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Mapping of pain curricula across health professions programs at the University of Toronto

ABSTRACT Background There is a growing societal need for health professional competency in pain care. The University of Toronto Centre for the Study of Pain–Interfaculty Pain Curriculum (UTCSP-IPC) has been offered since 2002. Content and process have been updated annually. In addition, participating health professions programs have advanced their pain teaching. A curricular scan was needed to creatively and constructively advance the UTCSP-IPC. Aim The aim of this study was to map curricular pain content in participating health professions programs onto the UTCSP-IPC content as a first step to further curriculum design. Methods UTCSP-IPC committee members and faculty representatives from six health profession programs completed a 27-item online survey in this collaborative action study. Descriptive statistics were completed in Microsoft Excel. Results The UTCSP-IPC provided an average of 43.3% (range 32%–62%) of total pain content teaching hours to participating health professions students and a range of 8% to 100% of total opioid-related teaching hours. Curricular overlaps and gaps in pain content were identified and will be used to update and inform the iterative design of the UTCSP-IPC. Ninety-three percent of participating health professions faculty indicated that the interprofessional focus on pain care in the UTCSP-IPC was important. Conclusion This study highlighted the value of the UTCSP and areas of curricular refinement to ensure continued relevance in relationship to pain content within the six participating health professions programs. Mapping a coordinated approach between uniprofessional and interprofessional teaching will both meet the demands of professional competence and create greater applicability to future practice settings.


Introduction
Pain is the most common reason that individuals seek health care. 1,2 There is a growing societal need for health professional competency in pain care and the continued need to improve pain education for health professionals, [3][4][5][6][7][8] including the multidimensional nature of pain. 8 The complexity of pain care often requires a collaborative, interprofessional approach. 2,9 Rational, multimodal pain management remains an important focus in the current climate of concerns about increased prescription opioid usage and associated harms. [10][11][12] Well-designed pain curricula can improve pain knowledge. 13 Education guidelines for prelicensure pain education have advanced from the original International Association for the Study of Pain (IASP) core curriculum guide 14 to reflect the need for content on the multidimensional nature of pain. 2,8,15,16 In 2013, a competency-based pain management guide for prelicensure health care professionals was developed at an interprofessional consensus summit to help bridge the gap between the needs of individuals in pain and interprofessional health care professional teams. 2 Currently, there are few prelicensure interprofessional learning experiences, despite IASP recommendations within the pain assessment and measurement domain for this collaboration.
The University of Toronto Centre for the Study of Pain-Interfaculty Pain Curriculum (UTCSP-IPC), developed initially in 2002, was based on the IASP core and discipline specific curricula. 13 It has been offered annually to approximately 1000 students from seven health professions programs ( Table 1). The 20-h curriculum is focused on the multidimensional nature of acute and chronic pain and collaborative patientcentered pain care, providing sessions that include facilitated interprofessional small group, case-based discussions; multiprofessional and uniprofessional didactic and panel presentations; and two online modules. 13,17 The curriculum has been evaluated and updated annually based on results from student pre/ post knowledge questionnaires, content and process surveys, and recommendations from clinician-facilitators and UTCSP-IPC committee members. Annual qualitative feedback from faculty and students indicate that pain content within each of the participating health professions programs has also advanced over recent years. After 15 years, the UTCSP-IPC committee deemed that a scan of curricular environments was necessary to compare pain content taught in the UTCSP-IPC and participating health professions programs for refinement of curriculum to continue to provide students with a relevant, value-added interprofessional pain education. This study's aims were to (1) examine and map current pain content in each of the participating health profession programs; (2) compare the uniprofessional  content with the UTCSP-IPC content, within IASP  pain curriculum domains; and, finally, (3) formally evaluate faculty's confidential perceptions of UTCSP-IPC curricular content, process, and value of the UTCSP-IPC. Of broader interest is an understanding of how uniprofessional teaching on pain fits with an interprofessional pain curriculum to meet pain-related competency development.

