Theme 1: Not All Disabilities Are Visible.

This theme captures the challenges associated with recognising and responding to chronic pain as an often invisible and unpredictable condition within the workplace. Stakeholders highlighted the difficulty in identifying employees in need of support and the implications this has for organisational responses.

This theme comprised two subthemes:

1. a). Policies and Provisions refer to the formal organisational structures, policies, and resources in place to support employees with chronic pain, including occupational health provision and reasonable adjustments.
2. b). Organisational Support captures the extent to which support is perceived to occur in practice, including managerial responsiveness.

1. a). Policies and Provisions

This subtheme explored the extent of organisational policies and provisions for chronic conditions, including pain, and how visible and accessible these are for employees. It also covers stakeholders’ perceptions of how supportive the organisational culture is, as well as any gaps in provision. This theme also addresses stakeholders’ motivations for participating in the Pain-at-Work Toolkit feasibility trial and stakeholder interviews.

By participating in the feasibility trial, organisations hoped to send a clear message to all staff that chronic pain should be taken seriously and, ideally, accommodations be put in place before it resulted in long-term sickness absence, thus benefitting both the individual employee and the employer. There was a willingness to learn from the Pain-at-Work feasibility trial and the resources available within the Pain-at-Work Toolkit and to use the results to inform evidence-based practice. Although this was only overtly stated by a couple of stakeholders, another potential contributing factor was that by being involved in the trial, organisations would improve their corporate image and metrics.

“Saying that to everybody across the organisation, whether you’re an employee thinking about do I need to have a conversation about this or how am going to approach this conversation… but also if you’re thinking about managers, if somebody is talking to you and having that conversation saying that the organisation treats that as something that’s important and needs support”. [ID15, Occupational Health & Wellbeing]

Several organisational policies and provisions were discussed within the subtheme Policies and Provisions (see Table 4). These represent examples reported by stakeholders rather than additional analytic categories.

Since organisational policies were self-reported rather than systematically audited, the list shown below (ordered by frequency of mention), is not necessarily exhaustive. The terminology below reflects stakeholder language.

1. i). Specific Policies for Chronic Pain

Although 11 of the 12 organisations were classified as large, none of the organisations surveyed had specific policies to support employees with chronic pain. Broader policies were mentioned, which aimed to support those with other long-term conditions or disabilities. Consequently, chronic pain was not clearly referred to in organisational policy or specifically provided for. Chronic pain was widely perceived as a “hidden” or “invisible” condition, both because employees may not disclose their experiences and because organisational support is often contingent on such disclosure, with implications for the support that employees receive. This interpretation was further supported by the finding that seven of the 15 stakeholders had no idea of the proportion of employees with chronic pain, and the remaining eight could at best guess at anything from occasional cases to a high proportion of the workforce.

“I don’t think there’s anything specific just for pain. I think it is wrapped up with everything else. It does come under sort of long-term conditions.” [ID07, Head of Wellbeing]

“In terms of policies and practices, it depends on what you mean by where they sit. I don’t think we still have anything that explicitly talks about it.” [ID15, Occupational Health & Wellbeing]

Stakeholders acknowledged that invisible disabilities, such as chronic pain, (often compared to mental health conditions), were poorly understood and could be stigmatised for example through scepticism about the legitimacy of chronic pain and concerns about being judged or not taken seriously by employers, managers, or colleagues and received less support than visible disabilities like physical or sensory impairments. This reflects an awareness of the challenges associated with invisible conditions, rather than a detailed understanding of the prevalence of chronic pain and its impact within the workplace.

“Stigma around some people with conditions like fibro(myalgia) is still quite apparent, and that’s even within healthcare, never mind a manager or an HR professional.” [ID11, MSK & OH Physiotherapist]

This quote illustrates both an awareness of the challenges associated with invisible conditions and the persistence of scepticism and misunderstanding surrounding chronic pain.

