting, 43% in an outpatient clinic, 37% in hospice agencies, 20% in a physician's office (nurses), and 6% in community or hospital pharmacies. Most had extensive involvement with cancer patients; 25% cared for 50 or more cancer patients in the preceding 6 months, 35% cared for patients, 31% cared for 1-10 patients. Only 9% indicated no recent cancer patient contact. Seventy-three percent indicated that their cancer pain expertise "needs improvement," 22% indicated it was "adequate," and 5% said it was "excellent." Eighty-five percent of participants noted that their professional roles included some teaching responsibilities. In the preceding year, 50% had given a lecture or in-service program (any topic) to nurses, 19% to physicians, and 37% had spoken to patient or public groups. In addition, 88% indicated some clinical contact with medical students or residents, 68% had such contact with nursing students, and 27% with pharmacy students. Conference evaluations indicated great acceptance of the conference format and educational content. On a Likert scale of 1-7 (1 = excellent, 7 = poor), the average score for the lectures and small group workshops was 1.5 (range, ). Greater than 94% of participants indicated that the course content was relevant to their practice and at an appropriate educational level. Greater than 90% indicated that the four main conference objectives were accomplished, specifically (a) disseminating up-to-date cancer pain treatment information, (b) encouraging appropriate attitudes, (c) training physician/nurse educators and partners in pain management, and (d) helping to promote information transfer (role modeling). Pretest and posttest results indicated significant improvement in cancer pain knowledge as a result of the 1-day conference. The Madison, WI, cohort had a mean of 67% correct answers on the pretest and 86% on the posttest (P < 0.001). The Fargo, ND, cohort improved from 60% to 88% (P< 0.001). Responses of the two cohorts to specific questions were quite similar. The questions most frequently answered incorrectly on the posttest were (a) calculation of an equianalgesic dose (43% incorrect), (b) the incidence of opioid-induced psychologic dependence (31% incorrect), and (c) the analgesic response rate of radiation for painful bone metastases (29% incorrect). Data collected at 12 months showed that 56 of the 87 teams (64%) had either fully (37) or partially (19) completed their proposed Action Plans. The remaining 31 teams either moved/ changed jobs (9), had not worked on their Action Plans (2), or did not respond to follow-up letters/phone calls (20). A total of 227 projects were completed by the 56 teams in the 12 months following the conference (mean of 4.2 projects/group) (Table 3). The most common project was a cancer pain lecture or in-service program for physicians, nurses, or pharmacists. Eighty-five projects with long-term impact were completed. These included integrating pain assessment into clinical practice, ongoing health-professional education programs, developing a "pain team," and developing pain treatment protocols or procedures to improve care on a con-

4 Vol. 10 No. 4 Mav 1995 Cancer Pain Role Model Program 295 Table 3 Action Plan Projects Completed Within 12 Months Postconference Short-term projects Lectures/in-service programs~workshops" Resource development b Quali~-assurance studies Research projects Miscellaneous Long-term pr~ects Pain-assessment programs' Treatment initiatives d Ongoing MD/RN education ~ Patient education Total N ~%ectures, etc. refers to an educational presentation to health professionals not part of an established, ongoing pain education program (see note 4 below). These include medical staff conferences, grand rounds, nursing in-service programs or half-day pain education workshops. ~'Resource development refers to obtaining and distributing cancer pain educational materials or establishing an institutional cancer pain reference libraw. 'Pain assessment program refers to development and/or implementation of pain assessment tools and/or bedside monitoring programs. ~I'reatmeut initiative refers to establishing a dedicated pain team, writing new policies/procedures or protocols for pain management activities or ongoing review of medication usage. eongoing MD/RN education refers to establishment of an education program that is more than a one-time program such as yearly or monthly lectm-es to medical students, residents or nurse staff development programs given periodically to nurses in training or practice. tinuing basis. Projects of particular note included the following: 1. three role model programs organized and conducted by participants, including two in North Dakota and one in Michigan; 2. institution by an oncologist of wide-ranging cancer pain activities at her medical school, including lectures to preclinical medical students and medical house staff, weekly patient care discussions, and new pain-assessment programs; 3. development of an 8-hr nursing staff-development program by a North Dakota group; and 4. multiple activities by two hospital-based nurses who posted pain-rating scales in each patient's room, made pain "rulers" available to all RNs, distributed written pain information to all physician staff members, made individual contacts with local physicians, completed an in-service program, and wrote articles and letters to the editor of their local newspaper. D/scuss/on The concept for the RMP dates to 1987, when the WCPI proposed a model for physician cancer pain education. 4 The model stressed that three components were necessary to bring improvements in clinical practice: (a) dissemination of information about pain assessment and treatment, (b) prioritization of pain management in clinical practice settings, and (c) the creation of role models. Since 1987, there has been tremendous growth of state, national, and organizational pain education resource material and educational programming, activities that have helped to begin the process of accomplishing the first two components. The RMP represents the next step toward improving pain management through integration and practical application of existing knowledge into clinical practice. The process of transforming a health-care professional with an interest in cancer pain into a cancer pain role model requires several steps. First, the individual must acquire basic knowledge of cancer pain management, not necessarily be an "expert," but have a good foundation along with appropriate attitudes. Second, an existing or latent motivation to teach others, confront inappropriate attitudes, and work for institutional change must be sparked. Third, the individual must acquire knowledge about ways to develop focused educational programs for particular audiences along with ways to assess and change clinical practice. Fourth, resources must be available to enhance information transfer. Fifth, the individual must not feel alone, but know that there are others working toward similar goals, with similar problems. The results of the first year of the RMP are very encouraging and indicate success in training role models. The accomplishments of the program can be measured in several ways: achievement of recruitment goals, improvement in knowledge, satisfaction with the educational program, and use of knowledge gained to teach others and to change practice patterns.