Design
This study was designed as collaborative action research. 18,19 An online survey was constructed. 20,21 UTCSP-IPC committee members and health professions programs faculty were surveyed to explore the curricular environments of the UTCSP-IPC and the seven health professions programs that participate annually.

Participants
Individuals were invited to participate by email if they met inclusion criteria: University of Toronto health professions faculty members who teach or have knowledge of pain and/or opioid-related curricular content or who are members of the UTCSP-IPC committee were invited. "Primary participants" responsible for program curricula were invited from each of the health professions programs. These individuals were also identified as having knowledge of and experience with the UTCSP-IPC as past facilitators for small group sessions or UTCSP-IPC committee members, though this was not an inclusion criterion.

Materials
A survey of 27 quantitative questions was developed by co-investigators based on IASP Interprofessional Curriculum learning objectives and pain content domains: multidimensional nature of pain, pain assessment and measurement, management of pain, and clinical conditions. 15 The framework to categorize pain content used by the Johns Hopkins curricular development team was also referenced. 8,16 The Pain Curricular Mapping Survey was composed of four sections: (1) health professions curricula general information (program specific, required completion by primary participants only); (2) participant demographics; (3) course/module format and content; and (4) attitudes, opinions, and perceptions on pain and opioid curricular gaps and overlaps and the value of the UTCSP-IPC. Within the course/module format and content section, participants were asked to describe the context of pain content on the interprofessional continuum of increasingly complex knowledge and understanding of other professions (i.e., uniprofessional, multiprofessional, interprofessional). The attitudes, opinions, and perceptions section included one Likert-scale question, 21 one question with a dichotomous scale (yes/no or undecided), and a series of qualitative feedback questions that is summarized elsewhere (unpublished observation). Pain Curricular Mapping Survey questions were reviewed by co-investigators and piloted with the UTCSP-IPC evaluation subcommittee prior to administration. Minor changes in wording were made to questions based on feedback obtained. The survey was programmed in REDCap software, password protected, and administered online via an Internet link.

Procedures
This study was approved by the University of Toronto Health Sciences Research Ethics Board. Invitations were sent to key individuals responsible for curriculum in each faculty/department by email describing the study and seeking informed consent. Once signed informed consent forms were received, these individuals were designated as primary participants and, in collaboration with the investigators, determined how best to complete the survey on behalf of the UTCSP-IPC and their respective faculties/departments. Primary participants were encouraged to recruit secondary participants (i.e., course coordinators, instructors, lecturers, other faculty members) as needed to complete surveys and optimize data collection. Secondary participants also provided informed consent. The online survey link was provided to participants by email after signed informed consent forms were received by the research team. When the survey was completed by a group and facilitated by a study investigator, they accessed the survey link of the primary participant and a study investigator recorded responses and submitted this file. All survey responses were stored on a passwordprotected website that could only be accessed by the research team. Support from a study investigator to record responses was provided upon request to all survey respondents. When present, the investigator did not influence any responses. Professional ethics of the academic faculty involved in providing group feedback were relied upon. Individual and collective responses were agreed upon in terms of accuracy and completeness. Participants agreed to share their confidential opinions verbally and the investigator recorded responses. The consent form estimated the anticipated length of time as 1-2 h to complete the survey. Time required to complete the survey was dependent upon the number of courses that the respondent was providing responses for. Two scheduled reminder emails were sent to encourage survey response and completion. Data collection and analysis were completed between November 2015 and July 2016.

Analysis
Data were automatically collected online in REDCap and were downloaded to Microsoft Excel. Descriptive analyses were performed on quantitative data. Data were analyzed by health professions program and the UTCSP-IPC. Primary participants reviewed results from their respective programs and confirmed accuracy and completeness. Results were compared across health professions programs and to the UTCSP-IPC. the survey was completed as a group of faculty members responsible for teaching pain content or individually by a primary participant seeking input from colleagues. At least one respondent from each health professions program had experience as a UTCSP-IPC committee member and curriculum facilitator. All but one primary participant (Pharmacy) had experience as a UTCSP-IPC committee member and facilitator. Responses reflected curricula of the 2014-2015 academic year. The Faculty of Medicine did not participate because they were engaged in curricular revisions during the study period. Participants representing the UTCSP-IPC committee completed the survey as a group. See Table 1 for more details.