“If you can’t see it, it isn’t a broken leg. You haven’t got a bad back; you know that sort of thing, or you’re not in a wheelchair…I really don’t understand what the issue here is. And it’s a bit like mental health. You know the two go hand in hand.” [ID07, Head of Wellbeing]

1. ii). Reasonable Adjustments

As required by the Equality Act 2010 [36], all 12 organisations made reasonable adjustments typically in conjunction with a personalised enhanced Display Screen Equipment (DSE) assessment often undertaken by the Health and Safety Team. Stakeholders were generally familiar with typical adjustments required for some types of chronic pain, mainly musculoskeletal. These included customised workstations such as ergonomic chairs, standing desks and adjustable footrests, and a few stakeholders specifically referenced the UK Government’s Access to Work scheme as a means of providing additional resources.

Stakeholders often described reasonable adjustments in relation to specific functional limitations rather than chronic pain as a condition, for example:

“So, if it was about if it was about chronic pain it would depend on what kind of problem at work that was. But if it was about difficulty sitting for long periods of time then you might be directed to have an enhanced DSE assessment with the health and safety team.” [ID01, Head of Workforce Policy and Wellbeing]

“So, we do the DSE assessments, you know, so that’s about your screen, your keyboard, your mouse, your chair, things like this.” [ID12, Lead Research Nurse]

Adapted working patterns for employees with chronic pain, such as frequent breaks, flexible working hours, and/or hybrid working arrangements, were also provided. These arrangements were typically implemented as part of reasonable adjustments in response to specific functional limitations associated with chronic pain. However, stakeholders noted that accommodating such adjustments could be challenging in practice, as explored further in relation to the role of line managers (Theme 2: Not All Line Managers Are Equal). However, some stakeholders noted that it could be challenging to accommodate these changes while still meeting operational demands. This, together with other comments about limited resources and high workloads in support services, such as occupational health, highlights the real-world challenges of accommodating an employee with chronic pain.

“A typical adjustment, say, for someone with an arthritic condition…whether that’s in winter, cold conditions, or humid conditions, or if their pain is worse in the mornings is that they they’re allowed to start later, or if they have the ability to do that, to be able to work from home to avoid having to do that commute”. [ID14, Occupational Therapist]

“So, if I give you an example of the of a tailored work plan for somebody with back pain. So, what we might do is we introduce rest breaks to move around, which is sort of 5 minutes or 10 minutes in between each patient. We might reduce the amount of driving so they can do a mixture of hybrid working… And we alter their working rota so that they’re still seeing the same amount of patients or still having the same amount of patient contacts, but it’s spread out a bit more. The difficulty is you still got patients to see as well.” [ID10, Service Lead]

Some stakeholders recognised the need for individualised adjustments rather than a “blanket” solution but acknowledged this was not always reflected in policy and practice. One individual who had lived experience of chronic pain had themselves experienced a “one size fits all” approach at work: “Myself and several colleagues all have lower back pain after childbirth. We are all very different but we all got a blanket set of advice.” [ID08, Senior Clinical Research Practitioner]

“But, you know, reasonable adjustments are, gosh, they’re just so varied, aren’t they? It’s about how long can you sit? How does that affect you? … this is why I say it’s a really individual basis because you can’t put a blanket set of questions on one person. And if you do, all you do is make it a process.” [ID12, Lead Research Nurse]

Two stakeholders, each representing a different organisation (both third sector), demonstrated a particular willingness to provide a wide range of equipment in offices to help with disabilities, including walking pads, TENS machines and heated pads and blankets. In one case, this appeared to be influenced by the values and lived experience of a senior leader. The other was working with estates and facilities to embed wellbeing into office design so that a range of needs were accommodated. This included considering how carpets impacted wheelchair users and chairs with arms for individuals who needed support to stand up, as well as chairs without arms for those who use walkers or sticks. These actions were the result of a proactive Occupational Health and Wellbeing Lead who had implemented learnings from a previous role. However, among stakeholders, this was the exception rather than the norm, with most organisations relying on standardised solutions.

