Cancer patients’ return-to-work adaptation experience and coping resources: a grounded theory study

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Human Research Ethics Committee of the Affiliated Hospital of Nantong University (No.201,915). All participants provided written informed consent before participating in the study. Inclusion criteria for enrollment of patients in the study were: [1] age 18 to 60 years old; [2] diagnosis of cancer; [3] completed the treatment plan formulated by the physician based on the condition, and the results of the tumor imaging and/or markers showed that only regular monitoring is required; [4] working before treatment and had returned to work by the start of the study; [5] understand their own conditions; The exclusion criteria were: [1] other severe systemic complications and [2] diagnosis of stage IV cancer. The sample size is based on data saturation. From June 2019 to January 2020, with the support of the Nantong Cancer Friends Association, the researchers visited cancer patients’ group exercise sites (where patients usually work out in pairs) and the Cancer Friends Association’s science halls (where patients usually share their recovery experiences with each other) in the field. Then, using purposive sampling, the researcher recruited the first three patients who were considered to be informative. After completing interviews with these three patients, the researcher used snowball sampling to obtain contact information for additional patients and to schedule appointments with them for interviews. Data saturation was achieved when interviews with 25 patients were finished. To build the theory and refine it, the researchers recruited 5 patients with some special characteristics and experiences by theoretical sampling. Finally, 30 patients (numbered N1 to N30 according to the interview order) participated in the study. (Table 1).

The researcher needs to reflect on his or her role as a research instrument in qualitative research [1]. The role of the researcher, the person present when the interviews were conducted in this study was a nursing master’s student who had completed training and obtained a certificate in qualitative research [2]. Relationship with the study participants. The researcher established a closer relationship with the patients through the preliminary field visits and online contact, and because of the study and internship experience, the researcher was seen by the patients as a more professional medical practitioner [3]. The perceptions of cancer patients’ return to work were mainly derived from clinical internship experience during undergraduate studies and relevant literature reading during graduate studies. During the conduct of the study, the researcher also avoided subjective bias and increased sensitivity to the research questions by keeping a reflective journal, memos, and participating in group discussions.

The constructivist grounded theory was used to collect and analyze data, it is a bottom-up approach to construct a theory that allows for close integration of theoretical research and practical aspects of return-to-work with cancer patients. The study data were collected by face-to-face interviews. Most of the interview locations were in cafes, quiet corners of parks, patients’ offices, etc. The interview environment meets the conditions of quietness, privacy, and not easily disturbed, which is conducive to recording. Each interview lasted for about 30 min. Before the interview, the researcher spent approximately five minutes presenting the purpose of the study and creating a relaxed atmosphere. The outline of the interviews was determined through literature review [16] and pre-interviews. Researchers began interviews with preliminary questions such as “How are you recovering now? " And “How do you feel about returning to the workplace after cancer?“. The main questions were then posed: “How are you adapting to your return to work after having cancer?“, “What resources are available to help you return to work?“ In interviews, the researchers responded positively to patient responses, but did not interrupt or comment. The patients’ facial expressions and body language were observed and questions were constantly updated during the interview according to the information provided by the interviewee.

After each interview, researchers transcribed the recordings word by word. A total of 119,980 words were transcribed in the study. Interviewees’ tone, pauses, and other relevant information was also used to assist the analysis. MAXQDA software was used to analyze the data. First set of codes were generated by assigning code to each line of an interview (line-by-line coding). The most frequent and critical codes were further classified and integrated into focus codes. The theoretical coding was achieved by combining theoretical sampling and memo information. At the theoretical coding stage, charts were used to express results to analyze deficiencies. After deficiencies were found, the researchers use continuous comparisons between data and results to improve the accuracy of the analysis.

