Multiprofessional assessment of patients with chronic pain in primary healthcare

2.1 Multiprofessional assessment

This study was part of a pilot project aimed at evaluating a new way of working with chronic pain patients, where they undergo a multiprofessional assessment and receive a rehabilitation plan. This has been done at the primary healthcare centre in Jakobstad, Finland since August 2015. Jakobstad is a bilingual city, where both Finnish and Swedish are spoken. Patients with chronic pain are recruited to a multiprofessional assessment. They fill out the Swedish Quality Registry of Pain Rehabilitation (SQRP) primary care questionnaire. SQRP is used in Sweden to evaluate patients taking part in MMR [14], [20]. The patients then undergo an individual assessment where they sequentially meet a physician, physiotherapist, and nurse. Afterwards, the team meets and discusses the best rehabilitation design. If the team finds that further investigations are required, the patient is referred to specialty care. After this, a rehabilitation plan based on the team members’ assessments and participant’s wishes is outlined. The time required for completing these steps varies from a few weeks to many months, depending on the patient’s problems. The rehabilitation plan may contain recommendations for physiotherapy, medication changes, contact with a social worker, a plan for lifestyle changes, or something else that the team considers essential to ease the individual’s pain. The main responsibility on following the rehabilitation plan lies on the patients, and they are expected to participate actively in rehabilitation. The aim of the assessment is also to better coordinate patient care, which is done by a nurse coordinator whose goal is to facilitate future contact with healthcare. All of the patients can directly contact the coordinator when needed. One year after the assessment, results for each patient are evaluated using the SQRP-primary care questionnaire.

2.2 Subjects and setting

Each patient who entered the assessment project from August 2015 to January 2016 was recruited to this study. Criteria for entering the project were: pain lasting over 3 months, age between 18 and 65 years, a score of over 50 points on the Örebro musculoskeletal pain questionnaire [21], [22], and lack of access to a similar multiprofessional assessment through occupational healthcare.

For this study, participants must have finished the multiprofessional assessment. Twelve patients met these criteria. Each was contacted by telephone in February or March 2016, and asked to take part in an interview. Participants were informed that participation was voluntary. Two patients refused or did not show up for interview. Ten patients agreed to participate and were included in the study. Six were women and four were men. Their age spanned from 22 to 59 years, and they had gone through assessment 3–6 months prior to being interviewed. Since the evaluation of the assessment was done after 1 year, none of the participants had at the time of interviewing yet evaluated the results of their assessment. Table 1 shows background data of the participants.

2.3 Data collection

The interviews were conducted during February and March 2016, 3–6 months after the patients had finished the assessment and received their rehabilitation plans. Nine interviews took place at a local hospital and one was performed at the participant’s home. Each participant gave written informed consent prior to the interview. Individuals were interviewed once, for a period of 15–45 min. Seven interviews were performed in Swedish and three were in Finnish. All interviews were performed by the first author, using an interview guide with open-ended questions in order to allow the participant to answer more freely. An interview guide was used as a tool for covering the same areas in each interview, even though the questions differ. The interview guide covered participant expectations and experiences of the multiprofessional assessment, their role in the assessment, and questions about how they view themselves and their future after going through the assessment.

All interviews were digitally recorded in MP3-format, transcribed verbatim in the language of the interview, and anonymized.

2.4 Analysis

The data was analysed by qualitative content analysis with an inductive approach [23]. Each interview was read through several times, to gather information about the participant’s thoughts. The interview text was split into meaning units that included words, sentences and paragraphs, which were related through content and context. Each meaning unit was labelled with a code using OpenCode 4.03 software [24]. The Swedish and Finnish interviews were coded in Swedish. The first author coded all interviews, and the other authors each coded a few interviews. Throughout this process, the authors worked in close collaboration. Codes sharing a common content were grouped together to form preliminary categories. Preliminary categories were further processed into subcategories and the final categories. The first author documented her thoughts throughout the entire process, and used these notes to help find the preliminary categories during the analysis. Table 2 shows an example of how the analysis process works.

3.1 Feeling chosen or not quite fitting in

This category describes different feelings participants had when entering the assessment. Most expressed a feeling of thankfulness, and of being chosen when they were given the opportunity to participate in the assessment. They felt the assessment was important, as a place where people suffering from chronic pain could be taken seriously and offered help. The entire experience was described as a positive surprise.