1. iii). Sickness Absence

All of the 12 organisations had what is officially termed a ‘sickness absence policy’ although this exact terminology was used by less than half of the 15 stakeholders; the most common language being ‘sickness’ or ‘sick’. The widespread use of these terms may reflect unconscious attitudes—for example, framing sickness as the individual employee’s problem rather than something the organisation should support – and some stakeholders indicated that individuals were expected to take responsibility for their own health. A few stakeholders spontaneously referenced chronic conditions (although not necessarily chronic pain) noting that policies outlined expectations for both employees and line managers, particularly in managing extended or frequent absence. However, stakeholders acknowledged that this process was far from perfect since support was typically only offered when sickness absence had become an issue for an employee’s line manager rather than aiming for early intervention (e.g., a reactive rather than proactive approach). As one stakeholder noted, “It shouldn’t just be when people have been off sick… how can we be having those open conversations in advance of that.” [ID15, Occupational Health & Wellbeing]

This was further reflected in accounts suggesting that support is often only initiated once problems escalate: “they have tried to self-manage for a while… it’s normally when they feel that there is a tipping point… and then the manager refers in.” [ID09, Senior Occupational Health Advisor]

In contrast, examples of more supportive approaches were limited. One of the 12 organisations (third sector) also offered a ‘disability leave policy’ which, in addition to annual leave, allowed staff up to 5 paid days a year to attend medical appointments. This particular organisation was one of two that provided a particularly wide range of accommodations for workers with disabilities.

Analysis of stakeholder accounts indicated that chronic pain was sometimes associated with long-term health conditions, including long COVID, fibromyalgia and musculoskeletal conditions such as lower back pain and rheumatoid arthritis. However, while some chronic conditions could be recorded within organisational systems, sickness absence reports were not structured in such a way that employees with chronic pain could be easily identified. As a result, accurate data relied on individual disclosure which was influenced by both organisational culture and, as discussed subsequently, line manager practices (Theme 2: Not All Line Managers Are Equal).

“We don’t have those figures and it’s in part because of the way we record the statistic, because quite often with chronic pain, it’s going to be something that comes up in conversation as a secondary order even if it actually turns out to be primary. I haven’t found it really is something that people lead with, and so it won’t be recorded necessarily either in their occupational health referral or with their sickness absence.” [ID15, Occupational Health & Wellbeing]

“So, we do have arthritis codified. We do have, you know, obviously injuries that occur in the workplace and I’ll just scan down here to see what we’ve got. Chronic fatigue and fibromyalgia, connective tissue disorder. Let’s have a look to see if we’ve got any chronic pain. We have muscles, skeletal disorder, broken down... fracture injury, lower and upper limb. Capture whether somebody’s had surgery for orthopaedic reasons. So, it’s not even close, we do have simply neurological. So yeah, so the answer is we don’t capture, don’t codify chronic or persistent pain.” [ID09, Senior Occupational Health Advisor]

1. iv). Occupational Health

Ten of the 12 organisations provided occupational health services, the majority of which were provided internally but this may reflect the predomination of larger companies in the sample. Occupational Health was accessed mainly by referral from line managers and hence an individual’s line manager had considerable influence on employees’ access to support. Only two organisations allowed an employee to self-refer to occupational health; in the majority of cases this route was not available. Interestingly, one organisation had changed the process so that human resources rather than line managers could make staff referrals: the rationale being greater consistency and expertise; a theme which is explored in more detail later when we consider the impact of line managers on employee support at work (Theme 2: Not All Line Managers Are Equal).

“I know in lots of organisations, then it might be the line manager that can do a direct referral to occupational health. As we’re trying to get this consistency of support and as we’re trying to support managers in how to approach this, we don’t actually do that at xxx at the moment that got changed a couple of years ago. So, you would talk to my HR colleagues and they would do that referral so they would be able to mediate and support and help.” [ID15, Occupational Health & Wellbeing]

Several stakeholders in occupational health felt that a lack of staff and restrictions on the amount of time they were able to spend with employees limited the support they could provide. While all but two of the 12 organisations offered occupational health services, there was noticeable variation in their capacity. Examples of the ratio of occupational health staff to other workers ranged from one occupational health worker for approximately 3,500–5,700 employees to one occupational health worker for every 250 staff.

“I think there is something around expanding the remit of occupational health. So, you know, having more staff to enable us to be able to see people once, see people again a month later and then maybe meet with the manager as well to provide more ongoing follow-up, I don’t think a one-off consultation report cuts it for people who have been living with chronic pain for potentially years”. [ID14, Occupational Therapist]

1. v). Physiotherapy

Eight of the 12 organisations also mentioned employees having access to physiotherapy, which in a few cases was subcontracted to an external organisation, and regardless of provider, was most often accessed by a referral from occupational health. Relatively little was discussed about the role physiotherapy could play in chronic pain although individuals noted that employees needed to be motivated to do the exercises recommended by the physiotherapist and that physiotherapy needed to be supported by changes in the working environment typically made under the umbrella of reasonable adjustments.

