Patients' Experiences With Vehicle Collision
to Inform the Development of Clinical
Practice Guidelines: A Narrative Inquiry

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:

FROM:   J Manipulative Physiol Ther 2016 (Mar);   39 (3):   218–228 ~ FULL TEXT

Gail M. Lindsay, RN, PhD, Silvano A. Mior, DC, PhD, Pierre Côté, DC, PhD,
Linda J. Carroll, PhD, Heather M. Shearer, DC, MSc

Associate Professor,
Faculty of Health Sciences,
University of Ontario Institute of Technology,
Oshawa, ON

OBJECTIVE:   The purpose of this narrative inquiry was to explore the experiences of persons who were injured in traffic collisions and seek their recommendations for the development of clinical practice guideline (CPG) for the management of minor traffic injuries.

METHODS:   Patients receiving care for traffic injuries were recruited from 4 clinics in Ontario, Canada resulting in 11 adult participants (5 men, 6 women). Eight were injured while driving cars, 1 was injured on a motorcycle, 2 were pedestrians, and none caused the collision. Using narrative inquiry methodology, initial interviews were audiotaped, and follow-up interviews were held within 2 weeks to extend the story of experience created from the first interview. Narrative plotlines across the 11 stories were identified, and a composite story inclusive of all recommendations was developed by the authors. The research findings and composite narrative were used to inform the CPG Expert Panel in the development of new CPGs.

RESULTS:   Four recommended directions were identified from the narrative inquiry process and applied. First, terminology that caused stigma was a concern. This resulted in modified language ("injured persons") being adopted by the Expert Panel, and a new nomenclature categorizing layers of injury was identified. Second, participants valued being engaged as partners with health care practitioners. This resulted in inclusion of shared decision-making as a foundational recommendation connecting CPGs and care planning. Third, emotional distress was recognized as a factor in recovery. Therefore, the importance of early detection and the ongoing evaluation of risk factors for delayed recovery were included in all CPGs. Fourth, participants shared that they were unfamiliar with the health care system and insurance industry before their accident. Thus, repeatedly orienting injured persons to the system was advised.

CONCLUSION:   A narrative inquiry of 11 patients' experiences with traffic collision and their recommendations for clinical guidelines informed the Ontario Protocol for Traffic Injury Management Collaboration in the development of new Minor Injury Guidelines. The values and findings of the qualitative inquiry were interwoven into each clinical pathway and embedded within the final guideline report submitted to government.

Copyright © 2015 National University of Health Sciences. Published by Elsevier Inc. All rights reserved.

KEYWORDS:   Accidents, Traffic; Neck Pain; Outcome and Process Assessment (Health Care), Personal Narratives as Topic; Qualitative Research; Whiplash Injuries

From the FULL TEXT Article:


Whiplash and neck pain and associated disorders affect more than 80% of individuals with minor injuries after a motor vehicle collision. [1] Many who are injured seek treatment by attempting to navigate the management corridor lined with various health care, insurance, legal, and regulatory systems. In Ontario, Canada, the government regulates the management of treatment for injuries following traffic collisions. [2] Currently, such injuries are classified as “minor,” “noncatastrophic,” or “catastrophic.” In 2011, the Ontario government called for the development of a new evidence-based clinical practice guideline (CPG) for the management of minor traffic injuries.

The Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration [3] was established to develop the new Minor Injury Guidelines (MIGs). The OPTIMa Collaboration included a multidisciplinary guideline expert panel of clinicians, academics and scientists, a consumer advocate, a retired judge, automobile insurance industry experts, and a patient liaison. Well-accepted standardized wording and criteria were used by the OPTIMa Collaboration for conducting research and developing clinical guidelines for people injured in traffic collisions. Systematic reviews and the translation of the scientific evidence into evidence-based recommendations were augmented by a qualitative inquiry which includes patient perspectives as per guideline development standards. [4–9]