“I have been very grateful. […] I have a new opportunity. It’s such a wonderful feeling.” – Participant 7

However, some of the participants did not feel like they actually belonged in the assessment. This was attributed to different reasons, such as not having enough pain or not having the right type of pain.

“I thought before [as I was offered an assessment], ‘What is this, really?’ […] Because I am not that sick.” – Participant 10

Some participants described one of the most important motivators to participate was to be able to help other patients with similar problems, since participants were told that the assessment was a part of an evaluation project.

3.2 More than just an examination

Participants found it important to be thoroughly examined. Several of them described satisfaction in this aspect of the assessment. They were satisfied with how the examination covered more than just the most obvious dimensions of their pain.

“Instead of being sent here and there, you know, someone really looks into what is behind it all.” – Participant 3

The examinations were described as helping participants to see themselves and their situations in another light. In that way it also likely fostered their rehabilitation process.

“Because you had to sit and think when you were with [the coordinator]. Think a little about how you actually live, and treat yourself. […] It was an eye opener.” – Participant 2

Participants thought that a thorough examination was important because they had such a strong desire to find a cause to the pain. They described a strong trust in the team’s competence, and therefore trusted the team’s actions. Some of the participants found that answering the SQRP-questionnaire was difficult. Others expressed satisfaction with the questionnaire and how well it covered all aspects of their pain problems. The follow-up was also described as important. One reason was that the follow-up provided motivation, and helped participants see more clearly how they had improved. The follow-up was felt to be proof that they would not be abandoned to take care of themselves.

“It is really important that it gets followed up, that it actually has changed. That it isn’t just abandoned.” – Participant 1

3.3 Being affirmed

In this category, participants described different aspects of satisfaction with the way they were treated by the team members. When compared to treatment outside of the team, they were especially satisfied. The experience of being taken seriously by team members was a big relief. This attitude helped to create a feeling of truly being seen, and this was described as important and increasing trust in the team. Examinations by each of the professions on the team were experienced as important because they made the patients feel important. The fact that the team felt that participants were worthy of a thorough examination was valued and played an important role in the rehabilitation process. This was often compared to earlier healthcare encounters.

“…and I felt like she [the coordinator] actually wanted to help. And took seriously what I said, and not just looked at the papers.” – Participant 10

Another positive experience was how team members took the time needed to do their jobs thoroughly, including examinations and medication follow-up.

“…we were discussing, I can’t remember anymore how long I sat there, but it felt like I sat there for two hours and discussed all the possibilities.” – Participant 2

The discussion was described as important, how getting the chance to talk about the situation was helpful and improved the participant’s mood. The team members were described as good at listening.

“Sometimes you are in a bit of a better mood, when you have been talking to someone, […] already that affects a lot in itself.” – Participant 9

Another important aspect was the feeling of being taken care of. Sometimes just meeting someone was helpful, and the participants also described a relief in being helped. The participants were mostly pleased with how they were treated by the team, especially compared to earlier health care encounters.

3.4 Receiving support

Team members were described as providers of support. The fact that the team, especially the coordinator, stayed in touch with the participants after the assessment provided participants with a feeling of safety. When extra team support was needed, staying in touch was perceived as an important factor. Participants thought that having a team contact person was important. Contact with the healthcare system at large was eased, mostly by the work of the coordinator. However, some participants did not feel that things had become any easier, but expectations that future health contact would become easier were expressed.

“Because I know that if I have something to ask or anything […], I know that I can call her [the coordinator] and ask.” – Participant 10

Participants described how team members spurred them on by providing extra motivation to help them reach the goals in their rehabilitation plan. Providing concrete goals and a clear rehabilitation plan was an important motivational boost. Some participants described a rise in motivation from knowing that the team had expectations that they would achieve their goals.

“But it still kind of spurs you that she will call and ask, and I don’t want to sit and lie to her. So you… do it a bit better then.” – Participant 2

3.5 Confusion and disappointment

Participants were less pleased about some aspects of the assessment. Some were confused by the assessment, and this was primarily due to an experience of not receiving enough – or any – information. There was some confusion about the meaning of terms related to the project, for example, what the coordinator did, what was included in the assessment, and what the rehabilitation plan was. Some participants explained that they found it difficult to know which healthcare professionals were a part of the team at times. Sometimes the information provided increased confusion rather than making things clearer.