Pain-related content
Pain-related content was mapped within health professions program curricula, categorized according to IASP Interprofessional Curriculum domains, and compared to content within the UTCSP-IPC. Courses/modules with pain-related content were required by each of the six programs (Table 2). Programs varied as to when required courses with pain-related content are offered by year of program. Some programs (i.e., Nursing and Pharmacy) also offered elective courses/modules with pain-related content to senior students. The number of pain content hours mapped by year (Table 3) also was variable among programs. For example, Nursing and PA students received the majority (88% and 89%, respectively) of their pain-related content in year 1 of their 2-year program, whereas pain content hours for Dentistry and OS&OT are weighted heavier later in their programs (i.e., 69% of content in Dentistry is offered in year 3 or 4, 100% in OS&OT is offered in year 2). The PT program had equal distribution of pain-related content between both years of their 2year program. The Pharmacy program pain-related content hours were distributed over the first 3 years of their curriculum, with 50% offered in year 3. Teaching hours for Pharmacy and Nursing in Table 3 underestimate hours devoted to pain content because selective and elective courses are excluded.
All UTCSP-IPC learning objectives were mapped onto those of the IASP Interprofessional Curriculum and the degree to which these were reflected in the objectives of individual programs was examined (Table 4). To compare pain-related content in more detail, subtopics of each of the four IASP Interprofessional Curriculum domains were mapped within each health professions program and the UTCSP-IPC ( Table 5). Details of the mapping of   . Similar pain curricular domain subtopics were identified between the UTCSP-IPC and across programs, although consistency across programs was lacking as some were covered in only one program (Table 6). Opioid-related content was provided by Dentistry, Nursing, Pharmacy, and PA programs.

Time devoted to pain-related content
Including the 20 h of pain-related content provided by the UTCSP-IPC, pain-related content hours within the six health professions programs ranged from 32.25 h for OS&OT to 61.85 h for Pharmacy (Table 7). These hours included required and elective courses/modules. The UTCSP-IPC provided an average of 43.3% (range 32%-62%) of total pain-related content hours to health professions students. The UTCSP-IPC provided a range of 8% to 100% of opioid-related teaching to health professions students in the interprofessional context (Table 8). Opioid-related content represented 5% of total pain-related content within the UTCSP-IPC.

Teaching and learning
In the UTCSP-IPC, patient-centered pain care was the focus of the curriculum. Only Dentistry, Nursing, and Pharmacy reported having courses/modules in their Relate the basic science of acute and persistent pain to clinical interventions.
Describe the prevalence and impact of unrelieved pain on individuals, families, and societies.
Discuss inadequately managed pain assessment and management from an ethical, safety, social, and political perspective.
Describe the impact of ethical, legal, social, and political challenges on patients' pain assessment and management.
Discuss clinical assessment and measurement approaches and misbeliefs common to health care professionals.
Complete a comprehensive assessment of the multiple factors that contribute to the pain experience, including evaluation of pathological sources, possible underlying neurophysiological pain mechanisms, impairment, activity limitation, participation restriction, psychosocial factors.
Develop and discuss as part of an interprofessional student group the rationale for patient-focused pain assessment and management plans based on authentic patient cases (actual or scenarios).
Describe the role of the person in pain in the interprofessional team.  curricula where pain was the primary focus. All other painrelated content was embedded within other courses and modules (e.g., focused on special populations such as older adults, pediatric, mental health, substance use disorders, childbearing, women/families), clinical conditions (e.g., neurological injuries, oncology, musculoskeletal). The context of pain-related content within the interprofessional continuum across programs was examined. 22 Pain-related content was taught to students from all faculties and programs interprofessionally in the UTCSP-IPC. PT also provided pain-related content in an interprofessional context outside of the UTCSP-IPC. Nursing and OS&OT provided some pain-related content multiprofessionally, whereas in the Pharmacy and the PA programs, all pain-related content outside of the UTCSP-IPC was taught uniprofessionally.

