Family Practice Vol. 19, No. 5, 511-515
© Oxford University Press 2002
Health Services Research |
The acceptability to primary care staff of a multidisciplinary training package on acute back pain guidelines
a Department of General Practice and Primary Care, Queen Mary University of London, Mile End, London E1 4NS,
b NHS Centre for Reviews and Dissemination and
c Department of Health Sciences, University of York, Heslington, York YO10 5DD and
d MRC General Practice Research Framework at the MRC Clinical Trials Unit, Wolfson Institute of Preventive Medicine, Charterhouse Square, London EC1M 6BQ, UK.
Dr Emma Harvey, Yorkshire Research Network (YReN), Centre for Research in Primary Care, Hallas Wing, Nuffield Institute, 71–75 Clarendon Road, Leeds LS2 9PL, UK; E-mail: e.l.harvey{at}leeds.ac.uk
Underwood M, O’Meara S, Harvey E and The UK BEAM Trial Team. The acceptability to primary care staff of a multidisciplinary training package on acute back pain guidelines. Family Practice 2002; 19: 511–515.
Received 27 July 2001; Revised 11 December 2001; Accepted 13 May 2002.
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Abstract |
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Background. Implementing clinical guidelines is more likely to be successful when the whole practice team is committed to the process. Practices from the MRC General Practice Research Framework in two distinct geographical centres in the UK (West Yorkshire and Greater Manchester) participated in the feasibility study for the UK Back pain Exercise And Manipulation (UK BEAM) trial. Practice teams were randomized to continue with their usual care for back pain patients, or to be trained in managing back pain in line with national guidelines. Those randomized to the intervention arm of the trial were invited to attend training, delivered by either a generic trainer or a back pain expert.
Objectives. Our aims were to assess the general acceptability of the training package to staff, to assess the acceptability of the multidisciplinary approach and to determine if a generic primary care educator could deliver the training as effectively as a clinical back pain expert.
Methods. All staff (clinical and non-clinical) from intervention practices were invited to attend multidisciplinary training sessions on the active management of back pain. Practice staff in West Yorkshire were trained by a generic primary care educator and practice staff in Greater Manchester were trained by a clinical back pain expert. The content of sessions was standardized for both trainers and included didactic and interactive components and small group, case study discussions. Detailed notes were taken of observations made of participants during sessions, and evaluation forms were completed by all those who attended.
Results. The majority of participants found the training useful and said that the session had lived up to their expectations. Most found that the session was well planned and that they had sufficient opportunity to participate in learning. The training package was well received by clinical staff, but was less acceptable to non-clinical staff. GPs dominated the small group work discussions. No differences were found between the preferences of participants for the two different trainers.
Conclusion. The training package was appropriate for clinical staff, but did not always meet the needs of non-clinical staff and may require modification for this group. A generic educator can successfully lead multidisciplinary educational sessions addressing clinical issues.
Keywords. Low back pain, primary health care, teaching, training.
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Introduction |
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Successful implementation of clinical guidelines is seen as more likely when an entire clinical team (or practice) is committed and trained to deliver the innovation in a coherent and consistent manner.1 As one part of the feasibility study for the UK Back pain Exercise And Manipulation (UK BEAM) trial,2 practice staff were trained to implement an active management approach to back pain.3–5
This training was assessed to determine:
- its acceptability to primary care staff;
- the acceptability of multidisciplinary teaching; and
- if there were differences between training provided by a local generic trainer and a clinical expert.
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Methods |
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Thirteen out of 26 participating Medical Research Council General Practice Research Framework6 practices within two localities were randomized to receive the active management training package.
All practice staff were invited to attend one of six training sessions during early 1998. A generic trainer, with minimal prior knowledge of back pain, provided training in one locality, and a clinical back pain expert in the other. Both used a similar training model and materials developed by an expert in guideline implementation. The generic trainer had a day’s training on the content of the package before starting.
Training
The objectives of the training sessions were to:
- inform primary care staff of UK national acute back pain guidelines;5
- provide advice on applying the guidelines; and
- instruct staff on the distribution of The Back Book7,8 and on reinforcing its key messages.
Each session lasted 3.5 hours starting with a light meal and an outline of the UK BEAM trial. The content of the guidelines was presented, then, following questions, participants split into small multidisciplinary groups to discuss prepared case studies. Participants subsequently regrouped for feedback and general discussion. The sessions closed with an explanation of the practical aspects of the trial. All staff received copies of The Back Book.7 Clinical staff also received copies of the guidelines’ evidence review.5
Data collection and analysis
Questionnaire..
Participants completed four-point Likert scales9 on relevance, planning, participation, resource use, areas of difficulty with the topic, encouragement to learn more and usefulness of the training. Free text comments were encouraged. Participants also indicated their preference for training by a generic trainer or a clinical back pain expert.
Responses were re-categorized as favourable or unfavourable. Responses from clinical staff (GPs and nurses) and non-clinical staff (practice managers, receptionists, secretaries and administrators) were compared. Data were analysed using the chi-squared test with a continuity correction using SPSS for Windows version 6.1.
Observation.. An external researcher who attended three training sessions, one at each training site, assessed the training using participant observation methods.10
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Results |
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Ninety-five practice staff attended the training sessions. Thirty-five (37%) were GPs; 21 (22%) were nurses; 34 (36%) were non-clinical staff; and five (5%) did not state their profession. Sixty-eight (72%) were trained by the generic trainer, and 27 (28%) by the clinical expert.
