Table 1 Stakeholders’ barriers and needs to implement a chronic pain training program
COM-B | Â | Barriers of HCPs | Needs of HPCs |
|---|---|---|---|
Capability | Psychological capability (the capacity to engage in the necessary thought processes) | ||
Knowledge | - Lack of knowledge about pain and its characteristics [75,76,77],E - Lack of knowledge about an adequate assessment of pain [75] - Lack of knowledge about the biopsychosocial modelE - Lack of knowledge about the role, opportunities and barriers of other disciplinesE - Not familiar with research and literature [77] - Unfamiliar with adverse effects of narcotics [77] - HCPs have a biomedical perspective [78],E - Patients have a biomedical perspective, and managing it is difficult [79],E | - Focus training on basic knowledgeE - Increase knowledge of pain mechanisms[64] - Increase awareness of all factors to consider when treating a person with chronic painE - Provide knowledge not only on managing chronic pain but also on preventing patients from developing chronic painE - Increase knowledge and values of a patient-centred approachE - Increase awareness of social influences (e.g. Friends and family)E - Increase knowledge of the added value of interprofessional learning and workingE - Emphasise the importance of a follow-up in treatment programsE - Increase awareness that behaviour change techniques pairing is more effective [65] - Make caregivers aware of the burden of chronic painE - Provide awareness of insufficient undergraduate education regarding (chronic) painE | |
Skills: cognitive and interpersonal | - Difficulty applying psychosocial perspective [76, 78],E - Difficulty with assessing pain in people with communication difficulties [75] - Problems with interdisciplinary communication [75, 77],E - Lack of communication and listening skills with patientsE - Inability to treat without an established diagnosis [75] - Incompetence to give PSE to patients [75] - Difficulty in dealing with patients with psychological problems [79],E | - Make the training practicalE - Integrate effective resources for multimodal pain managementE - Practice skills to encourage patients’ self-managementE - Practice adapting treatments based on the individual [64] - Practice using metaphors [64] - Train communication strategies/skills [79],E - Enhance skills to include and assess social and family factorsE | |
Memory, Attention and Decision processes | - HCPs don’t apply a patient-centred approach [76, 77] - No assessment of patient behaviours and beliefs [76] - HCPs apply an inadequate assessment of pain and pain relief [75, 77] - Poor patient reporting in pain management [75] - HCPs work monodisciplinary, no or too few interdisciplinary consultations are made [76],E - Follow-up of between HCPs are highly variable [76] - Patients have different expectations [76, 79] - Quality of life is not a central objectiveE - Patients are not open to PSE [79, 80] - Patients have conflicting informationE - HCPs have unhelpful attitudes regarding pain [75] - HCPs do not known whether patients ask for pain relief or pain medication [77] | - Use case studies of common problem areas that are applicable to largely the whole group (or can be adapted to the specific caregiver)E - Promote interventions co-facilitated by HCPs with different skillsE - Promote interdisciplinary collaboration [81],E - Take into account therapeutic alternativesE - Practice developing interdisciplinary treatment plansE - Provide the message to take the patient seriously [64] - Encourage acceptance of chronic pain and the biopsychosocial approachE - Provide sufficient time to discuss the participant’s current situation during trainingE - HCPs think that a therapeutic alliance is important [79],E | |
Behavioural regulation | - Too little interest in overly theoretical informationE - Patients with fear of pain and consequences communicate less well [75] | - Implement the application and handling of "yellow flags" in the ambulatory settingE - Spend attention and time for interest in meeting other HCPs within the training (build a "social" identity)E | |
Physical capability (physical capacity to engage in the activity concerned) | |||
Skills: physical | |||
Opportunity | Social opportunity (the cultural milieu that dictates the way that we think about things) | ||
Social influence | - Lack of social support for patientsE - Lack of society's recognition of the problems of chronic painE - Cultural/religious differences [77] - Reluctance of patients to report pain [75] - Patients ashamed of symptoms [81] - Experiences and stories of family and friends [75] - Dominance of anaesthesiologists, giving preference to technical treatments [76] | - Create a status for pain managementE - Use "Local Opinion Leaders" to increase impact [67] - Let participants discuss chronic pain with colleagues to increase social support [81] | |
