1. RUNNING HEAD: Qualitative Paper 1
Qualitative Research Analysis Paper
Misty McClelland
University of South Alabama
2. Qualitative Paper 2
Qualitative Research Analysis Paper
Chronic, nonmalignant pain is increasingly prevalent in society today, and can cause great
distress for the affected person. Exacerbation of chronic pain causes many patients to visit
emergency departments (ED) rather frequently for management of acute symptoms. The
International Association for the Study of Pain (IASP) describes this type of pain as persisting
beyond the normal time of healing. This multifaceted condition can be categorized into four
manifestations- disease, illness, suffrage, and pain behaviors. Chronic pain can negatively
impact the quality and longevity of life, activities of daily living, relationships for the sufferer
and their family. The primary objective of this paper is to critically appraise two different types
of qualitative research articles with respect to validity, end results, and applicability to the DNP
students’ selected phenomenon of interest (POI), in addition to discussing an action plan
formulated from findings of both quantitative and qualitative literature analyses.
Clinical Question Summary
The DNP students’ clinical question is as follows: In adult patients in the ED with chronic
non-cancer pain, what is the effect of prescribing non-opioid therapies, in comparison to
prescribing narcotics, on effective pain management and decreasing opioid dependence,
diversion and misuse? The advanced practice nurse (APN) student performed a literature search
for research studies that examined various perspectives of both patients and ED staff regarding
chronic pain management within the ED. This author selected two articles and reviewed each
article using a specific appraisal tool known as Critical Appraisal Skills Programme (CASP).
The reviewer analyzed a systematic review (SR) by Toye et al. (2013) concentrating on
patient experiences with chronic non-cancer related musculoskeletal (MSK) pain (see Appendix
3. Qualitative Paper 3
A for full article). Wilsey, Fishman, Ogden, Tsodikov, and Bartakis (2008) completed a survey
of various ED nurses and physicians, as well as chronic pain sufferers regarding their beliefs
about chronic pain management occurrences in the ED (see Appendix B for full article). The
clinical question is important to practice because a better understanding of chronic pain
syndromes may be helpful in helping patients move forward with their diagnoses as well as
reveal potential opportunities to intervene in the current opioid crisis.
CASP Discussion
Validity
To determine if the study and results were valid, the DNP student analyzed the studies with
respect to the extent to which the study really addressed its stated research question,
including the research design and its appropriateness to measure the topic. The reviewer first
addressed the SR, and determined that the results and study were valid using the corresponding
CASP tool (see Appendix C for completed tool). The SR used a meta-ethnography design, and
described the design as being a form of interpretational knowledge synthesis that aims to create
new conceptual understanding (Toye at al., 2013). This study design was effectively selected to
measure the topic because according to Polit and Beck (2017), a meta-ethnography is more than
just a listing of previous study results, it associates key subject matter and metaphors across the
studies, then reciprocally translates them into each other, yielding new insight and interpretation.
Secondly, the APN student examined the survey study using the appropriate CASP tool, (see
Appendix D for completed tool), and found that the results were valid. Wilsey at al. (2008)
sought to arbitrate if personal believes held by patients and medical staff affected management
and evaluation of chronic pain in the ED, and using the survey methodology was deemed
4. Qualitative Paper 4
appropriate. The survey was designed to recognize barriers to treating chronic pain in the acute
setting as perceived by the patients and providers in the ED (Wilsey et al., 2008).
Results
This author considered whether data was collected in a manner that adequately addressed the
research question, whether the data analysis was sufficiently rigorous, and if the findings were
clearly stated or discussed per the corresponding CASP tools. The SR authored by Toye et al.
(2013) reviewed and synthesized 77 papers, and 60 studies that provided adequate concept and
methodological descriptions. The meta-ethnography design is formulated to identify key
concepts, and compare them across studies. In the SR study, it was found that the key theme
between the evidence was an adversarial struggle with multiple levels (time, self, relationships,
healthcare, explanation of suffering, proving legitimacy, and moving forward) that all gave
patients the sense of guilt and the task of proving their innocence (Toye et al., 2013).
Regarding the survey study authored by Wilsey at al. (2008), the results were resolved to
portray that out of the fifteen total barriers to care identified, the only common barrier
acknowledged by ED providers and patients alike was that a low priority was assigned to chronic
pain patients. Several other barriers such as time limitations, addiction, tolerance, forgery,
diversion, symptom magnification, etc. were identified, but none were agreed upon by both
providers and patients. The data analysis rigor was sufficient due to the use of odds ratios using
antilogarithms, resultant values of 95% confidence intervals (CI), and expression of proportional
odds ratios for overall results (Wilsey et a., 2008).
Local Application
The SR and survey studies can be appropriately applied to the DNP students’ setting.
5. Qualitative Paper 5
The survey study was completed in the ED, the same setting as the DNP student’s POI and
current practice area. The SR study had the same patient population as the APN students’ POI,
patients experiencing chronic, non-cancer pain presenting to the ED for acute management. The
study designs allowed for generalizability and the results gave sufficient influence to guide this
authors practice. Toye et al. (2013) suggested that implications for practice provided theoretical
substructure to improve patient experience and strengthen the provider patient relationship to
become a collaborative partnership to permit and entrust self management.
Outcome Measures Summary
Outcomes are the changes, whether wanted or unwanted, that happen in a person or
population as a result of health care practices (Hall & Roussel, 2014). According to Mateo and
Foreman (2014), an outcome measure should define and assess whether the new policy or
program has indeed promoted the patient’s ability to self improve their health and or functional
status. In accordance with this description, the first outcome measure this author would consider
with a new chronic pain management process within the ED would be as follows: Has the
chronic pain patient been positively impacted as a result of this new program and has it
facilitated the patient’s ability to move forward with their pain as evidenced by redefining a
positive sense of self, recognizing limitations, communicating rather than hiding pain, regaining
a sense of independence and social interaction, empowerment to take control of their chronic
pain, etc. This outcome measurement is congruent with the domains of safety and is patient-
centered as outlined by the Institute of Medicine (IOM) Aims, and is qualitative in nature.
Another outcome measurement of great importance is cost containment or reduction. It is
said by Mateo and Foreman (2014) that a program that maintains or evens reduces cost to the
organization and patient is considered an effective program. Cost is a quantitative measurement.
6. Qualitative Paper 6
According to Hall and Roussel (2014) usage of quantified outcomes provides immense
reinforcement for the resultant of practice on patient care. This outcome measure meets the IOM
domain of efficiency, which is described as avoidance of waste, whether it be supplies, energy,
ideas, money or equipment. The APN student would work with financial management personnel
to consider factors such as supply and equipment costs, personnel time, hospitalizations, resource
allotment and utilization, length of stay (in the ED or inpatient), etc. to evaluate cost efficiency.
This can be a lengthy process, and requires multiple follow-ups and poses risks to programs with
resource limitations.
Lastly, a third outcome measure that this author would use is provider (MD and RN)
satisfaction. As described by Mateo and Foreman (2014), when staff is frustrated or unhappy
with a newly implemented quality improvement initiative program or policy, the less it will be
adhered to, leading to diminished quality of care delivered and received, decreased patient and
provider satisfaction, negatively impacted health statuses, and potential failure of the entire
program itself. It is an absolute must that satisfaction of the staff that implements the
intervention(s) and interacts with patients on a daily basis be addressed and held in high regard.
In reviewing the findings from both the quantitative and qualitative analyses, this author
understands that the clinical question at hand is highly multidimensional and requires a
tremendous amount of consideration regarding structure, design, implementation and evaluation
in respect to policy development and application. With the quantitative analysis, the reviewer
found that only two of the three studies could be applied to the setting, as the cohort study
actually raised more questions than it provided answers, yet it provided sufficient enough
evidence to perform more experiments to be potentially used in acute care settings. As discussed
previously in this paper, the qualitative analysis yielded positive results. The superiority of
7. Qualitative Paper 7
utilizing outcome as a quality measurement is that it emulates what was done for the patient, but
also how well it was done (Hall & Roussel, 2014).
Barriers to Moving Forward
In every setting barriers will be present. Readiness to change, stakeholders, policies,
organizational structure, budgets, cost, patient population and setting are common examples of
barriers faced when implementing a quality improvement initiative. According to Hall and
Roussel (2014), integration of a new evidence-based practice (EBP) guideline must take place in
an environment that is open to change, exhibiting collective respect and communication, and the
clinical question must be supported by involved parties for any hopes of achieving a successful
implementation. This author believes that her current ED exemplifies the environmental
standards previously mentioned. In order for the new practice program or policy to work, it
would need to be user friendly, easily added into the routines of practitioners during their
evaluations, assessments and disposition decision making criteria, as the ED is a fast paced and
ever evolving area that requires immense ability to adapt and overcome adversities quickly.
Conclusion
In conclusion, the DNP student critiqued two qualitative studies that were of different literary
structure, and attained a better understanding of differences between quantitative and qualitative
research. The research gathered from all analyses provided a significant knowledge
advancement within the APN student, in that it presented unique and extensive conceptual
synthesis regarding multiple dimensions of policies, guidelines, evidence, barriers, research
design, proper analytical evaluations, etc. This author has been able to fine tune her research
skills to better understand the process of EBP and QI guideline construction and integration.
8. Qualitative Paper 8
References
Hall, H. R., & Roussel, L.A. (2014). Evidence-based practice: An integrative approach to
research, administration, and practice (2nd
ed.). Burlington, MA: Jones & Bartlett. Joanna
Briggs Institute New JBI Levels of Evidence (2013).
Institute of Medicine (IOM). Crossing the quality chasm: A new health system for the 21st
century. Washington, D.C: National Academy of Press, 2001. Retrieved from:
https://www.ahrq.gov/professionals/quality-patient-
safety/talkingquality/create/sixdomains.html#_ftn1
International Association for the Study of Pain (ISAP). Classification of chronic pain.
Description of chronic pain syndromes and definition of pain terms. Pain
1986;(Suppl.3):S1—226.
Mateo, M., & Foremand, M. (2014). Research for advanced practice nurses: From evidence
to practice (2nd
ed.). New York, NY: Spring Publishing.
Polit, D. F., & Beck, C. T. (2017). Nursing research: Generating and assessing evidence for
nursing practice (10th
ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Toye, F., Seers, K., Allcock, N., Briggs, M., Carr, J., Barker, K. (2013). Patients’ experiences of
chronic non-malignant musculoskeletal pain: A qualitative systematic review. British
Journal of General Practice. 829-841. DOI: 10.3399/bjgp13X675412
9. Qualitative Paper 9
Wilsey, B., Fishman, S., Ogden, C., Tsodikov, A., Bertakis, K. (2008). Chronic pain
management in the emergency department: A survey of attitudes and beliefs. American
Academy of Pain Medicine, 9(8), 1073-1080. DOI: 10.1111/j.1526-4637.2007.00400.x
11. request from the authors. Contents list
of particular journals agreed by the team
were hand-searched for 2001–2011. The
list of journals is also available on request.
