A meta-ethnography of health-care professionals' experience of treating adults with chronic non-malignant pain to improve the experience and quality of healthcare

Article history

The research reported in this issue of the journal was funded by the HS&DR programme or one of its preceding programmes as project number 14/198/07. The contractual start date was in July 2015. The final report began editorial review in May 2017 and was accepted for publication in August 2017. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.

Declared competing interests of authors

Fran Toye, Kate Seers and Karen Barker authored two studies that are included in this qualitative evidence synthesis. Kate Seers is a Health Services and Delivery Research board member and a Health Services Research Commissioning board member.

Copyright statement

© Queen’s Printer and Controller of HMSO 2018. This work was produced by Toye et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.

2018 Queen’s Printer and Controller of HMSO

Objectives

• To undertake a QES (meta-ethnography)26–28 that will increase our understanding of what it is like for HCPs to provide health care to people with chronic non-malignant pain and, thus, to inform improvements in the experience and quality of health care.

• To make our findings easily available and accessible through a short film.

• To contribute to the development of methods for QES that aim to bring together qualitative research findings so that health care can be improved.

Stage 1: getting started

This stage incorporates the background, rationale, aims and protocol development.

Stage 2: deciding what is relevant

In their original text on meta-ethnography, Noblit and Hare26 do not advocate an exhaustive literature search, and the number of studies included in meta-ethnographies ranges widely. 22,24,27 The aim of meta-ethnography is not to perform statistical analyses but to draw on knowledge for conceptual development. Some argue that including too many studies makes the analysis ‘unwieldy’. 27,29 However, we aimed to produce a conceptual analysis with a weight of evidence that has resonance with the health research community and thus undertook a systematic search of the published literature. Our previous meta-ethnography has demonstrated the value of undertaking a systematic search and including a larger number of studies into a QES. 28

Stage 3: reading the studies

This stage of meta-ethnography involves thoroughly reading and re-reading the studies to identify and describe the ideas or concepts. 26 The raw data of meta-ethnography are ideas or concepts in the primary studies. To allow us to refer to the original studies, we uploaded the study findings onto NVivo 11 software (QSR International, Warrington, UK) for qualitative analysis. NVivo is particularly useful for collaborative analysis as it allows the team to keep a record and compare the reviewers’ unique interpretations. NVivo 11 also allows the researchers to write memos and link them to data in order to keep track of developing analysis. We maintained a Microsoft Excel^® database (Microsoft Corporation, Redmond, WA, USA) of study demographics, appraisal and decisions on inclusion or exclusion. We read the studies in batches related to the topic/professional group and in the order in which they were retrieved, and did not use an index paper. In other meta-ethnographies, for example those of Campbell and colleagues,27 researchers have used an index paper as a way of ‘orienting the synthesis’. 38 In these examples, concepts from an early or index paper are used for comparison with concepts from subsequent studies. However, we felt that there were methodological issues with using an index paper:

• How do we decide which paper to use as an index paper?

• How do we define a ‘classic’ paper with no consensus about what makes a study good?

• An index paper can have a dramatic effect on the resulting interpretation.

• Using an index paper can mean that we become constrained by a priori concepts. This is important because we will not necessarily find the conceptually rich papers first. The process of searching and analysing is iterative and analysis does not start when the full body of data is collected but continues alongside data collection.

• When synthesising a large number of studies, comparing concepts across these studies from an index paper can become unwieldy.

Stage 4: determining how studies are related to each other

Determining how studies are related to each other involves creating ‘a list of key metaphors, phrases, ideas and/or concepts’ (p. 28). 26 The purpose of careful reading in meta-ethnography is to identify and describe the ‘metaphors’/ideas/concepts in each study and ‘translate’ or compare them to those found in other studies. This is fundamental to meta-ethnography because concepts are the raw data of the synthesis. However, at times it can be a challenge to decipher the concepts from primary studies. 36 Two reviewers read each paper to identify and describe the concepts and compiled a list of concepts from the original papers. Our analysis was based on clearly articulated concepts from the originating papers. Schütz39 distinguishes between (1) first-order constructs (the participants’ ‘common sense’ interpretations in their own words) and (2) second-order constructs (the researchers’ interpretations of first-order constructs). In meta-ethnography, the ‘data’ are second-order constructs that are further abstracted to develop third-order constructs (reviewer’s interpretations of second-order constructs). However, the distinction between first- and second-order constructs is not clear-cut:40 primary authors choose narrative exemplars to illustrate a second-order construct. Meta-ethnography attempts to identify themes not from original narrative data but from the reported concepts. We did not recode narrative data as any attempt to recode is not embedded in the primary research process. Rather, we excluded data from analysis if both reviewers could not decipher a clear concept.

Owing to the scale of the study and the potential number of second-order constructs, our interpretation of each concept needed to combine clarity, precision and brevity. We therefore used a combination of the author’s description of the second-order construct (which briefly and clearly described the construct), and our interpretation of the construct (if the original was unclear or lengthy). In some cases, we found that there was a section of narrative exemplar provided by the original authors that was enough to give the essence of the concept. Our aim was to compile a list of concise interpretations of second-order constructs that were grounded in the primary studies.

Stage 5: translating studies into each other

The next stage in meta-ethnography involves exploring how the concepts are related to each other and, thus, sorting concepts into conceptual categories. 26 All three reviewers organised, discussed and then reorganised the concepts into categories. ‘Translation’ is achieved through the constant comparative method41 through which the reviewers begin to see similarities and differences and organise concepts into further abstracted conceptual categories.

Stage 6: synthesising translations

The next stage of meta-ethnography is to synthesise, or make sense of, the conceptual categories by developing overarching themes and integrating these themes into a conceptual model. This is part of an ongoing process in which findings are further abstracted to form a conceptual framework. We planned to develop a line-of-argument synthesis, which involves ‘making a whole into something more than the parts alone imply’ (p. 28). 26 In our experience of performing large meta-ethnographies, a line of argument can incorporate reciprocity and refutation into a useful conceptual model. This is achieved by constantly comparing concepts and developing ‘a grounded theory that puts the similarities and differences between studies into interpretive order’ (p. 64). 26 We described and printed conceptual categories on postcards and sent these to our advisory group members to read and sort into thematic groups. Then, during the next advisory group workshop, members formed small groups to discuss and reorganise the postcards together. Each of the groups then chose a spokesperson to describe its themes. The complete advisory group then discussed and agreed on the final overarching themes. The aim of the workshop was to develop thematic groups that would underpin a conceptual model. Once the thematic groups had been finalised at the advisory group meeting, all three reviewers discussed and agreed on a conceptual model that they felt was greater than the sum of the individual themes.

Stage 7: expressing the synthesis

The final stage of meta-ethnography involves output and dissemination of findings. Our outputs included a short YouTube film (YouTube, LLC, San Bruno, CA, USA) (see Report Supplementary Material 1; URL: www.journalslibrary.nihr.ac.uk/programmes/hsdr/1419807/#/documentation). The script for the film was woven together from narrative exemplars from the primary studies to illustrate each overarching theme. The reviewers worked closely alongside a media company, RedBalloon (URL: www.redballoon.co.uk/; accessed 24 July 2017), which specialises in outputs from qualitative research. The team had worked successfully together to produce a film from a previous HSDR-funded meta-ethnography that explores patients’ experiences of living with chronic musculoskeletal pain (www.youtube.com/watch?v=FPpu7dXJFRI; accessed 24 July 2017).

Search results

The results of the systematic search are shown in Figure 2. We screened 954 potentially relevant studies and excluded 770 after screening the abstracts. We retrieved 184 full-text articles and excluded 101 for the following reasons:

• not about chronic pain12,44–87

• did not include HCP voice88–100

• not qualitative, or limited qualitative data101–116

• out of scope117–143

FIGURE 2.

Systematic search results.

Of the 83 potential studies, we unanimously excluded six on the grounds of methodological report. 144–149 We included 77 published studies reporting the experiences of > 1551 HCPs. 11,150–225 Table 3 provides the author, year of publication, professional/topic group, geographical context, number of participants, data collection and analytical methods for each study. HCPs included a diversity of doctors, nurses and allied health professionals in various contexts and geographical locations. Not all of the studies reported the number of participants from specific professional groups, which meant that it was not possible to give the exact sample number from each profession. The majority of studies were from the USA, the UK, Canada and Sweden. The sample size from the studies ranged from 6 to 103 (average 22). One focus group study165 and three ethnographic studies156,200,223 did not report their sample size.

Quality assessment and inclusion

Table 4 provides the outcome of appraisal: the CASP score from each reviewer [from 10 (low) to 30 (high)]; the difference in CASP score between reviewers; the seven themes developed from a previous meta-ethnography;8 the global quality score (key, satisfactory, uncertain, irrelevant or fatal flaw); and reviewers’ assessment of potential value based on CASP question 10 (‘how valuable is the research?’). The difference in CASP score between two reviewers ranged from –4 to 2 (a possible score of 10–30). They did not agree about the inclusion of four studies,172,178,196,201 which were subsequently included by a third reviewer. Two reviewers agreed that 89% of primary authors had reported their study aim and 84% had described their sample. They agreed that 89% of the authors had not reported their perspective and its potential influence on findings and 69% had not reported methods for challenging their interpretation. Reviewers also agreed that only 65% of authors had provided clear examples to demonstrate that their findings were drawn from the data and only 55% of authors had clearly described all their findings. Twenty-eight studies11,150,151,153,154,156,157,159,165–167,174,176,179,187,190,195,204,207–209,211–214,221–223 were reported as having ‘changed the thinking’ of at least one reviewer. However, reviewers’ appraisal comments (see Appendix 1) suggested that, even if they did not change their thinking, the primary studies encouraged reviewers to think. Two reviewers unanimously appraised five studies150,151,214,222,223 as ‘key papers’ and 72 as ‘satisfactory’ (see Table 3). At least one reviewer appraised 26 studies11,150,151,154,156,157,160,170,171,176,187,190,191,195,198,204,205,210,211,214,219–223,225 as potentially making a ‘valuable’ contribution to the analysis. They agreed on 21 of 26 of the valuable studies. To allow readers to evaluate the transferability of findings, Table 5 shows the reviewers’ assessment of relevance (direct, indirect, partial or uncertain) and aim of each study. We rated 60 studies11,150,152–164,168–171,173–178,180,181,183–188,190–193,195,196,198,200–211,214,215,217,218,221,222,224,225 as directly relevant, seven151,165,166,197,219,220,223 as indirectly relevant, nine172,179,182,189,194,199,212,213,216 as partially relevant and one167 as uncertain.

