Improving educational resources for people with back pain in Sheffield

The NICE guideline [NG59] for the assessment and management of low back pain and sciatica in over 16s recommends that “people are provided with advice and information tailored to their needs and capabilities, to help them self-manage their low back pain with or without sciatica, at all steps of the treatment pathway.”

This project aimed to achieve this recommendation by designing and developing educational resources that could be used by people with low back pain (LBP) accessing the Physioworks service in Sheffield.

The resources would:

• Be available throughout the health care journey
• Provide a consistent and believable explanation of back pain that reflects current scientific evidence
• Help patients make sense of their own back pain problem
• Guide patients in the creation of a personal action plan of self-management
• Aid physiotherapists in the promotion of thinking and behaviours that improve health outcomes for people with back pain
• Be something service users want and use
• Be something clinicians felt confident and capable of using
• Be implementable within the current health service and able to demonstrate added value
• Be flexible enough to take into account all individuals unique circumstances
• Be adaptable enough to be used in multiple contexts. (1:1 consultations, group interventions and online)

Physioworks is a community based NHS specialist musculoskeletal (MSK) therapy service in Sheffield. We are part of the Sheffield teaching hospitals MSK directorate and we receive 21000 GP referrals a year.

The starting point for this project was a request for information that could be sent to Physioworks back pain patients using the new Mypathway system.  Mypathway is an online patient communication system that Sheffield teaching hospitals is in the process of implementing across all of its services. It allows patients to book appointments online but can also be used for sending out and receiving other targeted information.

We reviewed the various resources of information currently being used within our trust and also by other trusts across the country. Although there were some good examples there was nothing that really met our specific needs. It also became apparent that information provision was not consistent within our service and the resources being used were often presented in ways that would not engage patients or lead to meaningful change. This was concerning because understanding the problem and being engaged in your treatment is very important in back pain management.

It was therefore decided that we would apply for a small grant and take a more comprehensive approach to improving back pain information provision in our service. The project team realised that to produce something that really worked the design and development process would have to involve all those concerned. We therefore used a creative co-production approach. Patients and therapists were brought together to share ownership of the project and be part of the creative design process.

Recruitment was initially a problem as indirect marketing approaches such as posters or flyers were ineffective. However, when staff and patients were approached directly by the project team and given adequate explanation of what was involved and what we were trying to do we rapidly recruited sufficient participants. Working directly with patients and staff has been one of the highlights of the project. Their insights and ideas have made a real difference to what has been produced and was vital to achieving our aims.

Health care is complex and research developed interventions often fail as they do not take into account context and person specific factors. In this project, the boundaries between knowledge producer and knowledge user were purposely blurred and utilised. Knowledge from multiple stakeholders was combined with research knowledge to create real world solutions. Getting diverse stakeholders to work together creatively and constructively is not easy.  Pre-existing accepted ways of doing things and ideas about who knows best may stifle creativity. Differing priorities and assumptions may lead to conflict. To overcome some of these difficulties our project used a creative co-production method and included an experienced health care design researcher in the team. Stakeholders took part in a series creative making activities. Making helped us explore, reflect and consider both our own and others experiences. This shared understanding was important in the early stages to build trust and mutual respect.  Our shared learning was then taken forward in a series of prototypes.  Through negotiation these prototypes were blended into something that embodied inclusion and shared ownership but still reflected the individual contributions.

The project was completed in 4 phases:

Phase 1-A literature review with 3 interconnecting strands

A systematic rapid review of current evidence for low back pain education, a review of currently available resources and a review of contemporary scientific literature concerning broadly accepted theories of belief and behavioural change

Phase 2-Creative coproduction workshops.

Two half day stakeholder workshops were held. In the first workshop, we came together as a group and explored the lived experience of back pain. In the second workshop, we took what we had collectively learned from workshop 1 to generate ideas that could be developed

Phase 3-Prototype development

The outputs of the workshops were synthesized with the knowledge from the literature. Taking into account what was achievable within the constraints of the health service ideas were iteratively developed with further feedback from stakeholders into tangible prototype resources that could be tested in the clinical setting

Phase 4-Creating Impact and planning for the future

It was important to the project team that the project lead to real changes within the health service. Impact strategy was considered from the outset and imbedded into the project plan.

The literature review demonstrated reasonable evidence for education but there was no clear consensus on the best way to provide it. A further review of educational and behavioural change research highlighted the importance of providing information in engaging ways that are specifically designed to bring about real change.

The outputs of the first workshop were analysed and four themes emerged that stakeholders all agreed on

• Consistent and effective communication is very important.
• Back pain can be difficult to explain and difficult to understand.
• Peer support can make a big difference to the recovery process.
• Early access to practical information helps people do the right thing

In the second workshop participants developed many different ideas of how to tackle these themes. By this stage they were really engaged with the creative process and the imaginative things they created really helped us understand how they would want solutions to work for them.

The ideas and themes from the workshops were mapped to opportunities within the existing service that could be developed. Through a further process of prototyping, feedback and refinement our talkback concept was developed.

Talkback is a series of thematically linked resources that are available throughout the patient journey.  Together they provide a believable, logically consistent explanation of back pain that makes sense and has utility. The resources use active learning strategies, easy to understand explanations and provides opportunities for people to relate the information to their own circumstances and create a personal action plan. They will be available to use in physiotherapy sessions, online and in our new education and peer support session. 

We held a test of this talkback session and used the prototype resources. The session was attended by project stakeholders, Physioworks patients and staff who would be running the sessions in the future. Feedback was collected throughout the session and confirmed that this was something that patients wanted to engage with a staff wanted to provide.

The resources are being put online through the Mypathway system and training is being put in place so that all staff can integrate the system into their current practice.

Further evaluation and development will continue throughout the implementation process.

Getting specific funding for the project allowed us the time and resources to work at producing a high quality solution that is noticeably different and better than what came before.

Patient involvement is a vital requirement of all health service research and innovation projects however doing this well takes significant effort. The creative co-production methods we used in this project have been developed by CLAHRC over the last few years. They helped us overcome common coproduction problems and were very effective and efficient at engaging people.

The design process of collective making, prototyping, feedback and refinement allowed us to create solutions that all stakeholders were proud to share ownership of.

There is an empowering quality to having your idea turned into a physical tangible thing. It demonstrates what you say has been listened to and acted on. The created object allows ideas to be externalised. They provide a focus for negotiation and conflict resolution that is more constructive and less personal.

Our experienced facilitators helped stakeholders surface and express important knowledge that they were unaware they possessed. This was very empowering for the patients and gave them the confidence to express influential ideas throughout the project.

Including representatives of the staff who will be using the resources day to day helped create something that worked for them and that they would champion through the implementation process.

Regular feedback to key decision makers and influencers helped keep the project on track for integration into every day practice.

The involvement of diverse stakeholders meant that we were always working towards a system based solution. This approach is well suited to dealing with the complexity of health problems.