Aims and objectives

This meta-ethnography explores experiences of returning to work, as perceived by people with chronic non-malignant pain and by employers, and develops a conceptual model.

Study design

There are two main approaches to synthesising qualitative research, one that aggregates findings to describe the literature and one that aims to interpret findings and develop a conceptual understanding.4 14 15 Meta-ethnography is an interpretative form of knowledge synthesis that was chosen for this study in order to both integrate and develop a greater understanding of existing knowledge and identify any other overarching concepts that would explain the data. The seven phases of meta-ethnography are outlined by Noblit and Hare15 and elaborated on by Toye et al.14 These are (1) getting started by identifying the area of interest; (2) deciding what is relevant; (3) reading and rereading the studies; (4) determining how the studies are related, which involves creating a list of key phrases, ideas, metaphors and concepts; (5) translating the studies into one another, where direct comparisons are made and similar concepts are sorted into categories; (6) synthesising the translations, where researchers make sense of the conceptual categories to develop new knowledge and understanding; and (7) expressing the synthesis. A line of argument was constructed by examining how the conceptual categories relate to each other.

Identifying and appraising the review articles

Analysis

Initially, the first 10 papers (in alphabetical order of author) were read by MG, KS and JO-B-E in order to identify key ‘concepts’, the raw data of meta-ethnography.14 These concepts are ideas drawn from the findings of the original papers. They are also known as second-order concepts because they are the authors’ interpretations of the participants’ narratives (known as first-order concepts).24 The participants’ narratives chosen by the author are examples of second-order concepts.14 After reading these 10 papers, the concepts identified by each researcher were amalgamated through discussion and grouped into conceptual categories that the team then worked collaboratively to name. This took place over a series of three meetings. These conceptual categories are third-order concepts insofar as they are the researchers’ interpretations of second-order concepts. All concepts were identified by all three authors (KS, MG, JO-B-E), and even if exact wording differed the concept was the same. This is the way that studies were translated and related to each other. The first author then proceeded to read the rest of the papers and continue this process of analysis. Five additional papers were also read by KS and JO-B-E where MG felt a collaborative discussion would be helpful due to the nature and/or findings of the studies. Thus 25% of papers were checked (n=10), then an additional 10% were checked (ie, 35% in total) to ensure ratings and concepts were in agreement. All the included papers were uploaded to QSR International’s NVivo V.11 software,25 and nodes were created for the conceptual categories. The next stage was to make sense of these categories through further discussion, make decisions about which were the core categories and develop a line of argument and conceptual model,14 involving a further four meetings. Recurring and common concepts were compared across studies,15 where directly comparable (reciprocal translation) together they contributed to our line of argument. We did not find studies that stood in opposition (refutational translation). The line of argument makes a whole of something more than a sum of the parts.15 MG, JO-B-E and KS independently drew their own conceptual model before coming together to agree a model, which was revised through several discussions, and the final version is presented in this paper. The culture described by Toye et al 26 of a core team that provided a safe environment in which to freely discuss, agree, disagree and change their position in relation to conceptual analysis was seen as a key strength, laying the foundations for a rigorous review. This approach was adopted in this review. We explored alternative interpretations and explanations, including locus of control, navigating relationships, normalising participants’ pain condition and agency but these ideas were not supported as major concepts. Many of these concepts were subsumed in other categories.

Patient and public involvement

A patient and public representative was involved in the development of the research funding submission for the overall study as a coapplicant and endorsed the importance of the focus of this meta-ethnography recognising the central nature of obstacles to return to work.

Search outcome and overview of studies reviewed

We include 41 papers and the search outcome is illustrated by a flow chart in figure 1. The initial 3191 hits were screened by titles and abstracts, duplicates excluded, and a further 1466 were excluded at this stage. Following the reading of full texts, papers were excluded as they were neither about chronic pain nor specifically about return to work. All studies that were critically appraised passed the first two screening questions of the CASP tool that related to whether there was a clear statement of the aims of the research and if qualitative methodology was considered appropriate to address the research goal.17 CASP scores are presented in online supplementary file 2. Of the 41 articles included, 32 reported interview studies and 9 focus group studies. Twenty-one studies were from Scandinavia (14 in Sweden, 4 in Norway and 3 in Denmark), 7 were from the UK, 7 were from Canada, 2 in France, and 1 each from Australia, South Africa, Switzerland and USA. Only five studies were from the employer’s perspectives. One study included in the review did not specify the type of chronic pain, but the majority of the studies involved people or employers of people with musculoskeletal pain, mainly affecting the back and neck, and some were injury/work-related. Studies of people with musculoskeletal disease, including arthritis, fibromyalgia and systemic lupus erythematosus, were also included (table 1).

