Background
Methods
Research design, sample and recruitment
Data analysis
Results
Study number | Age range | Gender | Type/Cause/ Location of pain | Duration of pain | Work situation | Site recruited from |
---|---|---|---|---|---|---|
PI01 | 35–40 | Male | Injury to neck while using rowing machine in gym leading to painful left shoulder and arm with little function (nerve damage) Back pain | 2 years | Unemployed since injury due to pain as unable to do previous job (warehouse work) | NHS Pain clinic via physiotherapy |
PI02 | 65–70 | Male | Back injury at work – threw a pallet in anger about a colleague being bullied and his back went into spasm and now has pain from back down to toes and pins and needles – diagnosed with sciatic nerve compression | Constant pain since 1992 (25 years) but had back problems before that | Retired now – retired earlier than he would have liked due to back pain | NHS Pain clinic via physiotherapy |
PI03 | 30–35 | Male | Accident with machinery at work – caused back pain linked with hernia of spine at L5 and degeneration of discs | 4 years | Suspended from work due to number of episodes of sickness absence because of pain | NHS Pain clinic via physiotherapy |
PI04 | 60–65 | Female | Hip replacement in 2004 then in 2007 started getting spasms in left thigh from the groin down to the knee but nothing found on scans and X –rays Back pain due to osteoarthritis - diagnosed with stenosis of spine & five bulging discs from base of spine to waist | 10 years | Off sick from work due to pain – waiting for meeting at work to discuss return | NHS Pain clinic via physiotherapy and attended pain management programme |
PI05 | 30–35 | Female | Lower back pain since age of 13 linked with childhood abuse – diagnosed with degenerative arthritis of coccyx, two bulging discs Torn disc of spine two years ago – following severe coughing caused by respiratory infection | 18 years | Became self-employed due to back pain causing difficulties and sickness absence in previous job (residential care work) | NHS Pain clinic via physiotherapy and attended pain management programme |
PI06 | 35–40 | Female | Fell over and twisted ankle – fracture not diagnosed initially but diagnosed sometime after injury when already healed Complex Regional Pain Syndrome diagnosed later | 5 years | Unable to continue with jobs due to pain so now unemployed and claiming benefits | NHS Pain clinic via consultant physician |
PI07 | 60–65 | Male | Pain in feet at night due to nerve damage secondary to diabetes Pain in leg linked with fall – found two small metal pieces in leg (maybe as a result of previous motorbike accidents) Pain in left arm coming from neck into shoulder | Since heart attack 2 years ago | Unemployed. Went onto Employment and Support Allowance (ESA) after heart attack as no longer able to do previous job (fork lift truck driver) and was recently moved from ESA to Job Seekers Allowance (JSA) following health assessment | Job Shop |
PI08 | 55–60 | Male | Congenital disability that affected one side of body and wore a calliper as a child. Has had a number of operations on his affected foot to straighten it as used to walk on tiptoe. Has pain in both sides of his body and especially the foot that was operated on | Since childhood | Unemployed – recently moved from ESA to JSA following health assessment | Job Shop |
PI09 | 20–25 | Female | Pain (burning and stabbing pain) from knees downwards – worse at night and in the morning – cause unknown – nerve tests inconclusive Morton’s Neuroma in feet cause pain Pain linked with Chronic Fatigue Syndrome (CFS) | Pain in legs - last year and a half Pain in feet −1 year Pain linked with CFS – 6 years. | Unemployed – on ESA but does not get any money as partner works more than 20 h | NHS Pain Clinic via clinical psychologist in Multi-Disciplinary Team (MDT) |
PI10 | 50–55 | Male | Fractured spine – internal fixation and has five degenerating vertebrae | 13 years | Unemployed – on benefits | NHS Pain Clinic via consultant physician |
PI11 | 50–55 | Female | Lower back pain linked with previous job | Many years of intermittent back pain but more severe in last 6 months | Unemployed – unable to do previous job due to pain | Job Shop |
PI12 | 45–50 | Female | Arm pain linked with tennis elbow | 8 years | Unemployed due to pain | Job Shop |
PI13 | 50–55 | Male | Slipped disc at bottom of lumbar spine – work related injury Trapped nerve in left shoulder | Back pain – 7 years Shoulder pain – 10 years | Unemployed due to difficulties in previous job linked with pain and disability | NHS Pain clinic via physiotherapist |
PI14 | 25–30 | Female | Knee pain – ligament damage exacerbated due to fall | Couple of years ago | Unemployed | Job Shop |
