“Whose job is it anyway?” Exploring work participation for people in pain

Musculoskeletal disorders (MSD's) are a group of disorders that affect the body’s bones, joints, muscles and the tissues that connect them. The most common MSD is low back pain (LBP). The prevalence of MSD’s is rising globally. This is concerning as MSD’s lead to very significant personal, social and economic costs. There is good evidence to support the role of work in recovery from MSD’s. Employment is proven to be important for people’s physical and mental health and long term unemployment is associated with poverty, social exclusion, poorer physical and mental health and reduced quality of life. Despite the known benefits of work for this population, work disability rates remain stubbornly high amongst people with MSD’s. Work disability among people with MSD’s is complex and is not explained by physical factors alone. Studies of interventions to support the work participation of people with MSD’s recommend good communication, collaboration and coordination between the individual, the workplace and healthcare providers. In practice, this has been difficult to achieve and there has been little research conducted to date on this topic. The views and experiences of the various stakeholder groups are central to understanding how multi-stakeholder collaboration can be achieved in practice. Although some international literature on this topic does exist it is imperative to explore this topic in an Irish context given the international variation in workers compensation systems, social protections systems and employment legislation. This thesis comprises two main studies which aim to: o To synthesise the available qualitative literature on the experience of workforce participation amongst workers with low back pain (LBP) and the barriers and enablers of same. o To examine the experiences of people with musculoskeletal disorders (MSDs), employers, health professionals and other key stakeholders involved in the return to work process to explore their experiences of work rehabilitation and retention. Both aims were achieved through qualitative research methods. A meta-ethnographic synthesis of qualitative literature related to the work participation experiences of people with LBP was conducted to achieve the first aim. Following a systematic database search fifteen primary studies involving 320 people with LBP were included in the review and seven main themes were identified. These synthesised themes highlight that individuals with LBP largely feel unsupported at work and engage in strategies to remain working without actively seeking support from those around them due to a perceived sense of judgement confounded by a lack of understanding about LBP. Where help was offered, this was largely in a format that served to ease the biomedical aspect related to LBP by easing the load related to the work task. Rarely were the biopsychosocial dimensions of pain addressed or considered by the employer. The review identified two major issues: (1) employees with back pain feel largely unsupported with regard to enabling and maintaining work participation and (2) employees perceive that rehabilitation professionals and employers are focused on symptoms related to LBP and the work task rather than the emotional well-being and coping skills of the employee with LBP. In the second study in this thesis a qualitative interview study with key stakeholders in the work rehabilitation process was conducted to explore in-depth their experiences related to the retention and return of work of people with MSD’s. Semi-structured interviews were conducted with twelve people with MSD’s, six employers with experience of managing and retaining employees with MSD’s and five health professionals with experience of working with patient with MSD’s. The transcribed interview data were analysed thematically. Four themes were identified: 1) The employee experience of working hard to balance pain and work participation; 2) Employers and HCP’s are willing but not fully ready to support the work participation of people with MSD’s; 3) Perceived dominance of a biological basis for pain, and 4) The Ominous nature of occupational health. These findings mirror to a large degree the findings of the qualitative meta-ethnographic synthesis. Across all stakeholder groups biological factors were most implicated as the reason for work absences and the resolution of symptoms was identified as the single greatest enabler of return to work. Although pockets of good practice were identified, in the main, health professionals and employers describe uncertainty about their role and responsibilities and describe a narrow scope of practice. Patients report a mostly adversarial experience of vocational supports (e.g. Occupational Health services). Mirroring international research, Irish work rehabilitation stakeholders do not report awareness of the complex interplay of biological, psychological and social factors influencing work participation for people with MSD’s. Vocational supports and services are hampered by role uncertainty and consequentially adversarial experiences for service users. In the discussion chapter both studies are considered in light of one another and clinical implications and future research directions are proposed. iv practice were identified, in the main, health professionals and employers describe uncertainty about their role and responsibilities and describe a narrow scope of practice. Patients report a mostly adversarial experience of vocational supports (e.g. Occupational Health services). Mirroring international research, Irish work rehabilitation stakeholders do not report awareness of the complex interplay of biological, psychological and social factors influencing work participation for people with MSD’s. Vocational supports and services are hampered by role uncertainty and consequentially adversarial experiences for service users. In the discussion chapter both studies are considered in light of one another and clinical implications and future research directions are proposed. This thesis found that:  The return to work process for people with MSD’s is complex and work participation for people with MSD’s is influenced by broader factors than the physical injury / disorder alone  Employees with MSD’s bear heavy burden of stigma, symptom management and selfmanagement and feel largely unsupported in the workplace  Employee experiences of occupational health services are mainly negative  Although pockets of good practice were reported, in the main employers and health professionals have limited capacity and knowledge to support employees with MSD’s Key recommendations arising for this thesis are:  Specific training and skill development among employers and HCPs is recommended to build competence in supporting employees with MSD’s to return to and remain in work. Future research should identify how education is best delivered to achieve changes in practice and outcomes for people with MSD’s  Stigma reduction initiatives focused on back pain and MSDs should be considered. Future research should explore the perspectives of colleagues on working alongside employees with MSD’s and the effectiveness of stigma reduction initiatives in the workplace and broader community oriented stigma reduction campaigns.