Introduction
Cancer survival rates have increased, due to earlier diagnosis and improved treatment [
1,
2]. At the time of diagnosis, half of all cancer patients are employed or available for employment [
3,
4]. A recent review showed that 64 % of cancer survivors (CSs) returned to work within 6 months after diagnosis [
5]. CSs try to get back to work to re-establish their former structure of everyday life as a normal and healthy existence [
6]. It is known that work has both psychological benefits (e.g. identity, normalcy and fairness) [
7] and practical benefits (e.g. income and social support) [
8]. To date, many studies have focused on return to work (RTW) after cancer [
9‐
11], but little is known about work functioning of CSs after RTW.
Work functioning captures the interplay between health status and performance (e.g. work scheduling demands, flexibility demands) and can be viewed as a continuum varying from working without any problems to not working at all [
12,
13]. Work functioning refers to how CSs perform work tasks and goes beyond RTW in terms of the simple dichotomy of whether or not having resumed work [
14]. Work functioning differs from related but more general constructs such as work ability and work engagement, because it focusses on the ability to meet specific work demands, expressed in percentage of time. Earlier studies showed that CSs experience health complaints for years after primary treatment, which may affect CSs functioning [
15,
16], also at work [
17]. To date, only a few studies have investigated CSs work functioning. For example, brain CSs were less productive than a control group without a life-threatening illness or chronic disease due to depressive symptoms, fatigue, cognitive limitations, insufficient sleep and negative problem solving orientation [
18]. Breast CSs with fatigue or hot flashes reported work productivity below the healthy worker norm [
19] and lower work productivity than their peers who never had cancer [
20]. To date, research on work functioning is limited to cancer-related symptoms and little is known about other factors influencing CSs work functioning.
Many factors can affect work functioning of CSs. Feuerstein et al. [
21] introduced the Cancer and Work model, a conceptual framework including health and well-being, symptoms, function, work demands and work environment of CSs as well as policies, procedures and economic factors. This theoretical model is valuable for identifying factors that affect work functioning, but it is important to get insight on barriers and facilitators of work functioning from different perspectives (e.g. CSs, occupational physicians, labour experts). The objective of this study was to explore barriers and facilitators of work functioning from the perspectives of CSs and occupational health professionals (OHPs).
Methods
This qualitative study used focus groups to explore authentic themes, independent of prevailing constructs or questionnaires.
Inclusion criteria and recruitment
Inclusion criteria for the CSs were RTW in the past 3 years, currently working (≥12 h/week) and able to communicate in Dutch. There was no restriction on cancer types. OHPs had to have experience in guiding CSs back to work. The absence of exclusion criteria ensured a diversity of experiences to provide a comprehensive insight into CSs’ work functioning. CSs were recruited via occupational physicians and by contacting patient forums. OHPs were recruited from our professional network. CSs and OHPs interested to participate in a focus group received a letter from the research team with additional information about the study. Based on the information, CSs and OHPs decided to participate in the focus groups. Recruitment of participants stopped when a minimum of six and a maximum of nine persons per focus group agreed to participate.
Focus group method
Four focus groups were conducted: three with CSs and one with OHPs. Each focus group met once. The focus group discussions lasted up to 2 h and were led by an experienced moderator. Semi-structured interview schedules were used, facilitating wide-ranged explorations of the participants’ thoughts and experiences [
22]. The key question in all focus groups was as follows: Which factors hinder or facilitate the performance at work? Cues were the disease itself and its treatment, psychological and social aspects or work-related aspects.
Before the focus groups started, participants gave informed consent and completed a brief questionnaire about socio-demographics (i.e. age, gender, education level). CSs received additional questions about their cancer diagnosis and work situation (i.e. RTW date, job type, working hours per week). All procedures were reviewed and approved by the Medical Ethical Committee of the University Medical Center Groningen (M12.125242).
Data analysis
The discussions were audiotaped and transcribed verbatim by a professional transcriber. Sandelowski’s qualitative description method was used for data analysis [
23]. First, key topics were identified by listening to the taped discussions. Next, each transcript was thematically analysed using the key topics, to find the concepts that arose in the group discussions. Each transcript was coded by two independent reviewers. The codes were compared, contrasted, refined and grouped. During this process, researchers stayed close to the original transcripts to ensure that the themes reflected the actual data, not the researchers’ interpretations [
24]. All codes and themes were discussed until consensus was reached. To obtain a comprehensive picture of the relevant factors affecting work functioning, both CSs’ and OHPs’ perspectives were taken together. The Cancer and Work model [
21] was used as theoretical framework to structure themes. Quotes from participant were used to illustrate the themes.