Collecting, understanding, and integrating persons’ experiences in the development of clinical practice guidelines are necessary to ensure the relevance and implementation of recommendations. In the United Kingdom, the National Institute for Clinical Excellence states that an essential value of “a high quality guideline” is the “embod(iment) of values that are generally held by the population.” [10]

This expectation of patient involvement is explicitly reflected in the Appraisal of Guidelines, Research and Evaluation (AGREE II) instrument which is used to assess the quality of a clinical guideline. [4] Similarly, the Ontario Health Technology Advisory Committee (OHTAC), which is a government-appointed committee mandated to develop health-related recommendations, requires that social and ethical values and the patient’s experience be considered when developing recommendations for medical technologies. [11]

The OPTIMa Collaboration adapted the OHTAC framework by incorporating 3 sources of information in developing its recommendations. [12] It first critically reviewed published clinical practice guidelines for the management of traffic injuries. Secondly, it conducted best-evidence synthesis of scientific literature, screening approximately 235,000 abstracts and summarizing their results in 43 new systematic reviews. Thirdly, to address the framework’s social and ethical constructs and to ensure that patients’ experiences were considered during the entire process of clinical guideline development, a qualitative narrative inquiry needed to be conducted to reveal the unique narratives of Ontarians who had sustained minor injuries in traffic collisions. This type of research would help to capture evidence-informed qualities that include scientific best evidence, clinical judgment, and patient preference. [13]

To develop this study, we conceptualized that the inclusion of patient experiences within a CPG process structured around best-evidence synthesis could be captured within the theoretical stance of pragmatism. Pragmatism supports a methodology that enables the mixing of research designs to address complex issues. [14] Combining evidence from qualitative inquiry and systematic reviews is contextualized within a research paradigm [15] that

(a) partners with the philosophy of pragmatism

(b) follows the logic of mixed methods research

(c) relies on qualitative and quantitative viewpoints, data collection, analysis, and inference techniques combined, and (d) is cognizant, appreciative, and inclusive of local and broader sociopolitical realities, resources, and needs.” [16]

We conceptualized that pragmatism was one way to study human experience. [17–19] The aim of narrative inquiry is to explore experience, [20] and it is grounded in Dewey’s [21] philosophy of pragmatism that posits that experience is education; hence, it was the basis of our selected qualitative method. Narrative inquiry complements the examination of best evidence by providing a perspective through the lens of patient experience during the construction of CPG recommendations.

The overarching approach taken by the OPTIMa Collaboration was combining a purist perspective (ie, systematic reviews) with a moderating perspective (ie, qualitative study of patient views) to develop CPG recommendations. Given that our inquiry phenomenon was injured persons’ experience after a traffic collision and their recommended directions for a new CPG, we posed 2 questions:

(1) What is injured persons’ experience with health care following traffic collision–caused injury?

(2) What would injured persons want a group of experts (health care professionals, scientists, insurers, public representatives, and policy makers) to know about their experience as they make decisions about the development of guidelines for the management of minor injuries after collisions?

Thus, the purpose of this qualitative study was to explore the experiences and describe the recommendations of injured persons to inform the development of a new evidence-informed CPG for the management of common traffic injuries in Ontario, Canada.


This study highlights a unique application of the pragmatic stance of narrative inquiry where systematic reviews are combined with a qualitative study of patient views [14] to develop CPG recommendations. By using the moderating position of patient views, the injured persons’ narrative played an active role in the development and approval of CPG recommendations. The injured persons’ emergent directions permeated the recommendations discourse and informed the framework for resultant CPGs.