Coding and conceptual categories

We coded batches of studies in the following order according to topic/professional grouping:

1. Ten studies reported the experiences of primary care physicians/GPs. 11,158,164,192,195,196,204,205,209,222

2. Four studies explored the experiences of a mixed group of HCPs. 172,194,203,220

3. Three studies explored the experiences of physiotherapists. 170,201,214

4. Three studies explored the experiences of physiotherapists specialising in chronic pain management. 151,154,210

5. Five studies explored the experiences of a mixed group of HCPs providing health care to people with fibromyalgia. 152,161,181,183,206

6. Eleven studies explored the experiences of a mixed group of HCPs working in specialist chronic pain services. 150,156,163,186,200,202,215,216,219,221,225

7. Five studies explored the experiences of a mixed group of HCPs working in pain management related to employment. 167,168,179,182,224

8. Twelve studies explored the experiences of a mixed group of HCPs prescribing opioids to patients with chronic pain. 153,155,157,174,175,177,190,191,198,211,217,218

9. Six studies explored the experiences of a mixed group of HCPs utilising guidelines for chronic pain. 169,173,180,207,212,223

10. Three studies explored the experiences of a mixed group of HCPs working with older adults. 160,162,208

11. Thirteen studies explored the experiences of a mixed group of HCPs working with older adults in long-term care facilities. 165,166,171,176,178,184,185,187–189,193,197,199

12. Two studies explored nurses’ experiences of providing health care to people with chronic non-malignant pain. 159,213

Appendix 2 provides a coding report of included and excluded concepts. Two reviewers identified 492 potential concepts in 77 primary studies (Figure 3). They excluded 115 potential concepts for the following reasons: inadequate conceptualisation (31 concepts in 17 studies11,150,155,160,162,169,173,178,181,188,192,196,197,206,208,219); did not explore HCP experience (18 concepts in seven studies168,174,198,202,203,215,223); and explored a topic with limited transferability beyond a specific context (five concepts in five studies166,167,197,208,223). We agreed that for some topics there were insufficient concepts to allow us to develop robust conceptual categories: return to work (seven concepts in two studies167,182), ethnicity (11 concepts in five studies171,204,205,215,216), gender (seven concepts in one study206) and older people (21 concepts in nine studies159,160,162,165,176,187,194,199,208). Fifteen potential concepts did not fit our developing conceptual analysis (Table 6).

FIGURE 3.

Concepts that were included and excluded.

All reviewers organised the remaining 377 concepts into 42 conceptual categories. Table 7 gives an example of one of the conceptual categories (‘is the pain real?’) and its included concepts. Our description of the concepts that formed the raw data of analysis were a combination of the primary author’s description of the second-order construct (in which they briefly and clearly described the construct), and our interpretation of the construct (if the original was unclear or lengthy). In some cases we found that there was a section of narrative exemplar provided by the original authors that adequately described the essence of the concept.

Once the reviewers had agreed on a description of each conceptual category, Fran Toye wrote a statement of this finding in the first person.

For example:

This conceptual category described how endless paperwork eats into HCPs’ limited patient time

became:

This endless paperwork eats into my limited patient time.

We have found that writing concepts in the first person is a powerful way for reviewers and their advisory group members to fully engage in the meaning and sentiment of each concept. It also facilitates the use of accessible language for a diverse audience in both analysis and dissemination.

Table 8 provides a description of each of the 42 conceptual categories written in the first person. The reviewers worked with a research fellow and a project advisory group that included patients and HCP members to further abstract these 42 conceptual categories, printed on postcards, into six overarching themes that underpin HCPs’ experience of providing health care to people with chronic non-malignant pain (Figure 4). Table 9 provides a list of the conceptual categories underpinning each of the six final themes. Table 10 shows the number of studies and concepts for each theme organised by topic/professional group. It also indicates the global appraisal score given for individual studies supporting the theme.

FIGURE 4.

Illustration of conceptual analysis with advisory group.

Assessment of confidence in findings (GRADE-CERQual)

Indicators of confidence in each review finding are shown in Table 11 [including the number of studies rated as key/valuable or satisfactory (methodological limitations); the number of concepts (adequacy); the number of studies out of 77 (coherence); an assessment of study relevance; and our overall assessment of confidence]. We rated our confidence in the review finding as high when it was supported by more than half of the studies. However, there is currently no agreed way of assessing confidence.

Conceptual themes

We illustrate the six themes with narrative exemplars. The film output ‘Struggling to support people to live a valued life with chronic pain’ can be watched on YouTube (see Report Supplementary Material 1; URL: www.journalslibrary.nihr.ac.uk/programmes/hsdr/1419807/#/documentation).

A sceptical cultural lens and siren song of diagnosis

This theme describes a cultural lens that provides a sceptical view of chronic pain. With this view, clinical work focuses on determining whether pain is ‘something’ (biomedical) or ‘nothing’. Although some acknowledged the dangers of ‘judging a book by its cover’, HCPs viewed the world through this sceptical lens and at times found themselves making non-clinical judgements about whether a patient’s pain was real or imagined. HCPs described how they could experience a dissonance between what they saw and what the patient said:

Sometimes I could have a patient sitting there and saying that they are hurting, 10 out of 10, and they are sitting like you and I.

Bergman 2013158

Some people say ‘This is the worst pain I’ve had in my whole life’ without any real sort of physical signs of pain so it’s really tough; we have a complex job in assessing that.

Kaasalainen 2010189

The patients tell me with a smile on their lips that they are suffering immensely from all kinds of bodily disorders. How on earth can they look so terribly healthy?

Hellström 2015183

However, HCPs recognised the dangers of their scepticism and acknowledged a need to not make hasty judgements. Although they knew that patients did not always look like they were in pain, HCPs remained ‘on guard’ against being exploited by fraudulent claims of pain:

You’d have to be on guard this man isn’t laying it on.

MacNeela 2010196

It is not clear to me why he is the way he is . . . this catastrophic pain and what he is telling himself about it . . . but there is always a little bit . . . of concern; am I being manipulated, is this really real?

Esquibel 2014174

Such people . . . ones whose wishes you cannot fathom – provoke anger and frustration because at some point, you don’t always know how to verify their complaints. You feel somewhat exploited. It is a very unpleasant feeling.

Dahan 2007169

Health-care professionals thus engaged in moral ‘boundary work’ in order to second-guess patients’ claims and determine credibility. The process of boundary work hinged on a multiplicity of dualities superposed on a polarity of ‘good’ and ‘bad’ (Figure 5).

FIGURE 5.

Dualities of moral boundary work.

In contrast, some HCPs recognised that moral boundary work was flawed and advocated trust as the basis of a therapeutic relationship:

Sometimes we say ‘oh she came in with back pain but I don’t think she’s really in pain’ . . . but really even if somebody is in pain and distress, [it] doesn’t always have to be in how they present themselves . . . that doesn’t mean she is not in pain.

Toye 2015220

I hate to say it . . . but I used to be one of the people that used to say, ‘Oh, well, they are probably just wanting attention’. But I’ve changed in that matter. People are in pain, and it’s not just to get attention.

Clark 2006166

Pain is so subjective and so that’s where the difficulty lies . . . I find it hard to say how someone’s pain can be judged by someone else . . . You have to show a patient you’re empathetic to him. There is a pain. Pain is real.

Bergman 2013158

The craft of pain management

The final theme described clinical work as an experience-based competence or ‘craft’. 170 This craft was gained from experience and patient mileage rather than through didactic education or research. At times HCPs felt underskilled in chronic pain management, particularly in relation to psychological therapies:

The problem is, we don’t know how to treat pain. And so everybody is telling me I’m not treating pain well, but nobody is helping me figure out how to treat the pain.

Spitz 2011217

I am not a psychologist . . . Someone bringing out a lot about their past . . . we don’t want to say the wrong thing and it be to someone’s detriment . . . you don’t want to open this can of worms.

Barker 2015154

It’s fine saying [to a patient] yes well you know that is part of the pain . . . you feel depressed with it . . . I don’t really feel I’m at all competent in knowing what to say to try and help them round that.

Parsons 2012203

Personal experience and maturity, patient mileage and learning from more-skilled professionals (apprenticeship) were described as integral to craft knowledge:

One becomes more stable as a person [with age], and does not really have the same demands and does not believe that one can do everything, that one is able to solve everything . . . Young doctors can have in them, that they believe that they will solve everything.

Åsbring 2003152

New grads can’t learn all of this, they need a certain number of years, you can’t teach them all of this, there’s so much they’ve got to learn.

Slade 2012214

If you have a patient who’s not responding the way that you expect, it’s nice to have someone there who can have a look and see . . . you can see and hear what everybody else is doing and that is how you learn . . . it’s like osmotic learning.

Slade 2012214

Pragmatic use of guidelines

There was a sense that evidence-based guidelines could challenge or constrain craft knowledge. Although some HCPs felt that evidence guidelines supported a holistic approach,180,207 there was a stronger feeling that guidelines did not facilitate individualised care:

Treatment has to be tailored to patients’ needs and prescriptive guidelines promoting ‘one size fits all’ is not acceptable.

Wilson 2014223

If you work according to the guidelines, you are constrained in your performance . . . what would be left of your independence, your own competence, your own practical experience . . . Am I to conclude then that my training was useless?

Harting 2009180

Most pain specialists spend most of their time treating people with low back pain that’s what we do. And a guideline comes out that says, you’re not needed. Full stop. It can be managed without any reference to you whatsoever . . . no need for doctors and nurses.