PI15 | 55–60 | Female | Osteoarthritis causing knee pain One partial knee replacement | A few years Partial knee replacement one year ago | Unemployed – made redundant five months previously when store where she worked closed down | Job Shop |
Study number | Interviewee role | Employing sector | Size of company/ organisation | Number of employees | Nature of business |
---|---|---|---|---|---|
EI01 | Chief Executive Officer (CEO) | Private/ Service producing | Small | 10 employees | Construction industry |
EI02 | Head of Inclusion, Engagement and Wellbeing (nurse by background) | Public/ Service producing | Large | 10,000 employees | Acute NHS Trust |
EI03 | Practice manager | Public/ Service producing | Small | 17 employees | NHS GP |
EI04 | Occupational Health Lead (GP by background) | Private/ Goods producing | Large | 100,000 employees globally 13,500 permanent UK staff 5–6000 UK complementary workers | Health care company – research and manufacturing |
EI05 | Company director | Private/Service producing | Small | 12 employees | Digital marketing agency |
EI06 | Senior Human Resources (HR) Manager for employee relations and wellbeing | Private/Goods producing | Large | 35,000 employees | Car manufacturing company |
EI07 | Owner/manager | Private/Service producing | Small | 9 employees | Gym and personal training studio |
EI08 | Managing director and key account manager for automotive business | Private/Goods producing | Large/ Small | 14,000 employees globally 7 UK employees | Tier 1 supplier to the automotive industry (97%) and industrial business (3%) UK – Sales and distribution |
EI09 | HR and Facilities Manager | Private/Service producing | Medium | 120 employees | Private equity partnership offering legal services/ advice |
EI10 | Manager (and past experience as HR manager in large private companies) | Public/Service producing | Small | 8 employees | NHS GP practice |
Theme | People with chronic pain | Employers | Common themes |
---|---|---|---|
Obstacles to return to work | Psychological obstacles - Fear and anxiety - Fear of pain becoming worse - Worried about what others think (of me) - Negative experiences in the past Pain related obstacles - Unpredictability of pain - Reduced mobility - Sleep difficulties Financial and economic obstacles - No financial incentive - Competitive job market - Cost to company (productivity) Educational obstacles - Lack of qualifications - Challenges of dealing with technology Work history obstacles - Being out of work for a long time - Gaps in CV Work environment and nature of work - Pressure of work - Finding suitable employment - Not being able to pull your weight - Feels work offered is unsuitable - Unable to fulfil job requirements - Difficulties fulfilling previous role Employer related obstacles - Inflexible manager - Perceived discrimination and unfair treatment - Employer unwilling to make adjustments - Being judged by potential employers - Unsupportive manager | Attitudinal obstacles - Attitude of person with chronic pain - Attitudes of others towards people with chronic pain - Stigma Managerial obstacles - Managers lack of people skills - Managers lack of understanding about pain Organisational context - Reasonable adjustments not possible or affordable - Dismissal if unable to redeploy - Ageing work population and increased demand for redeployment - Conflict between occupational health and employer about what adjustments are reasonable and realistic - Austerity and limited rehabilitation & resources in NHS - Culture and size of organisation - Fairness and potential for conflict with colleagues - Fear of litigation Capability related obstacles - Ability to do the job - Poor performance - Physical demands of job - Absence - Hospital appointments | - Lack of confidence - Reliability - Travelling to work |
Facilitators of return to work | Workplace adjustments - Temporary job swap - Finding suitable job - Flexibility from employer - Small family run business Good working relationships - Good relationship with employer, manager and colleagues - Understanding manager and colleagues - Being listened to - Being treated as a person and not a disability - Help from colleagues Education - Education for managers about pain - Understanding of capabilities Preparing for RTW - Interview preparation support - Placements - Support looking for a job - Training - Trial period Interventions - Effective pain relief - Specialised physiotherapy | Workplace adjustments - Accommodation of hospital appointments - Reducing physical demands of job - Support, training and investment from employer Interventions - Provision of ergonomic work space - Coaching - Individually