This is the second article in a series looking at work-related musculoskeletal pain (WRMSP). Specifically, it considers the risks and experiences related to this phenomenon within the Early Years sector. In the first article in this series, we presented the findings of the UK’s first empirical study into WRMSP within this population. The data were striking: 98% of the 196 participants reported experiencing pain associated with their work, with the lower back affected in 89% of cases. Pain was not transient; average onset exceeded 12 months, episodes recurred every 7–14 days, and each lasted, on average, 1–2 weeks. Analyses showed that frequent exposure to physically demanding tasks predicted higher pain frequency and earlier onset, and that the number of painful body locations increased with years of service, independently of age. Pain intensity and the frequency of ergonomically demanding activities predicted sickness absence, while pain frequency, bothersomeness, and a perceived lack of protective measures predicted whether staff had considered leaving the profession entirely.

Those findings reveal the scale of the problem. But they also raised a question that statistics alone could not answer. Despite the high levels of pain, recorded sickness absence remained relatively low. Why do so many practitioners continue working through significant discomfort? Furthermore, why do many choose not to report it? And what happens when they do? To answer these questions, Work SMARTey carried out qualitative analysis of written responses provided by the same group presented in our first article. The outcomes from that work will be presented here.

Our data and supporting theories

The qualitative data were drawn from the same method outlined in the first article. Alongside the closed-ended questions on pain, role demands, and employment outcomes, participants were invited to describe in their own words:- the impact of WRMSP on their work and daily life; their reasons for reporting or not reporting pain to an employer; and the outcomes when reports were made. In total, 239 free-text comments were generated from the 196 participants. These responses were analysed using conventional content analysis.

Our analysis was framed by three established theoretical frameworks. The Job Demands–Resources (JD-R) model (Bakker & Demerouti, 2017) describes how strain increases when sustained demands exceed available resources. Psychosocial Safety Climate (PSC) theory (Dollard & Bakker, 2010) evaluates workplace health and safety reporting practices through workers’ perceptions of management commitment and communication. And the concept of ‘Safety Silence’ (Tucker et al., 2008) describes the phenomenon of workers opting not to report safety concerns due to fear, futility, or normalisation of hazards.

What we found

Four categories emerged from the analysis: the perception and impact of pain; pain expectations, culture and reporting; the work environment and support; and mental health and employment decisions. Together, these factors describe a “painogenic” (Johnson and Woodall, 2022) environment (one in which the role conditions increase the risk of developing new or exacerbating existing pain), while the culture within work means these pain experiences are frequently overlooked and unaddressed.

The lived reality of pain

Participants described pervasive, multi-site pain that affected both their working and personal lives. Their accounts went beyond clinical descriptors. Practitioners spoke of being “fed up with always aching,” of requiring strong painkillers daily to fulfil their duties, and of being so physically depleted by the end of the working day that they had, as one put it, “nothing left to give to my family.” Pain was not simply present; for some participants, it was routinely managed with painkillers to continue meeting the demands of their work.

Some participants linked their pain to the specific physical demands of working in Early Years: prolonged periods working at children’s level, sitting on small furniture or on the floor, repeated kneeling and squatting, and frequent lifting of children and equipment. Some described situations of presenteeism (being physically present but functionally limited due to poor health) where pain compromised their ability to carry out aspects of their role. As one leader noted, it was “hard to do the present job when in pain”. Others expressed anxiety about their professional capability and future capacity, “Very physical nature of being a pack away Preschool means a lot of heavy lifting and moving. Not sure how long I’ll be able to keep doing it.“.

For several participants, however, the connection between pain and work was not recognised. Some attributed their discomfort to ageing or personal failings (“incorrect posture”), rather than to the demands of the role. Others reasoned that because they had not suffered a specific injury or accident, their pain was not a workplace issue. This dissociation is significant. Where cumulative strain is not understood as occupational in origin, the impetus for risk assessment or ergonomic intervention is reduced.

A culture of silence

Perhaps the most striking finding was the degree to which pain had been normalised across the sector. Participants described WRMSP as something that “comes with the job” or is “just part of my job.” This was not merely individual stoicism; it appeared to function as a shared cultural script reinforced by social comparison. One practitioner observed that pain felt like “an expected part of the job judging by the way other staff members describe their pain.” When pain is universal, it ceases to be a significant, reportable incident and just becomes the status quo. Leaders and practitioners alike described simply having “just got on with it.”

Even where pain was acknowledged as work-related, a high threshold for reporting was evident. Participants described a self-triage process in which pain was deemed not “bad enough to mention” unless it resulted in some form of incapacitation. This reveals a culture in which pain is only validated when it is severe, rather than being treated as an early warning requiring attention. The analysis identifies a pattern of ‘Safety Silence’ (the withholding of safety concerns), driven in this case not primarily by fear of repercussions but by a belief that reporting is pointless, that nothing can be done, “nothing can be done really to prevent”, or that raising the issue would be a burden. As one practitioner put it, they “don’t want to be a bother.”.

Notably, a structural barrier to reporting for some participants was also identified. Thirty-three respondents, when asked why they hadn’t reported pain to a manager, simply responded “I am the manager”. For these individuals, there is an apparent lack of reporting channels. Some described a sense of futility in raising concerns with governance structures such as committees. This is a gap in occupational health infrastructure that standard frameworks do not seem to readily address.

