For the December meeting of the Qualitative Methods Journal Club, faculty and students from Simon Fraser University (Canada) discussed an article examining the experiences of doctors and nurses in primary care who work with people experiencing chronic pain. The study findings spoke to the challenges of doctors and nurses providing chronic pain care, and the challenges their patients faced due to health and social inequities.
About this month’s journal club
The article (available here) was discussed online (Zoom) within Simon Fraser University. Members included research and teaching faculty as well as postgraduate and graduate students from across institutions and organisations. Alissa Greer (School of Criminology, Simon Fraser University) presented and led the discussion alongside Sheri Fabian, Naomi Zakimi (School of Criminology, Simon Fraser University), Amanda Butler (Health Sciences, Simon Fraser University), and Jessica Xavier (British Columbia Centre for Disease Control). They gave the following insight into the December 2021 meeting of the journal club:
“Members of our journal club loved this article. It was beautifully written, and we all genuinely enjoyed reading it. The paper served as an excellent basis for discussion about methodology, writing style, and real-world implications. We enjoyed the emphasis on intersecting social conditions, including poverty and other marginalised positionings, of people experiencing chronic pain and how this impacts their care. The findings were especially relevant to current public health policies related to safer supply prescribing across Canada.”
Summary of the article
The article by Webster and colleagues focused on the experiences of doctors and nurses in primary care who work with people experiencing chronic pain in Ontario, Canada. The researchers took an institutional ethnographic approach to examining the everyday work problems of primary care providers that are situated within institutions, policies, and discourses.
In-depth interviews were combined with ~40 hours of observation data of care providers’ daily work. The sample included 19 physicians and 9 nurses. The researchers used several techniques to improve the methodological rigour of the study, including researcher and data triangulation, reflexivity, debriefing, field notes, and other methods – thus increasing the trustworthiness of the findings.
The findings of this study spoke to the challenges and experiences of doctors and nurses providing chronic pain care. Chronic care providers spoke about the challenges their patients faced due to health and social inequities. Providers felt overwhelmed, frustrated, and ill-equipped to provide support for chronic pain patients with co-occurring social or health issues. They also grappled with prescribing opioids and their training and beliefs around substance use and addiction. Prescribing opioids was difficult in the context of the opioid crisis and the guidelines they were given.
The study highlighted two main issues. First, that physicians feel ill-equipped in their work of prescribing opioids to chronic care patients and require more training, support, and guidance. And second, that it is important for healthcare providers to recognise the socioeconomic position of their patients to, as the authors suggested, meet the complex needs of people with chronic pain.
Discussion of the article
Institutional ethnography as an approach
Institutional ethnography was a new approach to qualitative research for some of our members. As the authors noted, institutional ethnography is an approach rather than a prescriptive set of methods. Institutional ethnography takes everyday work or daily activities and points to the institutional arrangements that might be linked to them – in this case, by examining how pain care providers’ everyday work is organised and shaped by both health and social institutions. We discussed the utility of this approach and agreed that exploring day-to-day work challenges is an excellent way to illuminate the institutional forces at play. In doing so, this methodology can produce findings with real-world implications. In reading this article, some members now want to apply institutional ethnography to their own research.
Although we appreciated the use of observations in healthcare settings for data triangulation, we were looking for more details about how this was done. Institutional ethnography was different from other ethnographies we have read, which are often in long-form (i.e. books). Ethnographic observations seemed to be used as a tool, rather than methodology, to complement, corroborate, and expand on the interview data.
Narrative findings and use of quotes
The findings in this paper were presented as one long narrative without subheadings or themes. Our group particularly liked this style. The findings section was detailed and flowed without being interrupted by headings and new ideas. We liked that the authors introduced and explained the overall findings at the beginning of this section. Webster et al.’s use of quotations was particularly effective: they presented what they saw in the data and their interpretation, and the quotations were supportive. The use of quotations was refreshing as many qualitative papers rely on the reader to interpret quotations on their own.
“This study sparked a lively conversation around the implications of opioid prescribing.”
This study sparked a lively conversation around the implications of opioid prescribing. For us, there were several practice implications, raising questions around differences in risk threshold across care providers, the need for clearer pain care and prescribing guidelines, and the comfort and role of clinicians in the healthcare system. For example, providers acknowledged their inability to offer social supports because of their lack of training – yet were aware of the need to address social inequities to effectively manage their patients’ pain.
Providers received little guidance on how to prescribe opioids, yet there were high expectations on prescribing and a demonstrable need to offer chronic pain care. The authors pointed to the need for better guidance, training, and an examination of provisions that may support and/or impede providers’ willingness to prescribe. The study made us think critically and question both the role and overall expectations that are placed on healthcare providers to offer pain management and prescribing. Pain care providers therefore may need better training and practice guidelines to inform their everyday work and decision-making, particularly amid the overdose crisis.
We talked about how the experiences of the nurses and physicians in this study may not be unique to just pain care providers; other professionals positioned within health and social systems may also experience similar challenges. This reflection led us to discuss the transferability of the findings, or how the findings could be applicable to other groups or contexts. Specifically, we discussed the experiences of police officers and how the current study’s findings might apply to their day-to-day work.
Further discussion points:
- It was refreshing to see a socioeconomic lens being used in this study; it “turn[s] a sociological eye” on clinicians offering care to people experiencing chronic pain and considers social determinants of health-consequent inequities and the positionality of clinicians within that structure.
“We thought that socioeconomic differences between providers and patients was interesting, as a lack of empathy was a barrier to care.”
- We wondered if there were differences between nurses and physicians, as we see differences across nurses and physicians in safer supply access.
- It was good to see that the authors noted differences between northern and urban locations in their study.
- We hoped to see more use of an intersectional lens in the findings, including poverty, race, and ethnicity, which is noted in the discussion. We wondered if the disconnect might be due to the subsample. But we thought that socioeconomic differences between providers and patients was interesting, as a lack of empathy was a barrier to care.
- The paper would serve as an excellent reading for a graduate-level qualitative methods course.
About the article
Webster, F., Rice, K., Katz, J., Bhattacharyya, O., Dale, C., & Upshur, R. (2019). An ethnography of chronic pain management in primary care: The social organization of physicians’ work in the midst of the opioid crisis. PLOS ONE, 14(5), e0215148. https://doi.org/10.1371/journal.pone.0215148
The article can be accessed here.
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