“When it comes to sort of managing pain, usually there is quite a lot of input required, particularly with the main sort of processes that we push, say things like physiotherapy.” [ID03, Head of Occupational Health & Wellbeing]

“Staff have access to physios via self-referral or referral by Occupational Health. They are an external provider, but we closely manage the process, including holding records on site.” [ID06, Occupational Health Advisor]

1. vi). Employee Assistance Programme (EAP)

Three of the 12 organisations offered an Employee Assistance Programme (EAP) which provided independent resources and services such as counselling and advice on mental or physical health issues. Chronic pain was not mentioned specifically, so the ability of the programme to provide tailored advice is unknown.

“People can call that, if they want to talk to someone about a medical concern they’ve got. That’s staffed by a nursing team so they can get some support there.” [ID01, Head of Workforce Policy and Wellbeing]

“We do have an online Employee Assistance Programme which offers employees the opportunity to speak to somebody independent of the organisation for a range of advice topics, whether that be health-related or psychosocial issues.” [ID09, Senior Occupational Health Advisor]

1. vii). Health and Wellbeing

Eight of the 12 organisations offered Health and Wellbeing, although the scope and form of this varied. Examples included regular events, such as presentations and webinars, from both internal staff and external experts, covering a range of topics. Wellbeing advice and signposts to resources were also typically available on the organisation’s intranet, and individuals mentioned specific campaigns, for example, aligned to national ‘awareness’ days or weeks. Arthritis UK (a UK charity providing support for people with arthritis) and ‘Flippin’ Pain’ (a UK-based public health campaign focused on changing how people understand, talk about, and treat pain) were specifically mentioned by a couple of stakeholders as valuable resources for employees with chronic pain. Some stakeholders referred to staff who were designated as wellbeing champions or advocates and whose role was to offer advice and support to colleagues. However, mental health conditions appeared to be given a higher profile, with musculoskeletal (not specifically chronic pain) only being mentioned twice spontaneously.

1. viii). Employee Networks

Six of the 12 organisations had employee-led networks as a means of providing a safe space for staff to discuss, share experiences, and offer support to one another. These spanned a wide range of groups, typically under the banner of Equality, Diversity, and Inclusion (EDI), including gender, sex, and sexual orientation, parental leave, working practices, and disability. Chronic pain was most likely to be covered in networks for people with disabilities and/or long-term health conditions rather than a specific forum.

“We tried to listen to what, you know what our demographic wants and needs, and we tried to make sure that they have a safe space within the organisation that they feel represented in.” [ID04, People Business Partner]

“So, for example, we have one which is titled xxx which is designed for employees with some form of underlying health issue or long-term health condition or you know those who find themselves subject to the need for workplace adjustments. It’s a peer-led work group.” [ID09, Senior Occupational Health Advisor]

1. ix). Wellbeing/Work Adjustment Passport

Four of the 12 organisations offered what was either described as a ‘Wellbeing or Work Adjustment Passport,’ which seems comparable to a Health Adjustment Passport (Department of Work and Pensions). The work document was primarily described as a means of providing a record of the employee’s needs and adjustments should they change roles and/or managers. In one instance, it was a response to numerous queries from employees with long-term conditions, including chronic pain. In a couple of cases, the document was also seen as a way of structuring a conversation between the employee and their line manager about health and wellbeing, for example, by exploring how the condition affected them, what triggered it, what the individual could do to support themselves, what they needed from their manager and the organisation and examples of what was possible. Although atypical, this extension of use may have merit, particularly given the important role that line managers play in supporting employees at work (Theme 2: Not All Line Managers Are Equal).

1. x). Human Resources

Four of the 12 organisations mentioned Human Resources, although it seemed that some aspects of the role were shared with the Health and/or Wellbeing team.