Reference lists were searched for further
potential studies. Titles, abstracts, or full
texts were screened to exclude articles that
did not meet the inclusion criteria.
The use of quality criteria for qualitative
research is mooted14,18–22
and it is known
that quality appraisal does not produce
consistent judgements.21
To be utilised
within a meta-ethnography, studies must
provide adequate description of their
concepts.14,17
It was also agreed that papers
should provide an adequate methodological
report. Checklists were used to provide
a focus for team discussion on quality. It
was not intended to use these checklists to
‘score’ papers for the purposes of inclusion
or exclusion. A full description of the
teams’ approach to appraisal for qualitative
synthesis has been published elsewhere.22
Three appraisal tools were used: Critical
Appraisal Skills Programme (CASP) for
appraising qualitative research;23
Qualitative
Assessment and Review Instrument (JBI-
QARI);24
and finally papers were categorised
as key papers (KP) (‘conceptually rich
and could potentially make an important
contribution to the synthesis’), satisfactory
papers (SAT), irrelevant papers, or fatally
flawed (FF) papers.21
The concepts fatally
FF, SAT, and KP have not been defined,
but are global judgements made by a
particular appraiser which comprise several
unspecified factors. Two team members
appraised all papers, and if they did not
reach an agreement the paper was sent to
two other team members for a decision.
The methods of meta-ethnography17
were
used to synthesise the data.14,25,26
Central
to meta-ethnography is identification of
key ideas or ‘concepts’, and comparison
of these concepts across studies.17
A full
copy of all papers was uploaded onto QSR
International’s NVivo 9 software to help
organise the qualitative analysis. NVivo 9
allows for collection, organisation, and
analysis of a large body of knowledge by
‘coding’ data under ‘nodes’. It also helps
to keep track of developing ideas and
theories via ‘memos’. Three members of
the team read each paper to identify and
describe the concepts in each paper. These
independent descriptions were compared
and combined descriptions of each concept
were constructed. The aim was not to reach
consensus but to develop ideas through
discussion. These concepts formed the
primary data for the meta-ethnography.
If team members agreed that there was
no clear concept articulated in the original
study, then it was labelled ‘untranslatable’.
In short, if the original study was more
descriptive with no clear ideas, there were
no ‘data’ to analyse. Concepts were then
collaboratively organised into categories
with shared meaning through constant
comparison,27
and a conceptual model was
developed.17
RESULTS
In total, 24 992 titles, 676 abstracts, and 321
full texts of potentially relevant studies were
screened (Figure 1). Of the 321 potential
studies, 228 were excluded that did not
meet the study aims. Details of reasons for
excluding studies are available from the
authors. Two team members appraised 93
papers. The ranges of agreement for CASP
and JBIQ rank were 52–75% and 29–82%
respectively. The team members agreed
that five studies were key,28–32
one team
membergradedafurtherfiveaskey,33–37
and
the other graded a further seven as key.38–44
Full details of the appraisal scoring are
also available from the authors. The team
members did not agree over 24 papers and
sent these to two other team members for
a decision. Sixteen studies were excluded
after quality appraisal,44–59
hence 77 papers
were included reporting 60 studies. These
studies explored the experiences of 1168
adults ranging from 18 to 91 years of age.
Forty-nine papers (37 studies) explored
chronic MSK pain.29–37,39,40,43,48,60–95
Twenty-
eight papers (23 studies) focused primarily
on fibromyalgia (FM).28,38,41,42,96–119
Studies
were included from a range of countries:
Iceland (1); Northern Ireland (1); Switzerland
(1); Finland (2); the Netherlands (2); New
Zealand (2); Australia (3); Canada (4);
Norway (8); the US (8); Sweden (19); and
the UK (26). Appendix 1 describes the study
characteristics.
How this fits in
Chronic musculoskeletal (MSK) pain
accounts for a large portion of the
workload in primary care. There is a
growing body of qualitative research
exploring patients’ experience of chronic
MSK pain, but no study that brings
together or synthesises this large body
of knowledge to make it accessible for
clinical practice. Chronic MSK pain is
experienced as an adversarial struggle on
multiple levels (self, time, relationships,
health care). The model in the present
study suggests possibilities for helping
patients to move forward with chronic pain.
British Journal of General Practice, December 2013 e830
12. e831 British Journal of General Practice, December 2013
Conceptual categories
The overriding theme emerging was an
adversarial struggle, giving a sense of
being guilty until proven innocent. Patients
struggled to with the following.
1. Affirm self. This category incorporates a
struggle to affirm my self: Firstly, my body
has become alienated from me, and has
become a malevolent it.33, 82
I no longer
am a body but have a body.120,121
Secondly,
although I struggle to prevent the erosion
of my old ‘real self’ and not ‘give in’ to
my painful body, I face the fact that I am
irreparably altered.94
Finally, loss of roles
that made me what I am has undermined
my self-worth, and I feel guilty because I
cannot meet other people’s expectations.
Fear of overburdening others, and the
desire to appear like my old self, encourage
me to hide pain. However, this can be a
double-edged sword because people do not
necessarily believe what they cannot see.
2. Reconstruct self in time (construction
of time altered — unpredictable now and
future). This category shows how the
construct of self now and in the future
is altered. The day-to-day unpredictability
of my pain creates an endless timeless
present where my life has become
dominated by caution and spontaneity is
lost. Plans, expectations, and dreams of
the future are irreparably altered and life
focuses inwards.
3. Construct an explanation for suffering.
This concept describes the struggle to
explain pain that does not fit an objective
biomedical category.122,124
Diagnosis
remains highly valued and is integral to a
sense of credibility.123–125
Disbelief by others
threatens my personal integrity.117
The
discrepancy between culturally accepted
explanations and personal experience
creates powerful emotions. I feel
worthless, afraid, agitated, ashamed, and
guilty. Overwhelming doubt permeates my
experience at work, my social life, health
care, and family.
4. Negotiate the healthcare system.
This category describes the struggle to
negotiate the healthcare system. I feel ‘like
a shuttlecock’ referred back and forth to
various health professionals. It describes
an ambivalent stance, although reticent
to engage in a system that is not meeting
my expectations, at the same time I am
compelled or ‘trapped in the system’. I
continue in health care in hope of a future
cure. I need to feel valued as a person
within the system. Paradoxically, although
I want my body problem to be diagnosed
and treated, I also need to be treated as
more than just a body. This is central to the
therapeutic relationship, not an adjunct.
5. Prove legitimacy. This category describes
an etiquette, or ‘right way’, of being in
pain to appear credible. It does not imply
that pain is not real. I struggle to find the
right balance between hiding and showing
pain. The pull to hide pain and to appear
‘normal’ is increased by my sense of shame
at having medically unexplained pain.31
Paradoxically, hiding pain can further
threaten my credibility. I strive to present a
picture of myself as a ‘good’ person who is
not to blame for my pain.
However despite this struggle, there was
a sense of moving forward.
6. Moving forward alongside my pain.
Despite the adversarial struggle, our model
describes six ways of moving forward
alongside pain:
a) Listening to and integrating my painful
body shows a developing relationship
of trust and cooperation with the body.
The alienated body becomes integrated
through listening to, and respecting it. I
am no longer at the mercy of the body but
a co-expert.
b) Redefining normal describes a way of
Additional records
Citation (n = 273),
Handsearch (n = 77)
Records identified
via Database searches
(n = 24992)
(AMED = 1431, Cinahl = 5566,
Embase = 6253, Medline = 7599,
Psychinfo = 3971, HMIC = 171)
Excluded on
title screening
(n = 23833)
Retrieved for
further screening
(n = 1159)
Duplicates removed
(on Endnote)
(n = 483)
Screened title,
abstract, keyword
(n = 676)
Excluded on abstract
(n = 355)
Full text screening
(n = 321)
Excluded on full text
(n = 228)
Quality appraised
(n = 93)
Excluded following
quality appraisal
(n = 16)
Total included
(n = 77)
Figure 1. Number of studies identified, screened,
excluded, and included.
13. British Journal of General Practice, December 2013 e832
Table 1. Conceptual categories and source studies with example of narrative from primary studies
Thematic sentence to describe
conceptual category (primary studies Example of narrative from primary study chosen to illustrate
Conceptual category supporting this category) conceptual category
1. Struggling to affirm My body is now against me (30, 32, 33, 40–42, 60, I mean ... a normal person isn’t aware of their legs because they just say
a sense of my self 61, 68, 72, 73, 83, 95–97, 99-104, 106, 107, 109, ‘right walk’, you know their brain tells them to walk and they walk,
112, 117, 118) whereas when you’re in pain you’re aware of them all the time (62).
The old me is my real self (28, 29, 31–33, 37– It’s like living with this [person] who follows you around all the time ...
39, 41, 68, 69, 76, 78, 83, 93-97, 99, 103, You’re cursed with him and he gets in the way, he embarrasses me, he’s
106, 107, 113, 117) unsociable and sometimes downright rude ... I know there is no
‘person’ ... but it’s not me, that’s not me (31).
I am becoming isolated from others (29, 31, I have two small children, and I don’t want them to say when they’re older,
32, 34, 35, 38, 41, 42, 48, 61, 62, 65, 69, 73, 76, 78, we couldn’t do this or that because my mum was sick. They’re entitled to
86, 91, 95, 96, 97-99, 101, 102, 104–107, better than that (42).
109, 112, 113, 117, 118)
2. Altered construction My days are unpredictable (28, 29, 32, One day you feel like doing something. Then, all of a sudden, bang! The
of time 41, 42, 60, 66, 83, 89, 97–99, 101, 103, 105, 107, illness is so fickle, so capricious (106).
110, 112)
My future will not be what I thought I worked all my life and now I can’t enjoy my life … it’s (the pain) taken over
(29, 32, 41, 69, 72, 78, 89, 92, 95, 96, 101, 108, ... this is my future (78).
111, 118)
3. Struggling to explain It doesn’t make sense there is no medical When I had a broken arm, it was wonderful, they all rushed towards me to
why I am suffering reason (28, 30, 32, 43, 69, 70, 77, 78, 86, 92, 96, help me in the supermarket and I didn’t feel a bit guilty because it was in a
99, 101, 103, 108, 111, 113–115, 117, 119 plaster and it was OK. But now you ... look perfectly alright and you do
feel a bit of a fool (91).
No one believes me because I have People think that you’re swinging the lead, because it’s not a visible thing,
nothing to show for it (29, 32, 35, 36, 42, so many people use it as an excuse ... whenever a person says they’ve got
43, 64, 73, 78, 85, 91, 92, 94, 96, 99, 101, a back problem it’s ‘yeah, yeah’. I remember at my sickness interview —
103, 104, 111, 113, 115, 117) you can see the disbelief in the manager’s eyes (89).
There must be some other reason I feel that, all these rigid things that you try and put in place to protect
(28, 29, 32, 34, 39, 70, 73, 89, 93, 94, 103 yourself, quite often are actually a problem that you have in your mind rather
108, 113, 115) than your back. So I think your mind and your back are quite closely linked (93).
