Individualised placement support as an employment intervention for individuals with chronic pain: a qualitative exploration of stakeholder views

Complex needs

ESWs identified that patients’ flare ups of pain were difficult to manage and prevented them from remaining in work, despite the patients' desire to work. ESWs and HCPs discussed the need for planning and managing patients’ pain, including pacing, stress management, and emotional support. It was noted that people with chronic pain would have different work requirements:

'we just have to make sure we are pacing everything right for her. That she was going into a flexible environment, so if she needed to sit down that she would be able to.' (ESW1)

Clients spoke about the ‘boom and bust’ cycle of overexerting themselves on days they felt well, completing activities to a perceived level of normal:

'And you can push through maybe a day and you’d probably be ok the next day if you don’t do too much, but by the third day you’re in bed.' (C5)

HCPs had concerns that patients held deep-seated beliefs that may influence their view of work. They discussed the 'vicious circle' of chronic pain, acknowledging that it could be incapacitating for some individuals. There were concerns that some patients do not wish to change the management of their pain or coping strategies, for fear their pain or functioning may worsen:

'There are also people who become institutionalised in their own self-management.' (HCP2)

It was also felt that chronic pain could be rewarding for some individuals, both financially and for their lifestyle, and this could lead to people not wanting to change or improve their health:

'Our culture allows people to revel in the sick role a lot.' (HCP1)

Relationship with work

All three stakeholder groups alluded to the importance of the relationship between the client and their motivation to work. HCPs identified three groups of patients: those who are keen to return to work; those who could return to work if their work was modified due to their condition; and, those who do not want to return to work. Clients also spoke about wanting to return to work:

'I have been banging my head against the wall for a while, trying to get myself back into employment.' (C4)

All participants identified concerns about clients returning to work, and not knowing what employment they could now enter, due to their conditions:

'I'm not scared of work. I've always worked. I've worked ever since I've left school. It's only because I got the injury, so I've got to adapt now.' (C1)

Some clients were still not sure if they wanted to return to work:

'So, the cost to my personal life, for the benefit of me working, my pain would get worse, my tiredness would get worse.' (C5)

Additional reasons for lack of work were identified, such as the economic climate and state of industry. Stakeholders discussed the complex issues regarding state benefits:

'Because I was gonna go into work for them, but I would’ve been financially a lot worse off.' (C8)

Role of health care professionals

HCPs discussed their role in helping patients return to work:

'We are just medicalising their pain in terms of either prescribing analgesics or whatever and signing them off.' (HCP4)

Due to time constraints, they felt that they could contribute little into helping patients back to work. They felt their role was mainly around diagnosis, pain management, and providing medical certificates. However, they felt that more could be done for patients in this situation:

'my feeling is, as a clinician, to give a sick note is ... I really think I would give it as part of a treatment regime.' (HCP1)

HCPs suggested medical certificates should be part of a package of care, providing support and information in returning to work.

Current employment programmes compared to IPS priorities

Clients and ESWs were aware that there were a variety of employment interventions available, but considered many of them inappropriate for individuals with complex issues:

'The other programme, they understood my problems but they didn’t do anything about it.' (C4)

IPS was seen as a different approach, helping participants with a health condition identify their limitations, become ‘job-ready’, and support them into employment. The ESWs described the programme as giving clients time, continuous support, and tailoring the programme for them:

'I love my job. Because I know it works, I can honestly speak to clients, ”yes it does work“, and it does.' (ESW3)

Identification of unemployed people with chronic pain wishing to return to work

Stakeholders identified a range of ways in which eligible patients could be identified. The existing IPS intervention was recruiting through the job centre, but stakeholders felt that these patients could be identified elsewhere, including GP practices, local chronic pain services, physiotherapy services, rheumatology departments, support groups, community groups, and libraries. HCPs also felt they could personally identify individuals who would benefit from the programme.

Clients had varying expectations of the programme, although some were hopeful about it helping them, others were more sceptical:

'I'll do whatever they ask of me, but … what's going to come out of it? Or is it just a waste of time?' (C1)

There was confusion among clients on the voluntary or mandatory status of the programme. Although the programme was explained by the ESWs as being voluntary (IPS is designed for people who want to work), some clients had not felt that they had free choice when referred by the job centre. HCPs recognised the importance of client engagement with the intervention if it was to be successful. Clients emphasised the importance of providing good information about the programme and its aims before attending for the first IPS session:

'They didn't tell me why or anything, didn't know who I had to see. No one knew why I was here. So it was a bit… there was no explanation why I was sent here or what it's for.' (C3)

Employment support workers

Other clients felt that they had experienced little stability in the programme and not developed a relationship with any one adviser, having met multiple ESWs; this was felt to hinder their progress and undermine their experience of IPS. ESWs acknowledged that, although they tailor the programme to their participants, this was based on the discussion with clients. They recognised that, as non-healthcare professionals, they had only limited knowledge about the impact and management of chronic health conditions:

'It’s like a group, obviously workers, but like a family, they work well together.' (C9)

'You should have advisers that have training around chronic pain and there should be a fully comprehensive directory of signposting people.' (ESW4)

Timing

The existing IPS programme was offered to individuals with chronic ill health after 2 years of unemployment. All participants acknowledged that the sooner someone could enter the programme, the more it was likely to benefit individuals. Long waiting lists were considered a disadvantage of other interventions:

'Once they've made the first step to talk to us about it. Or they've put their hand up and said ”yes, I do need some help” they then have to wait for months to get that intervention, is quite demoralising for a lot of people.' (HCP2).