Faculty perceptions
Health professions faculty were asked to rate the importance for health professions students to learn about pain in an interprofessional context on a five-point Likert scale from not very important (1) to very important (5). Almost all respondents (93%) believed this to be important or very important. Most health professions faculty (77%) perceived the UTCSP-IPC as a value-added learning experience for students. Two health professions faculty were undecided and one responded negatively;   related feedback expressed concerns about repetition of selected pain content (unpublished observation).

Discussion
Pain content was categorized within the IASP Interprofessional Curriculum domains and compared across six health professions curricula and with the UTCSP-IPC in this collaborative action study. Curricular areas of overlap in pain-related content were identified in each of the four IASP interprofessional domains among UTCSP-IPC and uniprofessional health professions programs. Some of these topics were quite broad-for example, terminology for describing pain, valid and reliable tools for measuring pain, goals of management approaches, quantitative and qualitative measures, pain in selected special populations (pediatrics)-but the depth of content provided in these areas remains unclear. Overlap of these topics was value-added, considering their breadth and importance as foundational content. Curricular gaps in domains of the IASP Interprofessional Curriculum were identified within the UTCSP-IPC; for example, physical examination, selected pharmacological and nonpharmacological strategies, and selected special populations (i.e., older adults, pregnancy). Variability exists; some uniprofessional programs provided selected content. For example, physical examination and pain in older adults were covered by six health professions programs; pain in pregnancy was only covered by Nursing, PA, and PT; and medical cannabis was only covered by Pharmacy. In contrast, the UTCSP-IPC was the only source of selected pain content for students from some programs; for example, epidemiology of acute and/or persistent pain and consequences of pain as a public health problem were not covered in the PA program outside of the UTCSP-IPC. Theories and science for understanding pain and factors influencing neurophysiology were not covered in the Pharmacy program. Similarly, the OS&OT program did not cover consequences of pain as a public health problem, theories and science for understanding pain, or factors influencing neurophysiology. Results of this study should prompt participating health professions programs to consider opportunities for review of their own pain curriculum, to ensure a good fit to prepare students for and complement the UTCSP-IPC.
Teaching hours devoted to pain content, when compared with the 2009 survey by Watt-Watson et al., indicate that there was a trend toward increased painrelated teaching hours in Dentistry and Pharmacy programs. 4 Total pain content teaching hours reported by Dentistry (36.75 h) and Pharmacy (41.85 h) in our study exceeded the highest end of the ranges from the survey in 2009 for these respective professions (24 and 33 h, respectively). It is possible that this is due to differences in designation of formal teaching hours by participants. Despite reports that pain content increased in uniprofessional health professions programs over time, UTCSP-IPC provided an average of 43.3% (range 32%-62%) of total pain content hours of six health professions programs. A need for increased competency in opioid management by health care professionals has been identified in the literature to help cope with what has been described as the current "opioid crisis." 23 Although not all professions are prescribers, each has a role to play related to opioids. The UTCSP-IPC provided a range of 8% to 100% of opioidrelated teaching hours as a novel 1-h interactive online module for the health professions programs surveyed. Results found that time spent on opioid-related content across health professions programs varied widely, likely due to the differing roles related to opioids in practice (e.g., prescribing, dispensing, administering, or monitoring). The UTCSP-IPC promotes a patient-centered focus and development of interprofessional care plans, balancing physical, psychological, and pharmacological strategies. Therefore, opioid-related content remained a small component (5%) of total pain-related teaching hours within the UTCSP-IPC. A critical finding was that pain was not taught interprofessionally within most of the participating health professions programs. The complexity of pain care demands that health care professionals are competent in a collaborative patientcentered, multidimensional approach. One of the learning objectives of the IASP Interprofessional Curriculum, "Describe multiprofessional and interprofessional strategies for the planning, intervention and monitoring of pain management outcomes," addresses this need. Results from our survey indicated that outside of the UTCSP-IPC, Nursing, OS&OT, and PA students would not meet this learning objective. The interprofessional approach of the UTCSP-IPC provided all participating programs with this value-added educational experience. Ultimately, when health professions faculty respondents were asked to rate the importance for students to learn about pain in an interprofessional context, 93% indicated that they believed that this was important/very important.