Congruent with the OHTAC Decision Determinants Recommendation Subcommittee, we “recognized the importance of other forms of evidence including context-sensitive evidence.” [11] The inclusion of injured persons’ experiences and recommended directions in the development of clinical guidelines provides context-sensitive evidence that complements the context-free evidence of systematic reviews and randomized clinical trial. Clinical guideline development that incorporates a qualitative component provides an opportunity for health care providers and insurers to have a better relationship with the injured person. Along with a more in-depth knowledge of circumstances of the injury, this knowledge may lead to improved understanding of factors impacting recovery by “personal engagement with the circumstances, personally using instruments [new CPG], and then observing the effects.” [13] These recommended directions cannot be enacted without considering the context of the patient’s life.

Clinical practice guidelines must be relevant to the clinical reality of practitioners and patients and acknowledge that recovery is a dynamic process. Thinking with stories, in contrast to thinking about stories, [60] is an invitation to think with the composite narrative and to dwell in the experience of injured persons. It provides an opportunity to theorize on the impact of such experience not only on guideline development but also on our definition of evidence [61–64] and on our relationships with injured persons. This study demonstrates the value and social importance of exploring the experience of injured persons as complementary to systematic reviews in developing evidence-informed CPGs.

      Clinical Relevance

Caring for injured persons requires the establishment of relationships that are grounded in the life context of the patient. To do so, health care providers should ask about the patient’s recovery expectations and health goals and inquire about the injured person’s knowledge of the systems (eg, health and insurance). Moreover, health care providers should ensure that patients understand their injury, its natural course, and the available evidence-based treatments. The patient-provider relationship needs to be continually reassessed and adjusted based on the injured person’s daily life. Therefore, understanding injured persons’ experiences is important to ensure the relevance, applicability, and uptake of CPGs, as well as in making policy decisions.


A limitation of the study is that no one who was “at fault” in a collision was included in our research. Subsequent research could explore the experience of people who cause a collision and also the need for emotional support, regardless of fault, after collision. Only people with “minor injuries” were included in this study; thus, other types of injuries may have resulted in a different set of concerns and composite narrative. Other limitations include that questions used to interview patients were not pretested and could have influenced the outcome. We did develop the questions in an iterative fashion to ensure consistency with the study aims and made no modifications during the course of the study. As with any qualitative research, authors’ opinions, viewpoints, and participation are an essential part of the process and could have had an influence in the final narrative product and recommendations. We mitigated these concerns by having the team review transcripts and reach consensus to ensure the composite represented key findings. The findings of this study may not necessarily apply to people in other countries and of other languages and cultures.


This narrative inquiry process informed the new MIGs. We brought the participant-generated recommended directions to bear on each new recommendation for caregivers. This process influenced the terminology, role of patient-provider relationships, importance of shared decision-making, interventions, importance of advice and education, emotional support, and foundational principle of patient choice. The values and findings of the qualitative inquiry were interwoven into each clinical pathway and embedded within the final guideline report submitted to government.

Practical Applications

  • This study showed that the process of narrative inquiry can be used to explore experiences of injured persons to identify recommended directions for care.

  • Patients expressed concerns about terminology, relationships, choice, and emotional support.

  • Findings from this inquiry help to inform the development of clinical practice guidelines for care following vehicle collisions.


  1. Cassidy, JD, Carroll, LJ, Côté, P, Lemstra, M,
    Berglund, A, and Nygren, A.
    Effect of eliminating compensation for pain and suffering on the outcome of insurance claims for whiplash injury.
    N Engl J Med. 2000; 342: 1179–1186

  2. Financial Services Commission of Ontario.
    Minor injury guideline.
    Superintendent's guideline no. 02/10.
    FSCO, Toronto, ON; 2010

  3. Côté, P.
    Development of a minor injury treatment protocol.
    Ontario Ministry of Finance–Financial Services Commission of Ontario OSS_00267175.
    FSCO, Toronto; 2012

  4. Brouwers, MC, Kho, ME, Browman, GP et al.
    AGREE II: advancing guideline development, reporting and evaluation in health care.
    Can Med Assoc J. 2010; 182: E839–E842

