The clinical implications of these findings are two-fold. First, PCPs' needs cannot be ignored when considering pain care. PCPs need support, both instrumental and emotional, as they care for patients with chronic pain. Second, improving PCPs' patient-centered communication skills-including demonstrating empathy and encouraging shared decision-making-holds promise for alleviating some of the strain and burden reported by providers, ultimately leading to improved patient care.

OBJECTIVE To identify barriers and facilitators to self-management of chronic musculoskeletal pain among patients with comorbid pain and depression. DESIGN A qualitative study using focus group methodology SETTING Veteran Affairs (VA) and University primary care clinics PATIENTS Recruited after participation in a clinical trial INTERVENTION The Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) trial tested an intervention of optimized anti-depressant therapy combined with a pain self-management program versus usual care for primary care patients with comorbid chronic pain and depression. OUTCOME MEASURES Thematic content analysis from focus group data was used to identify patient-perceived barriers and facilitators to self-management of chronic musculoskeletal pain. RESULTS Patients (N = 18) were 27 to 84 years old (M = 54.8), 61% women, 72% White, and 22% Black. Barriers to pain self-management included: 1) lack of support from friends and family; 2) limited resources (e.g. transportation, financial); 3) depression; 4) ineffectiveness of pain-relief strategies; 5) time constraints and other life priorities; 6) avoiding activity because of fear of pain exacerbation; 7) lack of tailoring strategies to meet personal needs; 8) not being able to maintain the use of strategies after study completion; 9) physical limitations; and 10) difficult patient-physician interactions. Facilitators to improve pain self-management included 1) encouragement from nurse care managers; 2) improving depression with treatment; 3) supportive family and friends; and 4) providing a menu of different self-management strategies to use. CONCLUSIONS Future research is needed to confirm these findings and to design interventions that capitalize on the facilitators identified while at the same time addressing the barriers to pain self-management.

Objective To understand the professional and psychosocial factors that influence physicians' antibiotic-prescribing habits in the inpatient setting. Design We conducted semi-structured interviews with 30 inpatient physicians. Interviews consisted of open-ended questions and flexible probes based on participants' responses. Interviews were audio recorded, transcribed, de-identified, and reviewed for accuracy and completeness. Data were analyzed using emergent thematic analysis. Setting Two teaching hospitals in Indianapolis, IN Participants Thirty inpatient physicians (10 physicians-in-training, 20 supervising staff) Results Participants recognized that antibiotics are over-used, and many admitted to prescribing antibiotics even when the clinical evidence of infection was uncertain. Over-prescription was largely driven by anxiety about missing an infection while potential adverse effects of antibiotics did not strongly influence decision-making. Participants did not routinely disclose potential adverse effects of antibiotics to inpatients. Physicians-in-training were strongly influenced by the antibiotic prescribing behavior of their supervising staff physicians. Participants sometimes questioned their colleagues' antibiotic-prescribing decisions but frequently avoided providing direct feedback or critique, citing obstacles of hierarchy, infrequent face-to-face encounters, and the awkwardness of these conversations. Conclusion There is a physician-based culture of prescribing antibiotics, which involves over-using antibiotics and not challenging colleagues' decisions. The potential adverse effects of antibiotics do not strongly influence decision-making in this sample. A better understanding of these factors could be leveraged in future efforts to improve antibiotic-prescribing in the inpatient setting.

In response to increases in harms associated with prescription opioids, opioid prescribing has come under greater scrutiny, leading many health care organizations and providers to consider or mandate opioid dose reductions (tapering) for patients with chronic pain. Communicating about tapering can be difficult, particularly for patients receiving long-term opioids who perceive benefits and are using their medications as prescribed. Because of the importance of effective patient–provider communication for pain management and recent health system-level initiatives and provider practices to taper opioids, this study used qualitative methods to understand communication processes related to opioid tapering, to identify best practices and opportunities for improvement. Up to 3 clinic visits per patient were audio-recorded, and individual interviews were conducted with patients and their providers. Four major themes emerged: 1) explaining—patients needed to understand individualized reasons for tapering, beyond general, population-level concerns such as addiction potential, 2) negotiating—patients needed to have input, even if it was simply the rate of tapering, 3) managing difficult conversations—when patients and providers did not reach a shared understanding, difficulties and misunderstandings arose, and 4) nonabandonment—patients needed to know that their providers would not abandon them throughout the tapering process.