Wilson 2014223

Health-care professionals showed limited attention to guidelines in clinical decision-making. Clinical work was about the craft of learning from doing things:

My experience is that therapists say they adhere to the guidelines, although they still all work in different ways.

Harting 2009180

Such a huge heap, such a bundle of paper, such a bundle of characters . . . we have been educated to do things. So if you give this group a pile of papers, who will read them? I think nobody will.

Harting 2009180

Health-care professionals framed guidelines within the remit of their own professional knowledge and used them pragmatically and flexibly:

But of course, I’m free to take or leave these things, to look at whether they suit my own ideas of how to approach my patients.

Harting 2009180

Of course, it is not necessary to follow the guidelines exactly; it is more like: this is roughly the approach, regardless of the background you have.

Harting 2009180

For example, some used the evidence guidelines as a tool to convince patients or colleagues that their professional decision was the right one:

In the case of disagreement . . . about the treatment policy, you can always turn to the guidelines, and you can argue while showing them these national guidelines.

Harting 2009180

Health-care professionals described the decision to refer a patient for clinical testing as a craft. This highlights the multiplicities of clinical decision-making whereby HCPs face the challenge of balancing varied competing interests in order to achieve an optimum outcome (Figure 6).

FIGURE 6.

Multiplicity of clinical decision-making: do I refer for a test?

First, a test or investigation might be used to confirm or to rule out serious pathology. This might be to reassure patients or HCPs, or alternatively to convince a patient or HCP that there was no pathology:

‘Wear and tear’ is, in a way, quite nice to have. Most are satisfied with that . . . nothing dangerous, and nothing that needs surgery. It’s a short version of an explanation.

Espeland 2003173

At times, there might be a need to rule out pathology as a defence against complaints of malpractice. 173 However, there was a sense of ambivalence regarding the usefulness of tests in clinical decision-making:

What are we afraid of? After all, it occurs to every doctor sitting here that he may just miss something. That is how we were taught, we were told watch out, you may miss something. How much did we miss? Almost nothing.

Dahan 2007169

X-rays could also be used strategically to support patients’ credibility and to maintain trust. Referring a for an investigation was felt to be a strong statement that patient I hear you, believe you and I am even prepared to bend the rules for you. Some ordered X-rays because the patient asked for one, or as a compromise for a preferred or less accessible service:

[An X-ray referral] is interpreted as a definite signal that the physician thinks it is something physical. It means . . . [the patient] can come home and say, ‘I had an X-ray’, and then everybody will realise I have pain in my back.

Espeland 2003173

Investigations could also be used as a means of biding time or buying time. It was sometimes quicker just to order an X-ray. It might also save time en route to a different service:

I buy time by ordering an imaging test, even though I know it will not be helpful . . . It buys time . . . It’s a kind of therapy. It reassures the patient that they’re being cared for.

Shye 1998212

Sometimes I found myself referring a person for an X-ray in order to clear the waiting room and allow myself 2 minutes of breathing time . . . the patient keeps quiet while I write out his referral. Sometimes you find yourself doing this and it goes against any reasoning or logic.

Dahan 2007169

Some erred on the side of caution in ordering investigations and considered the potential repercussions of securing a false positive:

He’s got a scan of his disc, it’s there [a disc bulge], but I think he’s had it for years . . . but he’s now fixated on a disc.

Slade 2012214

It come back at me like a boomerang: ‘now I’m worn out, I can’t work any more, I’ll go over to social security benefit’.

Espeland 2003173

A word of caution given was to think very carefully about the person for whom the test was being done:

[Be] very self-aware when you're thinking about doing tests . . . sometimes in chronic pain doctors are doing the tests for themselves not for the patient . . . that uncomfortableness with not being able to fix or do something . . .

Toye 2015220

Conceptual model

The final phase of meta-ethnographic analysis is to develop a conceptual model that is abstracted from, but more than, the sum of its themes. The reviewers developed a model that helps us to understand the experience of providing health care to people with chronic non-malignant pain (Figure 7). The model is underpinned by a series of tensions: (1) between a dualistic biomedical model and an embodied psychosocial model; (2) between professional distance and proximity; (3) between professional expertise and patient empowerment; (4) between a need to make concessions in order to maintain relationships and known biomedical utility; and (5) between patient advocacy and health-care system advocacy.

FIGURE 7.

Conceptual model: complexity of providing health care to people with chronic non-malignant pain.

We conceptualised these tensions, on a mixing console, as underpinning the craft of chronic non-malignant pain management. The poles are neither inherently good nor bad; just as bass and treble are neither inherently good nor bad. It is the correct mix within a context that contributes to the quality of music. Our console also incorporates the pitch or level of loss, both professional and personal, that can contribute to the harmony or dissonance of a therapeutic encounter.

Opioid prescription

The reviewers also identified 76 concepts in 17153,155,157,161,174,175,177,187,189–191,198,208,211,213,217,218 of the 77 studies that uniquely explored the experience of prescribing opioids to patients with chronic non-malignant pain. The reviewers discussed and organised the 76 concepts (see Appendix 3) into 19 conceptual categories (Table 12), and then into six themes that underpin HCPs’ experience of prescribing opioids to patients with chronic non-malignant pain:

1. should I, shouldn’t I?

2. pain is pain

3. walking a fine line

4. social guardianship

5. moral boundary work

6. regulations and guidelines.

TABLE 12 - Conceptual categories: the experience of prescribing opioids to patients with chronic non-malignant pain

Conceptual category title	Description of conceptual category
A battleground	This describes how the clinical arena for prescribing opioids can become a battleground in which mistrust pervades and the HCP sometimes has to make some concessions to move forward
It’s quite a taboo	This describes the stigma of opioids, a culture hostile to long-term opioid use and the taboo of prescribing. HCPs compared their own prescribing practice with that of their colleagues and were concerned over being judged by their peers. Some felt that they had a personal responsibility to protect society from the consequences of drug misuse. There is sense of policing drug use
Concerns over misuse	This describes concerns over misuse of opioid prescriptions
I don’t want to feed a habit	This describes the concern about causing addiction or feeding a habit if there was already a history of abuse
Only as a last resort	This describes opioid treatment as a last resort. There needs to be a pretty good reason to prescribe opioids
It’s not gonna be my little old lady	This describes the moral boundary work to determine which patients are likely to misuse prescriptions. You have to go with your gut. This boundary work is complex and incorporates non-clinical judgements. However, some sensed the dangers of judging a book by its cover
No diagnosis is a trigger for suspicion	This describes an unwillingness to prescribe opioids to those who have chronic conditions with no biomedical cause, or in whom symptoms are vague. Suspicion arose when observed symptoms did not match the patients report (dissonance)
It’s my name on the bottle	This describes concerns about possible legal or regulatory sanctions as a consequence of prescribing opioids as treatment for chronic pain
Addiction not a barrier	This describes a view that drug addiction should not be a barrier to opioid prescription for pain. You can have pain and also addiction and you need to balance the benefits of adequate pain control
Pain is pain (non-malignant or malignant)	This describes how in theory pain is pain, whether malignant or not, and that this should not have an impact on the decision to prescribe. However, in practice it is different. The decision is complicated by the length of time that opioids would be prescribed for non-malignant pain and the fear of causing addiction. There is a sense that experience working in palliative care facilitates prescribing for non-malignant pain
Walking a fine line between gains and losses	This describes the need to carefully balance the benefits and adverse effects of opioids. An emphasis on adverse effects might lead to unnecessary suffering, or to a patient seeking out more harmful methods of pain control. Some HCPs erred on side of benefits and others on the side of harm. There was a sense that patients also have to walk this fine line and make difficult decision
Balancing adverse effects in older adults	This describes concerns over prescribing opioids to older adults because of the potential severity and impact of adverse effects (e.g. polypharmacy, cognitive function and falls). In principle, age should not make a difference, but in practice it does. Sense that you needed specialised knowledge to prescribe in this area
I learnt the hard way	This describes how a HCP had prescribed opioids in the past and got their fingers burnt. At times there was a feeling of being ‘deceived’ by patients. However, there was also an understanding that part of clinical work was to learn from your mistakes
Should I, Shouldn’t I?	This describes a sense of uncertainty about when to prescribe opioids and a feeling of ambiguity about the effects of medication. At times HCPs referred to other HCPs or prescribed medication in order to buy some time. This uncertaintly was compounded by not having the time to get to know the patient. A ‘let’s just wait and see what happens’ perspective
Lack of expertise in addiction	This describes a perceived lack of expertise in chronic pain and addiction
Prescribing guidelines: positive	This describes a positive attitude to guidelines that can be used to justify clinical decisions and help to deal with ‘challenging’ patients. Some also felt that guidelines could help to prevent potential social harm from abuse or misuse
Prescribing guidelines: negative	This describes a negative view of prescribing guidelines (the legislature seen as practising medicine without a licence). Guidelines can be used as a reason not to prescribe to those who need it and can interfere with professional autonomy. Some felt that guidelines would only be used pragmatically to support usual care
Opioid agreements: negative view	This describes a negative view of opioid prescribing agreements and drug screening as striking a blow at the heart of the patient–clinician relationship by creating mistrust and hostility. Also a feeling that they are ineffective at stopping misuse of opioids
Opioid agreements: positive view	This describes a more positive view of opioid prescribing agreements that struck a blow at drug misuse. They were useful in establishing boundaries and opening up honest discussion

A core concept overarching all six themes was a sense of ambiguity surrounding opioid prescribing. We illustrate the six themes with narrative exemplars. Indicators of confidence in our review findings as recommended in the GRADE-CERQual framework37 are given in Table 13.