4. Struggling to negotiate I can’t see the point of going to the doctor I just get passed [around] ... I don’t have any faith really, what I want to
the healthcare system again but I must (32, 35, 36, 38, 39, 40, find out is what is causing this pain all through my body and I seem to meet
42, 43, 66, 69, 78, 79, 80, 85, 87, 92, 101, 105, a blank wall (43).
101, 105, 111, 119)
I need someone to listen to me and You’re feeling like you are unimportant and insignificant, feeling as though
understand what pain has done to me you’re taking up their time, their time is more valuable than yours ... I
(38-40, 42, 43, 66, 67, 69, 80, 85, think quite often they don’t take into the equation that maybe you do
86, 87, 92, 99, 104, 111) understand ... and you have got a few brains (85).
5. Struggling to prove Should I hide or show my pain? Someone says to me: ‘Well you look so good, it is impossible to see that
that I am credible (28, 29, 31, 36, 39, 41, 42, 60, 62, 69, 70, 73, you are suffering’. Perhaps the reason is that the more I suffered, when
89, 94, 96, 99, 101, 102, 105, 111, 113, 114, 116) going somewhere, the more make-up I put on, so no-one would notice (69).
I need to show that I am not like I think there is an essential difference between my pain and theirs, but as long as
other people with pain I’ve a somewhat doubtful diagnosis, the only difference is that I complain more:
(32, 37, 38, 64, 86, 94, 114) I become the person who has pain because I need or want to have pain (37).
6. Moving forward with I now cooperate with my body and work Increase awareness and accept yourself as you are, just setting limits is
chronic pain with it (28, 35, 41, 63, 67, 68, 71, 72, 76, 85, 99, something I worked with a lot. It’s not the boundaries of the world around
100, 101, 103, 104, 106, 109, 112, 115, 116, 118) that matter, it’s my body and the signals from it that have to give me advice (100).
I am still me and can enjoy my life When I finally did accept the fact that, okay, I wasn’t going to be able to
(28, 35, 42, 61, 70, 71, 68, 69, 96, 99, 104, 107) work and that I was going to have to do things differently ... I shifted my
energies ... to the stuff that gives me pleasure (96).
There are other people like me that You know, it is so hard to have this illness ... but it kind of grew smaller
believe and value my experience when I noticed that others have it too and that I may talk about it ... earlier
(35, 67, 70, 80, 100, 103, 104, 114) when I had severe pains I just kind of shrank in to myself ... you were
finally allowed to talk about it aloud (114).
... continued
14. e833 British Journal of General Practice, December 2013
Table 1 continued. Conceptual categories and source studies with example of narrative from primary studies
Thematic sentence to describe
conceptual category (primary studies Example of narrative from primary study chosen to illustrate
Conceptual category supporting this category) conceptual category
6. Moving forward with I don’t have to hide my pain and can let Before when people asked how I felt, how it was, then I said okay, but now I
chronic pain (continued) people know my limitations dare to say more, straight out (100).
(35, 69, 100, 104, 112)
I realise that I have changed but don’t I came home with a diagnosis and [my brothers] said, ‘there is no cure,
need to continue searching for a medical deal with it.’ They say, ‘you either live with it or you sit at home and mope
answer (39, 41, 62, 75, 96, 99, 111, 115) about it. There is no cure, get on with your life.’ I’m like, ‘okay, guess I’ll
move on then (96).
I am confident to give things a go and You just keep experimenting. That’s all you do. You know, you hear of this,
make changes (67, 69, 75, 82, 85, 87, 96, you try that, this works, that doesn’t work. This person suggests this,
100, 104, 107, 113, 114, 117, 119) someone else suggests something else (87).
moving forward that no longer focuses
on losses but on reconstructing an
acceptable new self. It describes an
acceptance of change and a sense of
repairing existence; I have changed
but I am still me and can enjoy life.
This can be felt alongside grief for the
old ‘real self’. This concept supports
studies showing that ability to redefine
self, or psychological flexibility, might
help people move forward with pain and
reduce its impact.126,127
c) Being part of a community of others
describes a sense of sharing, being
valued and becoming credible. However,
despite the benefits of being part of group
of others with pain, there is a sense
of ambivalence; although I am like the
others,28,94,96,113,114
at the same time I am
not like them and need to be valued as an
individual.
d) Telling others about my pain describes
the release that comes with no longer
having to hide pain from others, and
the benefits of letting others know about
my limitations. I am learning to limit
demands from others and manage my
resources. There is a sense that I no
longerneedtogaintheapprovalofothers.
e) Realising that there is no cure for my
pain describes the liberation from the
ceaseless search for a cure which has
hitherto limited possibilities for moving
forward. There is a sense that recovery
is about becoming someone rather than
being what you once were.
f) Becoming an expert describes becoming
less reliant on a healthcare professional
to know and meet my needs. I am coming
to know my own body, and gain the
confidence to experiment and make my
own choices.
Table 1 describes these conceptual
categories and source studies with a
narrative exemplar of each category. Figure
2 shows the conceptual model drawn
from conceptual categories 1–5. Figure 3
shows the conceptual model drawn from
conceptual category 6 ‘moving forward
alongside pain’.
DISCUSSION
Summary
Thisresearchpresentsasignificantadvance
over previous studies in that it provides a
unique and extensive conceptual synthesis
of qualitative research exploring chronic
MSK pain using meta-ethnography. The
present model presents a line of argument
that highlights the adversarial experience of
peoplewithchronicMSKpain,butalsooffers
an understanding of how some aspects can
be surmounted. The innovation is to show
that struggle pervades multiple levels of
the person’s experience, sense of body
and self, biographical trajectory, reciprocal
relationships, and experience of healthcare
services. The struggle to keep hold of a
sense of self while feeling misunderstood
and not believed was described. Despite
this adversarial struggle, the present model
offers an understanding of how a person
with chronic MSK pain can move forward
alongside their pain. This adversarial
experience is central to the present model,
and more research exploring similarities
and differences between the experience of
MSK and other types of chronic pain (such
as cancer pain, headache, or visceral pain)
would help to understand the experience of
chronic pain.
Strengths and limitations
The findings of qualitative research are
an interpretation of data. This centrality of
15. British Journal of General Practice, December 2013 e834
Figure 2. Conceptual model: a constant adversarial
struggle.
Construction of time altered
Unpredictable now and future Moving
forward
alongside pain
(see Figure 3)
Alienated and
unrelenting body
New me is not
the ‘real me’
Integrated
body
Old me is the
‘real me’
Struggling
to find the
‘right’
balance’
(sick/well:
hide/show pain)
Isolated me
Connected me
Proving
I am a
good
person
Strategies to
gain
legitimacy
What is causing this
and what can I do?
Pain
non-legitimate
I don’t think
anyone believes
me
Struggling to
negotiate the
healthcare
system
No diagnosis
Fail test
Healthcare system
Healthcare system
I don’t feel valued
as a person
I am not just a body
Believe me
Be alongside me
Me in
pain
Struggle to
affirm self
interpretation is the strength of qualitative
research that aims at challenging and
developing ideas. The present model is
based on a rigorous collaborative process
over 2 years. The delay between final
search and publication is not a limitation
of this study. As qualitative syntheses do
not aim to summarise the entire body of
available knowledge, meta-ethnographers
do not advocate an exhaustive literature
search.14,17
Some argue that including too
many studies makes conceptual analysis
‘unwieldy’ or makes it difficult to maintain
insight or ‘sufficient familiarity’.14
There are very few meta-ethnographic
syntheses that include such a large
number of studies;14,26
some suggest that
meta-ethnography is more suited for
smaller syntheses.14
The present study
specifically focused on the experience of
MSK pain, which might mean that papers
were excluded in which the study sample
included chronic pain from other sites (such
as visceral pain or headache). However,
the present model may be transferable to
other chronic pain conditions, and further
research comparing this model with other
experiences of pain would be useful.
Qualitative syntheses do not tend to use
checklists and cut-off scores to determine
study inclusion,14
and the present results
Integrating
my painful
body
Redefining
normal
Telling
people
about
my pain
Moving
forward
alongside
pain
Being part
of a
community
Realising
there is
no cure
Becoming
the expert
Figure 3. Conceptual model: moving forward
alongside pain.
16. e835 British Journal of General Practice, December 2013
support the finding that there is limited
agreement about what makes a good
qualitative study.21
This raises issues about
how to decide what to usefully include
in qualitative systematic reviews.22
The
authors remain convinced that checklists
will continue to produce inconsistent
judgements regarding quality. One of the
issues is that although both methodological
and conceptual rigour contribute to the
quality of research, checklists tend to
focus on methods rather than conceptual
insight.22
Comparisons with existing literature
This study’s findings resonate with other
qualitative syntheses. For example,
in rheumatoid arthritis, the need to
explain symptoms, the unpredictability
of symptoms, the disruption to self, fear
of the future, and the negative effects on
social participation.14
In low back pain, the
impact of pain on self and relationships
with family and health professionals.128
In
fibromyalgia,129
the unrelenting quality of
pain,isolation,lostlegitimacy,andthesearch
for an explanation. However, these studies
report very few successful strategies. The
present innovation is to present a new
and internationally relevant model that
highlights the all-pervading adversarial
experience of people with chronic MSK
pain, and offers an understanding of how
some aspects can be surmounted.
Implications for research and practice
The present model provides a theoretical
underpinning for improving the patient
experience and enhancing the relationship
betweenpatientandhealthcareprofessional
as a ‘collaborative partnership’ to empower
self-management. Discussion of this model
with patients has the potential to show them
that their pain is understood and believed,
forming a basis for considering ways of
moving forward. People with chronic MSK
pain do not feel believed and this has
clear implications for clinical practice and
education. The present study highlights the
need for educational strategies to improve
patients’ and clinicians’ experience of
care.130
The model suggests that central
to the relationship between patient and
practitioner is the recognition of the patient
as a person whose life has been deeply
changed. Affirming a person’s experience
and allowing an empathetic interpretation
of their story is not an adjunct, but
integral to care. The model also suggests
possibilities for helping patients to move
forward. Importantly, the line of argument
supports a model of health care where
the healthcare professional sits alongside
the person as a collaborative partner.
This collaborative focus is recognised as
important in commissioning appropriate
health care; ‘good commissioning places
patients at the heart of the process’.130
The
present study thus illustrates the potential
value of qualitative research in articulating
the patient voice for both clinical practice
and policy.
The model supports an embodied, non-
dualistic approach that may be useful for
other chronic conditions. It also suggests
possibilities that might help patients to
move forward alongside their pain, namely
an integrated relationship with the painful
body; redefining a positive sense of self
now and in the future; communicating,
rather than hiding, pain; knowing that I
am not the only one with chronic pain;
regaining a sense of reciprocity and social
participation; recognising the limitations of
the medical model; and being empowered
to experiment and change the way I do
things. Further research comparing the
experience of chronic MSK pain with other
chronic conditions might help to more
fully understand and improve patients’
experience of chronic illness. In addition
to this, studies were not identified that
specifically considered the impact of age or
gender on the experience of pain. Finally,
research to explore the impact of qualitative
researchonpractitionersandpolicymakers
would help to maximise its usefulness for
improving health care.