“So, for example, every month we will have a wellbeing conversation where every colleague’s invited to join, they are all recorded if you can’t join and we invite expert speakers in to speak, to talk to colleagues and that will be a range of topics, it will change every month. But sometimes we do have things that would support things around pain, you know, so physical wellbeing.” [ID01, Head of Workforce Policy and Wellbeing]

“We have a UK Health and Wellbeing Lead and a deputy lead to look after that mandate within the organisation. They run sort of supportive webinars for staff as well as sort of oversee or coordinate the various staff networks.” [ID09, Senior Occupational Health Advisor]

Overall, while a range of policies and provisions were reported, stakeholders consistently highlighted a lack of specific recognition and tailored support for chronic pain within organisations.

1. b). Organisational Support

Stakeholders’ comments indicated inconsistent support for employees with chronic pain, both across and within organisations, which was potentially underpinned by a limited understanding of the nature of chronic pain and its possible impact on an employee’s working life. Six of the 12 organisations were said to be supportive of employees with chronic conditions generally. However, in the remaining half, stakeholders identified both strengths and weaknesses in the organisational culture. One key weakness was said to be inconsistent and inadequate support which stakeholders attributed to two main factors. Firstly, health was often seen as a binary construct by employers, where individuals were either well enough to work or needed to be off sick, rather than a scenario where an employee could be supported to stay in work. Secondly, the unseen, unpredictable symptoms of conditions with chronic pain, such as fibromyalgia, were poorly understood and often stigmatised.

“I definitely think physical impairment is probably more recognised and accepted than mental health and chronic pain because people just don’t understand… If you can’t see it, it isn’t a broken leg. You haven’t got a bad back; you know that sort of thing or you’re not in a wheelchair.” [ID07, Head of Wellbeing]

“I would say it is really similar sense to - we do a lot of work in terms of kind of mental health - and I kind of see a similarity there in that if something’s not visually obvious, sometimes it can be really quickly dismissed.” [ID03, Head of Occupational Health & Wellbeing]

“And I think there’s a very long time there’s been a distinction, and especially this sort of mentality that we’re challenging all the time in our managers of whether I’m fit enough to be at work or they’re not.” [ID01, Head of Workforce Policy and Wellbeing]

According to two representatives from the same organisation, one private sector company was very poor at supporting employees. This was attributed to the demographic of the workforce (typically older men) who were reluctant to disclose health issues. However, the culture was seen to be slowly improving, as evidenced by more employees seeking occupational health advice and support.

“I think because you’ve got a culture of requirement to meet deadlines coupled with the culture of people not necessarily wanting to ask for help or a bit scared to kind of raise concerns.” [ID03, Head of Occupational Health & Wellbeing]

Stakeholders typically felt that organisations needed to improve their support of employees with chronic pain. Currently, supportive intervention was said to occur when an employee’s attendance becomes an issue, but stakeholders wanted to see adjustments put in place earlier and, ideally, introduce preventative measures such as early identification of those individuals at risk. However, it was recognised that this relied on individuals being willing and feeling safe enough to disclose their health conditions, and line managers being more proactive in initiating such conversations within their teams, as well as being receptive to such discussions.

“I think most organisations are guilty of not paying enough attention to something until it’s gone wrong. So, it’s all tertiary rehabilitation.” [ID05, Wellbeing Lead & Occupational Health Technician]

A few also stated that even in a supportive workplace, making reasonable adjustments or gaining access to specialised resources was a lengthy process.

“Xxx is really good at reasonable adjustments, but things do take a long time to happen.” [ID08, Senior Clinical Research Practitioner]

Digital resources for self-management were the exception rather than the norm with only. one public sector organisation providing these. It offered mental health support via online yoga classes, the CALM application and a toolkit designed to help staff build psychological resilience but did not provide anything specifically for chronic pain.

In summary, stakeholders described organisational support as variable and often reactive, with a shared view that earlier and more consistent support for employees with chronic pain is needed.

Theme 2: not all line managers are equal.

This theme reflects variability in the role of line managers in supporting employees with chronic pain, highlighting differences in knowledge, attitudes, and willingness to provide effective support.

This theme comprised two subthemes:

1. a). Individual Variation refers to differences between line managers in terms of their attitudes, confidence, and willingness to engage and support employees experiencing chronic pain.
2. b). Supporting Line Managers captures the organisational structures and resources, if any, available to enable line managers to fulfil their role, including training, guidance, and support.