tailored to support to return to work - Private medical insurance provided by company - Occupational health provision Cultural factors - Caring and compassionate company - Changing culture and attitudes to employment for people with disabilities and chronic pain - Political will and coordination of Department of Work and Pensions and Department of Health | Workplace adjustments - Making changes to job and hours - Adaptation of the environment or provision of equipment - Making reasonable adjustments - Phased return - Redeployment - Working from home - Reduced hours - Taking breaks - Light duties - Help with travelling to work (Access to work or providing transport) Interventions - Access to cognitive behavioural therapy and counselling - Access to physiotherapy |
Disclosure of chronic pain to employer | - Not disclosing during application or interview process - Fear of not getting an interview or job - Fear of consequences of not disclosing - Fear of losing job | - Disclosure so employer can make reasonable adjustments - Disclosure to access interventions in the workplace - Disclosing to occupational health not recruiting manager - Understanding and accommodating non-disclosure | - Need to be open and honest |
Perceived obstacles to return to work
Psychological obstacles
Both people with chronic pain and employers perceived lack of confidence as a key psychological obstacle to work return. They explained that it is a highly influential obstacle that is linked with low self-esteem and negative thinking which can prevent someone being able to interact with the world around them because they have not been in the workplace for some time.‘Maybe just that because obviously I’ve been in pain for quite a while and I’ve been a bit out of, like, normal society that just, I think things are more anxious than obviously before it wouldn’t have been a problem at all. It’s all new things and stress. Yeah, it’s just massive. I wouldn’t know where to start on my own.’ (PI09 – 6 years of pain - unemployed)‘Fear stops you doing things and fear of putting people's backs up, cause it does happen.’ (PI15 – a ‘few years’ of pain - unemployed)
‘I think a lot of it may be confidence in themselves whether they deem they can still do tasks in hand, interaction possibly with people, just in general and to talk with people.’ (EI01 – Employer – CEO small private company)
‘It brings about quite a lot of negative imbalance, in thoughts and about yourself, your esteem goes, your confidence goes down, you withdrawing from society and it only gets worse.’ (PI06 – 5 years of pain - unemployed)
Attitudinal obstacles
‘Well, some people, to be honest, it’s just laziness. Like, in the way ‘cause they’ve had that time off and they’ve been paid to have that time off they don’t, you know, they can’t be bothered, they can’t, some people, this is being honest.’ (EI07 – Employer – small private company)
Authenticity with respect to pain conditions was questioned by two employers. One said that people with pain were just lazy, as quoted above, and another questioned whether a pain condition was the real reason why an employee left the organisation. Having had surgery was seen as legitimising chronic pain, whereas something invisible such as chronic back pain garnered less sympathy.‘And it’s an issue of personal pride to them, they feel they can’t keep up with what their colleagues would expect from them, or their employer would expect from them.’ (EI10 - Employer – manager in small public sector organisation and experience of HR role in large private sector organisation)
The above participant also pointed out scepticism and lack of sympathy towards people with fibromyalgia which she grouped with chronic fatigue syndrome due to these conditions not being visible.‘If you’ve had surgery then, yeah, you get, you get more sympathy because, well, people don't give you a new knee if you haven’t actually got something wrong, do they? But you can be taking painkillers for a bad back and it ... how bad is a bad back? You know, I think some illnesses are classed as lazy people’s illnesses.’ (PI15 - a ‘few years’ of pain - unemployed)
Capability and reliability
This was also reflected in the interviews with people with pain, who were worried they would not be able to fulfil the job requirements or that they would try to do so and this would cause the pain to worsen.‘Our job out on site is a lot of physical aspect of it … Whether they’d be able to actually physically undertake the job would be an issue as well as obviously if it was more office based it’s you know what state of mind they are in ‘cause we have to do quite a lot of interaction with members of the public.’ (EI01- Employer – CEO – Small private company)
