Process evaluation of the Workwell Trial : perspectives from therapists and line managers

Background/Aims Over half of individuals diagnosed with inflammatory arthritis (IA) are of working age, often facing work instability due to the condition. The Workwell vocational rehabilitation programme, delivered by occupational therapists in NHS rheumatology clinics, aims to help individuals with IA retain their jobs by aligning their abilities with job demands. Conducted as part of a multicentre randomised controlled trial (RCT), this qualitative process evaluation explored therapists’ and their line managers’ perspectives on the training, delivery, and implementation of the intervention, providing critical insights to improve the program’s future application. Methods A qualitative design was employed using semi-structured pre- and post-trial interviews with therapists and line managers from 17 NHS Trusts across England, Wales and Scotland. Interviews were transcribed verbatim and analysed using a two-step approach: an inductive thematic analysis followed by deductive analysis guided by Normalisation Process Theory (NPT) constructs of coherence, cognitive participation, collective action, and reflective monitoring. These constructs informed the interpretation of how the intervention was integrated into clinical practice and its potential for scalability. Results Pre-trial interviews revealed that work-related support provided by occupational therapists was inconsistent, with referrals often coming from other health professionals or through patient self-referral. While therapists addressed work-related issues during consultations, the use of standardised work assessments was limited. Work advice typically lasted only 10-15 minutes, and most therapists expressed hope that the Workwell programme would offer a more structured approach to assessment and intervention planning. In post-trial interviews, Workwell was perceived as a valuable and structured intervention. Therapists appreciated the training and toolkit, which enabled them to address work-related challenges more effectively. Remote delivery, particularly during the COVID-19 pandemic, was considered an effective adaptation, with most patients completing the intervention remotely. However, therapists reported challenges in implementing the programme due to time constraints, increased workloads, and staffing shortages. Line managers were less involved and largely relied on therapists for feedback. While they recognised the benefits of the programme, they expressed concerns about its time-intensive nature and the difficulties of sustaining it given post-pandemic resource limitations in the NHS. Conclusion The Workwell programme demonstrated successful adaptability and integration into NHS services, including during the pandemic, with remote delivery showing promise for future practice. Nevertheless, challenges such as resource constraints and rising patient demand must be addressed to ensure sustainability. These insights highlight the need for continued investment in vocational rehabilitation programs and the potential benefits of digitising the Workwell program to facilitate its widespread implementation and accessibility.