Philosophical and theoretical foundations of interpretative phenomenological analysis

In the health sciences, phenomenology has been used in qualitative research for thorough understanding of the lived experience of pain.

Interpretative phenomenological analysis (IPA) is a qualitative research method that examines how people make sense of major life experiences and offers an accessible approach to phenomenological research, intended to give an immersed account of the individual experience [30]. Its theoretical framework is mainly based on phenomenology, hermeneutics, and idiography [31], which makes it possible to explore the ambiguous and elusive nature of the pain phenomenon, especially persistent pain, involving complex bio-psychosocial interactions [32]. Further, it allows for a detailed account of each participant’s experience, both within and between the different accounts.

Participants and settings

Participants were purposively sampled from a pain clinic and an addiction clinic at a university hospital in Sweden. The clinics are tertiary care units with patients from all over Sweden, offering multimodal, interdisciplinary pain rehabilitation, consultation visits, and pharmacological therapy. The clinics offer both inpatient and outpatient care. The pain clinic treats about 2000 patients per year, and about 170 of these are on COT. The addiction clinic provides treatment for substance use disorders. Patients with chronic pain are referred to the clinic for opioid agonist therapy, where their opioids are switched to methadone or buprenorphine, to induce better pain relief and reduce opioid tolerance, withdrawal symptoms, and cravings. Patients recruited from the addiction clinic were attending an outpatient program that treats about 150 patients with chronic pain and problematic opioid use without current illicit drug use.

Eligible for participation were individuals 18–65 years of age with chronic pain and COT, currently in employment or work rehabilitation, and with work experience. Being a full-time student was considered equivalent to current employment. We aimed to recruit a reasonably homogenous sample of participants, where all had experiences of chronic pain, COT, and work. Thus, we could examine similarities and differences within the sample in some detail as regards COT and chronic pain [31]. A sample size of about 10 individuals was considered to be sufficient, since we aimed for a detailed account of individual experiences, rather than thematic saturation, in accordance with IPA methodology [31].

Procedures

Following approval from the regional ethical review board in Uppsala (Number 2017/265), information about the study was posted in the clinics’ waiting rooms. It provided contact information to the first author so that interested participants could volunteer for the study. However, a majority of the participants, 9 out of 10, were recruited through physicians who treated patients with chronic pain with opioids. Suitable participants who agreed to be contacted were approached through e-mail or phone by the first author, and received first-hand verbal and written information about the study, including information about the possibility of an observer participating during the interview. Immediately prior to the interviews, consent forms were provided and signed by the participants. Before their interview started, each participant filled out a medical data form providing demographic information and data regarding pain duration and medication. An observer was present in 5 out of 10 interviews and conducted field notes describing the context, flow, and ambience during the interview. If only the interviewer was present, field notes were taken in conjunction with the interview, but not during. Eight out of the 10 interviews took place in the facilities of the addiction clinic, which offered an environment suitable for confidential and sensitive conversations. The facility is open to the public, with a large variety of people coming and going, e.g., patients with various kinds of psychiatric problems (not only substance-related), students, and health care personnel, which makes it a non-stigmatising environment to visit. Upon request from one of the participants, her interview was held in her home. One interview was held at a participant’s workplace, as this was most convenient for her. The interview was conducted in her office with no one present except the participant, the interviewer, and an observer who was a member of the research team.

Data collection and analysis

Medical data were retrieved from medical records and from the medical data forms completed by the participants prior to the interviews.

The first author (HL) conducted the interviews. HL has long experience as a clinical social worker, working with patients on opioid agonist therapy, and is an experienced clinical interviewer trained in the qualitative method. A semi-structured interview guide based on open-ended questions was used for the interviews and is presented in Fig. 2. The guide was developed with guidance from the literature regarding qualitative methods [31, 33], and important topics were established by going through current literature on research regarding chronic pain and COT. The interview guide was used in a way that could promote openness and allow the informants to discuss the matters most pertinent to them. The participants were encouraged to raise topics of importance to them; by doing so, they led the interview and disclosed their experiences of pain and opioid use. The interviewer was free to probe further on topics generated during the interviews that were consistent with the aims of the study, e.g.: “In what way have you had to change tasks?” “Do you mean…?” The interview guide was piloted once before data collection started, which mainly generated comments on interviewer technique. Interviews lasted between 44 and 75 min. The interviewer had no prior relationship to the participants.

