Healthcare professionals’ experiences of interdisciplinary collaboration in pain centres – A qualitative study

2.1 Setting

Most pain centre facilities, including the Norwegian pain centres situated at the regional university hospitals, have been established as tertiary care facilities [20,21]. These Norwegian pain centres offer outpatient services where potential patients are referred by their general practitioners or medical specialists. The aim of the interdisciplinary Norwegian pain centres’ treatments is to relieve pain and/or provide better pain management, and also to improve the patient’s physical, psychological, occupational, and social functioning [21].

According to the national guidelines, the referrals to an interdisciplinary pain centre in Norway are to be assessed within 10 days, preferably by an interdisciplinary admission team comprising pain physicians, clinical psychologists, and physiotherapists [22,23]. The criteria for being granted pain centre treatment are expected benefit from the health care, that the expected costs are reasonably proportionate with the outcome of the intervention and that all other available primary and secondary care services have been tried before the pain centre referral [22]. This means that most individuals attending the Norwegian pain centres are persons not helped by other services in primary or secondary care [20]. The interdisciplinary pain centres should employ staff representing various health professions with special interest and expertise in working with long-term pain, exemplified in the guide for the Norwegian pain centres with doctors from various specialities, psychological/psychiatric specialists, physiotherapists, and nurses [21].

As a result, the pain centres care for a heterogeneous group of patients [5,23], typically those who generally have poor functioning and who often have tried many treatments without effect [24]. Because of this, the pain centres respond to different treatment needs. Examples of treatments offered at the pain centres are interdisciplinary assessments and classification of long-term pain conditions, educative group treatments and in collaboration with the general practitioner, try out or suggest treatments, and rehabilitations that can be continued in primary care [21]. The staff at each of the pain centres vary, but common for their treatment is thus the interdisciplinary approach, which typically comprises an interdisciplinary assessment followed by outpatient treatment by one or more of the pain centre professionals. This is followed by a final session with the patient in which all involved professionals are present [23].

2.2 Informants and recruitment

Eligible participants for this study were healthcare professionals who had worked for at least 1 year at one of the Norwegian regional pain centres. The aim was to have a variation of informants reflecting the healthcare professionals at the pain centres in terms of profession, age, sex, duration of work experience, and from which pain centre they worked. There were no exclusion criteria.

To recruit informants, the staff who met the inclusion criteria were sent an invitation by the pain centre management that included information about the intentions of the study and a consent form. Those who wanted to participate contacted the study to schedule a time and platform for the interview. The inclusion criteria were then checked and appointments for interviews were made. Recruitment continued until the data were considered sufficient to answer the research question.

In total, 15 persons responded positively to participate in the study. Three were excluded to avoid an imbalance in the number of informants from the various pain centres, and one did not respond to further contact. Accordingly, 11 informants were included in the study.

2.3 Data collection and interview guide

Data were collected with individual semi-structured interviews by the third author. The first four interviews were conducted face-to-face at the informant’s workplace while the remaining interviews were done by telephone due to Covid-19 restrictions. The interviews lasted from 28 to 59 min.

An interview guide was developed based on previous research and the authors’ experiences in the field. The main question asked was “Can you describe how you work interdisciplinary here at [location]?”, followed by questions on “How do you perceive that the interdisciplinary collaboration works?”, “Is there anything that you think works particularly well?”, and “Is there something you find difficult/challenging?”.

All interviews were audio recorded and transcribed verbatim.

2.4 Data analysis

The data were analysed using systematic text condensation, a descriptive thematic cross-case analysis strategy involving an iterative four-step analysis procedure [25]. In the first step, the authors read four interviews to gain an overall impression of the data and identified the preliminary themes: “What does interdisciplinary collaboration bring to the treatment of pain patients”, “What is important for a good interdisciplinary collaboration?”, “What challenges interdisciplinary collaboration”, and “How to develop the interdisciplinary work further”. In the second step, the first and third authors systematically reviewed all the interviews to identify meaning units relevant to the research question. The meaning units were then coded, classified, and sorted into code groups related to the preliminary themes.