Clients and ESWs also felt the programme could, in some cases, need to involve support for longer than a year, as it could take longer to get someone 'employment ready' and into a job.

One-to-one contact and personalised advice

One-to-one contact was seen as the most important aspect of the programme. ESWs were seen as supportive and friendly in the way they communicated with clients:

'They’ve got the experience and the attitude about what they need to support you, but they’re good at listening and they’ll listen to your problems and they’ll work out a solution.' (C4)

Alongside the one-to-one contact, clients appreciated peer support, if they could talk to someone who had already been through the same issue, and guided self-learning. ESWs and clients had to build rapport for the programme to work, and clients had to be committed to the programme:

it’s critical that we start to have that trust […] Once that trust is instilled, the customer will come along on the journey with us.' (ESW4)

ESWs also identified that they work holistically:

'I make a thing of the person. Who is being listened to, as is right and proper. That’s the key. Forget ticking and dotting, you look at the person.' (ESW3)

Clients also discussed the personalised advice and support they were given, feeling that the ESWs were looking out for their best interest, by identifying their potential, their skills, their needs and barriers in to create an individual plan.

Liaison with employers

Clients felt that one of the key roles of the ESW was to liaise with employers:

'She can bridge that gap. So, having an adviser who’s liaising with people who are looking for employees is great, because there is an understanding.' (C5)

ESWs acknowledged this role, but also identified that more could be done to collaborate with other agencies. They felt that a job was possible for all clients:

'I’m racking my brains, there is always something somebody can do.' (ESW3)

They did, however, find difficulties: in general, more employers needed awareness of the potential of people with chronic ill health, and they felt that government could do more to promote work participation among people with health conditions.

Courses, practical advice, drop-in services, and placements

Clients described a number of courses they could undertake to improve their skills and employment opportunities. However, there was often a limited range, and courses were not always relevant to individuals on the programme. Clients appreciated the practical advice given to them by ESWs and during drop-in sessions, such as advice on applying for jobs, editing their CV, completing cover letters, practice interviews, and state benefits:

'I don’t have a time limit […], none of it is rushed, I can take my time, I can concentrate, and that’s the key thing, when you’re on this type of programme.' (C4)

ESWs discussed supporting clients into a paid placement scheme, which is tailored to each client. Only one client in this study had completed a placement, which he felt was not personalised and felt unsupported within the role:

'I said I couldn’t do it no more. I didn’t feel safe.' (C2)

Changing mentality

HCPs talked about the necessity of changing patients’ attitudes towards work. The ESWs found through the support of the programme, identifying employment options, tackling social isolation, and improving confidence and self-worth, clients’ mentality towards work often changed:

'They can see it’s realistic for them to move into work, whereas at one time they might have thought it’s really hard, they won’t achieve it, but they are just realising now it’s quite realistic and they could do it.' (ESW5)

Clients also spoke about themselves changing throughout their time on the programme:

'I think the programme itself is fine, it’s just me, I need to take on a complete change. I’m doing my bit now, I got a different attitude.' (C4)

Confidence

HCPs and ESWs discussed the need to build clients’ confidence for them to return to work:

'They find it difficult to go to these things, and they need more of a one-to-one relationship to build up their confidence to be able to get to that stage.' (HCP11)

ESWs discussed how some clients have the skills to return to work but, due to their unemployment, have lost confidence in their skills and ability to undertake work. This was seen as a key benefit of the programme.

'But yeah, I'm now confident so if I do get something I can move forward, even if it's just part time. I feel confident about finding something.' (C2)

Progress

Although the outcome of the programme was to find paid employment, ESWs and clients discussed the progress that clients would make:

'And, yeah, they all seem to get something out of it. And we do try and make sure they feel like they are achieving.' (ESW1)

As the clients were still participating in the programme, none of the clients had yet found paid employment, however, clients were keen to discuss their progress:

'I’ve done so much this year, it’s unbelievable. I can look back and think I’ve had a really good year actually … And there’s still a long way to go, but it’s positive.' (C9)

Job readiness

Clients discussed the skills they had gained from the programme that would make them qualified for employment, such as job searching techniques, practice interviews, improving CVs and cover letters, and qualifications in new employment areas. Clients reported that developing confidence and communication skills was also getting them ready for employment, and helping them understand and overcome the personal challenges they would face:

'At first I was a bit sceptic, thinking about what sort of office work I could take, I was never any good at admin work, I would say I am intermediate now.' (C4)

Benefits of working

HCPs discussed the benefits of working for individuals with chronic pain:

'The less they do, the more their pain is. That's the benefit of being more active. That does reduce their pain levels.' (HCP5)

HCPs and ESWs also discussed the link between chronic pain and mental health, highlighting that many individuals with chronic pain also have symptoms of depression. It was suggested that working can help depression, by improving social interaction, and giving individuals a sense of achievement and accomplishment, ' a degree of hopefulness ' (HCP8), and improved quality of life.