Funding
This project was funded by the National
Institute for Health Research Health
Services and Delivery Research (NIHR
HS&DR) Programme (09/2001/09). Visit the
HS&DR website for more information. The
views and opinions expressed therein are
those of the authors and do not necessarily
reflect those of the HS&DR programme,
NIHR, NHS or the Department of Health.
Ethical approval
No ethics review was required for this
study.
Provenance
Freely submitted; externally peer reviewed.
Competing interests
The authors have declared no competing
interests.
Acknowledgements
We thank the authors of the primary
qualitative studies included and the
patients who told their stories. The full
report of the study from which this paper
is drawn is available online at http://www.
journalslibrary.nihr.ac.uk/hsdr/volume-1/
issue-12
Discuss this article
Contribute and read comments about
this article on the Discussion Forum:
http://www.rcgp.org.uk/bjgp-discuss
17. British Journal of General Practice, December 2013 e836
REFERENCES
1. Price C, Ellis B, Taylor A, Group motPSS. Putting pain on the agenda: the report
of the first English pain summit. http://www.painsummit.org.uk (accessed 22
September 2013).
2. Croft P, Peat G, van-der-Windt D. Primary care research and musculoskeletal
medicine. Prim Health Care Res Dev 2010; 11: 4–16.
3. Breivika H, Collettb B, Ventafriddac V, et al. Survey of chronic pain in Europe:
Prevalence, impact on daily life, and treatment. Eur J Pain 2006; 10(4): 287–
333.
4. Elliott AM, Smith BH, Penny KI, et al. The epidemiology of chronic pain in the
community Lancet 1999; 354: 1248–1252.
5. König HH, Bernert S, Angermeyer MC, et al. Comparison of population health
status in six European countries: results of a representative survey using the
EQ-5D questionnaire. Medical Care 2009; 47: 255–261.
6. Croft P, Blyth FM, Windt Dvd, eds. Chronic pain as a topic for epidemiology and
public health. In: Chronic pain epidemiology from aetiology to public health.
Oxford: Oxford University Press, 2010: 1–8.
7. Covinsky KE, Lindquist K, Dunlop DD, Yelin E. Pain, functional limitations, and
aging. J Am Geriatr Soc 2009; 57: 1556‑1561.
8. Smith B, Elliott A, Chambers W, et al. The impact of chronic pain in the
community. Fam Pract 2001; 18: 292–299.
9. McBeth J, Jones K. Epidemiology of chronic musculoskeletal pain. Best Pract
Res Clin Rheumatol 2007; 21(3): 403–425.
10. Britten N, Campbell R, Pope C, et al. Using meta ethnography to synthesise
qualitative research: a worked example. J Health Serv Res Policy 2002; 7(4):
209–215.
11. Campbell R, Pound P, Pope C, et al. Evaluating meta-ethnography: a synthesis
of qualitative research on lay experience of diabetes and diabetes care. Soc Sci
Med 2003; 56: 671–684.
12. Malpass A, Shaw A, Sharp D, et al. ‘Medication career’ or ‘Moral career’? The
two sides of managing anti-dperessants: A meta-ethnography of patients
experience of antidepressants. Soc Sci Med 2009; 68: 154–168.
13. Sandelowski M, Barrosso J. Handbook for synthesising qualitative research.
New York, NY: Springer Publishing Company, 2007.
14. Campbell R, Pound P, Morgan M, et al. Evaluating meta-ethnography:
systematic analysis and synthesis of qualitative research. Health Technol
Assess 2011; 15(43): 1–164.
15. Dixon-Woods M, Agarwal S, Jones D, et al. Synthesising qualitative and
quantitative research evidence: a review of possible methods. J Health Serv
Res Policy 2005; 10(1): 45–53.
16. Barnett-Page E, Thomas J. Methods for synthesis of qualitative research: a
critical review. Economic and Social Research Council Research Methods.
National Centre for Research Methods Working Paper Series (01/09).
Southampton: National Centre for Research Methods, 2009
17. Noblit G, Hare R. Meta-ethnography: synthesising qualitative studies. Thousand
Oaks, CA: Sage Publications, 1988.
18. Eakin J, Mykhalovskiy E. Reframing the evaluation of qualitative health:
reflections on a review of appraisal guidelines in the health sciences. J Eval Clin
Pract 2003; 9(2): 187–194.
19. Barbour R. Checklists for improving rigour in qualitative research: a case of the
tail wagging the dog? BMJ 2001; 322: 1115–1117.
20. Centre for Reviews and Dissemination. Systematic Reviews — CRD’s guidance
for undertaking reviews in healthcare. York: York Publishing Services Limited,
2009.
21. Dixon-Woods M, Sutton A, Shaw R, et al. Appraising qualitative research for
inclusion in systematic reviews: a quantitative and qualitative comparison of
three methods. J Health Serv Res Policy 2007; 12(1): 42–47.
22. Toye F, Seers K, Allcock N, et al. ‘Trying to pin down jelly’ — exploring intuitive
processes in quality assessment for meta-ethnography. BMC Med Res
Methodol 2013; 13: 46.
23. CASP. Critical Appraisal Skills Programme: making sense of evidence about
clinical effectiveness: 10 questions to help you make sense of qualitative
research. http://www.casp-uk.net/wp-content/uploads/2011/11/CASP_
Qualitative_Appraisal_Checklist_14oct10pdf. 2010 (accessed 29 Oct 2013).
24. The Joanna Briggs Institute. The Joanna Briggs Institute Reviewers Manual.
http://joannabriggs.org/assets/docs/sumari/ReviewersManual-2011.pdf
(accessed 4 Nov 2013).
25. Hannes K, Macaitis K. A move to more systematic and transparent approaches
in qualitative evidence synthesis: update on a review of published papers. Qual
Res 2012; 12(4): 402–442.
26. Dixon-Woods M, Booth A, Sutton A. Synthesizing qualitative research: a review
of published reports. Qual Res 2007; 7: 375–422.
27. Charmaz K. Constructing grounded theory. Thousand Oaks, CA: Sage
Publications, 2006.
28. Mengshoel AM, Heggen K. Recovery from fibromyalgia — previous patients’
own experiences. Disabil Rehabil 2004; 26(1): 46–53.
29. Osborn M, Smith J. The personal experience of chronic benign lower back pain:
an interpretative phenomenological analysis. Br J Health Psychol 1998; 3: 65–83.
30. Rhodes LA, McPhillips-Tangum CA, Markham C, Klenk R. The power of the
visible: the meaning of diagnostic tests in chronic back pain. Soc Sci Med 1999;
48(9): 1189–1203.
31. Smith JA, Osborn M. Pain as an assault on the self: an interpretative
phenomenological analysis of the psychological impact of chronic benign low
back pain. Psychol Health 2007; 22(5): 517–535.
32. Snelgrove S, Liossi C. An interpretative phenomenological analysis of living with
chronic low back pain. Br J Health Psychol 2009; 14(Pt 4): 735–749.
33. Osborn M, Smith JA. Living with a body separate from the self. The
experience of the body in chronic benign low back pain: an interpretative
phenomenological analysis. Scand J Caring Sci 2006; 20: 216–222.
34. Sanders C, Donovan J, Dieppe P. The significance and consequences of having
painful and disabled joints in older age: co-existing accounts of normal and
disrupted biographies. Sociol Health Illness 2002; 24(2): 227–254.
35. Werner A, Steihaug S, Malterud K. Encountering the continuing challenges for
women with chronic pain: recovery through recognition. Qual Health Res 2003;
13(4): 491–509.
36. Werner A, Malterud K. It is hard work behaving as a credible patient:
encounters between women with chronic pain and their doctors. Soc Sci Med
2003; 57(8): 1409–1419.
37. Werner A, Isaksen LW, Materud K. I am not the kind of woman who complains
of everything: illness stories on self and shame in women with chronic pain.
Soc Sci Med 2004; 59: 1035–1045.
38. de Vries H, Brouwer S, Groothoff JW, et al. Staying at work with chronic
nonspecific musculoskeletal pain: a qualitative study of workers’ experiences.
BMC Musculoskelet Disord 2011; 12: 126.
39. Harding G, Parsons S, Rahman A, Underwood M. ‘It struck me that they didn’t
understand pain’: the specialist pain clinic experience of patients with chronic
musculoskeletal pain. Arth Rheum 2005; 53(5): 691–696.
40. Osborn M, Smith A. The fearfulness of chronic pain and the centrality of the
therapeutic relationship in containing it: an interpretative phenomenological
analysis. Qual Res Psychol 2008; 5(4): 276–288.
41. Paulson M, Danielson E, Soderberg S. Struggling for a tolerable existence: the
meaning of men’s lived experiences of living with pain of fibromyalgia type. Qual
Health Res 2002; 12(2): 238–249.
42. Sturge-Jacobs M. The experience of living with fibromyalgia: confronting an
invisible disability. Res Theory Nurs Prac 2002; 16(1): 19–31.
43. Walker J, Holloway I, Sofaer B. In the system: the lived experience of chronic
back pain from the perspectives of those seeking help from pain clinics. Pain
1999; 80(3): 621–628.
44. Reid J, Ewan C, Lowy E. Pigrimage of pain: the illness experiences of women
with repetition strain injury and the search for credibility. Soc Sci Med 1991;
32(5): 601–612.
45. Busch H. Appraisal and coping processes among chronic low back pain
patients. Scand J Caring Sci 2005; 19(4): 396–402.
46. Chew CA, May CR. The benefits of back pain. Fam Pract 1997; 14(6): 461–465.
47. Cudney SA, Butler MR, Weinert C, Sullivan T. Ten rural women living with
fibromyalgia tell it like it is. Holistic Nurs Pract 2002; 16(3): 35–45.
48. De Souza LHL, Frank AO. Experiences of living with chronic back pain: the
physical disabilities. Disabil Rehabil 2007; 29(7): 587–596.
49. Liedberg GM, Burckhardt CS, Henriksson CM. Young women with fibromyalgia
in the United States and Sweden: Perceived difficulties during the first year
after diagnosis. Disabil Rehabil 2006; 28(19): 1177–1184.
50. Morone NE, Lynch CS, Greco CM, et al. ‘I felt like a new person’ the effects of
mindfulness meditation on older adults with chronic pain: qualitative narrative
analysis of diary entries. J Pain 2008; 9(9): 841–848.
51. Raak R, Wahren LK. Health experiences and employment status in subjects
18. e837 British Journal of General Practice, December 2013
with chronic back pain: a long-term perspective. Pain Manage Nurs 2006; 7(2):
64–70.
52. Schaefer KM. Struggling to maintain balance: a study of women living with
fibromyalgia. J Adv Nurs 1995; 21(1): 95–102.
53. Silva FC, Sampaio RF, Mancini MC, et al. A qualitative study of workers with
chronic pain in Brazil and its social consequences. Occup Ther Int 2011; 18(2):
85–95.