Discussion
This focus group study provided new insight in barriers and facilitators of work functioning after cancer diagnosis from the perspectives of cancer survivors (CSs) and occupational health professionals (OHPs). Cancer-related symptoms, psychosocial factors, lack of support, ambiguous communication and poor working environment were mentioned as barriers of work functioning. In contrast, high (workplace and private) social support, an honest dialogue, appropriate work accommodations and high work autonomy facilitated work functioning.
Cancer has long-lasting adverse effects on work functioning. Fatigue and cognitive problems have shown to be present for a long time after cancer diagnosis and treatment [
25‐
28]. In line with earlier studies [
18‐
20], both CSs and OHPs mentioned that fatigue and cognitive problems affected work functioning. In addition, adaptation to the new situation after cancer diagnosis takes time. Most CSs experienced RTW as a new start and realised the physical and emotional burden of having been diagnosed with and treated for cancer when returning to work. Previously, Grunfeld et al. [
28] reported that CSs needed an adaptation period when back at work and the demands of their role. Fatigue, poor concentration and the emotional confrontation with having had cancer impeded the adaptation process to being back at work. In our study, CSs mentioned that family and friends facilitated adaptation by encouraging them to stay at work. Alternatively, family and friends can hinder work functioning after RTW by expressing concerns about being at work.
OHPs mentioned that the societal view on cancer has changed and that cancer is more and more considered a chronic condition instead of a ‘death sentence’. Nowadays, OHPs encourage CSs to think about staying at work during treatment. OHPs were very clear about the importance of staying involved in work, because prolonged absence from work may set up a threshold for RTW. Knott et al. [
9] found that CSs who have been out of work for a long time lost self-confidence in how to cope with colleagues. The Dutch Guideline Cancer and Work [
29] recommends OHPs to encourage CSs to continue working throughout cancer treatment. In the present study, some CSs mentioned that continuing work during treatment gave them a sense of ‘normal life’ and distracted them from worrying about cancer. Earlier research showed that CSs disliked the social isolation of being off work and valued the social contact they experienced at work [
28]. CSs thought that an empathic supervisor, who motivates CSs to visit the workplace (e.g. for a coffee break), may facilitate work functioning. In our study, not all CSs agreed on the importance of social support at the workplace. Some CSs indicated that social support did not affect work functioning. Furthermore, CSs mentioned that social support wore off over time [
30].
CSs experienced communication with the supervisor about mutual expectations towards work as important. Disease disclosure reduced ambiguity, helped to tailor work accommodations to the specific needs of CSs and provided a pleasant work climate. A ‘safe’ and open situation for dialogue is an important prerequisite for disease disclosure [
30]. CSs who did not want to share information about their disease and treatment with supervisors and colleagues experienced difficulties due to unrealistic expectations towards work. McKay et al. [
31] found that not disclosing any information to colleagues could also lead to uncertainty and resentment in CSs. OHPs mentioned that the attitude of CSs towards work and their coping with cancer were important for work functioning. Earlier, Abma et al. [
30] stated that the way workers cope with chronic health problems was more important for work functioning than the medical diagnosis. De Boer et al. [
32] reported that self-assessed ability to cope with work was a strong predictor of RTW among CSs, but the relationship with work functioning after RTW was not examined.
All focus groups were led by the same experienced moderator who ensured the quality of the group discussions, which was an asset of this focus group study. The participation of different stakeholders, the variety of cancer diagnoses and the semi-structured discussions provided a comprehensive picture of work functioning after RTW, although employers were not involved in the focus groups. A limitation of the focus group study is that the majority of the CSs were highly educated. Therefore, the result might be difficult to generalise to workers with a low educational level.
This qualitative study has several potential implications. Supervisors and OHPs have to be aware of the long-term effects of cancer and cancer treatment. Furthermore, they have to realise that CSs become aware of the physical and emotional burden of cancer when they resume work. Understanding and compassion from supervisor and OHPs can help CSs to familiarise with being back at work. Supervisors and OHPs have to tailor their guidance to the specific needs of the CS and have to motivate CSs to visit work during or after treatment. Disease disclosure and an open and honest dialogue increase mutual understanding and are necessary to facilitate appropriate work accommodations. These aspects can improve work functioning after RTW. In addition, supervisors, OHPs and colleagues should be aware of the importance of continued social support and their role in creating a safe and familiar work environment. Further research is needed to investigate the relative importance of the barriers and facilitators of staying at work and to examine work functioning of CSs after RTW over time.
Acknowledgments
This research project was funded by the Dutch Cancer Society (RUG 2011-5266). The funding institute had no role in the design, collection, analysis, and interpretation of data; in the writing of the manuscript and in the decision to submit the manuscript for publication.
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