1. a). Individual Variation

As shown previously, there were many organisational roles involved in supporting the health and wellbeing of employees. However, stakeholders identified line managers as having a critical role in putting organisational values into practice at the local level.

“Day-to-day they’re the person that has the biggest impact; they are the person that mediates the organisational values into your team. They’re the ones that are judging you. In want of a better word in terms of agreeing your objectives, and then how did, you do and if you do have any issues, they’re the ones that are supposed to be your first stopping point to get that support so they are hugely impactful.” [ID15, Occupational Health & Wellbeing]

Approximately one third of stakeholders had management responsibilities or prior experience and felt that line managers generally tried to be supportive and make appropriate adjustments for their direct reports when required, although it was acknowledged that they had to balance this against what was practically feasible at work.

“The managers are pretty good and pretty supportive in that because they’re involved in the process of referring that person in. They’re then more likely to listen to that advice because they’ve asked for it...doesn’t always work that way.” [ID05, Wellbeing Lead & Occupational Health Technician]

Several commented that it could be challenging to meet individual needs without negatively impacting on the workload of other team members and also ensuring that everyone was appropriately supported. Furthermore, stakeholders observed that, as managers, they had to balance accommodations against work productivity.

“And it means that other people are having to take the slack ultimately and increase their patients and increase their workload. And you know, a lot of the other team members might already be on the edge themselves of burnout or stress or had sickness leave, and that’s enough just to tip people over the edge.” [ID14, Occupational Therapist]

“It’s really difficult because as me, as [xxx] I would say, fine, you get up and stretch when you want you, you know you can move around. But for me as lead of the service you can’t do that, so it’s a balancing act between making reasonable adjustments that are helpful to the individual that don’t impact hugely on essentially productivity.” [ID10, Service Lead]

Two individuals pointed out that, as line managers, they also needed support because managing individual adjustments in a team could be time intensive and sometimes challenging.

“So, it depends as well on the workload of the line manager as to how far you can actually pursue that line of thought as well. So, if you have a team of five, you have more time to pursue you, if you’ve got a team of 50, that’s very tricky”. [ID12, Lead Research Nurse]

Three quarters of stakeholders were concerned that the support line managers provided to their team varied depending on the individual manager and as a result support was inconsistent across the organisation. This was exacerbated by the fact that line managers were highly influential at all stages of the process; from an employee’s willingness to disclose, to providing reasonable adjustments and access to supportive services like occupational health. As mentioned previously, in the majority of cases, referrals such as to occupational health usually required the line manager to refer.

“I would say that it’s hit and miss…So yeah, you know it depends on where you are, who your line manager is, the team that you work in and the job that you do, how much support is offered and what is available to you”. [ID07, Head of Wellbeing]

“The caveat I will put on it because it’s all about the delivery locally with the line manager. So, some line managers will look at the policy and go right every month I’m supposed to talk to everyone in my team about their health and wellbeing … However, in the real world, we have 4 1/2 thousand employees…So, do I think it happens exactly in exactly the same way in every team? No.” [ID01, Head of Workforce Policy and Wellbeing]

Only a few organisations required line managers to be proactive and have regular (weekly or monthly) meetings with each team member which theoretically included checks on the employee’s health and wellbeing although it was not known if these took place. There were also a few cases where the organisation had developed guides/forms to help line managers have those potentially ‘difficult conversations’ about sickness absence, attendance, and adjustments and to signpost additional resources. One organisation had developed a toolkit specifically for managers above a certain level of seniority which was supplemented by a course which took place over several weeks. Another had designated representatives who attended all discussions between an individual and their line manager and acted as an advocate for the employee if required.

“In terms of some of those wellbeing discussion tools can be quite helpful especially you know because it helps both sides have a structure and to help them work through that conversation.” [ID15, Occupational Health & Wellbeing]

However, these kinds of early checks and balances were the exception rather than the rule and tools to support line managers in supporting their staff were not typically supplied by the organisation. Stakeholders recognised that line managers (like many other staff) typically did not understand chronic pain and were often inexperienced and under skilled in managing staff with complex, chronic conditions.