Physical opportunity (what the environment facilitates in terms of time, resources, location, physical barriers etc.) | |||
Environmental context and resources | - Lack of adequate training for the issue of 'chronic pain' in the curriculum of training and courses [76, 79],E - Previous received training was biomedically oriented [80] - Lack of finance/financial compensation (for a comprehensive approach to treating patients with chronic pain) on the Micro, Meso, and Macro level [75,76,77, 79],E - Not trained for sociofamilial initiatives [76],E - Lack of pain specialists and training of teams [76],E - Excessive workload [76],E - Inadequate or non-existent education materials [77],E - No accessibility for patients to receive certain treatments (nonavailability/long travel time) [81] - Uneven geographical distribution of interdisciplinary pain centres [62],E - Lack of time (Micro, Meso, Macro) [75, 77, 79],E - Lack of leadership within chronic pain treatment organisations [75, 77] - Available information on chronic pain does not support its implementation, nor does it identify its limitsE - Lack of time to start and complete chronic pain trainingE - Insufficient incentives to support HCPs in such treatments and training initiativesE - (Excessive) cost prevent patients from accessing therapy or cause them to stop treatment earlyE - Lack of training in dealing with sensitive topics [79] | - Create a network of therapists working in the field of chronic pain; Create peer review groupsE - Encourage the use of peer groups for patients with chronic painE - Develop patient pain educational materials like booklets and videos that are available for patients and HCPs as support for PSEE - Creating postgraduate PSE coursesE - Encouraging and creating more available training courses about painE - More hours of education are needed about pain in training coursesE - Make use of apps on smartphones to coach patients and evaluate treatment progressE - Use apps and videos to train caregivers and encourage self-management of caregivers to improve knowledge and skillsE | |
Motivation | Reflective motivation (involves self-conscious planning and evaluations) | ||
Social/Professional Role & Identity | - Lack of interest in interprofessional collaboration and to be in a dynamic of integrated careE - Negative attitudes about the role of other disciplines and patients with chronic painE - Lack of interest in (chronic) painE - Lack of motivation in patients to participate in long-term treatment pathwaysE - Lack of awareness of their actions [78, 80] - Different expectations from other HCPs or organisation [78] | - Empower HCPs that their management can include psychological and social factors [79],E - Use feedback(loop) and action goals to increase the effectiveness of the training program [68] | |
Beliefs about capabilities | - Lack of confidence in assessing psychosocial factors and in nonpharmaceutical treatments [78, 79, 81],E - Less motivated HCPs will be challenging to recruitE | - Encourage acceptance that chronic pain management can be ineffective to change pain intensity for some patients and should not be the major goalE - Build confidence for effective therapeutic educationE | |
Optimism | Â | - Provide training with a positive attitude towards pain [81] | |
Beliefs about consequences | - Lack of visibility of benefits when collaborating between HCPs in treating patientsE - Possible loss of trust in HCPs who have to perform theoretical educationE - Anaesthesiologists do not want to go along with guidelines because of increased workload, fear of licensing problems and reduced revenue [77] - Knowledge about the addictive effect of pain medication did not worry HCPs [77] | Â | |
Intentions | - Many HCPs prioritise the importance of other diseases above pain for treatment and training [75] - HCPs seem to lack interest in implementing accumulated knowledge and skillsE - Change in behaviour is complex, and resistance from HCPs is expected [80],E - Lack of willingness and empowerment of HCPs to start and continue a training programE - Not wanting to believe the patient's reported pain [77] | Â | |
Goals | - Lack of goal to encourage patient self-managementE - Patients have different values than HCPs E | - Focus your training on improving patients’ quality of life rather than pain managementE | |
Automatic motivation (involves wants and needs, desires, impulse and reflex responses) | |||
Reinforcement | Â | - Reward HCPs with credits for attending trainingE | |
Emotions | - Length of treatment is discouraging for the patient and frustrating for the counsellor [76] - Fear of mistakes when implementing new behaviour [77] - Uncertainty of HCPsE - Patients feel helpless, that they cannot be helped with their problemE - Many HCPs have little trust in the healthcare systemE | Â | |