TABLE 13 - Confidence in review findings (opioids): GRADE-CERQual assessment

Review finding	Methodological limitations (satisfactory studies)	Relevance (partial or direct)	Adequacy (number of concepts)	Coherence (number of studies out of 17)	Assessment of confidence
Should I, shouldn’t I?	All	9 direct	19	9155,157,161,174,175,177,191,198,217	High confidence
Pain is pain	All	5 direct, 1 partial	8	6153,177,187,189,211,217	Moderate confidence
Walking a fine line	All	9 direct, 2 partial	20	11153,157,162,177,187,188,190,194,208,211,217	High confidence
Social guardianship	All	10 direct, 1 partial	17	11153,155,157,174,175,177,190,191,208,211,217	High confidence
Moral boundary work	All	12 direct, 2 partial	27	14153,155,157,174,175,177,190,191,198,208,211,213,217,218	High confidence
Regulations and guidelines	All	8 direct	18	8155,157,175,177,190,191,217,218	Moderate confidence

Should I, shouldn’t I?

The theme ‘should I, shouldn’t I?’155,157,161,174,175,177,191,198,217 described uncertainty about when to prescribe opioids, and a feeling of ambiguity about the effects of medication:

Depending on who I run into, I may get into all kinds of problems . . . ‘You’re just being unfair because he’s a drug addict . . .’. But if I run into somebody else, they might say ‘No . . . that was a good clinical decision‘.

Berg 2009157

The aetiology of the disease is not really known and you have few means of knowing what you’re doing. You’re treating the pain and you don’t know why there is no response . . . No matter what you give them, the pain doesn’t go away.

Briones-Vozmediano 2013161

Some felt that clinical education did not prepare them to make these decisions:

We took an advanced pharm[acology] class, and we discussed it in one lecture, but that was it. Isn’t that ridiculous considering how many people we see in pain?

Fontana 2008175

Nobody here knows how to treat pain in anybody who has a history [of addiction] and already on something like methadone. Nobody knows how to treat them . . . Most of us in primary care end up [doing it] by default. But that’s not good.

Barry 2010155

Uncertainty was compounded by the sense that specialist referrals were either restricted or unproductive:

Often I find that they are not accomplishing any more than I was and [patients] are often sent back to me with them [pain specialists] essentially saying, ‘we did our best.’ It’s very frustrating, because if they were easy patients they wouldn’t have been seeing them.

Barry 2010155

Pain is pain

The theme ‘pain is pain’153,177,187,189,211,217 was underpinned by the concept that if a person is in pain then the primary aim of the HCP should be to try to relieve their pain. If a person is in pain, even drug addiction should not be a barrier to opioid prescription:

At the end of the day, if someone’s got chronic pain it doesn’t matter if they’re addicted to painkillers if it sorts out their quality of life.

Gooberman-Hill 2011177

I had a guy last week who’d been stabbed . . . and he had to discharge himself because they wouldn’t give him any pain control . . . he wasn’t even getting his prescribed dose of methadone . . . there’s a protocol . . . they choose not to know about it and it’s just pure stigma.

Baldacchino 2010153

However, HCPs felt that the decision to prescribe opioids was complex and that, although in theory pain is pain, in practice it is different. HCPs described differences in practice that would make them less likely to prescribe opioids. For example, in the case of chronic non-malignant pain, they would need to carefully balance the risks and benefits of long-term opioid prescription:

With [malignant pain] . . . your aim always is to get complete relief of pain . . . For chronic pain . . . you’ve got to weigh up . . . the potential side effects . . . you are not necessarily going to get them pain free because they’ve got the rest of their lives to live.

Seamark 2013211

Health-care professionals explicitly compared prescribing practices for palliative care and chronic non-malignant pain:

We tend to focus too much on pain control for palliation as opposed to just everyday clients. Certainly nobody wants to die in pain, but nobody wants to live in pain either.

Kaasalainen 2007187

It might be that you are . . . just getting them through the last few weeks . . . so maybe we feel more comfortable, whereas the patient with chronic back pain you don’t how long you’re going to be treating . . . I think it’s a risk–benefit issue.

Spitz 2011217

Walking a fine line

The theme ‘walking a fine line’153,157,162,177,187,188,190,194,208,211,217 described the need for HCPs to carefully balance the benefits and adverse effects of opioids. On the one hand, emphasising adverse effects might lead to unnecessary pain, but, on the other hand, emphasis on pain control might lead to harm or abuse:

There are two mistakes you make . . . the mistake of undertreating or of giving medicines that end up being sold or used for unintended purposes. You’re going to make errors both ways, and I think it’s generally better to risk opiates being misused versus not treating someone’s pain.

Berg 2009157

This sense of walking a fine line was heightened when prescribing opioids for older adults, and HCPs felt that specialised knowledge was necessary to effectively prescribe opioids to older people with chronic pain. Although in theory age should not affect decisions, there was a sense that in practice it did:

But there are safety issues, and at the end of the day if they came to grief . . . you’d feel . . . excessive side effects . . . that contributed to some major event . . . So we walk a fine line sometimes between giving adequate pain relief and giving safe treatment.

Gooberman-Hill 2011177

Older people metabolise medication differently . . . so you don’t want to give them medication that’s going to impair their ability to function . . . You don’t want to interfere with their ability to make judgements and so on, so I don’t like using opioids in elderly people at all.

Ruiz 2010208

I just have a hard time prescribing opioids in my older patients. I get frightened with 80+ year olds; how are they going to respond? Am I going to absolutely drop them to the floor even with a small dose?

Spitz 2011217

Social guardianship

The theme ‘social guardianship’153,155,157,174,175,177,190,191,208,211,217 described a culture hostile to opioid use and the professional taboo of prescribing opioids for chronic non-malignant pain. HCPs compared their own practise with that of their colleagues and were worried that they would be harshly judged by their peers for prescribing opioids. Some felt a personal responsibility to protect society from the consequences of opioid misuse and viewed certain patients with suspicion, particularly those who requested opioids. To protect society, some implemented strategies to control patients’ behaviour (e.g. bottle checks, opioid contracts and background checks). HCPs were also concerned that opioid prescriptions might be diverted to others:

I am a naysayer on opiates . . . too much of my day is spent policing how many [opioids] have been prescribed and how many times a patient is a return patient and how often they visited requesting opiate prescriptions.

Kilaru 2014190

If you prescribe to a population where you think diversion is going on, you definitely have a responsibility. I also worry about who is getting the drug, is it my son? I mean, we are members of society after all.

Fontana 2008175

Some HCPs discussed indicators of potential abuse (e.g. lost prescriptions, early requests for medication and frequent attendance), whereas others acknowledged that these might actually indicate poorly managed pain and, therefore, a greater need for pain relief:

If people are taking it genuinely for pain they tend to stick to the prescribed dosage . . . addicts tend to be the ones who are always ordering early . . . you don’t lose your tablets if you are . . . getting great benefit from them for pain.

Baldacchino 2010153

The concern would be is this pain real, or is it just put on to obtain opioid? . . . I mean, an assessment of the pain and whether I think it’s genuine or not. I think it’s very difficult; it’s something I’m currently dealing with at the moment, and not very successfully.

Seamark 2013211

Moral boundary work

The theme ‘moral boundary work’153,155,157,174,175,177,190,191,198,208,211,213,217,218 was underpinned by the clinical work of deciding whose pain is ‘real’ and thus who should be prescribed opioids. There was a sense of an underlying unwillingness to prescribe opioids for pain with no clear biomedical cause, or if symptoms were vague. Suspicion arose when there seemed to be dissonance between the patient’s report of pain and the symptoms observed by the professional:

A lot of patients . . . they really need it . . . based on their underlying pathology . . . a patient who has a cancer or a real anatomic foundation . . . you have to count on more observation, combined with other clinical data . . . you pretty much know who is abusing and who is not.

Krebs 2014191

I think for patients who have chronic pain it’s more challenging and I think that’s the place where I’m constantly rethinking my practice . . . You’re always on the fence: am I doing the right thing for my patient?

Kilaru 2014190

Health-care professionals described good patients (e.g. those who made appropriate demands, took advice and did not cause trouble) and ‘difficult’ patients (the demanding, non-adherent and trouble-making):

For those patients that have a legitimate reason for wanting to take it and if I can trust them . . . most of these are older patients of mine. They never request early refills, they don’t go to the [emergency room] in between visits to get them . . .

Krebs 2014191

Non-clinical moral judgements or gut feelings contributed to prescribing decisions. HCPs recalled episodes when they had made a mistake by trusting ‘the wrong’ patient. Over time they felt that they had become better at making the right decision. Examples were given of HCPs getting their fingers burned when prescribing opioids, along with an understanding that lessons had to be learnt from mistakes:

At times there was a feeling of being ‘deceived’ by patients so that you prescribed opioids:

I’ve had trust in people, and it’s been betrayed – sometimes the trust is betrayed multiple times. I find I’m not always that great a judge of who to trust and who not to trust, so, I don’t trust my own judgement on trust all the time . . . I think people feel like they’ve been violated, you know, cheated, like they’ve been taken advantage of. I feel some of that, too. Ultimately you feel you’ve made a poor judgement, and you get mad at yourself . . . My impression was that he had a true ankle problem. Then you find out it was all lies, but you know, at that time and at that moment, that was my assessment, and I did it. You’re allowed to make mistakes.

Berg 2009157

Prescribing . . . is a sort of rather woolly, nebulous product . . . I’ve been moulded by the successes and the failures . . . we all learn on the hoof, don’t we? . . . I think everybody’s fingers get burnt with people who you give the opioids to with a more trusting attitude.

Seamark 2013211

However, some sensed the dangers of judging a book by its cover and acknowledged that basing clinical decisions on their gut feeling might not be fair or accurate:

There’s a disconnect . . . even if it’s the sweetest little 85-year-old woman who looks like your grandmother, versus, you know, some guy from the ghetto wearing his pants down at his knees . . . it shouldn’t really matter.

Starrels 2014218

Regulations and guidelines

The theme ‘regulations and guidelines’155,157,175,177,190,191,217,218 described HCPs’ views about external regulation of opioid prescription (specifically guidelines, opioid agreements and drug screening). Some described a negative view of prescribing guidelines and felt that they interfered with professional autonomy, an example of the ‘legislature practising medicine without a licence’:190

You’re there to help them and they can tell you their deepest, darkest secrets, but yet you’re policing them . . . I like to see the person as a person . . . You can’t do your job when you are thinking about these things.