‘I’ve had individuals who’ve worked for us before and their time keeping and having days off and being unreliable and any business would say that … unreliability whether it’s … no matter what trade, it’s reliability is the key thing.’ (EI01 – Employer - CEO small private company)
Employers were concerned with potential increased workload on other employees and managing potential conflict amongst their employees as a result.‘And it’d be like, you wouldn’t get 24 hours’ notice that I’m not coming in. It’ll be in the morning, “I can’t make it today,” you know. So it’s that a reliability issue as well. That’s a big thing.’ (PI10 – 13 years pain - unemployed)
‘A phased return to work, that does put quite a strain on the other people in the teams and that can sometimes develop into animosity. So from my concern is not just dealing with the individual and trying to get them back into the workplace, it's also the impact on the other people that are left here to do the work as well.’ (EI09 - Employer – HR Manager - Medium sized private company)
‘I feel if I can’t pull my full weight … that’s going to be a difficulty for me to overcome, if I can’t do the job I am paid for I’m gonna find that a bit difficult … but I know that I’ve got to be careful!’ (PI04 – 10 years pain – off sick)
It was evident that people with chronic pain have a sense of pride in doing the job to the best of their ability and felt their pain prevented them from achieving this.‘And there were times when we were overrun and we had ... “I’m sorry, I can’t physically do it.” And that makes you feel that you’re letting the team down.’ (PI15– a ‘few years’ of pain - unemployed)
‘Because I can’t use the computer or anything like that, them sort of jobs are out of the question ... you know. It’s no good to me.’ (PP10– 13 years of pain - unemployed)
Organisational context
Some employers expressed frustration with the way outsourced occupational health services sometimes made unrealistic recommendations for adjustments as illustrated by the quotation below‘I think the key thing is the organisation understanding what ‘reasonable adjustment’ means because I know of some cases where we’ve gone totally above and beyond and the person hasn’t accepted that they can’t do the work and we need to help them realise that they can’t do the work so from an organisation perspective. I often say to people it doesn’t say ‘bank of [organisation name] outside’ we do not have untold resources and money to make adjustment after adjustment after adjustment for somebody who really can’t do the work that they were employed to do but then we’ve also got managers who don’t even want to make any adjustment!’ (EI02 – Employer - Head of Inclusion, Engagement and Diversity, Large Public Sector Organisation)
UK welfare reforms, the introduction of more ruthless absence management policies, and an ageing workforce were some aspects of the socio-political context which added pressure to the limited resources of organisations, limiting their ability to support people with chronic pain.‘Most people in occupational health are there because they genuinely believe in what they’re doing. But I think they are very focused on the individual in front of them and their duty of care to that person and I can only praise that. I don’t necessarily think that translates into a great degree of reality. Occupational health specialists employed by companies have a much healthier dose of realism, because they know who’s paying their wages’ (EI10 - Employer – manager in small public sector organisation and experience of HR role in large private sector organisation)
‘I think some of the things that might make people feel a bit anxious … there's lots of focus around what employers need to do when there's disabilities or conditions that need to be managed.’ (EI06 – Employer - Senior Human Resources Manager – Large manufacturing company)
Facilitators of return to work
Preparing for return to work
One participant who was off sick suggested a trial period would be very helpful in addressing the uncertainty around how work would affect their pain condition.‘ … but if I was to apply for a job and go for an interview, I don’t even know how they’d do it anymore, so there’s a fear of that, you don’t know if you are prepared, maybe that’s something that could be implemented in helping, like doing fake interviews to show them the process all over again … get used to it.’ (PI03 – 4 years pain – suspended from work due to sickness absence)
‘I think to give them the chance to do it … the employer to actually say “if you feel you want to come back now we’ll give you a trial period over three months or whatever and we’ll take it from there” I think that would help me because I’m thinking “will I ever go back to work?” and then it’s “do I want to go back to work”?’ (PI04 – 10 years pain – off sick)