54. Sokunbi O, Cross V, Watt P, Moore A. Experiences of individuals with chronic
low back pain during and after their participation in a spinal stabilisation
exercise programme — a pilot qualitative study. Manual Ther 2010; 15(2):
179–185.
55. Tavafian SS, Gregory D, Montazeri A. The experience of low back pain in Iranian
women: a focus group study. Health Care Women Int 2008; 29(4): 339–348.
56. Wade BL, Shantall HM. The meaning of chronic pain: a phenomenological
analysis. S Afr J Physiother 2003; 59(1): 10–9.
57. May CR, Rose MJ, Johnstone FC. Dealing with doubt. How patients account for
non-specific chronic low back pain. J Psychosomatic Res 2000; 49(4): 223–225.
58. Holloway I, Sofaer B, Walker J. The transition from well person to ‘pain
afflicted’ patient: the career of people with chronic back pain. Illness Crisis
Loss 2000; 8(4): 373–387.
59. Schaefer KM. Health patterns of women with fibromyalgia. J Adv Nurs 1997;
26(3): 565–572.
60. Hunhammar C, Nilsson-Wikmar L, Lofgren M. Striving to master variable pain:
An interview study in primary care patients with non-specific long-term neck/
shoulder pain. J Rehabil Med 2009; 41(9): 768–74.
61. Bair MJ, Matthias MS, Nyland KA, et al. Barriers and facilitators to chronic
pain self-management: a qualitative study of primary care patients with
comorbid musculoskeletal pain and depression. Pain Med 2009; 10(7):
1280–1290.
62. Campbell C, Cramb G. ‘Nobody likes a back bore’–exploring lay perspectives of
chronic pain: revealing the hidden voices of nonservice users. Scand J Caring
Sci 2008; 22(3): 383–390.
63. Dragesund T, Råheim M. Norwegian psychomotor physiotherapy and patients
with chronic pain: Patients’ perspective on body awareness. Physiother Theory
Pract 2008; 24(4): 243–255.
64. Johansson E, Hamberg K, Lindgren G, Westman G. ‘I’ve been crying my way’
— Qualitative analysis of a group of female patients’ consultation experiences.
Fam Pract 1996; 13(6): 498–503.
65. Johansson EE, Hamberg K, Lindgren G, Westman G. ‘How could I even think
of a job?’ — Ambiguities in working life in a group of female patients with
undefined musculoskeletal pain. Scand J Primary Health Care 1997; 15(4):
169–174.
66. Patel S, Greasley K, Watson PJ. Barriers to rehabilitation and return to work for
unemployed chronic pain patients: a qualitative study. Eur J Pain 2007; 11(8):
831–840.
67. Steen E, Haugli L. From pain to self-awareness–a qualitative analysis of the
significance of group participation for persons with chronic musculoskeletal
pain. Patient Educ Couns 2001; 42(1): 35–46.
68. Lundberg M, Styf J, Bullington J. Experiences of moving with persistent pain–a
qualitative study from a patient perspective. Physiother Theory Pract 2007;
23(4): 199–209.
69. Skuladottir H, Halldorsdottir S. The quest for well-being: self-identified needs
of women in chronic pain. Scand J Caring Sci 2011; 25(1): 81–91.
70. Dickson GL, Kim JI. Reconstructing a meaning of pain: older Korean American
women’s experiences with the pain of osteoarthritis. Qual Health Res 2003;
13(5): 675–688.
71. Aegler B, Satink T. Performing occupations under pain: the experience of
persons with chronic pain. Scand J Occup Ther 2009; 16(1): 49–56.
72. Afrell M, Biguet G, Rudebeck CE. Living with a body in pain – between
acceptance and denial. Scand J Caring Sci 2007; 21(3): 291–296.
73. Johansson EE, Hamberg K, Westman G, Lindgren G. The meanings of pain: an
exploration of women’s descriptions of symptoms. Soc Sci Med 1999; 48(12):
1791–1802.
74. Strong J, Ashton R, Chant D, Cramond T. An investigation of the dimensions of
chronic low back pain: the patients’ perspectives. Br J Occup Ther 1994; 57(6):
204–209.
75. Strong J, Large RG. Coping with chronic low back pain: an idiographic
exploration through focus groups. Int J Psychiatry Med 1995; 25(4): 371–387.
76. Satink T, Winding K, Jonsson H. Daily Occupations With or Without Pain:
Dilemmas in Occupational Performance. OTJR: Occup Participation Health
2004; 24(4): 144–150.
77. Allegretti A, Borkan J, Reis S, Griffiths F. Paired interviews of shared
experiences around chronic low back pain: classic mismatch between patients
and their doctors. Fam Pract 2010; 27(6): 676–683.
78. Campbell C, Guy A. ‘Why can’t they do anything for a simple back problem?’
A qualitative examination of expectations for low back pain treatment and
outcome. J Health Psychol 2007; 12(4): 641–652.
79. Cook FM, Hassenkamp AM. Active rehabilitation for chronic low back pain: The
patients’ perspective. Physiotherapy (London) 2000; 86(2): 61–68.
80. Cooper K, Smith BH, Hancock E. Patients’ perceptions of self-management of
chronic low back pain: evidence for enhancing patient education and support.
Physiotherapy 2009; 95(1): 43–50.
81. Cooper K, Smith BH, Hancock E. Patient-centredness in physiotherapy from
the perspective of the chronic low back pain patient. Physiotherapy (London)
2008; 94(3): 244–52.
82. Crowe M, Whitehead L, Gagan MJ, et al. Listening to the body and talking to
myself — the impact of chronic lower back pain: a qualitative study. Int J Nurs
Studies 2010; 47(5): 586–592.
83. Crowe M, Whitehead L, Jo M, et al. Self-management and chronic low back
pain: a qualitative study. J Adv Nurs 2010; 66(7): 1478–1486.
84. Liddle SD, Baxter GD, Gracey JH. Chronic low back pain: patients’ experiences,
opinions and expectations for clinical management. Disabil Rehabil 2007;
29(24): 1899–1909.
85. Slade SC, Molloy E, Keating JL. Stigma experienced by people with nonspecific
chronic low back pain: a qualitative study. Pain Med 2009; 10(1): 143–154.
86. Slade SC, Molloy E, Keating JL. ‘Listen to me, tell me’: a qualitative study of
partnership in care for people with non-specific chronic low back pain. Clin
Rehabil 2009; 23(3): 270–280.
87. Teh CF, Karp JF, Kleinman A, et al. Older people’s experiences of patient-
centered treatment for chronic pain: a qualitative study. Pain Med 2009; 10(3):
521–530.
88. Coole C, Drummond A, Watson PJ, Radford K. What concerns workers
with low back pain? Findings of a qualitative study of patients referred for
rehabilitation. J Occup Rehabil 2010; 20(4): 472–480.
89. Coole C, Watson PJ, Drummond A. Low back pain patients’ experiences of
work modifications; a qualitative study. BMC Musculoskelet Disord 2010; 11:
277.
90. Coole C, Watson PJ, Drummond A. Staying at work with back pain: patients’
experiences of work-related help received from GPs and other clinicians. A
qualitative study. BMC Musculoskelet Disord 2010; 11: 190.
91. Holloway I, Sofaer-Bennett B, Walker J. The stigmatisation of people with
chronic back pain. Disabil Rehabil 2007; 29(18): 1456–1464.
92. Toye F, Barker K. Persistent non-specific low back pain and patients’
experience of general practice: a qualitative study. Prim Health Care Res Dev
2012; 13: 72–84.
93. Toye F, Barker K. ‘I can’t see any reason for stopping doing anything, but I might
have to do it differently’ — restoring hope to patients with persistent non-specific
low back pain — a qualitative study. Disabil Rehabil 2012; 34(11): 894–903.
94. Toye F, Barker K. ‘Could I be imagining this?’ — the dialectic struggles of
people with persistent unexplained back pain. Disabil Rehabil 2010; 32(21):
1722–1732.
95. Walker J, Sofaer B, Holloway I. The experience of chronic back pain: accounts
of loss in those seeking help from pain clinics. Eur J Pain 2006; 10(3): 199–207.
96. Lachapelle DL, Lavoie S, Boudreau A. The meaning and process of pain
acceptance. Perceptions of women living with arthritis and fibromyalgia. Pain
Res Manage 2008; 13(3): 201–210.
97. Arnold LM, Crofford LJ, Mease PJ, et al. Patient perspectives on the impact of
fibromyalgia. Patient Educ Couns 2008; 73(1): 114–120.
98. Cunningham MM, Jillings C. Individuals’ descriptions of living with fibromyalgia.
Clin Nurs Res 2006; 15(4): 258–273.
99. Gullacksen AC, Lidbeck J. The life adjustment process in chronic pain:
psychosocial assessment and clinical implications. Pain Res Manage 2004;
9(3): 145–153.
100. Gustafsson M, Ekholm J, Ohman A. From shame to respect: musculoskeletal
pain patients’ experience of a rehabilitation programme, a qualitative study.
J Rehabil Med 2004; 36(3): 97–103.
19. British Journal of General Practice, December 2013 e838
101. Hallberg LR, Carlsson SG. Coping with fibromyalgia. A qualitative study. Scand
J Caring Sci 2000; 14(1): 29–36.
102. Hallberg LR, Carlsson SG. Psychosocial vulnerability and maintaining forces
related to fibromyalgia: in-depth interviews with twenty-two female patients.
Scand J Caring Sci 1998; 12(2): 95–104.
103. Hellstrom O, Bullington J, Karlsson G, et al. A phenomenological study of
fibromyalgia. Patient perspectives. Scand J Prim Health Care 1999; 17(1):
11–16.
104. Kelley P, Clifford P. Coping with chronic pain: assessing narrative approaches.
Soc Work 1997; 42(3): 266–277.
105. Lempp HK, Hatch SL, Carville SF, Choy EH. Patients’ experiences of living with
and receiving treatment for fibromyalgia syndrome: a qualitative study. BMC
Musculoskelet Disord 2009; 10: 124.
106. Liedberg GM, Henriksson CM. Factors of importance for work disability in
women with fibromyalgia: an interview study. Arth Rheum 2002; 47(3): 266–
275.
107. Lofgren M, Ekholm J, Ohman A. ‘A constant struggle’: successful strategies of
women in work despite fibromyalgia. Disabil Rehabil 2006; 28(7): 447–455.
108. Madden S, Sim J. Creating meaning in fibromyalgia syndrome. Soc Sci Med
2006; 63(11): 2962–2973.
109. Mannerkorpi K, Kroksmark T, Ekdahl C. How patients with fibromyalgia
experience their symptoms in everyday life. Physiother Res Int 1999; 4(2):
110–122.
110. Paulson M, Danielson E, Larsson K, Norberg A. Men’s descriptions of their
experience of nonmalignant pain of fibromyalgia type. Scand J Caring Sci 2001;
15(1): 54–59.