In the third step, the first and third authors performed a systematic abstraction of meaning units within each of the themes, reducing the content into a condensate that maintained the informants’ sayings. The authors had several discussions resulting in adjustments and renaming of the themes. In the final step, the content of the condensates was synthesised into generalised descriptions and concepts, while ensuring that the result still reflected the original interview data. These are the descriptions that are presented in Section 3.

The first author identified illustrative citations, which were translated by the first author and validated by the co-authors. MindManager [26] was used as a systematisation tool during the analysis.

3.1 The best approach for chronic pain treatment

The informants said they considered an interdisciplinary health service to be the best approach for chronic pain treatment due to the complexity and long-lasting nature of the condition their patients suffered from, often including physical and psychosocial difficulties, trauma experiences, substance abuse problems, and opioid addictions. According to the informants, patients who were referred to the pain centre had already tried treatments from a wide range of separate health services across care levels without being sufficiently helped. Having several professionals together under one roof gave the patients access to expertise in several fields and this made the pain centre unique, in specific with regards to a psychological/physiological dichotomy.

“I am aware that many people may think that ‘it is all in the head’ or have a very dichotomous view that either it is psychological, or it is physical. But we who work here have a foot in both worlds and see the bigger picture. A service where you get that kind of treatment at the same time; you only get that here.”

(psychologist, informant 7)

Some informants talked about how the interdisciplinary collaboration at the pain centre was especially suited to handle patients who had tried several other healthcare services without being relieved of their pain. These informants argued that the interdisciplinary approach provided new perspectives on the patients’ situations, which led to new insights that could be used for discovering other types of treatment than the ones tried before. It was also said that they ought to interact more with the patient, specifically with regard to setting treatment goals and also, that they had to be aware so that they did not present the patients with treatments they already had received in other parts of the healthcare system. To achieve this, they had to collaborate interdisciplinary.

“That is when the interdisciplinary approach comes to its right when everything else has been tried. The reason why people have ended up here is because they have tried so much that has not helped.”

(nurse, informant 3)

To describe their interdisciplinary collaboration some informants pointed to the biopsychosocial model as a model that could guide their work regardless of profession. It was said that the model enabled a common understanding of pain and a language for how to talk about and discuss pain issues with each other. The emphasis of the model was explained by one informant who said that if you were not familiar with the model, you would be quickly socialised to think about different aspects of complicated explanatory models in line with the biopsychosocial model at the pain centre. However, some also said that they lacked a model that everyone agreed with and that the absence of such a common model made them struggle to make the interdisciplinary collaboration work.

“To a large extent, one lacks a common model. I think that is a challenge. Because then it is a bit too much up to the individual.”

(psychologist, informant 5)

3.2 Collegial collaboration

Working together with other disciplines in a team was something the informants enjoyed and found rewarding. One reason given was a shared mutual understanding of their patients’ needs. Another reason was a culture and a collaborative climate with a flat structure where the experience of a united “we” was strong and where conflicts or battles for positions between the various professionals in the team rarely arose. Also, because many of the patients at the pain centre had long and complex stories, the informants said that they appreciated the opportunity to share experiences with their colleagues and to lean on their colleagues’ expertise as well as support.

“Many people [patients] are very burdened with traumatic stories and experiences so that it is difficult to sit with it alone. If we are in a team, we have the opportunity for some debriefing afterwards.”

(physiotherapist, informant 11)

Knowing, respecting, and listening to each other and acting in a manner that helped each other to do a good job, was talked about as important for succeeding with the interdisciplinary collaboration. Specifically collegial support was seen as important because it helped them to reflect upon their practices as well as providing them with new knowledge. The informants said that the staff at the pain centre complemented each other, and they experienced working together as beneficial in terms of how they all were needed to enable good treatment for their patients. One concrete example talked about was sharing the responsibility for decisions:

“That you are not alone in the responsibility for it [the decision], that there are three of us who decide. I think the responsibility is less when more people are involved in it.”