“Another one of our huge priorities kind of moving forward is upscaling managers…a lot of our managers are excellent from an operational perspective. But we haven’t historically kind of provided the skills that you need to be a manager from the people perspective.” [ID03, Head of Occupational Health & Wellbeing]

As a result of late disclosure and/or a lack of proactive engagement from line managers, the most likely scenario was that supportive interventions such as reasonable adjustments and occupational health were often only instigated when sickness absence had already become problematic.

“We kind of catch up with the other wellbeing leads at the other [xx] networks quite regularly and they say pretty much the same thing; it needs that culture change to focus more on the prevention than just fixing things once they’ve gone wrong.” [ID05, Wellbeing Lead & Occupational Health Technician]

“I want to promote prevention much more as well, but it shouldn’t just be when people have been off sick and how do we support them to come back?” [ID15, Occupational Health & Wellbeing]

Stakeholders recognised that individuals with chronic pain might hide this at work, being fearful to disclose symptoms which were invisible and often misunderstood and stigmatised. Some stakeholders also recognised that adjustments that worked for one employee might not help another and that the adjustments an individual required could vary over time as symptoms fluctuated. As a result, putting reasonable adjustments in place was perceived to be challenging.

“It’s hard sometimes for managers to understand that how an employee presents could fluctuate without kind of rhyme nor reason, and so, for example, there are those symptoms which could deteriorate or improve without warning.” [ID11, MSK & OH Physiotherapist]

Across stakeholder accounts, there was strong agreement that line manager support was highly variable and had a significant influence on employees’ access to and experience of workplace support. While flexible working and other adjustments were available, their implementation in practice was highly dependent on individual line managers, with variation in knowledge, capacity, and confidence shaping how effectively employees were supported.

(b) Supporting Line Managers

Stakeholder suggestions regarding support for line managers covered what content was needed and how it might be delivered.

During the discussion, some stakeholders spontaneously identified a need for additional resources to support managers – including in one case a version of the Pain-at-Work employees toolkit and this concept was hence explored further. Given the variability of line manager support and the lack of organisational tools, stakeholders reacted favourably to the concept of a developing a Pain-at-Work Toolkit specifically for managers hoping that a unified resource would educate managers and help them better support their staff. Stakeholders suggested that such a resource should include key information (e.g., conditions that can cause chronic pain, and the symptoms an employee might present with), guidance on communication and engagement (e.g., how to have constructive conversations with employees and practical examples (e.g., of reasonable adjustments and case studies showcasing how other organisations have supported staff to continue working, as well as signposting to additional resources. Individuals suggested that these resources should be aligned with the organisation’s specific policies and practices. These suggestions were intended to support managers, particularly those with limited experience or confidence in managing chronic conditions.

Stakeholders recognised that many of their suggestions reflected the current structure of the employee Pain-at-Work Toolkit [24], and an individual proposed this could be adapted to produce a managers version. This highlights a clear opportunity to extend existing resources to better support managers in their role.

“Yes, short answer, yes. Long answer is yeah even at a basic level, which is advice… So yeah, so I’d definitely support that. It potentially could be digital, an online resource.” [ID11, MSK & OH Physiotherapist]

“When it comes to when it comes to support, there’s the age-old saying, isn’t here? You join an organisation; you leave the manager.” [ID15, Occupational Health & Wellbeing]

“As I said, we’ve got a lot of junior managers that are out there. I think they would find it (toolkit) useful because they’ve not got that experience, they haven’t got prior knowledge to draw on.” [ID13, Practice Educator]

However, a few had reservations that managers would not have the time or inclination to engage with such resources.

“You would get your sort of trailblazing managers who are incredibly passionate about staff welfare and wellbeing who would attend but I guess your managers who are preoccupied with all the other responsibilities they would be difficult to access.” [ID09, Senior Occupational Health Advisor]

Stakeholders consistently emphasised the need for additional resources and training to support managers, particularly those with limited experience, in managing employees with chronic pain in the workplace.

Theme 3: Who Has Control?.

This theme explores how control over the management of chronic pain in the workplace is perceived and negotiated between individuals and organisations. Stakeholders described a dynamic interplay between personal responsibility and organisational influence, highlighting tensions around disclosure, self-management, and the provision of support.