111. Paulson M, Norberg A, Danielson E. Men living with fibromyalgia-type pain:
experiences as patients in the Swedish health care system. J Adv Nurs 2002;
40(1): 87–95.
112. Raheim M, Haland W. Lived Experience of Chronic Pain and Fibromyalgia:
Women’s Stories From Daily Life. Qual Health Res 2006; 16(6): 741–761.
113. Raymond MC, Brown JB. Experience of fibromyalgia. Qualitative study. Can
Fam Phys 2000; 46: 1100–1106.
114. Sallinen M, Kukkurainen ML, Peltokallio L. Finally heard, believed and accepted
– Peer support in the narratives of women with fibromyalgia. Patient Educ
Couns 2011; 85(2): e126‑e130.
115. Sallinen M, Kukkurainen ML, Peltokallio L, Mikkelsson M. Women’s narratives
on experiences of work ability and functioning in fibromyalgia. Musculoskelet
Care 2010; 8(1): 18–26.
116. Schaefer KM. The Lived Experience of Fibromyalgia in African American
Women. Hol Nurs Pract 2005; 19(1): 17–25.
117. Soderberg S, Lundman B, Norberg A. Struggling for dignity: the meaning of
women’s experiences of living with fibromyalgia. Qual Health Res 1999; 9(5):
575–587.
118. Soderberg S, Lundman B. Transitions experienced by women with
fibromyalgia. Health Care Women Int 2001; 22(7): 617–631.
119. Undeland M, Malterud K. The fibromyalgia diagnosis: hardly helpful for the
patients? A qualitative focus group study. Scand J Primary Health Care 2007;
25(4): 250–255.
120. Leder D. The absent body. Chicago, IL: University of Chicago Press, 1990.
121. Wall P. Pain the science of suffering. London: Phoenix, 1999.
122. Engel G. The need for a new medical model: a challenge for biomedicine.
Science 1977; 196: 129–136.
123. Helman C. Culture health and illness. 5th edn. London: Hodder Arnold, 2007.
124. Lupton D. Medicine as culture. London: Sage Publications, 1994.
125. Annandale E. The sociology of health medicine. A critical introduction.
Cambridge: Polity Press, 1998.
126. McCracken L, Velleman S. Psychological flexibility in adults with chronic pain:
a study of acceptance, mindfulness, and values-based action in primary care.
Pain 2009; 148(1): 141–147.
127. Vowles KE, McCracken LM. Comparing the role of psychological flexibility
and traditional pain managment coping strategies in chronic pain treatment
outcomes. Behav Res Ther 2010; 48: 141–6.
128. Snelgrove S, Liossi C. Living with chronic low back pain: a metasynthesis of
qualitative research. Chronic Illness 2013; 14 June: http://chi.sagepub.com/
content/early/2013/04/10/1742395313476901 (accessed 4 Nov 2013).
129. Sim J, Madden S. Illness experience in fibromyalgia syndrome: A
metasynthesis of qualitative studies. Soc Sci Med 2008; 67(1): 57–67.
130. Royal College of General Practitioners. Principles of Commissioning
Summary. http://www.rcgp.org.uk/revalidation-and-cpd/~/
media/6C164D7796EA49A3AC25AD5383AEC653.ashx (accessed 4 Nov 2013).
20. e839 British Journal of General Practice, December 2013
Appendix
1.
Characteristics
of
included
studies
Age
range,
Source
of
Number
Author
and
year
years
Condition
participants
Country
included
Males
Data
collection
Methodology
b
Aegler
2009,
71
29–61
MSK
PMP
Switzerland
8
3
Semi-structured
interview
Thematic
analysis
Afrell
2007,
72
30–72
MSK
PC,
PMP,
pain
clinic
Sweden
20
7
Semi-structured
interview
Phenomenology
Allegretti
2010,
77
28–72
MSK
(CBP)
PC
US
23
12
Semi-structured
interview
Thematic
analysis
Arnold
2008,
97
31–72
FM
Rheumatology
US
48
0
FG
Grounded
theory
Bair
2009,
61
27–84
MSK
RCT
US
18
7
FG
Thematic
analysis
Campbell
2007,
78
34–78
MSK
(CBP)
PMP
UK
16
NK
FG
Thematic
analysis
Campbell
2008,
62
36–66
MSK
Non-service
users
UK
12
3
Interviews
Thematic
analysis
Cook
2000,
79
22–63
MSK
(CBP)
Back
pain
rehab
UK
7
3
Semi-structured
interview
Thematic
analysis
Coole
2010
a
,
90
22–58
MSK
(CBP)
Back
pain
rehab
UK
25
12
Semi-structured
interview
Thematic
analysis
Coole
2010
a
,
88
22–58
MSK
(CBP)
Back
pain
rehab
UK
25
12
Semi-structured
interview
Thematic
analysis
Coole
2010
a
,
89
22–58
MSK
(CBP)
Back
pain
rehab
UK
25
12
Semi-structured
interview
Thematic
analysis
Cooper
2008
a
,
81
18–65
MSK
(CBP)
PT
UK
25
5
Semi-structured
interview
Framework
analysis
Cooper
2009
a
,
80
18–65
MSK
(CBP)
PT
UK
25
5
Semi-structured
interview
Framework
analysis
Crowe
2010
a
,
83
25–80
MSK
(CBP)
Adverts
and
PT
New
Zealand
64
33
Semi-structured
interview
Thematic
analysis
Crowe
2010
a
,
82
25–80
MSK
(CBP)
Adverts
UK
64
33
Semi-structured
interview
Thematic
analysis
Cunningham
2006,
98
30–70
FM
University
Canada
8
1
Semi-structured
interview
Thematic
analysis
De
Souza
2011,
48
27–79
MSK
(CBP)
Rheumatology
UK
11
5
Unstructured
interview
Thematic
analysis
De
vries
2011,
38
31–60
FM
and
MSK
Adverts
and
FM
website
Netherlands
21
9
Semi-structured
interview
Thematic
analysis
Dickson
2003,
70
63–80
MSK
PC
US
7
0
Interviews
and
observation
Thematic
analysis
Dragesund
2008,
63
26–68
MSK
PT
Norway
13
5
FG
Thematic
analysis
Gullacksen
2004,
99
23–55
FM
and
MSK
PMP
Sweden
18
0
In-depth
interviews
Phenomenology
Gustaffson
2004,
100
23–59
FM
and
MSK
Pain
management
Sweden
18
0
Semi-structured
interview
Grounded
theory
Hallberg
1998
a
,
102
22–60
FM
Insurance
hospital
Sweden
22
0
Semi-structured
interview
Grounded
theory
Hallberg
2000
a
,
101
22–60
FM
Insurance
hospital
Sweden
22
0
Semi-structured
interview
Grounded
theory
Harding
2005,
39
29–71
MSK
PMP
UK
15
3
In-depth
interviews
Framework
analysis
Hellstrom
1999,
103
32–50
FM
FM
group
Sweden
10
1
In-depth
interviews
Phenomenology
Holloway
2007,
91
28–62
MSK
(CBP)
Pain
clinic
UK
18
12
Semi-structured
interview
IPA
Hunhammar
2009,
60
19–58
MSK
PC
Sweden
15
6
In-depth
interviews
Grounded
theory
Johansson
1996
a
,
64
21–60
MSK
PC
Sweden
20
0
Semi-structured
interview
Grounded
theory
Johansson
1997
a
,
65
21–60
MSK
PC
Sweden
20
0
Semi-structured
interview
Grounded
theory
Johansson
1999
a
,
73
21–60
MSK
PC
Sweden
20
0
Semi-structured
interview
Grounded
theory
Kelley
1997,
104
50
mean
FM
PMP
US
22
0
In-depth
interviews
Narrative
analysis
Lachapelle
2008,
96
23–75
FM
and
MSK
Adverts
Canada
45
0
Ethnography
and
FG
Ethnography
Lempp
2009,
105
20–69
FM
Rheumatology
UK
12
1
Semi-structured
interview
Thematic
analysis
Liddle
2007,
84
20–65
MSK
(CBP)
University
N
Ireland
18
4
FG
Thematic
analysis
...
continued
21. British Journal of General Practice, December 2013 e840
Appendix
1
continued.
Characteristics
of
included
studies
Age
range,
Source
of
Number
Author
and
year
years
Condition
participants
Country
included
Males
Data
collection
Methodology
b
Liedberg
2002,
106
26–64
FM
Questionnaire
survey
Sweden
39
0
In-depth
interviews
Thematic
analysis
Lofgren
2006,
107
30–63
FM
PMP
Sweden
12
0
Diaries,
FG,
interviews
Grounded
theory
Lundberg
2007,
68
30–64
MSK
PT
Sweden
10
5
In-depth
interviews
Phenomenology
Madden
2006,
108
25–55
FM
Hospital
databases
UK
17
1
Semi-structured
interview
Induction/abduction
Mannerkorpi
1999,
109
29–59
FM
FM
group
Sweden
11
0
In-depth
interviews
Phenomenology
Mengshoel
2004,
28
37–49
FM
PMP
Norway
5
0
Semi-structured
interview
Thematic
analysis
Osborn
1998,
29
25–55
MSK
(CBP)
Back
pain
rehab
UK
9
0
Semi-structured
interview
IPA
Osborn
2006
a
,
33
36–52
MSK
(CBP)
Pain
clinic
UK
6
4
Semi-structured
interview
IPA
Osborn
2008,
40
36–52
MSK
(CBP)
Pain
clinic
UK
10
5
Semi-structured
interview
IPA
Patel
2007,
66
29–62
MSK
(CBP)
Benefits
office
UK
38
15
Semi-structured
interview
Thematic
analysis
Paulson
2001
a
,
110
41–56
FM
Rheumatology
Sweden
14
14
Narrative
interview
Phenomenology
Paulson
2002
a
,
41
41–56
FM
Rheumatology
Sweden
14
14
Narrative
interview
Phenomenology
Paulson
2002
a
,
111
41–56
FM
Rheumatology
Sweden
14
14
Narrative
interview
Phenomenology
Raheim
2006,
112
34–51
FM
PC,
PT,
FM
group
Norway
12
0
Life
form
interviews
Phenomenology
Raymond
2000,
113
38–47
FM
FM
association
Canada
7
1
Semi-structured
interview
Thematic
analysis
Rhodes
1999,
30
25–65
MSK
(CBP)
Healthcare
plan
US
54
20
In-depth
interviews
Thematic
analysis
Sallinen
2010
a
,
115
34–65
FM
PMP
Finland
20
0
Narrative
interview
Thematic
analysis
Sallinen
2011
a
,
114
34–65
FM
PMP
Finland
20
0
Narrative
interview
Thematic
analysis
Sanders
2002,
34
51–91
MSK
Survey
UK
27
10
In-depth
interviews
Grounded
theory
Satink
2004,
76
42–70
MSK
(CBP)
PMP
Netherlands
7
3
Narrative
interview
Phenomenology
Schaefer
2005,
116
37–59
FM
Adverts
US
10
0
In-depth
interviews
Phenomenology
Skuladottir
2011,
69
35–55
MSK
Adverts
Iceland
5
0
In-depth
interviews
Grounded
theory
Slade
2009
a
,
86
26–64
MSK
(CBP)
Adverts
and
university
Australia
18
2
FG
Grounded
theory
Slade
2009
a
,
85
26–65
MSK
(CBP)
Adverts
and
university
Australia
18
2
FG
Grounded
theory
Smith
2007
a
,
31
36–52
MSK
(CBP)
Pain
clinic
UK
6
4
Semi-structured
interview
IPA
Snelgrove
2009,
32
39–66
MSK
(CBP)
Pain
clinic
UK
10
3
Semi-structured
interview
IPA
Soderberg
1999
a
,
117
35–50
FM
Rheumatology
Sweden
14
0
In-depth
interviews
Phenomenology
Soderberg
2001
a
,
118
35–60
FM
Rheumatology
Sweden
25
0
In-depth
interviews
Thematic
analysis
Steen
2001,
67
Adults
MSK
RCT
Norway
48
NK
Semi-structured
interview
Phenomenology
Strong
1994,
74
30–75
MSK
(CBP)
Adverts
Australia
7
3
FG
Thematic
analysis
Strong
1995,
75
30–75
MSK
(CBP)
Adverts
New
Zealand
15
4
FG
Thematic
analysis
Sturgejacobs
2002,
42
20–57
FM
PMP
Canada
9
0
Unstructured
interview
Phenomenology
Teh
2009,
87
63–86
MSK
(CBP)
Pain
clinic
US
15
5
In-depth
interviews
Grounded
theory
Toye
2010
a
,
94
29–67
MSK
(CBP)
PMP
UK
20
7
Semi-structured
interview
Grounded
theory
Toye
2012
a
,
92
29–67
MSK
(CBP)
PMP
UK
20
7
Semi-structured
interview
Grounded
theory
...
