A meta-ethnography of health-care professionals’ experience of treating adults with chronic non-malignant pain to improve the experience and quality of health care
Toye F., Seers K., Barker K.
<jats:sec id="abs1-1"> <jats:title>Background</jats:title> <jats:p>People with chronic pain do not always feel that they are being listened to or valued by health-care professionals (HCPs). We aimed to understand and improve this experience by finding out what HCPs feel about providing health care to people with chronic non-malignant pain. We did this by bringing together the published qualitative research.</jats:p> </jats:sec> <jats:sec id="abs1-2"> <jats:title>Objectives</jats:title> <jats:p>(1) To undertake a qualitative evidence synthesis (QES) to increase our understanding of what it is like for HCPs to provide health care to people with chronic non-malignant pain; (2) to make our findings easily available and accessible through a short film; and (3) to contribute to the development of methods for QESs.</jats:p> </jats:sec> <jats:sec id="abs1-3"> <jats:title>Design</jats:title> <jats:p>We used the methods of meta-ethnography, which involve identifying concepts and progressively abstracting these concepts into a line of argument.</jats:p> </jats:sec> <jats:sec id="abs1-4"> <jats:title>Data sources</jats:title> <jats:p>We searched five electronic bibliographic databases (MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and Allied and Complementary Medicine Database) from inception to November 2016. We included studies that explored HCPs’ experiences of providing health care to people with chronic non-malignant pain. We utilised the Grading of Recommendations Assessment, Development and Evaluation Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) framework to rate our confidence in the findings.</jats:p> </jats:sec> <jats:sec id="abs1-5"> <jats:title>Results</jats:title> <jats:p>We screened 954 abstracts and 184 full texts and included 77 studies reporting the experiences of > 1551 HCPs. We identified six themes: (1) a sceptical cultural lens and the siren song of diagnosis; (2) navigating juxtaposed models of medicine; (3) navigating the patient–clinician borderland; (4) the challenge of dual advocacy; (5) personal costs; and (6) the craft of pain management. We produced a short film, ‘Struggling to support people to live a valued life with chronic pain’, which presents these themes (see <jats:italic>Report Supplementary Material 1</jats:italic>; URL: <jats:uri xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="http://www.journalslibrary.nihr.ac.uk/programmes/hsdr/1419807/#/documentation" xlink:role="web">www.journalslibrary.nihr.ac.uk/programmes/hsdr/1419807/#/documentation</jats:uri>; accessed 24 July 2017). We rated our confidence in the review findings using the GRADE-CERQual domains. We developed a conceptual model to explain the complexity of providing health care to people with chronic non-malignant pain. The innovation of this model is to propose a series of tensions that are integral to the experience: a dualistic biomedical model compared with an embodied psychosocial model; professional distance compared with proximity; professional expertise compared with patient empowerment; the need to make concessions to maintain therapeutic relationships compared with the need for evidence-based utility; and patient advocacy compared with health-care system advocacy.</jats:p> </jats:sec> <jats:sec id="abs1-6"> <jats:title>Limitations</jats:title> <jats:p>There are no agreed methods for determining confidence in QESs.</jats:p> </jats:sec> <jats:sec id="abs1-7"> <jats:title>Conclusions</jats:title> <jats:p>We highlight areas that help us to understand why the experience of health care can be difficult for patients and HCPs. Importantly, HCPs can find it challenging if they are unable to find a diagnosis and at times this can make them feel sceptical. The findings suggest that HCPs find it difficult to balance their dual role of maintaining a good relationship with the patient and representing the health-care system. The ability to support patients to live a valued life with pain is described as a craft learnt through experience. Finally, like their patients, HCPs can experience a sense of loss because they cannot solve the problem of pain.</jats:p> </jats:sec> <jats:sec id="abs1-8"> <jats:title>Future work</jats:title> <jats:p>Future work to explore the usefulness of the conceptual model and film in clinical education would add value to this study. There is limited primary research that explores HCPs’ experiences with chronic non-malignant pain in diverse ethnic groups, in gender-specific contexts and in older people living in the community.</jats:p> </jats:sec> <jats:sec id="abs1-9"> <jats:title>Funding</jats:title> <jats:p>The National Institute for Health Research Health Services and Delivery Research programme.</jats:p> </jats:sec>