(doctor, informant 4)

3.3 Challenges with interdisciplinary teamwork

One challenge with the interdisciplinary collaboration that was talked about was to know how much room each professional should have for making decisions about the treatment. Finding the line between what they as individuals wanted to do at the same time as they should function as a coherent group, could be challenging. One of the informants described this as an act of balancing the care of one’s professional field at the same time as sharing and participating in teamwork. For interdisciplinary teamwork, it was important that everyone in the team felt that they could speak freely at the same time as it was acknowledged that interdisciplinary work involved making decisions that not everyone agreed on. About this, the demand for flexibility from all professionals involved in the interdisciplinary work was emphasised but also talked about as demanding.

‘All of us have worked for many years, we have our point of view and are quite strong in our opinions’.

(doctor, informant 8)

According to some informants, the treatments could be hierarchically organised, for instance, reflected in which treatment options were given the highest priority. Imbalance in the team composition, ambiguities around the distribution of responsibilities, and varying degrees of knowledge about the competence and contribution of the other professions, were highlighted as possible explanations for why it sometimes was difficult to achieve a more equal and harmonious collaborative climate.

“It may be that we have two different points of view and such, it happens. Then we must solve it in the best possible way and not show the patient or next of kin that we strongly disagree.”

(doctor, informant 9)

Some of the informants had experienced that they had to fight to be included and heard in some of the interdisciplinary meetings and that they even felt disrespected and rejected by the other team members. For some, this was related to the team consisting of individuals with different understandings and the interdisciplinary work was dependent upon the different people working at the pain centre. One example was how it could be difficult to summarise interdisciplinary pain assessments when their suggestions for follow-up did not coincide. Another concrete example talked about, was the admission team meetings. There were different experiences as to whether these meetings were monodisciplinary or interdisciplinary, and that this often was related to resources more than to professional judgements or the actual patient’s needs.

“It is about not starting any form of treatment until all the therapists have spoken to each other. And in an interdisciplinary discussion, any treatment method should be able to take precedence.”

(psychologist, informant 5)

4.1 How does the interdisciplinary work in pain centres unfold?

It came across as a clear understanding among the informants that they worked in a setting where they cared for patients who had tried several other services before coming to them and that most individuals attending the pain centres were those not helped by primary or secondary care services, similar to descriptions in other studies [20] and the national guidelines [22]. Moreover, working with professionals representing different disciplines was emphasised by the informants as valuable and necessary when caring for this group of patients. This is in line with the described requirements for an interdisciplinary approach to meet the treatment needs of chronic pain patients, as well as with the framework for interdisciplinary pain clinics [5] and recommendations for chronic pain management [14]. Hence, the current study adds to previous knowledge on the perceived value healthcare professionals place on including several disciplines and perspectives when caring for persons with complex and long-term pain conditions with a history of trying several treatments.

One of the settings for interdisciplinary collaboration the informants talked about was the pain centres’ admission meetings. They reported that it varied whether these were monodisciplinary or interdisciplinary. According to the national guidelines, the referrals are to be assessed within 10 days, preferably by an interdisciplinary admission team comprising pain physicians, clinical psychologists, and physiotherapists [22,23]. Notably, it has been shown that referrals for admissions at Norwegian pain centres are assessed differently [27]. Although the current study did not focus on the admission process, it can be assumed that what happens in the admission meetings has implications for how the interdisciplinary work unfolds. Moreover, not having an interdisciplinary admission process could be regarded as a contrast to the overall recommendations on interdisciplinary collaboration in pain management which emphasise that the professions should work “under one roof” [14], implying that the work processes should in principle be carried out interdisciplinary.