continued
22. e841 British Journal of General Practice, December 2013
Appendix
1
continued.
Characteristics
of
included
studies
Age
range,
Source
of
Number
Author
and
year
years
Condition
participants
Country
included
Males
Data
collection
Methodology
b
Toye
2012
a
,
93
29–67
MSK
(CBP)
PMP
UK
20
7
Semi-structured
interview
Grounded
theory
Undeland
2007,
119
42–67
FM
FM
group
Norway
11
0
FG
Thematic
analysis
Walker
1999
a
,
43
28–80
MSK
(CBP)
Pain
clinic
UK
20
12
In-depth
interviews
Phenomenology
Walker
2006
a
,
95
28–80
MSK
(CBP)
Pain
clinic
UK
20
12
In-depth
interviews
Phenomenology
Werner
2003
a
,
35
26–58
MSK
PC
and
PMP
Norway
10
0
In-depth
interviews
Phenomenology
Werner
2003,
36
31–53
MSK
PMP
Norway
6
0
In-depth
interviews
Phenomenology
Werner
2004
a
,
37
26–58
MSK
PC
and
PMP
Norway
10
0
In-depth
interviews
Phenomenology
a
More
than
one
paper
reporting
experience
of
same
group
of
people.
b
The
authors’
original
description
to
define
methodology
was
used.
CBP
=
chronic
back
pain.
FG
=
focus
group.
FM
=
fibromyalgia.
IPA
=
interpretative
phenomenological
analysis.
MSK
=
chronic
musculoskeletal
pain.
PC
=
primary
care.
PMP
=
pain
management
programme.
PT
=
physiotherapy.
RCT
=
randomised
controlled
trial.
24. limited access to medical records, and 24-hour
availability of the ED increase the potential for
abuse of prescription medications [5]. Patients
may visit multiple ED providers for specific pain-
related diagnoses (i.e., ureteral colic, toothache,
back pain, abdominal pain, or headache) and travel
to different hospitals, sometimes even employing
different aliases [6]. Clearly, the brief ED encoun-
ter is not conducive to accurately identifying and
responding to such aberrant behaviors. Thus, the
ED is likely to be a particularly challenging place
to attempt caring for patients with chronic pain. In
this exploratory survey, we sought to assess the
influence of several recognized barriers [7,8] from
other venues to treating chronic pain, as perceived
by ED patients and providers.
Methods
Setting
Approval to survey ED physicians and nurses was
obtained from the institutional review boards of
four institutions in Sacramento, California: the
University of California, Davis, Medical Center;
the Sacramento Veterans Administration Hospital
at Mather; Mercy San Juan Hospital, and Sutter
Memorial Hospital. Permission to survey patients
was also obtained from the University of Califor-
nia, Davis, Medical Center and the Sacramento
Veterans Administration Hospital at Mather.
Selection of Participants
Patients were at least 18 years of age and had
previously received opioid analgesics for chronic
pain, for which they were currently seeking refills.
Patients with a coexisting acute medical or surgical
condition were excluded. Patients consented to
participate in the current survey and, when pos-
sible, for another study not reported on here,
involving the relationship of prescription opioid
abuse and emotional factors, which required a
return visit on a separate day to complete clinical
interviews.
Physicians and nurses completed the survey
during off-duty hours, either immediately before
or after ED shifts. No identifying information was
obtained from providers, to preserve anonymity
and confidentiality; waivers of authorization and
consent were provided by the institutional re-
view boards at the respective hospitals for these
respondents.
Methods of Measurement
The survey consisted of 15 questions that solicited
the beliefs and experiences of patients and provid-
ers about barriers to chronic pain management in
the ED (Table 1). The questions were taken from
work on barriers to chronic pain in other health
care settings [7,8] and from issues considered to
be unique to the ED. Responses were indicated
on a 6-point ordinal scale: strong disagreement,
moderate disagreement, some disagreement,
some agreement, moderate agreement, and strong
agreement. Wording of the questions for the dif-
ferent groups surveyed (patients vs providers) was
altered slightly to project relevant orientation to
care and, when feasible, to enhance autobiogra-
phical recall [9] (Table 1).
Data Collection and Processing
Data were collected between September 2003 and
August 2005 from 103 patients (Table 2), 34 phy-
sicians, and 44 nurses (Table 3). Nineteen patients
who were asked to participate in the study
declined; only one provider refused to participate.
Patients with chronic pain who presented for
treatment to the ED at the UC Davis Medical
Center or the Sacramento Veterans Administra-
tion Urgicenter between 5 pm and 11 pm were
asked if they would participate in the study. In
addition, patients who came to the Urgent Care
facility of the UC Davis Family Practice Clinic
between 8 am and 4 pm seeking a same-day
appointment to obtain opioids for chronic pain
were also approached.
Patients were approached if their records
revealed a complaint associated with a chronically
painful condition (e.g., headache, neck pain,
extremity pain, abdominal pain, low back pain, or
diffuse body pain) of three or more months dura-
tion. To avoid interfering with patient care, the
consent and survey process took place during
periods only when medical personnel were not in
attendance. Surveys were completed in 10 to 15
minutes. Patients were reimbursed a modest sum
for their time and trouble.
Providers in the ED were contacted either by
phone or email and approached by research assis-
tants before or after an ED shift for survey
response. Physicians and nurses were not paid for
their participation in this study.
Primary Data Analysis
The six ordinal categories were given values of zero
(strong disagreement) to 6 (strong agreement), and
the mean values for each group were graphed for
each of the 15 barriers. The proportion of “strong,”
“moderate,” or “some” responses were combined
and expressed as a proportional odds ratio. The
Wilsey et al.
1074
25. Table 1 Questionnaire on beliefs and experiences about the treatment of chronic pain in emergency departments (EDs)
No. Questions for Providers (MDs and RNs) Questions for Patients
1 I do not believe the validity of a pain complaint in the
absence of physical findings or a lack of objective findings
on imaging studies, EMG, etc.
When the physician cannot find something wrong on exam
or by an X-ray, they tend not to believe you could be in
pain.
2 The treatment of chronic pain in the ED takes a back seat
to treatment of more pressing issues like trauma or
myocardial infarctions.
Physicians and nurses have more pressing issues than
chronic pain like seeing injured people or those with heart
attacks.
3 I do not have adequate time to assess and treat ED patients
complaining of chronic pain.
Physicians and nurses avoid spending enough time to talk
about your chronic pain.
4 I avoid administering opioids because patients will develop
physical dependence and go through withdrawal when
they abruptly halt the intake of the medicine.
I avoid taking pain medications because taking them will
lead to withdrawal symptoms if I have to stop them.
5 I find myself labeling chronic pain patients as “bad patients”
or “drug seekers.”
I believe that telling physicians and nurses about my pain
leads them to consider me to be a “bad patient” or a
“drug seeker.”
6 I tend to ignore patients when they become frequent flyers
and turn to the ED for help for their chronic pain.
I think that physicians and nurses tend to ignore my
complaints because I have to come to the emergency
room often.
7 I am reluctant to treat chronic pain with opioids because
these medications are not likely to work.
I think that opioid pain killers do not really work to control
pain.
8 I believe that a opioid contract automatically limits the use of
the emergency department by a chronic pain patient.
I understand that a chronic pain contract generally restricts
my use of the emergency department as a way to get
pain medications.
9 I think that most of the patients who come to the ED for
pain medications because they do not have a primary
care physician who will manage the pain complaint.
I have to go to the emergency room for pain killers because
I cannot find a primary care physician to treat this
problem.
10 I get annoyed easily by chronic pain patients. I am reluctant to talk with the physicians and nurses in the
emergency room because they get annoyed with me.
11 I believe that chronic pain patients who come to the ED are
addicted to their pain medications.
I think that I am addicted to pain medications.
12 I avoid administering opioids because patients will divert the
medication.
Other people have given me or tried to give me medications
for pain.
13 I think that most of the patients who come to the ED for
opioids are there because of lack of insurance or for
some other financial reason.
I find myself having to go to the emergency room for pain
killers because of issues with insurance.
14 I tend to ignore patients when they seem to be magnifying
their symptoms.
I sometimes have to alter my story in order to have a
physician pay attention like over emphasize my pain.
15 I think that writing prescriptions for schedule II or III
medications is a problem because the DEA number might
be forged on another prescription.
I have forged a pain prescription.
MD = physicians; RN = nurses; EMG = electromyography; DEA = Drug Enforcement Agency.
Table 2 Demographic characteristics of 103 patients
completing questionnaires on beliefs and experiences about
the treatment of chronic pain in emergency departments
Characteristic % (N = 103)
Sex
Men 57
Women 43
Self-reported ethnicity
Caucasian 46
African American 32
Asian 1
Hispanic 11
Other 10
Duration of chronic pain
3 to 6 months 6
6 months to 1 year 9
1 to 5 years 31
5+ years 54
Table 3 Demographic characteristics of 34 physicians
and 44 nurses completing questionnaires on beliefs
and experiences about the treatment of chronic pain in
emergency departments (EDs)
Physicians %
(N = 34)
Nurses %
(N = 44)
Sex
Men 76 66
Women 24 34
Self-reported ethnicity
Caucasian 88 68
African American 6 0
Asian 0 5
Hispanic 0 7
Other 6 20
Years as a health professional in the ED
0 to 1 0 9
1 to 5 23 34
5 to 10 15 16
10 to 20 53 27
20+ 9 14
Chronic Pain in Emergency Department Survey 1075
26. resultant values of the 95% confidence interval (CI)
for the physician vs patient and the nurse vs patient
responses were then converted to odds ratios using
the antilogarithms. An odds ratio greater than 1
implies that the physicians or nurses agreed more
with the construct than did the patients, whereas an
odds ratio less than 1 indicates that the patients
agreed more with the construct than the compari-
son provider group. A 95% CI for an odds ratio that
includes 1 is not statistically significant at the 0.05
level. The R statistical software program was used
for all analyses.