BackgroundFacilitation is a key component for successful implementation in several implementation frameworks; however, there is a paucity of research specifying this component. As part of a stroke quality improvement intervention in the Veterans Health Administration (VHA), facilitation plus data feedback was compared to data feedback alone in 11 VA medical facilities. The objective of this study was to elucidate upon the facilitation components of the stroke quality improvement.MethodsWe conducted a secondary evaluation of external facilitation using semi-structured interviews. Five facilitators and two program directors were interviewed. Qualitative analysis was performed on transcribed interviews to gain an understanding of the role and activities of external facilitators during the on-site and telephone facilitation. Quantitative frequencies were calculated from the self-reported time spent in facilitation tasks by facilitators.ResultsThe external facilitators saw their role as empowering the clinical teams to take ownership of the process changes at the clinical sites to improve their performance quality. To fulfill this role, they reported engaging in a number of core tasks during telephone and on-site visits including: assessing the context in which the teams were currently operating, guiding the clinical teams through their planned changes and use of process improvement tools, identifying resources and making referrals, holding teams accountable for plan implementation with on-site visits, and providing support and encouragement to the teams. Time spent in facilitation activities changed across time from guiding change (early) to supporting efforts made by the clinical teams (later). Facilitation activity transitioned to more monitoring, problem solving, and intentional work to hand over the clinical improvement process to the site teams with the coach’s role being increasingly that of a more distant consultant. Overall, this study demonstrated that external facilitation is not an event but rather a process where relationships and responsibilities evolve over time.ConclusionsThis study shows that external facilitation involves core elements related to communication, relationship building, methods training, monitoring performance over time, and facilitating team-based problem solving. Importantly, this work demonstrates the fluid nature of external facilitation over time, as teams learn, grow, change, and experience changing contexts.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-015-0252-y) contains supplementary material, which is available to authorized users.

Objective Patient-centered communication has been linked to patient satisfaction, treatment adherence and outcomes. Shared decision making (SDM) has been advocated as an important and ethically essential aspect of patient-centered care, but SDM has received relatively little attention in mental health care, despite studies indicating that consumers want to be involved in decisions. This is particularly important in a recovery-oriented system, where consumers are active participants in their treatment and rehabilitation. Because medication management is a key component of recovery from severe mental illnesses, this study explores how consumers and providers make decisions in medication management consultations. Methods Four providers (3 psychiatrists, 1 nurse practitioner) and 40 consumers with severe mental illness (10 consumers per provider) were recruited from a community mental health center with a recovery-oriented focus. We directly observed 40 medication management appointments. Observations were audio recorded and transcribed. We used emergent thematic analysis to characterize decision making processes. Results Providers initiated most decisions, although they often invited consumers to participate in decision making. Decisions initiated by consumers elicited a greater degree of discussion and disagreement, but also frequently resulted in consumers’ preferences prevailing. Consultations generally exhibited more characteristics of person-centeredness than SDM. Conclusions and Implications for Practice While we observed a high degree of person-centeredness, SDM was not prevalent. Interventions helping consumers to take greater initiative when working with service providers may be helpful. For example, programs using tools such as peer instruction, internet-based software, and individual case-manager instruction all have shown promise for enhancing SDM in mental health treatment. Further research is needed to determine the degree of SDM in other settings (e.g., with case managers) and the impact of SDM on consumers’ recovery.

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Objective: Traditional perspectives on shared decision--making (SDM) focus attention on the point in a clinical encounter where discussion of a treatment decision begins. We argue that SDM is shaped not only by initiation of a treatment decision, but by the entire clinical encounter, and, even more broadly, by the nature of the patient--provider relationship.Method: The Four Habits Approach to Effective Clinical Communication, a validated and widely used framework for patient--provider communication, was used to understand how SDM is integrally tied to the entire clinical encounter, as well as to the broader patient--provider relationship.Results: The Four Habits consists of four categories of behaviors: 1) Invest in the beginning; 2) Elicit the patient's perspective; 3) Demonstrate empathy; and 4) Invest in the end. We argue that the behaviors included in all four of these categories work together to create and maintain an environment conducive to SDM.Conclusion: SDM cannot be understood in isolation, and future SDM research should reflect the influence that the broader communicative and relational contexts have on decisions.Practice Implications: SDM training might be more effective if training focused on the broader context of communication and relationships, such as those specified by the Four Habits framework.