“I was mostly very confused, because I didn’t understand at all [after receiving information prior to the assessment].” – Participant 2

On the other hand, there were participants who were satisfied with the information provided and felt they received enough information at the beginning of the assessment.

Some were disappointed because they expected or wanted more (e.g. more examinations during the assessment, more meetings with team members).

“Well, I remember that I was thinking ‘Oh, was that all?’.” – Participant 9

Some participants wished for a different type of rehabilitation. There was a strong desire to find something other than medication to ease the pain. Some said that they did not get their desired results from participation. Slight disappointment with the team that was mainly due to poor communication was described. For example, when the participant had a different opinion than the team about the cause of pain, or the participant did not understand why certain examinations were done.

“My knees were x-rayed. […] I have never had pain in my knees.” – Participant 8

Some participants described how they had to seek private healthcare to sort out their problems because it took too long to get results, or they were disappointed in the care offered through the assessment.

3.6 Taking and receiving responsibilities

Even though participants received help and support from the team, in the end they felt that it was up to them whether or not they were going to get better. The team helped them by providing the opportunity to get better, but only the participants themselves could make the required decisions. Even though some participants said they had not taken the required steps, they knew they had to take them in order to get better, and said that they could manage to do so.

“I have learned that I would really need to get a grip and do something about it myself.” – Participant 2

Some of the participants described a strong motivation to take responsibility in the rehabilitation plan in order to achieve the desired results, and were willing to work hard for this.

“I want to do all that I can to get this arm back in shape.” – Participant 7

Others found it hard to manage it all on their own, expressed how hard it was to take responsibility and stick to the rehabilitation plan. However, most of the participants felt that they had successfully taken the responsibility of following the rehabilitation plan at home, and thought that they were managing well with this. They felt they were expected to take on a lot of responsibility.

“Well, my rehabilitation plan is mostly that I do all these exercises myself.” – Participant 8

Participants were satisfied with their contribution to the team. They described participation as being able to choose between different options of care, and felt that the team listened to their proposals.

“…I have discussed (it) with a few people, who all have asked what my opinion is.” – Participant 9

Some described how they wanted to participate more in developing the rehabilitation plan, while others felt that they had no need to participate to a greater extent.

3.7 Effects of the assessment and a look at the future

Most participants experienced an improvement in their situation, but some did not experience any relief of their pain problems. Some participants expected that the pain would continue to improve because of the assessment. When asked to describe how they saw their future, they had a positive view that ranged from being able to return to work, to being completely pain-free. Some participants did not expect their future to look any brighter than their present. When answering questions about future concerns, participants were afraid that the pain would increase again, and had some worries about what the future would bring in terms of pain, complications, and other related problems.

4.1 Methodological discussion

Two of the authors have extensive experience in qualitative studies, and the research group consisted of different professionals, as well as capturing clinical experiences from speciality clinics and primary healthcare. This permitted different perspectives on the findings and strengthen the study credibility and trustworthiness. One of the authors had work experience with MMR. During the analysis, the authors reflected on whether their clinical experiences might have influenced the analysis. The same person (AL) performed all the interviews and did the core coding of the interviews, as she could better understand the context because she saw the participant’s body language. Two seminars were arranged with personnel from two speciality clinics to enhance reflections on the results and further strengthen the credibility.

The participants’ various experiences (age, education, duration of pain, and gender) strengthen the credibility as we capture variety aspects on the research-question. For the same reason, it is a strength that participants were both Finnish-speaking and Swedish-speaking. However, it is a weakness that participants only came from one healthcare centre. The work would have been further strengthened if we had discussed and verified the results of the analysis with the participants. This was not possible due to time schedule.

To enhance dependability, the researchers prepared an interview guide to let all participants have the chance to reflect on all areas.

According to Granehim and Lundman it is the reader’s decision whether or not the findings are transferable to other contexts [23]. To facilitate transparency, we have described the context, and the participants in the study and clearly described the sampling and analysis procedure. Ethical considerations were made. All participants in the study gave written informed consent prior to the interviews, and were informed that they could stop the interviews whenever they wished. They were informed that their assessment and rehabilitation plan would not be affected by their decision to join the study or not. All interviews and information were anonymized when transcribed, and the results are not presented at an individual level. The participants were informed that anonymized quotes from the interviews could be used in the study reports.