  5. Brouwers, MC, Kho, ME, Browman, GP et al.
    Development of the AGREE II, part 2:
    assessment of validity of items and tools to support application.
    Can Med Assoc J. 2010; 182: E472–E478

  6. Davis, DA, Goldman, JB, and Palda, VA.
    Canadian Medical Association handbook on clinical practice guidelines.
    CMA, Ottawa; 2007

  7. Kmietowicz, Z.
    Campaign is launched to make patients the focus of evidence based medicine.
    BMJ. 2014; 349: 4443

  8. National Institute for Health and Care Excellence.
    The guidelines manual. 1.4 The development process for clinical guidelines.
    NICE, London; 2014
    Accessed 2014 Jan 28

  9. O'Flynn, N and Staniszewska, S.
    National Institute for Health and Clinical Excellence.
    Guideline Development Group.
    Improving the experience of care for people using NHS services:
    summary of NICE guidance.
    BMJ. 2012; 344: d6422

  10. Rawlins, MD and Culyer, AJ.
    National Institute for Clinical Excellence and its value judgments.
    BMJ. 2004; 329: 224–227

  11. Johnson, AP, Sikich, NJ, Evans, G et al.
    Health technology assessment: a comprehensive framework for evidence-based
    recommendations in Ontario.
    Int J Technol Assess Health Care. 2009; 25: 141–150

  12. Côté, P.
    Ontario Ministry of Finance–Financial Services Commission
    of Ontario OSS_00267175: development of a minor injury treatment protocol. 2012-2014

  13. Sackett, DL, Rosenberg, WM, Gray, JA,
    Haynes, RB, and Richardson, WS.
    Evidence-Based Medicine: What It Is and What It Isn't
    British Medical Journal 1996 (Jan 13); 312: 71–72

  14. Bostick, GP, Brown, CA, Carroll, LJ, and Gross, DP.
    If they can put a man on the moon, they should be able to fix a neck injury:
    a mixed-method study characterizing and explaining pain beliefs about WAD.
    Disabil Rehabil. 2012; 34: 1617–1632

  15. Tashakkori, A and Creswell, J.
    The new era of mixed methods.
    J Mixed Methods Res. 2007; 1: 3–7

  16. Johnson, R, Onwuegbuzie, A, and Turner, L.
    Toward a definition of mixed methods research.
    J Mixed Methods Res. 2007; 1: 112–133

  17. Dewey, J.
    The quest for certainty: a study of the relation of knowledge and action.
    Minton, Balch & Co, New York; 1929

  18. Feilzer, M.
    Doing mixed methods research pragmatically: implications for the rediscovery
    of pragmatism as a research paradigm.
    J Mixed Methods Res. 2010; 4: 6–16

  19. Morgan, D.
    Pragmatism as a paradigm for social research.
    Qual Inq. 2014; 20: 1045–1053

  20. Connelly, FM and Clandinin, DJ.
    Stories of experience and narrative inquiry.
    Educ Res. 1990; 19: 2–14

  21. Dewey, J.
    Experience and education.
    Macmillan, New York; 1938

  22. Chan, EA and Schwind, JK.
    Two nurse-teachers reflect on acquiring their nursing identity.
    Reflect Pract. 2006; 7: 303–314

  23. Lindsay, GM.
    Patterns of inquiry: curriculum as life experience.
    Nurs Sci Q. 2011; 23: 237–244

  24. Schwind, JK, Cameron, D, Franks, J, Graham, C, and Robinson, T.
    Engaging in narrative reflective process to fine tune Self-as-Instrument of Care.
    Reflect Pract. 2012; 13: 223–235

  25. Clandinin, DJ and Connelly, FM.
    Narrative inquiry: experience and story in qualitative research.
    Jossey-Bass, San Francisco, CA; 2000

  26. Lindsay, G.
    Constructing a nursing identity: reflecting on and reconstructing experience.
    Reflect Pract. 2006; 7: 59–72