Workplace adjustments and interventions
People with chronic pain emphasised the importance of a good working relationship with managers and colleagues and appreciated them listening and being understanding about pain. Some participants suggested that education for managers about pain and a greater understanding of the employee’s capabilities would be helpful.‘There is light duties you can do, they just tell you you’re not allowed but luckily enough with him he understood the score he know how much pain I was in so he’d be like “right I’ll do your job you just go and jump on the cardboard”.’ (PI03 – 4 years pain – suspended from work due to sickness absence)
The accommodation of taking time off work to attend hospital appointments was contentious for some small employers but supported by others.‘I think the people in charge, the management, they should take a course on people with back problems, so they know what they’re going through. Because they don’t ... do you understand what I mean? If I’d had a manager that knew the problems I’ve got .. I’d have felt more at ease and more comfortable working there.’ (PI13 – 10 years of pain – unemployed)
Coaching was seen as a more attractive option than counselling because it is more akin to mentoring and can encompass career development while simultaneously supporting people returning after a period of absence, and thus it does not carry the same stigma as counselling. In this particular company it has been called ‘Returners Coaching’ and covers people coming back from illness, surgery, maternity leave or after absence for other reasons.‘We also offer access to coaching for some individuals because we found that coaching can be really beneficial for some people and so the idea is very much that the nurse, as the case manager, pulls in and pulls on these resources and guides and signposts and we do our best to try and enable people to come back to work.’ (EI04 – Employer - Occupational Health Lead – Global health care company)
Disclosure of chronic pain to employer
Another employer suggested that failure to disclose could lead to dismissal if the condition impacted on the person’s ability to fulfil job requirements.‘Personally if somebody didn’t tell me then I employ them and three months later they are off work for six to eight weeks with an existing condition I just think it’s not fair’ (EI03 – Employer – small public sector organisation)
However, employers did generally understand employee’s lack of disclosure as shown in the quotation below.‘If they’ve only been there recently you make a decision to say “hold on there a second you should’ve told me this … it’s not working out I think we need to shake hands and move on!”’ (EI05 – Employer – Small private company)
Other employers said disclosure was important so they could make reasonable adjustments for employees or enable access to workplace interventions. In larger organisations, employers explained that people can disclose their health conditions in confidence to occupational health departments, keeping this process separate from the recruiting manager and thereby protecting an employee from discrimination.‘perhaps pressures from work, you know, ‘cause someone may have an illness and might be reluctant to kind of talk about it or feel as though that they can’t take time off for various reasons..so that’s sort of something you need to be mindful of’. (EI08 – Employer – Large private company)
Motivators for disclosing included a moral obligation to disclose, and fear of losing their job as a result of not disclosing.‘You feel like you wanna approach them and tell them but you also feel like you will be ridiculed for it so they’ll look at you as a hindrance and think “right then we’ve gotta look at somebody else now because he might not be able to do this job for much longer” and then it can get to a point where, as I say, you have time off and they think “right search for someone get them trained and we’ll get rid of him” that’s how you feel … you feel like you are always on eggshells so you can’t do much, you are always worried!’ (PI03 – 4 years pain – suspended from work due to sickness absence)
‘I wanted to be straight with him. I didn’t want no lies.’ (PI07 – 2 years pain - unemployed)
‘Well, I, I was going by the, the idea of, if you don’t tell them, they can sack you. So I always go to the interview and say, “Oh, by the way, I suffer with this, this and this.” Because that way, they, then know that you’ve got a problem.’ (PI13 – 10 years pain - unemployed)