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Figure 1

Flow chart illustrating search outcome.

Overarching conceptual categories

A total of 342 concepts were clustered into 16 conceptual categories summarised in table 2. The first column of table 2 contains third-order concepts. We worked with second-order concepts, and the second column of table 2 is second-order data, some of which are illustrated with first-order participant quotations. This table also highlights the CERQual profile. The three key conceptual categories identified by the team are described in this section. The balancing of these three inter-related categories and the way they are influenced by other factors appear to be central to negotiating a successful return to work. The scope for managing pain and making adjustments in the workplace can be influenced by the quality of the relationship an individual has with their employer and/or line manager and what is feasible within a particular work setting. The remaining 13 conceptual categories are described in more detail in online supplementary file 3. The concepts within each conceptual category are presented in online supplementary file 4.

Managing pain

Pain was seen as a major obstacle to return to work.27–29 A plethora of strategies to manage it were described,28–33 including use of sick leave.12 34

They used the strategies doing a little at a time, taking continuous breaks, working slower and being aware of body posture and workloads. These strategies improved their endurance and prevented further pain.32

However, the strain of living with chronic pain meant fatigue also became a problem and low-energy levels prevented work return.29

Pain developed and became continuous, was easily provoked by work tasks and relatively resistant to pain-controlling strategies. Life became strenuous and energy was reduced.30

The impact of pain on performance35 and ability to attend and travel to work,36 along with the fear of pain exacerbation,31 37 were also problematic.

Managing work relationships

Interpersonal conflict and mutual mistrust can arise between people with pain and their employers and colleagues,38 39 and if relationships with supervisors are perceived as poor then this is demotivating in relation to work return.40 Employers with few employees expressed reservations about how far to push an employee for fear of upsetting them and causing them to be off sick for longer than necessary.41 Managers in a public sector study appeared to be walking a fine line between supporting employees, making sure colleagues were not adversely affected and that services were delivered.35 Asking for help was perceived as frustrating by people in pain, and incurred feelings of inadequacy and negativity.42 Some struggled in their interaction with employers and tended to be passive, not believing their views were listened to, or valued, which led to difficulties in sustaining work return.12 Unsympathetic employer attitude and a lack of understanding of the person’s experience of pain were seen as major obstacles to work return,13 31 32 43 44 but those employers with personal experience of pain were perceived as more sympathetic and empathic.45 46

One of the important employment related obstacles is the perception that employers have limited understanding about pain due to ignorance and a lack of awareness. However, patients do acknowledge that chronic pain is difficult to understand without personal experience.13

Team management responsibilities of regulating tension between colleagues were perceived as challenging when work restrictions for those with pain caused unequal work distribution, leading to a sense of injustice.47

However, if duties were reduced indefinitely, with no extra cover, workers might feel that they were burdening their colleagues. There were doubts as to how long their colleagues support might continue.45

Making workplace adjustments

An economic climate of austerity was perceived as an obstacle to work due to reduced job availability and a competitive job market.13 Reorganisations and rationalisation in the workplace meant jobs had changed and become more demanding and potentially difficult to adapt for people with a pain condition.36 In this situation, age was also seen as influential, with some feeling they were too old to retrain for a different kind of job.13 44

The type of job influenced work return decisions, with physical work being perceived as more challenging with pain44 47 and more highly skilled work providing greater scope for flexibility and adaptation.48

Modifying work hours and days is a potential accommodation for women who develop musculoskeletal diseases, but it is only appropriate in certain work environments where such flexibility is allowed.43

People with chronic pain often felt they were not consulted or involved in the decision making about workplace redeployment or adjustment, and when desired modifications were not possible they could not return to work.43–45 48 Managers’ attitudes and efforts,46 combined with effective routine methods of regular communication of changes made to colleagues,49 were seen as ways of improving the success of workplace adjustments. Managers did not always have the resources or know what options would be available for making these adjustments and saw the planning of these accommodations as an additional demand on their time.46 Managers also felt that information about work restrictions from occupational health was not always realistic in the work setting and therefore difficult to implement.47