  27. Clandinin, D, Pushor, D, and Orr, A.
    Navigating sites for narrative inquiry.
    J Teach Educ. 2007; 58: 21–35

  28. Heron, J.
    Co-operative inquiry.
    Sage, London; 1996

  29. Mior, S.
    Patients perceptions of the primary care characteristics in a model of
    interprofessional patient-centred collaboration between chiropractors
    and physicians. (PhD thesis)
    Health Policy Management and Evaluation,
    University of Toronto, Toronto; 2010

  30. Tong, A, Sainsbury, P, and Craig, J.
    Consolidated criteria for reporting qualitative research (COREQ):
    a 32-item checklist for interviews and focus groups.
    Int J Qual Health Care. 2007; 19: 349–357

  31. Sandelowski, M.
    Focus on qualitative methods sample size in qualitative research.
    Res Nurs Health. 1995; 18: 179–183

  32. Newman, M.
    Health as expanding consciousness. 2d ed.
    Jones & Bartlett, Boston; 1994

  33. Guest, G, Bunce, A, and Johnson, L.
    How many interviews are enough?
    Field Methods. 2006; 18: 59–82

  34. Clandinin, DJ.
    Engaging in narrative inquiry.
    Left Coast Press, Walnut Creek, CA; 2013

  35. He, MF.
    A river forever flowing: cross-cultural lives and identities
    in the multicultural landscape.
    Information Age Publishing, Greenwich, CT; 2000

  36. Lindsay, G, Cross, N, and Ives-Baine, L.
    Narratives of NICU nurses: experience with end-of-life care.
    Illn Crisis Loss. 2012; 20: 239–253

  37. Lindsay, G and Schwind, JK.
    Arts-informed narrative inquiry into nurse-teachers’ legacy
    for the next generation.
    Reflect Pract. 2014; : 1–11

  38. Butler-Kisber, L.
    Qualitative inquiry: thematic, narrative and arts-informed perspectives.
    Sage, Los Angeles CA; 2010

  39. Denzin, NK and Linbcoln, YS.
    Introduction: the discipline and practice of qualitative research.
    in: The SAGE handbook of qualitative research. 4th ed.
    Sage, Los Angeles CA; 2011: 1–19

  40. Ziebland, S.
    Narrative interviewing.
    in: S Ziebland, A Coulter, J Calabrese, L Locock (Eds.)
    Understanding and using health experiences: improving patient care.
    Oxford University Press,
    Oxford, UK; 2013: 38–48

  41. Varatharajan, S, Côté, P, Shearer, HM et al.
    Are work disability prevention interventions effective for the management
    of neck pain or upper extremity disorders? A systematic review by the
    Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration.
    J Occup Rehabil. 2014; 24: 692–708

  42. Wong, JJ, Côté, P, Shearer, HM et al.
    Clinical practice guidelines for the management of conditions related to
    traffic collisions: a systematic review by the OPTIMa Collaboration.
    Disabil Rehabil. 2015; 37: 471–489

  43. Yu, H, Côté, P, Shearer, HM et al.
    Effectiveness of passive physical modalities for shoulder pain:
    systematic review by the Ontario Protocol for Traffic Injury Management Collaboration.
    Phys Ther. 2015; 95: 306–318

  44. Richmond, T, Guo, W, Ackerson, T et al.
    The effect of postinjury depression on quality of life following minor injury.
    J Nurs Scholarsh. 2014; 46: 116–124

  45. Russell, G and Nicol, P.
    “I've broken my neck or something!”
    The general practice experience of whiplash.
    Fam Pract. 2009; 26: 15–20

  46. Ciechanowski, PS, Katon, WJ,
    Russo, JE, and Walker, EA.
    The patient-provider relationship: attachment theory and adherence
    to treatment in diabetes.
    Am J Psychiatry. 2001; 158: 29–35

  47. Fox, S and Chesla, C.
    Living with chronic illness: a phenomenological study of the
    health effects of the patient-provider relationship.
    J Am Acad Nurse Pract. 2008; 20: 109–117