The experience of cancer patients can best be explained as health–illness-transitions [17]. Self-management can influence a patient’s ability to respond to transitions in physical and emotional symptoms, spiritual well being, interpersonal relationships, and functional ability and lifestyle [18]. Previous studies have shown that self-management intervention can help patients with chronic pain return to work, and formulating a reasonable self-management plan is the key [19, 20]. The change of state model [21] proposes that each individual who strives to make behavioral change has different needs and motives. Therefore, this study explores the return-to-work adaptation experience and coping resources, which may help cancer patients develop reasonable self-management plans. According to the ‘adaptive leadership’ framework, medical staff at all levels help patients adapt to difficult situations by assuming leadership roles [22]. The results of this study can help the medical staff and other professionals involved in the care of cancer patients to assist them in adapting to return to work.

The adaptation of cancer patients to return to work is primarily a process of rebuilding their lives by making most of the available resources. Personal resources including faith, resilience, beliefs, and cognition. More than half of the patients in this study regard their relationship with young children as motivating factor for returning to work so that they can provide a better life to them. Resilience enables individuals to recover from and cope with severe stress and danger [30]. This study found that resilience can help patients choose positive coping style for adapting to return-to-work. Resilience has been shown to effectively encourage return-to-work in patients with chronic pain and trauma [31]. Researchers should focus more on the role of psychological factors in the return to work of cancer patients. In this study, cancer patients with religious beliefs reported gaining positive psychological experiences such as reduced mental pain, improved sleep quality, and better interpersonal communications. Earlier studies also report that cancer patients with religious beliefs have better tolerance and higher quality of life [32, 33]. We also found that good cognition can help patients self-regulate their behavior resulting in positive outcomes related to return to work. Therefore, follow-up research can focus on developing cognitive-behavioral interventions to help patients rebuild positive awareness and promote self-regulation to adapt to return-to-work.

The external resources that are important for the return-to-work adaptation of cancer patients are family-, professional-, workplace-, and peer support. Social support has been shown to promote adaptive changes in cancer patients [34]. This is in line with the social network theory [35], which propounds that individuals get help through social relations and interpersonal communications. Cancer patients adapting to return to work require joint efforts from various groups. Family members need to establish a correct concept of recovery and help patients return to work and society as soon as possible. Studies have shown that professional support increases the quality of life in cancer patients [36]. However, most cancer patients fail to get professional help, particularly related to the mobilization of social resources matching their needs [37]. Therefore, hospitals should focus on meeting the professional needs of discharged patients to make their return to work adaptation experience less stressful. It was mentioned by a significant number of patients in this study that keeping in touch with the workplace and solving work-related tasks during sick leave increase their confidence in return-to-work. Studies have shown that workplace support is an essential factor determining cancer patients’ return to work [38].

It is important that the workplace should keep in touch with the patients during sick leave and allow them to gradually return to work. Support of workplace according to the patient’s specific physical, emotional, and personal requirements will further help cancer patients to return to work and avoid job loss.

As employers do not guarantee a return to work after illness, some patients choose to hide their illness. In this context, it may be useful to develop policies guaranteeing return to work for cancer patients. For example, in Belgium Flemish parliamentary legislation guarantees compensation during sick leave and provides a return to work protection for the patients [39] to prevent the financial distress caused by illness.

Thus, to promote return-to-work and provide a favorable adaptation experience for cancer patients, it is imperative that medical staff, vocational rehabilitation specialists, employers, and cancer patients jointly develop a return-to-work plan based on each patient’s recovery. This will help patients realize their self-worth and contribute positively to society.

There are certain limitations of this study that can be addressed in future studies. This study did not look into the differences in return-to-work experiences of patients with different types and stages of cancer. The treatment of cancer varies according to the type and stage of cancer, which result in different side effects and thus different challenges during return-to-work. Also, the included patients were from a single region of China which can affect the generalization of results to other regions with different socioeconomic conditions. We have also not categorized patients according to age in this study; age can have a significant influence on the return-to-work outlook and challenges of a person. In the future, researchers can further explore the return-to-work experience of cancer patients of different ages, different types of diseases, and different stages of the disease.