Fig. 2 Interview guide used for the semi-structured interviews Full size image

During the interviews with IPA01, IPA02, IPA08, IPA09, and IPA10, an additional researcher participated as an observer (SW or HZ, both trained physiotherapists and PhD students) and was allowed to pose relevant questions.

The interviews were audio recorded and transcribed verbatim for analysis. Transcript notations used in quoted extracts are presented in Fig. 3 in conjunction with the quotes.

Fig. 3 Transcripts notation used in quoted extracts Full size image

Interpretative phenomenological analysis (IPA), in accordance with Smith et al. [31], was used for analysing the data. Each transcript was first analysed separately to explore the distinctiveness in each case, as well as experiences, before making more general claims. The transcripts were read and reread several times by the first (HL) and second author (AR). AR is a pain specialist and medical doctor (MD) with long experience of working with patients suffering from chronic pain. She also has extensive experience working with patients with chronic pain and COT, including opioid agonist therapy. The two coders were from different disciplines, to ensure multiple perspectives on pain and opioids in the analysis. The first author followed the process outlined by Smith et al. [31], with a close reading of the transcripts, which generated initial notations that were descriptive, linguistic, and conceptual, to deepen the interpretation of the text. After the initial notations were made, the transcript and notes were entered into the coding program OpenCode 4.02, which is a tool for coding qualitative data generated from text, such as interviews, observations, and field notes [34]. Here, it was used to organise emergent themes and super-ordinate themes closely linked to the transcripts and the initial notes. After each transcript was analysed, the two analysts met to discuss the emergent and super-ordinate themes assigned to the transcript. Through this procedure, themes evolved further and enabled coders to consider the transcripts from different perspectives. This ensured that the interpretations stayed close to the text and the participants’ accounts. When new cases were included in the analysis, efforts were made to bracket, i.e. putting aside, prior ideas and themes that had emerged from previous cases.

After the completion of a separate analysis of every transcript, a cross-case analysis was conducted using the same strategy as for the individual transcripts. Shared themes across cases, relevant to the purpose and aim of this study, were identified, and corresponding texts from the transcripts were assigned accordingly. Patterns and connections between the shared themes were examined, and new super-ordinate themes evolved.

HL’s and AR’s analyses of data were triangulated by the last author (PÅ), who checked for methodological rigor, consistency between themes and quotes, and levels of interpretations. PÅ is a physiotherapist and a full professor in Physiotherapy who is experienced in qualitative method and has clinical expertise in behavioural medicine treatment for persons with chronic pain.

Methodological rigor

Procedures to enhance the standards of rigor, credibility, auditability, and fittingness were used in this study. These included engaging in reflexivity (e.g., questioning interpretations, becoming aware of one’s own expectations on the data) throughout the research process. The interviewer established the credibility or trustworthiness of the findings [35] by summarising and clarifying ambiguous or indistinct statements during the interviews, and a semi-structured interview guide was used to ensure consistent probing across participants. Further, data were collected through interviews, questionnaires, and medical records. Credibility was also established by using a multi-analyst, interdisciplinary triangulation and through a thorough literature review by the first author. This was done to identify any gaps in the existing literature regarding chronic pain and opioid therapy. To reduce the influence of the literature on the thematic construction, the literature review for comparative analyses with existing research was conducted after the data were analysed. Auditability was established by consistently following the format for coding and sampling, as suggested by Smith et al. [31]. Fittingness, or the transferability of findings, was confirmed by comparative analysis of the findings with existing literature.