Krebs 2014191

There could be negative implications to that if patients are actually leaving the emergency department because of the way they interpret that [regulations] poster . . . there’s potential that sick patients could actually leave your emergency department when they need help.

Kilaru 2014190

Health-care professionals feared legislative reprimand if they prescribed outside guidelines:

My name is on that bottle . . . I had a patient die. He took the entire bottle, and the police came to see me because they found him dead with the empty bottle with my name on it . . . I won’t accept that burden.

Fontana 2008175

[GPs] are scared of being in front of the coroner . . . with a load of angry family and relatives wagging a finger at us, when all we’re trying to do is really help . . . if it works, brilliant. If it doesn’t work . . . people are very quick to criticise.

Gooberman-Hill 2011177

Others described a negative view of opioid prescribing agreements and drug screening as striking a blow at the heart of a patient–clinician relationship by creating mistrust and hostility:

It can really strike a major blow to trust in the doctor patient relationship when you ask someone to sign a piece of paper . . . if there is already mistrust between the patient and the doctor, it could heighten that mistrust . . .

Starrels 2014218

Some used guidelines pragmatically as leverage or to justify decisions and thus help them to deal with ‘challenging’ patients:

I tell them this is standard protocol. I’m not singling you out. I’m not picking on you. I’m not treating you like an addict. This would happen to anybody. If you take our chronic pain meds long enough, anybody will become physically dependent on them.

Krebs 2014191

[An agreement] gives me leverage or comfort in discontinuing the medication . . . because we’ve kind of laid it out from the beginning that those behaviours were not okay . . . it made my life a little easier, but I’m not sure it did the patients a giant service.

Starrels 2014218

Others described a more positive attitude to regulation. For example, opioid agreements could be useful in establishing boundaries and opening up honest discussion:

I think it improves the care, because you are able to then have more open and frank discussions around their pain . . . and [about] other things going on in their life . . . In the best of circumstances it actually will make for a deeper more trusting relationship.

Starrels 2014218

Conceptual framework: prescribing opioids

Our conceptual model (Figure 8) hinges on the HCP’s need to decipher the ambiguity surrounding opioid prescription for chronic non-malignant pain (should I, shouldn’t I?). Social suspicion and hostility towards opioids (social guardianship) will tip the balance for prescribing towards the negative, whereas the pre-eminence of pain (pain is pain) might tip the balance towards prescribing. The decision is not clear-cut. First, HCPs might make non-clinical judgements about the person (moral boundary work). Second, they must determine the balance of positive and adverse effects for each individual (walking a fine line). Last, there is a sense of professional ambivalence towards prescribing guidelines (regulations and guidelines). This conceptual model demonstrates the complexity of making a decision to prescribe opioids to someone with non-malignant pain. It also demonstrates that the decision is influenced by intra- and interpersonal factors and broader external concerns.

FIGURE 8.

Conceptual model: the ambiguity of prescribing opioids to patients with chronic non-malignant pain.

Discussion

We aimed to undertake a QES using the methods of meta-ethnography reported by Toye and colleagues8 to increase our understanding of what it is like for HCPs to provide health care to people with chronic non-malignant pain and thus to inform improvements in the experience and quality of health care. At the outset of this study, we had intended to include HCPs’ experience of treating chronic non-malignant musculoskeletal pain in order to mirror a previous QES of patients’ experience of chronic non-malignant musculoskeletal pain. However, our preliminary reading indicated that HCPs’ experiences of treating chronic non-malignant pain were not boundaried to a particular body system, but were a summative experience that cut across conditions. After consultation and agreement with our advisory group, we therefore sought and attained permission from the funders to remove ‘musculoskeletal’ from our study title. Our search strategy then focused generically on chronic non-malignant pain. Further research might focus on specific diagnoses (such as neuropathic, visceral, pelvic or phantom pain or arthritis) to explore potential similarities and differences in HCPs’ experiences of treating these conditions.

This is the first time that such a synthesis has been undertaken on this topic. Already we know that, from the patient perspective, the experience of health care can be adversarial. 8 Patients with chronic pain struggle to affirm their sense of self; their present and future appears unpredictable; they search for a credible explanation for their pain; they do not always feel heard, believed or valued by HCPs; and they struggle to prove themselves in the face of scepticism. 8 Our findings can help us to consider this experience of health care from the perspective of HCPs. We identified six themes from 77 studies that help to explain the HCP experience of providing health care to people with chronic non-malignant pain and six themes specific to the experience of prescribing opioids to this group of patients. The innovation of our conceptual model is to propose a series of tensions that are integral to the experience of providing health care to people with chronic non-malignant pain. These tensions were between a dualistic biomedical model and an embodied psychosocial model; professional distance and proximity; professional expertise and patient empowerment; the need to make concessions to maintain therapeutic relationships and the need for evidence-based utility; and patient and health-care system advocacy. This model may be transferable to other chronic conditions.

Methodological issues

Contributions of authors

Fran Toye (Dr, Qualitative Researcher) made a substantial contribution to the design, acquisition, analysis and interpretation of data, drafted the first, subsequent and final versions of the report and designed the visual outputs.

Kate Seers (Professor, Qualitative Researcher) made a substantial contribution to the design, acquisition, analysis and interpretation of data, revised all versions of the report for important intellectual content and approved the final version.

Karen Barker (Associate Professor, Qualitative Researcher) made a substantial contribution to the design, acquisition, analysis and interpretation of data, revised all versions of the report for important intellectual content and approved the final version.

Publications

Toye F, Seers K, Barker KL. Meta-ethnography to understand healthcare professionals’ experience of treating adults with chronic non-malignant pain. BMJ Open 2017;7:e018411.

Toye F, Seers K, Tierney S, Barker K. A qualitative evidence synthesis to explore healthcare professionals’ experience of prescribing opioids to adults with chronic non-malignant pain. BMC Fam Pract 2017;18:94.

Data sharing statement

Requests for access to data should be addressed to the corresponding author.

Disclaimers

This report presents independent research funded by the National Institute for Health Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Health and Social Care. If there are verbatim quotations included in this publication the views and opinions expressed by the interviewees are those of the interviewees and do not necessarily reflect those of the authors, those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Health and Social Care.

Findings with inadequate conceptualisation

1. Allegretti 2010:11 convergence – many barriers exist to care.

2. Barry 2010:155 physician factors – continuity of care.

3. Blomqvist 2003:160 activities to manage pain.

4. Blomqvist 2003:160 activities to manage pain – no activity.

5. Cameron 2015:162 psychology, negative thoughts, coping and reinforcement.

6. Dahan 2007:169 the guideline – practical issues in relation to low-back pain guideline implementation.

7. Espeland 2003:173 the GP’s professional dignity.

8. Gropelli 2013:178 inability to recognise an individualised plan of care.

9. Gropelli 2013:178 nurses’ perceptions about older adults and families.

10. Gropelli 2013:178 nurses’ perceptions and the possible lack of self-awareness cause barriers.

11. Hayes 2010:181 treatment and management.

12. Kaasalainen 2007:187 barriers and facilitators – barriers.

13. Kaasalainen 2007:187 barriers and facilitators – facilitators.

14. Kaasalainen 2010:188 influential factors.

15. Kaasalainen 2010:188 nurse practitioner role in pain management in long-term care.

16. Kaasalainen 2010:188 perceived outcomes.

17. Kristiansson 2011:192 helped her.

18. Kristiansson 2011:192 life hurts.

19. Kristiansson 2011:192 sad and still.

20. MacNeela 2010:196 professional knowledge – a schema for back pain.

21. McConigley 2008:197 strengths to assist in the implementation process.

22. Oosterhof 2014:202 experiences concerning the treatment outcome (maintaining new behaviour).

23. Paulson 1999:206 needing human support (feeling alone and forlorn).

24. Paulson 1999:206 needing human support (searching for sympathy).

25. Paulson 1999:206 struggling for relief from pain (not being taken seriously).

26. Paulson 1999:206 struggling for relief from pain (seeking explanation and wanting to be cured).

27. Ruiz 2010:208 value of ancillary services.

28. Stinson 2013:219 pain management strategies (physical strategies).

29. Stinson 2013:219 service delivery recommendations.

30. Thunberg 2001:150 professionals’ caring reality: hierarchy.

31. Thunberg 2001:150 professionals’ caring reality: medical–physical treatment.

Concepts that did not explore health-care professionals’ experiences

1. Coutu 2013:168 harmony scenario.

2. Esquibel 2014:174 utility and proper usage.

3. Esquibel 2014:174 addiction.

4. McCrorie 2015:198 patient drivers to seek help.

5. Oosterhof 2014:202 experiences concerning the interaction – being involved.

6. Oosterhof 2014:202 experiences concerning the interaction – being taken seriously.

7. Oosterhof 2014:202 experiences concerning the treatment outcome (organisational problems).

8. Parsons 2012:203 legitimating suffering (patients’ beliefs about receiving a diagnosis label for their pain).

9. Parsons 2012:203 legitimating suffering (the interaction between patients and health professionals’ beliefs about pain causation).

10. Parsons 2012:203 the evolving nature of patients’ and health professionals’ models of understanding chronic musculoskeletal pain (patients’ and health professionals’ beliefs about pain causation).

11. Parsons 2012:203 the evolving nature of patients’ and health professionals’ models of understanding chronic musculoskeletal pain (patients’ adaptation of causation belief).

12. Parsons 2012:203 development and tailoring of consultation and treatment approaches throughout patients’ illness careers (patients’ beliefs about consulting for and treatment of chronic musculoskeletal pain).