The findings of this study reinforced the value of the UTCSP-IPC and will be used for iterative design and formative feedback purposes to enhance pain content within future iterations. These findings also allowed for a better understanding of how uniprofessional teaching on pain management fits within an interprofessional pain curriculum to meet pain-related competencies. Topics identified as not being covered in the UTCSP-IPC and a majority of health professions programs-for example, pain in mental health and medical cannabisare planned as future topics for multiprofessional lectures in the next UTCSP-IPC. Given the logistic challenges of providing an effective and engaging curriculum for approximately 1000 interprofessional students and the changing needs of these students over time, exploration of novel methods for teaching and learning is required. Two online modules created in dynamic platforms, "Pain: Mechanisms and Manifestations" and "Opioids As a Component of Pain Management, an Interprofessional Responsibility," have been implemented in the last few years of the UTCSP-IPC. Further changes and updates to other aspects of the curriculum are planned, including an interactive online format to facilitate case discussion in small groups.
The authors acknowledge limitations of this study. The Faculty of Medicine was unable to participate in this survey and, as a large contributor of resources to the UTCSP-IPC as well as faculty and student participants, inclusion of their results is missed. Although primary responders were selected in this study for their broad perspective on pain teaching in each health professions program, it is possible that the reporting was summarized and not reflective of all details. There was a potential for bias in the selection of the primary participants. They have chosen leadership roles and have self-selected to be involved in the UTCSP-IPC because they are interested in and supportive of interprofessional pain education. Potential bias in faculty involved in the UTCSP-IPC during participation may be a limitation; however, it was mitigated by evidence that could be confirmed through course documents, if needed. Social desirability of responses may be a limitation in a study of this nature. Examination of pain content and learning during clinical rotations was beyond the scope of the study. There is variability across clinical placements and uniprofessional requirements, and between clinical educators. Performing content validity could have strengthened the survey instrument. Some survey questions may have lacked clarity in terminology-for example, exposure vs. skill -and could be interpreted differently across professions. Particular survey questions presented inherent challenges to the UTCSP-IPC committee; for example, concurrent selective sessions were not included as part of the survey response but provide valuable content in the UTCSP-IPC. One of the strengths of UTCSP-IPC is case-based small group learning with several different cases. Students cover content pertaining to their assigned case topics in greater depth, potentially leading to variations in learning.

Conclusion
In conclusion, the pain curricular mapping study compared the pain content of six health professions program curricula and the UTCSP-IPC to the IASP Interprofessional Curriculum. Based on the findings from this study, the UTCSP-IPC committee will focus refinement of the curriculum on addressing gaps and incorporating relevant issues for improvement to continue to provide students with a value-added interprofessional pain education experience. Future steps will involve advancement of assessment pertaining to pain competencies in uniprofessional program content. These results will be of interest to health profession programs teaching pain care and those interested in developing pain education in an interprofessional context.
With the need for enhanced pain education recognized among health profession programs, faculty members will need to consider both content and approaches to best meet recommended competencies. A coordinated approach between uniprofessional and interprofessional teaching will both meet the demands of the profession and create greater applicability to future practice settings. The complexity of pain care requires competencies in both profession-and team-based approaches.