What happens when pain is reported

Of the 196 participants, just over half (52%) indicated they had reported their pain to a manager. The organisational responses described were notably inconsistent. Some participants received constructive, if reactive, support: ergonomic seating, adjusted duties, reduced hours. Others encountered responses that were dismissive or that failed to follow through: pain reports were “noted” without change or promised adjustments (such as a specialist chair) never materialised. Procedural responses such as manual handling refresher training were occasionally offered, but direct modifications to working conditions (risk assessments leading to lighter duties or lifting restrictions) were less frequently described.

This inconsistency matters. Where organisational responses are unreliable, the perceived cost of reporting (effort, vulnerability, potential stigma) may outweigh the expected benefit, reinforcing the silence described above. The absence of standardised protocols for managing reported pain means that outcomes depend largely on the individual manager or setting, rather than on a consistent standard or duty of care.

Three ways of coping

The analysis identified three distinct patterns in how participants understood and responded to their pain, each aligning with established models of stress and coping (Lazarus & Folkman, 1984). The first (Understanding and Action) reflected better occupational health literacy: participants recognised the occupational origins of their pain and considered active steps to try and mitigate it. The second (Acceptance and Normalisation) involved reframing pain as inherent to the role, often sustained by daily painkiller use. This emotion-focused strategy carries the risk of maladaptive endurance and presenteeism. The third (Dismissal and Minimisation) involved actively avoiding engagement with the problem, either by internalising pain as a personal failing or by concluding that reporting was futile.

These are not fixed traits. Evidence suggests they are context-dependent responses influenced by the organisational climate. Where organisational leadership demonstrates genuine commitment to staff health and communication channels are trusted, greater levels of psychosocial safety are found. These result in greater awareness of work-related health risks in at-risk populations and the use of proactive coping strategies. Where the psychosocial safety climate is poor, avoidant and fatalistic strategies are more common (Dollard and Bakker, 2010).

The push factor

Over a third (36%) of participants reported having considered leaving their role due to WRMSP. Their accounts often described not a loss of commitment to the work, but a growing fear that continuing would cause lasting physical harm. Concerns were not confined to older workers. One 26-year-old practitioner asked: “What is my body going to be like in the next 10 years?” Others described anticipating early retirement because they did not believe they would be physically able to work to retirement age. These were not people who have lost their passion for Early Years education; rather people who fear their bodies will not sustain it.

Combined with the quantitative findings from the first study (which showed that pain frequency, bothersomeness, and perceived lack of protective measures significantly predicted consideration of leaving), the qualitative data illuminate the mechanism. Many skilled practitioners exit the sector not because of dissatisfaction with the work itself, but because unmanaged physical strain makes continued employment feel unsustainable. In a sector already facing acute recruitment and retention challenges (Early Years Alliance, 2021), this represents a significant but addressable risk.

Implications for practice

The findings from both phases of the Work-SMARTey project highlight the need to shift from reactive management of WRMSP, to a proactive, “prehabilitative” approach that seeks to prevent incidence. This requires action across three areas.

First, cultural and educational change. Leaders need to recognise that pain normalisation (the belief that discomfort is simply part of the job) is itself a risk factor. Health awareness training and regular wellbeing check-ins can help foster a ‘safe reporting’ climate in which early symptoms are treated as actionable hazards rather than inevitable consequences. The gap identified in the first study between the protection leaders believed they provided and the protection practitioners felt they received underscores the importance of this.

Second, environmental adaptation. Risk assessments must specifically address the ergonomic realities that are particular to Early Years settings (low-height and floor-level working). Investment in appropriate infrastructure (appropriate furniture and ergonomic supports) and modification of working practices (redesigning pack-away routines and using lighter equipment or aids) can reduce cumulative strain. In line with best practice, upstream measures that eliminate or substitute hazards should be prioritised over behavioural fixes (Oakman, 2024).

Third, consistent management protocols. The inconsistency of organisational responses to reported pain needs to be addressed through clear, evidence-based procedures. This could include enforcing physiological recovery through scheduled breaks, rotating staff between high- and low-demand tasks and standardising legally compliant reasonable adjustments. The structural isolation of leaders and the self-employed, who may have no mechanism for their own occupational health support, also requires attention.

Study limitations

The limitations acknowledged in the first article apply here as well: a self-selected sample, cross-sectional design, and a predominantly female cohort (though this reflects the composition of the UK Early Years workforce). The survey format enabled a large and varied dataset but prevented deeper exploration of specific points. Future work using interviews or focus groups would allow for richer examination of the themes identified here. The qualitative analysis captures a snapshot of experience; it cannot track how individual responses to pain develop over time.

Looking ahead

Taken together, the two phases of the Work-SMARTey project present a detailed picture of a workforce under significant and largely unaddressed physical strain. The quantitative data established the prevalence and predictors; the qualitative data revealed the mechanisms, specifically a culture of normalisation, inconsistent organisational support, privatised coping, and a structural silence that means much work-related pain may remain unseen by those who might act on it. Addressing this will require sustained, sector-specific effort across culture, environment, and governance. In the next article in this series, we will describe the development and early piloting of the Work-SMARTey intervention itself.