5 296 Weissman and Dahl 17ol. 10 No. 4 May 1995 Recruitment The 50-participant recruitment goal was exceeded for each of the three conferences indicating sufficient interest in this b'pe of educational program. Each of the three conferences was over-subscribed, necessitating a waiting list and program expansion. The RMP was also successful at recruiting individuals with educational experience, including persons who have significant contact with health professional trainees. It was also demonstrated that recruitment was feasible in another state (ND). Since the April 1993 North Dakota program, RMPs have been conducted in Michigan, Kentucky, New Jersey, Connecticut, New Hampshire, and Texas. Each program met or exceeded its recruitment goal. Improvement in Knowledge The pre- and posttest results demonstrate that a 1-day conference can markedly improve the knowledge base of participants. Such improvement was also seen in a RMP in Texas, which involved the same fhcul~' and program agenda. Furthermore, a follow-up knowledge survey of the Texas cohort indicated excellent retention of information at 4 and 12 months after the conference) '6 Program Satisfaction Participants from all three disciplines, nursing, medicine, and pharmacy', consistently gave a high-approval rating to the program content and educational level, and felt that the stated program objectives had been accomplished. This degree of satisfaction is extraordinary given the diverse training and experience of the participants. Role Modeling Almost two-thirds of the teams partially or completely met the goals outlined in their Action Plans. The list of projects shows considerable depth in terms of both short- and longterm projects and a mixture of intended audiences, including physicians, nurses, pharmacists, patients, and the public. Projects included both educational programs and improvements in cancer pain services. Most notable was the emphasis on institutionalizing pain assessment, one of the most crucial and neglected areas of clinical care. The ve W pro- cess of establishing regular pain assessment within an institution is likely to put into motion a series of positive steps that may highlight the need for additional professional education. Other clinical care projects, such as establishment of a dedicated "pain team," development of written policies or protocols, qualiw-assurance projects, distribution of equianalgesic tables, etc., serve to improve and reinforce the entire pain-treatment environment, making it more likely that the correct information and skills will be available to meet a particular patient's need. The most disappointing outcome of these programs was that 36% of the teams had no documented postconference activities. Besides those participants who moved/changed jobs, there were undoubtedly those who were not truly aware of the program objectives as stated in the brochure or attended the conference solely for their personal education. This, however, does not necessarily mean that these individuals obtained no benefit from the program or that they did not enhance education and/or clinical care in their locale. The 36% figure may be unavoidable unless more-restrictive recruitment techniques are implemented. This report, combined with data from the pilot programs and reports from the role model programs held in Texas, indicates that it is possible to train role models for cancer pain education who will institute a cascade of educational efforts and important clinical practice changes. We believe the essential features of the program that contribute to success include the following: 1. recruitment of a team consisting of a physician or nurse educator with a clinical partner; 2. use of lectures to review basic factual information; 3. use of case-based workshops to learn how to confront inappropriate attitudes and reinforce clinical skills; 4. provision of abundant resource materialarticles, books, and slides; 5. development of an Action Plan to institute educational programs and clinical practice changes; and 6. use of faculty, with outstanding communication skills, extensive clinical experi-

6 Vol. 10 No. 4 May 1995 Cancer Pain Role Model Program 297 ence, and a personal commitment to improved pain management. Since inception, the Wisconsin Cancer Pain Initiative has worked to disseminate factual information about cancer pain assessment and treatment to health professionals, patients, the public, and state government. The Role Model Program has been WCPI's most intensive effort to improve education and change practice patterns. The availability of the NCI Cancer Pain Education Grant has allowed the RMP to be expanded beyond Wisconsin, thus helping to fulfill our role as a World Health Organization Cancer Pain Demonstration Project. We believe the RMP is a powerful educational program to help disseminate cancer pain information and improve clinical care. Acknowledgments The authors would like to thank the Role Model faculty: Virginia Bourne, RN, Cathy Rapp, RN, Kate Ford Roberts, RN, and William Rock, MD. Consultants for nursing education included Sandra Ward, PhD, and Judy Diekmann, EdD. Conference scheduling and data acquisition were coordinated by Shadow Bicknase, MSSW. Statistical support was provided by Pam Marcus of the University, of Wisconsin Clinical Cancer Center. The North Dakota RMP was coordinated by La Rae Palmer, RN, and John Harris, MD. Secretarial support was provided by Rita Gramza. Supported by a National Cancer Institute Cancer Pain Education Grant R25 CA R :q-6qlce$ 1. Dahl J, Joranson D, Engber D, et al. The cancer pain problem: Wisconsin's response: a report on the Wisconsin Cancer Pain Initiative. J Pain Symptom Manage 1988;3(suppl) : Weissrnan DE, Dahl JL, Beasley JW. The Cancer Pain Role Model Program of the Wisconsin Cancer Pain Initiative. J Pain Symptom Manage 1993;8: Guidelines on Cancer Pain Relief: an educational lecture (slide set). Obbens, EAMT (ed). WHO Cancer and Palliative Care Unit, Geneva, Switzerland. 4. Weissman DE, Gutman M, DahlJL. Physician cancer pain education: a report from the Wisconsin Cancer Pain Initiative. J Pain Symptom Manage 1991;6: Janjan N, Martin CG, Payne R, et al. Cancer pain management education for health care prm4ders in the Texas Cancer Pain Initiative role model prograin [abst]. J Cancer Education 1993;8(suppl): Janjan N, Martin CG, Payne R, et al. Durability, of education in cancer pain management principles with the role model program [Abst]. Proc Amer Society Clin Oncol 1994;13:444.