13. Sloots 2009:215 credibility with regard to foreign diagnosis.

14. Sloots 2009:215 trust in the rehabilitation physician.

15. Wilson 2014:223 articles of association.

16. Wilson 2014:223 calling for withdrawal of the guidance.

17. Wilson 2014:223 extraordinary general meeting.

18. Wilson 2014:223 the blog.

Concepts with limited transferability beyond specific context

1. Clark 2006:166 changes in pain knowledge, attitudes and practice – knowledge.

2. Côté 2001:167 approaches to manage occupational injuries – contact with the workplace.

3. McConigley 2008:197 toolkit development.

4. Ruiz 2010:208 value of computerised patient record system as a support tool.

5. Wilson 2014:223 guideline development group membership list.

Concepts with insufficient primary data to develop robust themes

Concepts that did not fit the conceptual analysis

1. Barry 2010:155 logistical factors – ancillary staff.

2. Barry 2010:155 logistical factors – insurance coverage.

3. Fontana 2008:175 critical analysis.

4. Holloway 2009:184 initiating clinical care.

5. Holloway 2009:185 perfect positioning (rewards of getting it right).

6. Kaasalainen 2010:188 interactions with long-term care staff and managers.

7. Liu 2014:193 instigator implementing non-pharmacological interventions.

8. Löckenhoff 2013:194 age differences in time horizons (treatment planning).

9. Lundh 2004:195 variation 1.

10. Oosterhof 2014:202 experiences concerning the treatment outcome (learning new behaviour).

11. Scott-Dempster 2014:210 ‘it’s not a one trick pony’.

12. Seamark 2013:211 cost.

13. Siedlecki 2014:213 core concepts/taking ownership.

14. Stinson 2013:219 barriers to care (patient-specific barriers).

15. Stinson 2013:219 pain management strategies (support systems), HCPs recognised the importance of peer support for patients.

Concepts included in analysis

1. Afrell 2010:151 a change of the relation to the patient – facing the negative.

2. Afrell 2010:151 a change of the relation to the patient – reconsidering the professional mandate.

3. Afrell 2010:151 a change in the patient – starts the processing.

4. Afrell 2010:151 the physiotherapists’ insights into the patient as a person – the patient’s view of the connection between body and life comes out.

5. Afrell 2010:151 the physiotherapists’ insights into the patient as a person – the pain is near to feelings.

6. Afrell 2010:151 the physiotherapists’ insights into the patient as a person – the pain mirrors life experience.

7. Afrell 2010:151 the physiotherapists’ insights into the patient as a person – the patient has the words.

8. Allegretti 2010:11 convergence – current treatments are ineffective.

9. Allegretti 2010:11 convergence – patients suffered from severe or serious chronic low-back pain.

10. Allegretti 2010:11 divergence – treatment goal of reducing pain versus improving function.

11. Allegretti 2010:11 divergence – biomedical versus biopsychosocial model.

12. Allegretti 2010:11 divergence – the importance of a definitive diagnosis.

13. Åsbring 2003:152 illness and the professional role.

14. Åsbring 2003:152 illness versus disease.

15. Åsbring 2003:152 moral judgement of illness.

16. Åsbring 2003:152 moral judgement of patient.

17. Åsbring 2003:152 strategies to manage patients with illness – adjusting the ideal to reality.

18. Åsbring 2003:152 strategies to manage patients with illness – doing something concrete.

19. Åsbring 2003:152 strategies to manage patients with illness – giving the patient responsibility.

20. Åsbring 2003:152 strategies to manage patients with illness – keeping a distance or getting closer.

21. Åsbring 2003:152 strategies to manage patients with illness – trying to find causes other than biomedical ones.

22. Åsbring 2003:152 strategies to manage patients with illness – trying to get the patient to accept the situation.

23. Baldacchino 2010:153 factors associated with abuse, misuse or diversion of prescription opioids.

24. Baldacchino 2010:153 judgements about whether or not patient is substance user affects chronic non-cancer pain management.

25. Baldacchino 2010:153 management of chronic non-cancer pain among people with a history of substance abuse.

26. Baldacchino 2010:153 physicians’ attitudes to prescribing opioids for chronic non-cancer pain management.

27. Barker 2015:154 it’s quite a long way from physiotherapy.

28. Barker 2015:154 reconstructing ‘acceptance’.

29. Barker 2015:154 understanding pain as an embodied experience.

30. Barker 2015:154 it’s quite a long way from physiotherapy.

31. Barker 2015:154 value-based goals a profound motivation for positive change.

32. Barry 2010:155 physician factors – opioid agreements.

33. Barry 2010:155 logistical factors – addiction referrals.

34. Barry 2010:155 logistical factors – diagnostic workup.

35. Barry 2010:155 logistical factors – pain management referrals.

36. Barry 2010:155 logistical factors – time.

37. Barry 2010:155 patient factors – attitudes towards opioid analgesics.

38. Barry 2010:155 patient factors – cost of specialty pain management.

39. Barry 2010:155 patient factors – motivation.

40. Barry 2010:155 patient factors – physician responsiveness to patients’ pain.

41. Barry 2010:155 physician factors – aberrant behaviours.

42. Barry 2010:155 physician factors – coexisting disorders.

43. Barry 2010:155 physician factors – expertise in pain management.

44. Barry 2010:155 physician factors – expertise in treating co-occurring chronic pain and opioid addiction.

45. Barry 2010:155 physician factors – interest in pain management.

46. Barry 2010:155 physician factors – pain assessment.

47. Baszanger 1992:156 centre 1 – establishing the patients pain situation.

48. Baszanger 1992:156 centre 1 – formulating advice to patients (a logic of description and demonstration).

49. Baszanger 1992:156 centre 1 – formulating advice to patients (face-to-face relations and the work of justification).

50. Baszanger 1992:156 centre 2 – establishing the patient’s pain situation.

51. Baszanger 1992:156 centre 2 – formulating advice to patients a logic of explanation and conviction.

52. Baszanger 1992:156 centre 2 – mutual involvement and the work of agreeing.

53. Berg 2009:157 practising in a context of ambiguity – decision-making frameworks.

54. Berg 2009:157 practising in a context of ambiguity – response to ambiguity.

55. Berg 2009:157 practising in a context of ambiguity – the ambiguity of pain.

56. Berg 2009:157 practising in a context of ambiguity; decision-making frameworks – pain management strategies.

57. Berg 2009:157 practising in a context of ambiguity; decision-making frameworks – perception and management of treatment risks (risk of deception).

58. Berg 2009:157 practising in a context of ambiguity; decision-making frameworks – perception and management of treatment risks.

59. Berg 2009:157 practising in a context of ambiguity; decision-making frameworks – perception and management of treatment risks (risk of disciplinary consequences).

60. Berg 2009:157 practising in a context of ambiguity; decision-making frameworks – perception and management of treatment risks (risk of abuse).

61. Berg 2009:157 treatment goals.

62. Berg 2009:157 acknowledgment of the reality of pain and the search for objective evidence (primary care practitioners).

63. Bergman 2013:158 recognition of patient individuality and consideration of relationship history.

64. Bergman 2013:158 role of discussing pain versus other primary care concerns.

65. Blomberg 2008:159 detecting pain problems – other professionals’ pain care collaborations with district nurses.

66. Blomberg 2008:159 detecting pain problems – the organisation’s pain care support regarding district nurses.

67. Blomberg 2008:159 district nurses involvement in pain care.

68. Blomberg 2008:159 responding to pain problems.

69. Blomqvist 2003:160 exaggerated pain.

70. Blomqvist 2003:160 real pain.

71. Blomqvist 2003:160 self-inflicted pain.

72. Blomqvist 2003:160 trivial pain.

73. Briones-Vozmediano 2013:161 diagnostic approach (health professionals).

74. Briones-Vozmediano 2013:161 evaluation of the health professional–patient relationship.

75. Briones-Vozmediano 2013:161 therapeutic management (health professionals).

76. Cameron 2015:162 consultation time and historical events (consultation time).

77. Cameron 2015:162 information retrieval.

78. Cameron 2015:162 physiology, comorbidities and signs of ageing.

79. Cameron 2015:162 resources.

80. Cartmill 2011:163 communication and collaboration among colleagues.

81. Cartmill 2011:163 organisational structure.

82. Cartmill 2011:163 the client population.

83. Chew-Graham 1999:164 making and negotiating a diagnosis.

84. Chew-Graham 1999:164 the doctor–patient relationship – negotiation or conclusion.

85. Clark 2004:165 relationship-centred cues to residents’ pain.

86. Clark 2004:165 resident characteristics and attitudes – resident attitudes.

87. Clark 2004:165 resident characteristics and attitudes – resident behaviours.

88. Clark 2004:165 uncertainty in pain assessment.

89. Clark 2006:166 changes in pain knowledge, attitudes and practice – attitudes.

90. Clark 2006:166 changes in pain knowledge, attitudes and practice – practice.

91. Clark 2006:166 progressive solutions and suggestions for changing practice.

92. Côté 2001:167 approaches to manage occupational injuries – chiropractic’s strength in diagnosis and treatment.

93. Côté 2001:167 approaches to manage occupational injuries – patient-centred care.

94. Côté 2001:167 barriers and facilitators of return to work – related to the worker.

95. Côté 2001:167 barriers and facilitators of return to work – related to rehabilitation.

96. Côté 2001:167 barriers and facilitators of return to work – related to payer.

97. Coutu 2013:168 little known about worker’s representations, modifiable problem targeted.

98. Coutu 2013:168 little known about worker’s representations, non-modifiable problem targeted.

99. Coutu 2013:168 scenario of differences between clinical judgement and worker’s representations.

100. Dahan 2007:169 patient–doctor interaction and relationship.

101. Dahan 2007:169 the guideline – practical issues in relation to low-back pain guideline implementation.

102. Dahan 2007:169 the physician’s low-back pain treatment agenda.

103. Daykin 2004:170 ‘good’ patients and the challenge of ‘difficult’ patients.

104. Daykin 2004:170 ‘good’ patients and the challenge of ‘difficult’ patients – impact of treating difficult patients.

105. Daykin 2004:170 developing craft knowledge.

106. Daykin 2004:170 developing craft knowledge – enlarging one’s tool bag.

107. Daykin 2004:170 developing craft knowledge – gaining patient mileage.

108. Daykin 2004:170 developing craft knowledge – personal pain experience.

109. Daykin 2004:170 pain beliefs within the therapeutic encounter.

110. Daykin 2004:170 the role of empathy in certified nursing assistant’s care of residents with pain.

111. Dobbs 2014:171 attitudes as barriers to communication about resident pain care.

112. Dobbs 2014:171 worker strategies to detect pain.

113. Eccleston 1997:172 Q-analysis (professional accounts).

114. Espeland 2003:173 access to radiology services.

115. Espeland 2003:173 pressure from other health-care providers or social security.

116. Espeland 2003:173 the GP’s expectations about the consequences of ordering radiography.

117. Espeland 2003:173 the GP’s perception of patients’ wishes for radiography.

118. Espeland 2003:173 the GP’s perception of whether or not the patient really is ill.

119. Espeland 2003:173 the GP’s response of keeping control and trying to help.

120. Espeland 2003:173 the GP’s uncertainty – radiography just to be sure.

121. Espeland 2003:173 effect of chronic opioid therapy on doctor–patient relationship – examples of chronic opioid therapy embittering the doctor–patient relationship.