Results
Of the 15 barriers, only the low priority given to
treating chronic pain in the ED was endorsed as
present by all three groups; the mean values of
agreement were between 3 and 4, indicating some
to moderate agreement (Figure 1, Mean Agree-
ment Scores). The providers only other endorse-
ment was the belief that patients chose the ED
venue because of a lack of a primary care provider.
Patients, on the other hand, agreed with two other
barriers of pain management. Concordant with
the belief that pain was not a priority in the ED,
patient respondents held that lack of time to evalu-
ate a chronic pain complaint was evident in their
encounters with ED providers. In addition, they
believed that when the physician cannot find
something abnormal on examination or on labo-
ratory or radiographic evaluation, the provider
tends to disbelieve the patient’s pain complaint.
Through calculation of proportional-odds
ratios of the ordinal data, patients’ evaluations dif-
fered significantly from those of both physicians
and nurses on eight barriers and from either
nurses or physicians on an additional five barriers
(shaded boxes in Figure 2). Several of these dis-
crepancies reaffirmed the above description of dif-
ferences in mean scores. Providers were slightly
more in agreement with the notion that chronic
Figure 1 Mean Agreement Scores
for the presence or absence of barri-
ers to chronic pain management in
the ED. The patients ( ) are repre-
sented on the top row, physicians (䉬)
on the middle row, and nurses (䊊) on
the bottom row of each barrier cat-
egory. Items are ordered in declining
degree of agreement by patients.
ED = emergency department.
Barrier
Belief in
Pathology
1.3
Low Priority
of Chronic
Pain
3.1
Lack of Time
2.2
Fear of Opioid
Dependence
0.6
Stigmatization
1.2
1.8
“Frequent
Flyers”
2.1
Nonefficacy of
Opioids
1.5
Opioid
Contract
2.0
No Primary
Care Physician
3.1
Annoyance
Factor
2.0
Fear of
Addiction
2.0
Fear of
Diversion
0.6
Lack of
Insurance
2.7
Symptom
Magnification
2.3
Prescription
Counterfeiting 1.2
1.1
0
Strong
1
Moderate
2
Some
3
Some
4
Moderate
5
Strong
Disagree Agree
Disagree Agree
Mean
3.5
0.8
3.3
4.3
4.1
2.6
2.8
0.9
2.3
1.9
1.5
1.7
1.5
1.5
1.5
1.3
3.2
2.5
0.8
1.2
0.9
2.2
1.9
1.8
1.1
0.1
1.9
0.6
Wilsey et al.
1076
27. pain had a lower priority in the ED than other
medical and surgical conditions. Patients were
much more concerned about physical dependence
than providers. They also more strongly held the
belief that a chronic pain condition had to be
validated by findings on physical examination,
imaging, or laboratory results. Providers were
more in accord with the rationale for ED visits
being lack of a primary care provider and lack of
medical insurance. They were also more in accord
with annoyance and symptom magnification as
barriers.
Although both physicians and nurses thought
that forgery or prescription counterfeit was more
of a potential problem than patients, only physi-
cians consider diversion to be more of a poten-
tial barrier than patients. Contrariwise, nurses
believed more than patients that the latter might
have an addiction problem. Nurses were not as
convinced as patients that there was a lack of time
in the ED encounter. Nurses also held that the
opioid contract limited the ability of providers to
prescribe opioids in the ED more than patients (by
a small margin). Physicians disagreed more than
patients that they labeled patients in chronic pain
as “bad patients” or “drug seekers.”
Discussion
The only barrier acknowledged by both patients
and providers was that chronic pain has a low
priority in the ED. This finding is consistent with
the cultural milieu of acute care medicine, in
which loss of life or limb justifies the most urgent
attention. Unlike providers in the present study,
patients coming to an ED or urgicenter for man-
agement of their chronic pain recognized that lack
of time was a barrier to their care. Taken together,
these finding suggests that patients and providers
Figure 2 Odds ratio with a 95% Con-
fidence Interval (CI) for the physician
vs patient and the nurse vs patient
responses.* Shaded relationships are
significant at the 0.05 level. *The
proportion of strong, moderate, or
some responses were combined and
expressed as a cumulative propor-
tional odds ratio. The values were
converted into odds ratios with a 95%
CI for the physician vs patient and the
nurse vs patient responses. Results
exceeding 1 imply that the providers
agreed more with the statement than
patients while values less than 1 imply
that patients agreed more with the
construct.
Barrier
0.02----------0.12 Physician
Belief in
pathology 0.05---------0.18 Nurse
Physician
Low Priority of
Chronic Pain Nurse
Lack of Time
0.20------0.67 Nurse
0.20-------0.90 Physician
Fear of Opioid
Dependence 0.12--------------0.93 Nurse
0.18--------0.74 Physician
Fear of “bad
patient”
“Frequent
Flyers” 0.82 ---------2.72
Nonefficacy of
Opioids
0.82 ------------3.32
Opioid
Contract Nurse
Physician
No Primary
Care Physician Nurse
Physician
Annoyance
Factor Nurse
Fear of
Addiction 0.12-----------0.55 Nurse
Physician
Fear of
Diversion
Physician
Lack of
Insurance 6.05------------27.11 Nurse
Physician
Symptom
Magnification Nurse
6.05-------------44.7 Physician
Prescription
Counterfeit Nurse
0.02
95% CI for the odds ratio (log scale) Patients vs
0.05 0.14 0.37 1 2.7 7.4 20.1 55
Physician
Nurse
Physician
Nurse
Physician
Nurse
Physician
Physician
Nurse
1.65--------------7.39
1.22---------4.48
0.27------------1.11
0.33------------1.35
0.40---------1.65
0.50--------1.82
1.49---------5.47
3.32------------14.88
3.32-----------13.46
1.49-----------6.69
2.01---------7.39
0.30------------1.35
1.11-----------4.48
0.37--------------1.82
4.95------------24.53
4.06--------------20.09
6.69---------29.96
4.95---------------36.6
0.50-------1.65
Chronic Pain in Emergency Department Survey 1077
28. recognize that the ED or urgicenter is not the
optimal venue for the treatment of chronic pain.
The barrier to care perceived by patients with
the strongest conviction was their impression that
a complaint would lack validity if it could not
be objectified through examination or testing.
Medical problems lacking a clear cause are com-
mon among this population and may be a source of
exasperation for both providers and patients. Pro-
viders, on the other hand, were much less likely to
believe that pain required objective findings to
be considered genuine. Their tolerance for the
absence of a rationale for chronic pain might
follow from their familiarity with noncardiac chest
pain, as approximately 30% of patients presenting
with angina-like chest pain have negative coronary
angiograms [10]. The different viewpoints on the
need for objective findings supports the potential
benefit of reassurance for patients regarding the
inexplicable nature of many chronic pain syn-
dromes. ED providers were more inclined than
patients to believe that patients who come to the
ED for pain medications do so because they lack a
primary care physician. This finding is consistent
with observations of the ED becoming a provider
of primary care services for a multitude of chronic
illnesses [11–13]. Contrary to the perception that
uninsured patients account for the majority of the
increase in ED use in the last few years, most of
the increase is the result of use by insured patients,
especially those with private insurance, and the
magnitude of nonurgent care provided to the
uninsured is only slightly more than that provided
to privately insured patients [14,15]. Nonetheless,
nonurgent use of the ED is a substantial medical
and social problem. According to a recent Institute
of Medicine report [16], overcrowding in the EDs
of our nation has reached crisis proportions. An
increasing number of visits has occurred during a
period of declining numbers of facilities providing
care for these patients.
Perhaps the most surprising finding was the
relatively few hindrances to care endorsed by
patients and providers (Figure 1). Most notable,
opioid prescribing was not considered particularly
challenging. This is consistent with the broad
revisions in the beliefs surrounding prescribing
opioids for nonmalignant pain. For many years,
concerns regarding addiction, tolerance, and
physical dependence were considered major
hurdles to prescribing opioids [17]. However,
many of these reservations have not been substan-
tiated or have been favorably altered by new find-
ings. For instance, the linking of misuse of
prescription medications to patients with a history
of illicit substance abuse [18] has allowed the selec-
tion of individuals for opioid therapy at a low risk
for aberrant behaviors. Unfortunately, the abuse
and diversion of prescription opioids has dramati-
cally increased as a by-product of the expanding
accessibility of opioids [19]. The yearly incidence
of opioid prescription abuse in the United States
rose from slightly over 600,000 in 1990 to more
than 2.4 million in 2001 [20]. In addition, the
number of opioid analgesic poisoning deaths in
the United States almost doubled between 1999
and 2002, and by 2002 there were more deaths
associated with prescription opioids than with
either heroin or cocaine [21]. Undoubtedly, a brief
ED visit does not allow monitoring for opioid
misuse that can be observed over time in a conti-
nuity setting; there is the potential that ED over-
crowding has lessened any degree of monitoring
previously present and contributed to prescription
opioid abuse.
Our group conducted interviews of ED physi-
cians in an effort to understand the barriers to
chronic pain treatment in the ED [22]. Inter-
viewees believed that chronic pain had to be
treated in the ED because their care represented a
“court of last resort.” Often, 20–30 pills of a short-
acting Schedule III opioid (i.e., hydrocodone or
codeine) were provided to act as a bridge dose for
a few days until the patient could see their conti-
nuity physician. Little time was afforded to search
the medical record for evidence of previous ED
visits and most physicians did utilize a habitual
paitent file (i.e., a “frequent flyer list”). Nor did the
physicians interviewed have access to an electronic
prescription monitoring system that might have
informed them of the presence of multiple provid-
ers [23]. Given this degree of pharmacovigilance,
one might suspect that some patients “work the
system” and take advantage of the lack of ability to
detect “doctor shopping.”
More work is needed as it relates to the use of
the ED as a potential source of diverted opioid
prescriptions. Our survey demonstrated so few
barriers as to make it almost certain that social
desirability [24] played a significant role. Rather
than rely upon this methodology, ED patients
might be gathered in focus groups to learn the
extent of diversion of prescriptions from this
venue. In another study [25], club drug users,
street-based illicit drug users, methadone mainte-
nance patients, and HIV positive individuals who
abuse and/or divert drugs informed investigators
about experiences with prescription drug abuse.
Wilsey et al.
1078