  48. Bellamy, R.
    An introduction to patient education: theory and practice.
    Med Teach. 2004; 26: 359–365

  49. Yu, H, Côté, P, Southerst, D et al.
    Does Structured Patient Education Improve the Recovery and Clinical Outcomes
    of Patients with Neck Pain? A Systematic Review from the Ontario Protocol
    for Traffic Injury Management (OPTIMa) Collaboration

    Spine J. 2014 (Apr 4); [Epub ahead of print]

  50. Little, P, Everitt, H, Williamson, I et al.
    Observational study of effect of patient centredness and positive approach
    on outcomes of general practice consultations.
    BMJ. 2001; 323: 908–911

  51. Greenhalgh, T, Howick, J, and Maskrey, N.
    Evidence Based Medicine Renaissance Group.
    Evidence based medicine: a movement in crisis?.
    BMJ. 2014; 13: g3725

  52. Bisson, JI.
    Single-session early psychological interventions following traumatic events.
    Clin Psychol Rev. 2003; 23: 481–499

  53. Irving, P and Long, A.
    Critical incident stress debriefing following traumatic life experiences.
    J Psychiatry Ment Health Nurs. 2001; 8: 7–14

  54. Bring, A, Soderlund, A, Wasteson, E, and Asenlöf, P.
    Daily stressors in patients with acute whiplash associated disorders.
    Disabil Rehabil. 2012; 34: 783–789

  55. Carroll, LJ, Liu, Y, Holm, LW, Cassidy, JD, and Côté, P.
    Pain-related emotions in early stages of recovery in whiplash-associated disorders:
    their presence, intensity, and association with pain recovery.
    Psychosom Med. 2011; 73: 708–715

  56. Wicksell, RK, Ahlqvist, J, Bring, A,
    Melin, L, and Olsson, GL.
    Can exposure and acceptance strategies improve functioning and life satisfaction
    in people with chronic pain and whiplash-associated disorders (WAD)?
    A randomized controlled trial.
    Cogn Behav Ther. 2008; 37: 169–182

  57. Buitenhuis, J, de Jong, PJ,
    Jaspers, JP, and Groothoff, JW.
    Relationship between posttraumatic stress disorder symptoms and the
    course of whiplash complaints.
    J Psychosom Res. 2006; 61: 681–689

  58. Carroll, LJ, Liu, Y, Holm, LW, Cassidy, JD, and Côté, P.
    Pain-related emotions in early stages of recovery in whiplash-associated disorders:
    their presence, intensity, and association with pain recovery.
    Psychosom Med. 2011; 73: 708–775

  59. Kongsted, A, Bendix, T, Qerama, E et al.
    Acute stress response and recovery after whiplash injuries. A one-year prospective study.
    Eur J Pain. 2008; 12: 455–463

  60. Frank, A.
    The wounded storyteller: body, illness and ethics.
    The University of Chicago Press, Chicago; 1995

  61. Epstein, RM and Street, RL.
    The values and value of patient-centered care.
    Ann Fam Med. 2011; 9: 100–103

  62. Nevo, I and Slonim-Nevo, V.
    The myth of evidence-based practice: towards evidence-informed practice.
    Br J Soc Work. 2011; 41: 1176–1197

  63. Oxman, AD, Lavis, JN, Lewin, S, and Fretheim, A.
    SUPPORT Tools for evidence-informed health Policymaking (STP) 1:
    what is evidence-informed policymaking?.
    Health Res Policy Syst. 2009; 7: S1

  64. Van de Bovenkamp, HM and Trappenburg, MJ.
    Reconsidering patient participation in guideline development.
    Health Care Anal. 2009; 17: 198–216

Return to the Whiplash Section

Since 3-08-2016

                       © 1995–2021 ~ The Chiropractic Resource Organization ~ All Rights Reserved