This theme comprised two subthemes:

1. a). Individual Locus of Control refers to the extent to which employees are perceived as responsible for managing their own condition at work, including decisions around disclosure, seeking help, and engaging with available organisational support. This subtheme captures beliefs about personal agency, motivation, and capacity for self-management.
2. b). Organisational Culture reflects the broader organisational context that shapes how control is distributed and enacted, including norms around disclosure, expectations of employee responsibility, and the degree to which organisations create environments that enable or constrain support.

1. a). Individual Locus of Control

The extent to which an individual employee could self-manage their chronic pain at work was thought to vary. One theme that underpins many of the stakeholder comments is the influence of employees’ locus of control; that is, the extent to which individual employees feel they are in control of their pain. Locus of control is a psychological concept which refers to the individual’s perception that events are determined by their own behaviour rather than due to chance, luck or external factors [37]. According to Sowden, an internal locus of control is associated with a more pro-active approach to managing pain [38]. In this study, the concept can be applied to the extent an individual employee discloses their condition, actively seeks organisational help and support, and actively engages with this. The resources in the Pain-at-Work Toolkit were designed to encourage employees to self-manage their pain and support them in doing so. By providing employees with chronic pain self-management strategies the aim was to prevent individuals from working until they were at “breaking point” and/or taking repeated or extended sickness absence.

“Trying to encourage people to take responsibility of the things that they can actually control, they can actually manage, I think are going to make a bigger difference than us just waiting for someone to come to us because they’re at breaking point.” [ID05, Wellbeing Lead & Occupational Health Technician]

Stakeholders observed that there were differences in the way individuals would tackle the challenges of chronic pain, with some hiding their struggles, suffering in silence, and trying to push through. Individuals thought that older men were more likely to soldier on or that younger workers were more likely to ask for and/or expect the employer to find a solution.

“It’s the kind of hidden thing, isn’t it? You kind of try and tone it down and say OK, I’ll just push through. I don’t want people to know that I’m finding that difficult.” [ID15, Occupational Health & Wellbeing]

Several stakeholders felt that employees had to take some responsibility for self-managing their chronic pain. This included the need to disclose their condition, ask for help, and ideally state how the condition impacted their work and what they needed to help them stay in work.

“I think there’s an individual responsibility as well, and that’s another thing we want to try and kind of push…and even if that is as far as saying, OK, admitting I’ve got pain, I should ask for help. That is again a message we want to try and get across.” [ID03, Head of Occupational Health & Wellbeing]

“I think the extent to which people self-manage pain varies, but I would like to see more of it. Of course, it depends on level and type of pain.” [ID06 Occupational Health Adviser]

“I think we live in a culture of dependency…And yeah, and we have a population that has forgotten how to self-care, and we’ve taught them that.” [ID10 Service Lead]

Stakeholders generally agreed that while individual responsibility for self-management is important, employees vary in their capacity and willingness to engage with support.

1. b). Organisational Culture

Stakeholders recognised that their workplace culture significantly impacted employees, even those who proactively self-managed their condition, and admitted that organisations sometimes struggled to adapt organisational policies to individual needs. Stakeholders talked about employees being fearful of disclosing chronic pain, fearing that the employer would not be understanding, and as previously discussed, the attitude of an individual’s line manager was seen to be highly influential.

“I guess people are somewhat reluctant to seek help and assistance, and they will quite happily kind of cover issues…I guess fear of disciplinary action would be a factor as well.” [ID03, Head of Occupational Health & Wellbeing]

“I think there’s a real fear that employers won’t be understanding. I think that’s real.” [ID01, Head of Workforce Policy and Wellbeing]

Recognising that organisational support could be inconsistent, almost everyone felt that there was a need for additional tools to support employees in self-managing chronic pain at work. Stakeholders were generally positive towards digital resources providing education and support for self-management of chronic pain. However, a few noted that not everyone would be willing or able to access these and that additional modalities should be available.

“It’s not a problem at all. I mean it’s (digital) where everything is. Where everything is, I think you can get better support.” [ID02, Director]

“I think even if you just factor in things like individual preference, neurodiversities as well as you need to factor in people’s familiarity with certain forms of media. So, for example older individuals might be less familiar with digital media.” [ID03, Head of Occupational Health & Wellbeing]

There was broad agreement that organisational culture plays a critical role in shaping disclosure, access to support, and the effectiveness of self-management strategies.