Questionnaire
Responses are summarized in Table 1
. A clear message emerged from free text comments that mixing clinical and non-clinical staff, particularly for the small group work, was not successful.
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Participant observation
Environment and participants.. The three sites were physically quite different, but this did not appear to affect the quality of the sessions. Between 13 and 30 participants attended each session. Trial team members were available to answer queries. Although there were some differences in style, both trainers used the same presentation materials and followed a similar timetable of activities.
Group work.. Group sizes ranged from five to eight individuals; all contained at least one GP. The trainer and study team members facilitated. The GPs appeared relaxed and tended to dominate, frequently discussing problems exclusively with each other or with the trainer. Nurses and non-clinical staff tended to look tense or display closed body language. Some groups had lively discussions, led by GPs. Others were more reliant on facilitators’ input to encourage discussion.
How the trainers encouraged participation.. The generic trainer made use of eye contact with the audience and used expressions that reflected her own knowledge of the subject. She referred to relevant research, the guidelines5 and to items she had learnt from the previous training sessions.
The expert trainer initially introduced himself and asked everyone else to do the same. He encouraged participation from people on the emptier side of the room. He adopted an expressive but relaxed presentation style and made use of anecdotes, movement, gesture, voice and facial expression. He referred to the relevant literature and to cases from his own practice, and exchanged views with other GPs. He acknowledged difficulties in the topic area and potential difficulties in accepting the active management approach.
The contribution of participants.. In the feedback sessions, most verbal interaction was between the trial team member and the GPs, with other group members generally remaining silent.
Acceptance of trainer and content of the session.. Both trainers appeared to be well accepted. The majority of participants showed attentiveness to the speaker during most parts of the sessions. Some participants expressed difficulties in advising patients to remain active or return to work early. Towards the end of one session, some people were looking tired and inattentive.
Acceptance between participants.. The same categories of staff tended to adopt similar body postures, and these differed from the other staff groups. For example, practice nurses tended to place their hand to the face or over the mouth, receptionists sat with arms folded, and GPs leaned forward in the chair.
The atmosphere.. The sessions generally were cordial, with nearly all of the verbal input from GPs. Other participants sometimes talked between themselves, or displayed various tense, non-verbal signs.
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Discussion |
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The training sessions appeared successful generally. The participants reported their appreciation of the case study work and the opportunity for learning. No important differences were found in the content of the training or the acceptability to participants between the two trainers, suggesting that training in guideline implementation is not dependent on the availability of a clinical expert. However, the support of a clinical representative to answer detailed clinical questions may be useful.
GPs tended to lead the sessions, in terms of input of questions and comments. In addition, they always acted as spokesperson for the small group feedback sessions. This indicates that GPs were more at ease with this format than other members of the practice team.
Practice nurses generally were limited in their level of participation. Non-clinical staff found the content of the session too technical, and some felt it to be of limited usefulness and relevance. Thus, the training failed to address their particular learning needs, potentially limiting the impact of the active management approach. Those devising and delivering training sessions for whole practice teams need to pay special attention to the different needs of non-clinical staff.
Postscript
For the main trial, the basic structure of the training sessions was retained. They were delivered by local generic trainers (with clinical knowledge). Separate scenarios and small group discussions were developed for non-clinical staff. They appeared to be well received.
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Acknowledgments |
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Thanks are due to Gene Feder for designing the training package and training the generic trainer; to Helen Moore and Martin Roland for delivering the training to practice staff; to the Department of Postgraduate Medical Education (General Practice), University of Leeds, for permission to adapt their PGEA assessment form for this study; and to all the staff who participated in the training sessions. A full list of contributors to the UK BEAM trial is available at: www.york.ac.uk/healthsciences/centres/trials/ukbeam/contrib.htm. The UK BEAM trial is funded by the Medical Research Council and NHS Research and Development.
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References |
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1 Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993; 342: 1317–1322.[Web of Science][Medline]
2 UK BEAM, UK Back pain, Exercise And Manipulation (UK BEAM) trial. The findings of a feasibility study and protocol for a national randomised trial of physical treatment. Controlled Clinical Trials 2002 (submitted).
3 Agency for Health Care Policy and Research (AHCPR). Acute Low Back Problems in Adults. Clinical Practice Guideline 14. Rockville (MD): US Department of Health and Human Services, 1994.
4 Clinical Standards Advisory Group (CSAG). Back Pain. London: HMSO, 1994.
5 Waddell G, Feder G, McIntosh A, Lewis M, Hutchinson A. Low Back Pain: Clinical Guidelines and Evidence Review. London: Royal College of General Practitioners, 1996.
7 The Back Book. London: The Stationery Office, 1996.
8 Burton AK, Waddell G, Burtt R, Blair S. Patient educational material in the management of low back pain in primary care. Hosp Bull Joint Dis 1996; 55: 138–141.
9 Wilkin D, Hallam L, Doggett A-M. Measures of Need and Outcome for Primary Health Care. Oxford: Oxford Medical Publications, 1992.
10 Spradley JP. Participant Observation. USA: Harcourt Brace Jovanovich College Publishers, 1980.
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