122. Esquibel 2014:174 effect of chronic opioid therapy on doctor–patient relationship – perspectives on ideal and difficult patients.

123. Esquibel 2014:174 effect of chronic opioid therapy on doctor–patient relationship – prescribing opioids (an unwanted burden, an ineffective solution).

124. Esquibel 2014:174 right to pain medications.

125. Esquibel 2014:174 understanding pain.

126. Fontana 2008:175 critical analysis – in the best interest of society.

127. Fontana 2008:175 critical analysis – in the best interest of the patient.

128. Fox 2004:176 barriers to the assessment and treatment of pain – caregiver-related barriers (beliefs and knowledge).

129. Fox 2004:176 barriers to the assessment and treatment of pain – caregiver-related barriers (insensitivity to patients’ pain).

130. Fox 2004:176 barriers to the assessment and treatment of pain – system-related barriers (documentation).

131. Fox 2004:176 barriers to the assessment and treatment of pain – system-related barriers (insufficient time for nursing staff).

132. Fox 2004:176 barriers to the assessment and treatment of pain – system-related barriers (lack of communication).

133. Fox 2004:176 barriers to the assessment and treatment of pain – system-related barriers (frustration).

134. Fox 2004:176 facilitation of the assessment and treatment of pain.

135. Fox 2004:176 facilitation of the assessment and treatment of pain – demonstrating understanding and compassion.

136. Fox 2004:176 facilitation of the assessment and treatment of pain – teamwork.

137. Gooberman-Hill 2011:177 are opioids the best option – managing adverse effects and assessing vulnerable patients.

138. Gooberman-Hill 2011:177 are opioids the best option – the importance of previous experience.

139. Gooberman-Hill 2011:177 are opioids the best option – views about opioid addiction, withdrawal and misuse.

140. Gooberman-Hill 2011:177 are opioids the best option.

141. Gropelli 2013:178 failure to communicate.

142. Gropelli 2013:178 lack of education.

143. Hansson 2001:179 working guided by medical ethics.

144. Harting 2009:180 confirmation stage.

145. Harting 2009:180 decision stage.

146. Harting 2009:180 implementation stage.

147. Harting 2009:180 knowledge stage – acquainted with innovation.

148. Harting 2009:180 knowledge stage – understanding of innovation.

149. Harting 2009:180 persuasion stage.

150. Hayes 2010:181 definition and diagnosis.

151. Hellman 2015:182 a coherent link with external actors facilitated the return to work process – enabling collaboration.

152. Hellman 2015:182 conflicting interests between implicit attitudes and explicit guidelines.

153. Hellström 2015:183 adhering to the biomedical paradigm.

154. Hellström 2015:183 avoiding recognising fibromyalgia as a possible biomedical anomaly.

155. Hellström 2015:183 establishing an instrumental relationship.

156. Hellström 2015:183 managing clinical uncertainty.

157. Hellström 2015:183 prioritising diagnostics.

158. Holloway 2009:184 advocating for residents.

159. Holloway 2009:184 clinical decision-making.

160. Holloway 2009:185 extended roles – clinical judgements.

161. Holloway 2009:185 extended roles – nagging.

162. Holloway 2009:185 perfect positioning.

163. Holloway 2009:185 perfect positioning (emotional attachment).

164. Holloway 2009:185 perfect positioning (frontline).

165. Holloway 2009:185 perfect positioning (knowing the resident).

166. Holloway 2009:185 perfect positioning (teamwork).

167. Howarth 2012:186 collective efficacy.

168. Howarth 2012:186 interprofessional development through negotiated space.

169. Howarth 2012:186 team maturity.

170. Kaasalainen 2007:187 reluctance of health-care providers to use opioids.

171. Kaasalainen 2007:187 uncertainty about the accuracy of pain assessment and diagnosis.

172. Kaasalainen 2007:187 working to individualise pain treatments.

173. Kaasalainen 2007:187 influence of physician trust of the nurse on prescribing patterns.

174. Kaasalainen 2010:189 health-care providers.

175. Kaasalainen 2010:189 residents/family.

176. Kaasalainen 2010:189 system.

177. Kilaru 2014:190 associations with underlying attitudes towards opioid prescribing.

178. Kilaru 2014:190 attitudes towards guidelines – liability.

179. Kilaru 2014:190 attitudes towards guidelines – patient diversion.

180. Kilaru 2014:190 attitudes towards guidelines – physician autonomy.

181. Kilaru 2014:190 attitudes towards guidelines – public health.

182. Kilaru 2014:190 definition and awareness of guidelines – hospital-based guidelines.

183. Kilaru 2014:190 definition and awareness of guidelines – state and national guidelines.

184. Kilaru 2014:190 how physicians use guidelines – communication.

185. Krebs 2014:191 need to protect patients from harm.

186. Krebs 2014:191 inadequate time and resources.

187. Krebs 2014:191 opioid monitoring as a ‘law enforcement’ activity.

188. Krebs 2014:191 relying on general impressions of risk.

189. Kristiansson 2011:192 distressed, offended and disappointed.

190. Kristiansson 2011:192 prepare for a race.

191. Kristiansson 2011:192 build a safe relationship.

192. Kristiansson 2011:192 no help.

193. Kristiansson 2011:192 see how it goes.

194. Kristiansson 2011:192 she disappointed.

195. Kristiansson 2011:192 she was really sad.

196. Kristiansson 2011:192 very high risk.

197. Kristiansson 2011:192 wants to try.

198. Kristiansson 2011:192 her whole tiredness over me.

199. Kristiansson 2011:192 scolded.

200. Kristiansson 2011:192 while away one’s days.

201. Kristiansson 2011:192 will be challenged.

202. Kristiansson 2011:192 not obvious without own assessment.

203. Kristiansson 2011:192 receive a dressing-down.

204. Kristiansson 2011:192 want to examine before a doctor’s letter.

205. Liu 2014:193 level of familiarity.

206. Liu 2014:193 pain assessor.

207. Liu 2014:193 reporter – appreciation of the importance of their role as proxy report.

208. Liu 2014:193 reporter – submissive attitudes.

209. Liu 2014:193 subordinate implementing prescribed medications.

210. Liu 2014:193 subordinate implementing prescribed medications – underused reassessor.

211. Löckenhoff 2013:194 age differences in time horizons (concerns about future side effects).

212. Löckenhoff 2013:194 patient–provider relationship.

213. Lundh 2004:195 an inconsistent patient.

214. Lundh 2004:195 devotion to help.

215. Lundh 2004:195 being a helpless helpoholic.

216. Lundh 2004:195 frustration.

217. Lundh 2004:195 helplessness.

218. Lundh 2004:195 ineffective tools.

219. Lundh 2004:195 variation 2.

220. Lundh 2004:195 variation 3.

221. MacNeela 2010:196 representing the person’s experience (depression).

222. MacNeela 2010:196 representing the person’s experience (social categories).

223. MacNeela 2010:196 representing the person’s experience (work and legal issues).

224. MacNeela 2010:196 the therapeutic relationship.

225. MacNeela 2010:196 the therapeutic relationship (gatekeeper).

226. MacNeela 2010:196 the therapeutic relationship (moral guardian).

227. MacNeela 2010:196 the therapeutic relationship (patient guide).

228. McConigley 2008:197 barriers to implementation – resource issues.

229. McConigley 2008:197 barriers to implementation – work role issues.

230. McConigley 2008:197 needs associated with implementation.

231. McConigley 2008:197 strengths to assist in the implementation process.

232. McCrorie 2015:198 features of transactions between patients and GPs – continuity of care.

233. McCrorie 2015:198 features of transactions between patients and GPs – mutuality and trust in the relationship.

234. McCrorie 2015:198 features of transactions between patients and GPs – locating control and responsibility for change.

235. McCrorie 2015:198 features of transactions between patients and GPs – absence of a shared management plan.

236. Mentes 2004:199 distraction, inspection and telling the charge nurse.

237. Mentes 2004:199 knowing the resident.

238. Mentes 2004:199 pain assessment face and eyes.

239. O’Connor 2015:200 being under one roof.

240. O’Connor 2015:200 case conferences or team meetings.

241. O’Connor 2015:200 patients as whole persons.

242. O’Connor 2015:200 patients help themselves.

243. O’Connor 2015:200 training.

244. Øien 2011:201 ambivalence and uncertainty.

245. Øien 2011:201 impatience and disagreement.

246. Øien 2011:201 seeking for common ground – a demanding negotiating process.

247. Oosterhof 2014:202 experiences concerning the interaction (being open).

248. Oosterhof 2014:202 experiences concerning the interaction (giving a clear explanation).

249. Oosterhof 2014:202 experiences concerning the treatment outcome – acknowledgement for the physical part or the pain.

250. Oosterhof 2014:202 experiences concerning the treatment outcome (shared understanding of the pain).

251. Parsons 2012:203 legitimating suffering (health professionals’ beliefs about being able to diagnose chronic musculoskeletal pain).

252. Parsons 2012:203 the evolving nature of patients’ and health professionals’ models of understanding chronic musculoskeletal pain (patients’ and health professionals’ beliefs about pain causation).

253. Parsons 2012:203 the evolving nature of patients’ and health professionals’ models of understanding chronic musculoskeletal pain (health professionals’ adaptation of causation beliefs).