However, due to its nature, interdisciplinary work also comes with a cost because more time is needed for each patient. This is one likely reason why access to interdisciplinary care is limited [28], and why nurses working in pain centres have commented on limited resources [19]. It might also be the reason why admission meetings not always are carried out interdisciplinary. Nevertheless, this points to a possible dilemma on how to conduct interdisciplinary work in both an efficient and sustainable way, as well as within resource boundaries and recommendations and guidelines. The example of having one professional seeing the patient at the time implied that experts within each discipline worked in parallel and were thus able to meet more patients using the same amount of time as if they only had common sessions with one patient where all professions were present. Whether doing more of the work together would lead to even better interdisciplinary collaboration or more efficient results is an open question. However, given the challenges described in reaching an agreement on which treatment to recommend, the results of the current study indicate that in some cases other solutions could be explored, as there are examples of studies that have not found interdisciplinary treatments or interprofessional collaboration to be better than other treatments or practices [29,30]. Hence, it might be that the potential of interdisciplinarity is not reached with the described organisation of the work, including the potential of including the patient to a larger extent in the team, for instance in activities related to setting treatment goals.

4.2 Facilitators and barriers to interdisciplinary collaboration

We found that the experiences of having a common model ranged from being spoken about as having the biopsychosocial model as a model to guide the interdisciplinary work to a lack of a common model. Having a common understanding and language for chronic pain, and especially working with the biopsychosocial model, was said to be a facilitator for interdisciplinary collaboration. This is in line with the well-established recognition that the nature of chronic pain conditions is influenced by a range of biopsychosocial factors, leading to clinical guidelines and recommendations that build on a biopsychosocial framework for management [31]. However, as indicated in previous studies, integrating and implementing the biopsychosocial model into clinical practice has been found suboptimal [32] and to be complex [33]. This is supported by a recent systematic review on physiotherapists’ perceptions of learning and implementing biopsychosocial interventions, which found that the physiotherapists reported feeling inadequately trained and lacking the confidence to deal with psychosocial issues and that this hampered their implementation of biopsychosocial interventions [34]. Following this, one could argue that by learning from each other, the members of the interdisciplinary teams could enhance their understanding, for instance of psychosocial issues [35]. This would align with how the informants spoke about collegial collaboration as important for providing them with new knowledge, including knowledge about each profession’s distinct character.

According to informants, occasionally, the different treatments at the pain centre could be looked upon as hierarchically organised, for instance, reflected in which treatment options were given the highest priority. This has previously been described as a challenge with teamwork when team members have different training, knowledge, and attitudes [36]. More specifically, it has been stated that interdisciplinary teamwork in health can contribute to reproducing existing divisions and hierarchies among healthcare professionals [17]. The magnitude of this in pain centres, cannot be said based on the current study. However, the identified dilemma between how much room each professional should have for making decisions about the treatment and the need for making joint decisions can lead to decisions not everyone agrees to. This is likely to require a good collaborative climate, to allow discussions that challenge their ways of working.

Previous research has described the importance of team training for improved efficiency in interprofessional teamwork [37]. A recent study on teamwork in hospitals [38] pointed out that learning does not just happen, it requires tools like for instance TeamSTEPPS or methodology for reflective teams [17,39]. Moreover, learning depends on a supportive climate and culture [13] where participants feel psychologically safe [40]. The informants in the current study emphasised that their colleagues were supportive of them in carrying out their work because the patient group they cared for most often had complex problems that had lasted over time. Hence, an open, equal, and supportive climate would serve as a facilitator to achieve the profits of interdisciplinary collaboration in the same way as a climate without mutual respect would be a barrier.

4.3 Strengths and limitations

A strength of the study is the novelty in the exploration of professionals’ experiences of interdisciplinary collaboration at pain centres. The aim was to obtain data that represented variations in health professionals’ experiences with interdisciplinary collaboration in Norwegian pain centres to answer the research question. In line with Malterud [41], our aim was not to head for a complete description of all aspects of professionals’ experiences in the pain centres but to offer new insights that can contribute substantially to or challenge current understandings. However, with that said, we cannot rule out that additional informants might have added other experiences to the analysis. Moreover, the sampling strategy could have led to a biased sample as the informants were initially identified by the pain centre management and other professionals might have had other experiences. This includes having more younger informants who would have been earlier in their careers and other professions working at pain centres not represented in this study. Nevertheless, our sample showed variation regarding various experiences of interdisciplinary collaboration at the pain centres.