This study explored the experiences of rheumatology clinicians who had undertaken brief training in approaches to support self-management. The aims were to understand which aspects were helpful or unhelpful, and to identify the barriers and facilitators of applying the skills in clinical practice. Three overarching themes were identified: putting theory into practice; challenging professional identity; and enhanced practice.
In Theme 1, participants identified the need for training to be brief, have an applied focus, and balance theory with time to practice skills. One issue to emerge was a preference for condition-specific training, using examples from rheumatology. This mirrors the finding from the patient perspective, that condition-specific self-management interventions are more effective than generic ones; and suggests the value of shared experience in a learning environment . Participants thought that it would be beneficial if whole clinical teams could train together. This could generate a better understanding of self-management and increase the likelihood of wide adoption of these approaches . However, participants acknowledged the logistical challenges of teams attending training at the same time. A key element of this theme was the positive impact of clinical supervision to help embed skills in clinical practice, and develop more advanced techniques over time. Transfer of training theory proposes that higher levels of supervision increase the likelihood of the successful transfer of learning outcomes into changes in practice . This was found in research into brief cognitive-behavioural training for clinicians working in palliative care, where clinical supervision was necessary to maintain skills and build confidence .
Theme 2 captured how the professional identities, working cultures and models of care of the clinicians influenced learning and implementation of self-management approaches. Job involvement (the degree to which someone identifies with their professional role, actively participates in it, and considers it important to their self-worth) has been established as an important factor in implementing skills after training. High job involvement increases the motivation to transfer learning to the work setting . In this current study, participants’ reflection on their professional role and their decision to undertake training to enhance their clinical skills could indicate high job involvement. Although many participants found that training made a positive difference to their clinical practice, support for using self-management approaches was not always widespread among their peers and managers. This is a significant finding, as research has found that a supportive work environment increases the likelihood that skills and knowledge acquired in training will be maintained over time . It is possible that the levels of organisational and team support will change over time, as it has been recognised that clinicians need skills in self-management support to assist patients to better adhere to medical management and lifestyle behaviour change, if optimal health outcomes are to be achieved and costs are to be contained [32, 33]. This theme showed that supporting self-management can be viewed as the responsibility of the team. However, clinicians in different professions are likely to work at different levels, and the important issue becomes effective use of the range of skills within the team . A study with general practitioners found that training and facilitation of self-management had to be within the framework of addressing biomedical aspects of care, as this was deemed to be their primary role . Therefore, it would be helpful to acknowledge the perceived remits of different rheumatology clinicians during skills training, and explore how skills to facilitate self-management can be used in their particular context. Participants’ descriptions of the impact of the wider team highlight that individual clinicians, managers, and systems are all needed to bring about change and to incorporate theoretically-informed approaches to supporting self-management into existing ways of working .
In Theme 3, participants perceived their consultations to be enhanced as they moved away from didactic advice-giving; talking less and listening more. This shift from clinician-dominated dialogues to interactions in which patients were helped to take a more active role fits with the UK and US promotion of a patient-centred approach to healthcare provision [36–38]. The techniques participants used, such as formulation and reflection, reinforce existing theory about the ways in which using cognitive-behavioural approaches can support self-management [22, 39, 40]. The data also highlighted many other techniques that some clinicians thought useful. Some techniques, such as goal setting, tended to be used more by physiotherapists and occupational therapists, where the clinical context enabled follow up within a shorter time-frame. Participants identified the creation of written or diagrammatic records during consultation, which patients then take away with them, as particularly useful. This extends our understanding of the type of material that can be helpful , and how it can be done through the co-production of resources by the patient and clinician. After brief training, participants were facilitating self-management to varying degrees, such as supporting patients to identify problems from their own point of view, and learn problem-solving skills which could be applied to medical, social and emotional aspects of IA .
Due to the low numbers of clinicians who have done brief skills training, the sample size was small for some of the disciplines. In addition, the interviews were not based on a specific course and consequently there was variation in the length and the content of the various training which each of the participants undertook. However, the focus was on understanding participants’ views of their training and impact on practice, and overall there were many commonalities in experiences. The clinicians who participated in this study were more likely to be those who were pursuing supportive self-management approaches than those who had not found training relevant or useful. Not all participants were self-management ‘naïve’ when they underwent training, and in these cases, it was a challenge to unpick which skills had been acquired during the training, rather than developed through other means.
Improving clinicians’ skills to help patients manage their own conditions has been identified as a priority for service development [43, 44]. Training and implementation strategies are being developed for a number of long term conditions in primary care, for example with diabetes, chronic obstructive pulmonary disease, and irritable bowel syndrome [45, 46]. However, the treatment of IA remains largely within secondary care, which offers different challenges and opportunities. Therefore, based on this study, several recommendations for brief training are proposed: provision of outline and reading material beforehand; use of practice sessions in formulation, agenda setting and goal setting; and understanding boundaries and the support available to the clinician. They should be rheumatology specific, to set practice and theory in a relevant clinical setting.