254. Parsons 2012:203 development and tailoring of consultation and treatment approaches throughout patients’ illness careers (HCPs’ beliefs about consulting for and treatment of chronic musculoskeletal pain).

255. Patel 2008:204 GPs’ personal challenges.

256. Patel 2008:204 psychosomatic interpretations.

257. Patel 2009:205 expectation mismatch.

258. Patel 2009:205 the challenges of secondary care services.

259. Paulson 1999:206 needing human support (disturbing feelings).

260. Poitras 2011:207 clinical relevance.

261. Poitras 2011:207 environment – work organisation.

262. Poitras 2011:207 environment – work organisation.

263. Poitras 2011:207 peers and stakeholders.

264. Poitras 2011:207 therapists – agreement with the guidelines.

265. Poitras 2011:207 therapists – compatibility with current practice.

266. Poitras 2011:207 therapists – impact on low-back pain disability.

267. Poitras 2011:207 therapists – understandability of the guidelines.

268. Ruiz 2010:208 waiting times for pain clinic.

269. Ruiz 2010:208 concerns about using pain medications (addiction dependency).

270. Ruiz 2010:208 concerns about using pain medications (medication diversion).

271. Ruiz 2010:208 concerns about using pain medications (side effects).

272. Ruiz 2010:208 poor training in pain management (on-the-job training).

273. Ruiz 2010:208 poor training in pain management (self-directed learning).

274. Ruiz 2010:208 poor training in pain management (training as a student resident).

275. Schulte 2010:209 communication between GPs and pain specialists.

276. Schulte 2010:209 GPs’ attitude towards pain specialists.

277. Schulte 2010:209 referral from GPs to specialised pain centres.

278. Schulte 2010:209 experiences of GPs after referral to specialist pain clinics.

279. Scott-Dempster 2014:210 changing practice from ‘fix it’ to ‘sit with’.

280. Scott-Dempster 2014:210 process of realisation that life can be different – encourage self-reflection.

281. Scott-Dempster 2014:210 process of realisation that life can be different – realise I can do something.

282. Scott-Dempster 2014:210 process of realisation that life can be different.

283. Scott-Dempster 2014:210 process of realisation that life can be different – encourage self-reflection.

284. Scott-Dempster 2014:210 process of realisation that life can be different – discover through trying.

285. Scott-Dempster 2014:210 process of realisation that life can be different – patients can’t see.

286. Seamark 2013:211 chronic non-cancer pain is seen as different from cancer pain.

287. Seamark 2013:211 concerns around tolerance and addiction.

288. Seamark 2013:211 difficulties in assessing pain.

289. Seamark 2013:211 effect of experience and events.

290. Shye 1998:212 access to referral services.

291. Shye 1998:212 management expectations a double bind.

292. Shye 1998:212 patient characteristics.

293. Shye 1998:212 patient expectations – building and maintaining trust.

294. Shye 1998:212 time the scarcest resource.

295. Shye 1998:212 ambiguity of internal referral processes.

296. Siedlecki 2014:213 core concepts – frustration.

297. Siedlecki 2014:213 core concepts – moral distress.

298. Siedlecki 2014:213 core concepts – taking ownership.

299. Siedlecki 2014:213 core concepts – tenacity.

300. Siedlecki 2014:213 nurse characteristics – attitude.

301. Siedlecki 2014:213 nurse characteristics – discernment.

302. Siedlecki 2014:213 nurse characteristics – knowledge.

303. Siedlecki 2014:213 system barriers.

304. Slade 2012:214 blame game – physiotherapists are critical when care-seekers fail to improve.

305. Slade 2012:214 physiotherapists are challenged by diagnostic uncertainty (physiotherapists use surrogates for pathoanatomical diagnoses to provide solutions).

306. Slade 2012:214 physiotherapists are challenged by diagnostic uncertainty (communicating the truth is difficult – physiotherapists feel pressured to diagnose).

307. Slade 2012:214 physiotherapists perceive that care-seekers want a clear diagnosis.

308. Slade 2012:214 physiotherapists seek ‘certainty’ from experienced colleagues (professional ‘experts’ are attractive models).

309. Slade 2012:214 physiotherapists seek ‘certainty’ from experienced colleagues (workplace culture and mentors are important).

310. Slade 2012:214 practitioners feel underprepared by traditional education models (physiotherapists believe they are underprepared by their education).

311. Slade 2012:214 practitioners feel underprepared by traditional education models (experience is the real teacher).

312. Slade 2012:214 practitioners feel underprepared by traditional education models (physiotherapists believe they are underprepared by their education).

313. Sloots 2009:215 expectations regarding the aim of treatment.

314. Sloots 2010:216 reasons for dropout in rehabilitation patients (acknowledgement or legitimisation of the pain complaints).

315. Sloots 2010:216 reasons for dropout in rehabilitation patients (credibility with regard to foreign diagnosis).

316. Sloots 2010:216 reasons for dropout in rehabilitation patients (trust in the rehabilitation physician).

317. Spitz 2011:217 facilitators of opioid use – perceived patient-level barriers to opioid use.

318. Spitz 2011:217 frustration treating pain in primary care.

319. Spitz 2011:217 greater comfort using opioids in patients receiving palliative care.

320. Spitz 2011:217 provider barriers to opioid use – concerns about opioid abuse, misuse or addiction.

321. Spitz 2011:217 provider barriers to opioid use – concerns about regulatory and or legal sanctions.

322. Spitz 2011:217 provider barriers to opioid use – fear of causing harm.

323. Spitz 2011:217 provider barriers to opioid use – pain subjectivity.

324. Spitz 2011:217 providers’ opioid prescribing practices and attitudes.

325. Starrels 2014:218 beliefs about the utility of opioid treatment agreements – prevention of opioid misuse.

326. Starrels 2014:218 beliefs about the utility of opioid treatment agreements – diagnosis of opioid misuse.

327. Starrels 2014:218 beliefs about the utility of opioid treatment agreements – physician self-protection.

328. Starrels 2014:218 perceived effect of opioid treatment agreement use on the therapeutic alliance.

329. Starrels 2014:218 perception of patients’ risk of misuse.

330. Stinson 2013:219 barriers to care (health-care systems barriers).

331. Stinson 2013:219 barriers to care (societal barriers).

332. Stinson 2013:219 pain impact (future).

333. Stinson 2013:219 pain impact (physical impact).

334. Stinson 2013:219 pain impact (role functioning).

335. Stinson 2013:219 pain impact (social and emotional impact).

336. Stinson 2013:219 pain management strategies (pharmacological strategies).

337. Stinson 2013:219 pain management strategies (psychological strategies).

338. Thunberg 2001:150 professional ambiguity.

339. Thunberg 2001:150 professionals’ thoughts on ideal care.

340. Thunberg 2001:150 professionals’ thoughts on ideal care (holistic approach).

341. Thunberg 2001:150 professionals’ thoughts on ideal care (the patient in his or her context).

342. Thunberg 2001:150 professionals’ thoughts on ideal care (validating).

343. Thunberg 2001:150 professionals’ caring reality.

344. Thunberg 2001:150 professionals’ caring reality illness carried by the patient.

345. Thunberg 2001:150 professionals’ caring reality monofactorial aetiology.

346. Thunberg 2001:150 professionals’ caring reality objective analysis.

347. Toye 2015:220 a glimpse beneath the surface.

348. Toye 2015:220 a glimpse beneath the surface (the challenge of clinical time constraints).

349. Toye 2015:220 bombarded by despair – I’ve used the phrase detached empathy.

350. Toye 2015:220 bombarded by despair – it was a bit uncomfortable listening to the things she said.

351. Toye 2015:220 a glimpse beneath the surface (I can now see her struggle to perform pain).

352. Toye 2015:220 reconstructing the clinical encounter as a shared journey – we are going to chip away at this in bite-sized chunks.

353. Toye 2015:220 reconstructing the clinical encounter as a shared journey – this is a journey to healing not fixing.

354. Toye 2015:220 pitfalls of the medical model – the challenge of ‘sitting with’ (not fixing).

355. Toye 2015:220 pitfalls of the medical model – the challenge of breaking down the dichotomy of mind and body.

356. Tveiten 2009:221 challenges of conducting a dialogue.

357. Tveiten 2009:221 different dialogues and varying purposes.

358. Tveiten 2009:221 patient participation and the patient as an expert – easier said than done.

359. Tveiten 2009:221 the importance and characteristics of the good dialogue.

360. Wainwright 2006:222 clinical uncertainty.

361. Wainwright 2006:222 psychosocial problems and the doctor–patient relationship.

362. Wainwright 2006:222 psychosocial problems and the doctor–patient relationship (negotiated diagnosis).

363. Wainwright 2006:222 psychosocial problems and the doctor–patient relationship (covert shift to the psychosocial paradigm).

364. Wainwright 2006:222 psychosocial problems and the doctor–patient relationship (negotiated diagnosis).

365. Wainwright 2006:222 psychosocial problems and the doctor–patient relationship (overt shift to the psychosocial paradigm).

366. Wainwright 2006:222 psychosocial problems and the doctor–patient relationship – covert shift to the psychosocial paradigm (bridging technologies: fibromyalgia).

367. Wainwright 2006:222 psychosocial problems and the doctor–patient relationship – covert shift to the psychosocial paradigm (bridging technologies: amitriptyline).

368. Wilson 2014:223 symbolic languages – legitimisation of practice.

369. Wilson 2014:223 symbolic languages – diagnostic expertise.

370. Wilson 2014:223 symbolic languages – the evidence base.

371. Wilson 2014:223 symbolic languages – the individual patient.

372. Wynne-Jones 2014:224 approaches to evaluating patients’ work problems.

373. Wynne-Jones 2014:224 issuing of fit notes – GP as ‘patient advocate’.

374. Wynne-Jones 2014:224 perceived ability to manage ‘work and pain’.

375. Wynne-Jones 2014:224 policies and penalties in the workplace.

376. Zanini 2014:225 patients’ perspectives of their health condition.

377. Zanini 2014:225 patients’ perspectives of treatments.