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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Teaching behavioral pain management to healthcare professionals: a systematic review of research in training programs

JE MacLaren and LL Cohen.

Review published: 2005.

CRD summary

The authors concluded that pain management training programmes may improve the knowledge and attitudes of health care professionals and also patient care, but the evidence was limited and further research is required. The authors' cautious conclusions appear appropriate given the limitations of the included studies, but the poor reporting of review methods and results data make it difficult to assess the reliability of these conclusions.

Authors' objectives

To evaluate programmes that aim to teach health care professionals about behavioural pain management techniques.


PsycINFO and MEDLINE were searched using the reported search terms. The reference lists of relevant articles were also checked.

Study selection

Study designs of evaluations included in the review

Inclusion criteria were not specified in terms of the study design.

Specific interventions included in the review

Studies that evaluated programmes aimed at teaching behavioural pain management techniques, either alone or in combination with physical and pharmacological methods, were eligible for inclusion. The included studies differed with respect to the types of intervention, format of delivery, types of pain targeted and duration of the programme (range: 2 hours to 2 weeks). Where reported, the interventions included relaxation, breathing and mental imagery techniques and strategies to increase their use, conditioning theory, acquisition and extinction of behaviour, reinforcement and punishment, distraction, cognitive restructuring, music, reassurance, environmental manipulation, provision of information and emotional support, promotion of autonomy, biofeedback, hypnosis, and unspecified 'non-pharmacological' and 'psychological' interventions. Delivery formats, where specified, were lectures, workshops, seminars, skill practice, quizzes, homework, discussion and observation. Where reported, the types of pain targeted included procedural, post-operative, acute, chronic and cancer-related pain in children and adults.

Participants included in the review

Studies of current or future health care professionals were eligible for inclusion. Most of the primary studies included nurses; others included medical students, medical residents, various health care professionals and hospital staff.

Outcomes assessed in the review

Inclusion criteria were not specified in terms of the outcomes. The included studies most commonly assessed knowledge and attitudes; others assessed outcomes such as patient pain scores, patient satisfaction, application of knowledge, number and quality of psychosocial techniques used, documentation of pain, perception of pain management techniques, skill acquisition, administration of analgesia and comfort with behavioural techniques. The majority of the included studies only assessed outcomes using self-report; some studies used direct observation or indicators of patient care. Most studies used measures developed for the study.

How were decisions on the relevance of primary studies made?

The authors did not state how the papers were selected for the review, or how many reviewers performed the selection.

Assessment of study quality

Study validity was discussed with respect to description of the intervention, justification for components of the intervention, multiple component interventions, measures used to assess outcomes, the presence of control groups, adequacy of reporting of statistical tests, and reporting of follow-up. The authors did not state how the validity assessment was performed.

Data extraction

The authors did not state how the data were extracted for the review, or how many reviewers performed the data extraction.

Methods of synthesis

How were the studies combined?

The studies were grouped by type of intervention (teaching of behavioural techniques alone versus combinations of techniques) and participants (student, nurses, or mix of professionals), and combined in a narrative.

How were differences between studies investigated?

Differences between the studies were discussed with respect to study quality and characteristics of the participants and interventions.

Results of the review

Twelve studies were included in the review (n greater than 1,126; the sample size of two studies was not reported). Three of the studies were non-randomised controlled studies; the others appeared to be before-and-after studies.

The studies had methodological limitations: inadequate description of the content and format of the interventions; lack of a rationale for the intervention; the use of multicomponent interventions; outcomes measured using self-reports; outcome not adequately defined; lack of reporting of the psychometric properties of the assessment instruments; lack of a control group; lack of reporting of methods of treatment assignment when control groups were present; potential for practice effects; lack of reporting of statistical tests; lack of follow-up; lack of reporting attrition rates; use of a convenience sample rather than a randomly selected sample; few details of sample characteristics; and small sample size.

Behavioural training programmes.

Three studies evaluated behavioural training programmes. These reported positive outcomes for knowledge of general principles, attitudes towards disabled patients and more adaptive responses (one study), increased knowledge of and more comfortable with the use of behavioural interventions in children (one study), and attainment of a 'high level of skill' (one study).

Combinations of behavioural programmes and nonbehavioural programmes.

Two studies evaluated teaching programmes directed at students. One study reported that the intervention was associated with some positive changes in knowledge and attitudes about pain management, but no change in overall knowledge of frequency of pain problems or awareness of the clinical difficulty of treating patients with pain. The other study reported greater relief of self-reported patient pain after the intervention. Three studies evaluated interventions aimed at nurses and reported improvements in measures of knowledge and attitudes after the intervention.

One study reported that the intervention was associated with a significantly longer wait for first dose of analgesia and a significant reduction in the number of analgesic doses in children post surgery.

Three studies evaluated programmes aimed at a variety of health care professionals. Two studies reported positive effects of the programmes on attitudes and knowledge; one of these studies also reported increased use of pain documentation and increased use of non-pharmacological techniques. The third study reported no effect of the programme on participants' perceptions or planned use of the techniques, but participants did report that they viewed behavioural strategies more positively than before the programme.

Authors' conclusions

The results suggest that pain management training programmes may improve health care professionals' knowledge and attitudes and patient care. However, the evidence was limited by methodological problems in the included studies and further research is required.

CRD commentary

The review question was defined in terms of the participants and intervention; inclusion criteria for the study design and outcomes were not specified. Limiting the search to two databases plus reference lists might have resulted in the omission of other relevant studies. No specific attempts to minimise publication or language bias were reported. The methods used to select studies and extract the data were not described, so it is not known whether any efforts were made to reduce reviewer errors and bias. Aspects of study validity were discussed.

The narrative synthesis was appropriate given the diversity of the studies. However, the limited reporting of results data for individual studies meant it was not possible to confirm the stated outcomes. The authors' cautious conclusions appear appropriate in view of the limitations of the included, predominantly uncontrolled, studies, but lack of reporting of review methods and results data mean it is difficult to assess the reliability of these conclusions.

Implications of the review for practice and research

Practice: The authors did not state any implications for practice.

Research: The authors stated the need for more rigorously designed studies (such as randomised controlled trials) to determine the most practical and effective methods of delivering training programmes on behavioural techniques for pain management. Future studies should use empirically supported components of the interventions, adequately describe interventions, and assess patient outcomes and clinical behaviour in addition to knowledge and attitudes.

Bibliographic details

MacLaren J E, Cohen L L. Teaching behavioral pain management to healthcare professionals: a systematic review of research in training programs. Journal of Pain 2005; 6(8): 481-492. [PubMed: 16084462]

Indexing Status

Subject indexing assigned by NLM


Behavioral Medicine /standards /trends; Clinical Trials as Topic /standards /trends; Education, Medical, Continuing /standards /trends; Humans; Interdisciplinary Communication; Pain Clinics /standards /trends; Pain Management; Pain Measurement /standards /trends; Patient Care Team /standards /trends



Database entry date


Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 16084462


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