Many charge and head nurses complained that occupational physicians formulated unrealistic restrictions that were impossible to respect due to work organization.47

A number of workplace adjustments were felt to be helpful, including flexible hours or a reduction in hours, but were not always forthcoming.36 43 48 The possibility of a gradual return to work,50 working from home or participating in a job sharing programme43 was also seen as helpful by people in chronic pain. Changes to the job itself, including physical adjustments and a reduction in job demands, were not always feasible, for example in a nursing,43 nursing assistant role36 or a preschool teaching role.51

Line of argument

A line of argument was constructed by examining how the conceptual categories relate to each other. A flow diagram/conceptual model was then developed (figure 2).

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Figure 2

Conceptual model: the work of return to work. This conceptual model of return to work is explained in the text, going anticlockwise from (1) to (7).

This conceptual model of return to work is now explained, going anticlockwise from (1) to (7).

1. The underpinning foundation lies in the cultural expectation within society that people should work and contribute to the economy. Societal expectations are manifested within institutions, families and the media.

2. Societal and family expectations influence the individual’s sense of self and what work means to each person. Meaning can relate to financial remuneration, rewards or survival, and meeting of social, cognitive and achievement needs or purpose in life. The individual’s level of self-belief and autonomy will both play a part in how much agency and control can be exerted over pain and the work situation.

3. The way someone thinks about their pain and the mental representation they create will also influence their behaviour and the possibility of returning to work. People’s perceptions of whether pain is a long-term disability could influence whether they feel able to work and thus their return to work decisions, whereas someone who has accepted the pain as part of their life and adapts may be more likely to consider return to work.

4. Some studies in the review evaluated prereturn to work support or rehabilitation programmes, and not being understood by health professionals was cited as an obstacle. In the same way, not being believed or being judged by people in the workplace was also perceived to make return to work challenging.

5. The three key tenets of return to work are managing pain, managing work relationships and making workplace adjustments. Tension exists between these three facets and they can be influenced by a mismatch between the individual and the employer expectations, difficulties asking for help and system factors in the workplace, and health and social security systems.

6. Individuals must negotiate a wide range of obstacles and navigate change.

7. This could result in a downward spiral (and not working) at one end of a continuum through to an upward spiral of mastering return to work despite pain.

Implications

This review identifies obstacles faced by people with chronic pain in returning to work after a period of sick leave or unemployment and can be used to inform the development of a return to work intervention. The focus of such intervention should be working collaboratively with the person who has chronic pain and the employer to explore ways of addressing managing pain, managing work relationships and making workplace adjustments. The way in which the different factors work together either to enhance or inhibit return to work is highly individual, and clinicians will need to assess what is most important for the person and employer with whom they are working. This intervention could be located in community/primary healthcare and delivered by case managers, for example, occupational therapists or occupational health nurses working alongside general practitioners. Alternatively it could be delivered by employment specialists working in employment services and trained in pain management strategies. This type of intervention would provide support tailored to the specific needs of people with chronic pain. Discussion may be needed between the employer, the employee and the case manager to enable exploration of the ways in which obstacles to return to work might be overcome. This collaborative approach has the potential to improve healthcare services and change workplace culture and is the kind of innovation envisioned by the UK government in their 10-year plan for people with long-term health conditions to realise their working potential.56

Limitations

It is apparent that more research is required from the employer’s perspective. The five studies included in the review were from the perspective of employers working in car making, university hospitals, home care provision for disabled people in France,38 public hospitals in France,47 and National Health Service Trust and local authority in Wales.35 The Canadian study that included small and large employers did not specify the nature of the industry in which they were engaged.41

It is likely that the reviewers’ backgrounds and experiences had an impact on synthesis findings. The authors came from healthcare professional and non-healthcare professional backgrounds, and these backgrounds and experiences of chronic pain provided certain lenses, which we would expect to influence our understanding.

At the time we did this work, the eMERGe Reporting Guidance for meta-ethnography57 had not been published. They were published close to the end of the peer review process for this paper.