To answer the research question about how Flemish women who have undergone breast cancer surgery and reported sick, mentally prepare for return to work, we interviewed 22 employees, on average two and a half years after breast cancer surgery. We found that once their treatment finishes, women start to mentally prepare their return and intensively reflect on their current and future situation. Four different matters are considered prior to RTW: 1) leaving the sick role and wanting to keep the job; 2) doubting whether working is worth the effort; 3) doubting their capability; and 4) doubting the acceptance from the workplace after returning. These inner reflections are accompanied by strong emotions. They are developed and affected by interactions with important actors from their social environment, especially the employer. The whole process is coloured by uncertainty and vulnerability.
Study adds to what is already known
There is still very little known about women’s concerns regarding work after breast cancer treatment, but our findings seem to be in line with earlier findings and clearly add to our understanding of the process of preparing RTW. From quantitative studies we know that the women’s decision about returning to work is negatively affected by several aspects of mental preparation: uncertainty about ability to work; uncertainty about possible job loss; and health and work characteristics on the women’s decision about returning to work [
22‐
24]. Our study shows how this mental process is shaped and how the women intensively reflect on their situation prior to RTW.
Quantitative studies do not agree on the effects of physical problems on RTW. Fantoni et al [
17] showed that not the physical, but the psychological concerns impact the time until return to work [
17]. Oberst et al [
25] however found physical problems to be more problematic for RTW than cognitive impairments for employees with either breast or prostate cancer [
25]. According to Munir et al [
26] the women’s appraisal of their ability to manage work tasks is influenced by (1) actual cognitive ability after chemotherapy, (2) awareness of cognitive failures, and (3) impact on their confidence in carrying out work tasks [
26]. Another factor that might elicit concern was demonstrated by Cooper et al [
27]. They found that some women with breast cancer might feel pressured to return to work too soon because of financial concerns [
27]. Our study indeed demonstrated the interrelatedness of the wish to return to work, the doubts about whether work is worth the effort and about physical and mental capacity and acceptance from the workplace. We have shown that the women have these inner reflections at the same time and that these reflections yield contradictory answers regarding the question of whether the woman wants to return to work. Women thus have ‘mixed feelings’ regarding RTW. However, quantitative research seems unable to grasp this ambiguity.
In a recent qualitative research by Tamminga et al [
28] a large variety of concerns regarding health and RTW of women with breast cancer is also found. Since they conducted a content analysis, focusing on describing the process rather than developing a new theory, they did not prioritise concerns nor analyse their interrelatedness [
28]. According to other authors [
29,
30] women wish to return to the labour market after illness, which is regarded as a sign of returning to life in spite of concerns about their physical problems. In the current study we also noticed the women’s wish to leave the sick role and keep their job.
Previous studies do not deal with the ambiguity regarding RTW that woman with breast cancer experience. Few studies focus on uncertainty and concerns but none of the studies on RTW of breast cancer patients reveal the experienced vulnerability. This is a general picture of RTW research, including that dealing with other illnesses. Recently Stewart et al [
31] found five categories of expectations of RTW for injured workers with back pain. All these expectations relate to uncertainty: (1) perceived lack of control over the RTW process; (2) perceived lack of recognition by others of the impact of the injury; (3) perceived inability to perform the former job; (4) the fear of re-injury, and (5) the perceived need for workplace adaptations. This study was able to demonstrate the negative effects of employees’ perceived uncertainty regarding ‘active coping’ with the illness and RTW having a back injury [
31]. In their qualitative research of breast cancer patients, Repass and Matusitz [
32] found uncertainty to be a central concept of the recovery phase. The women feared recurrence and being socially stigmatized. According to the authors, empowerment is needed by rebuilding healthy lifestyles through physical activity, to regain confidence through the realisation of the return to normality [
32]. Women who have breast cancer seem to make a kind of transition from patient to survivor [
33,
34]. Despite fearing recurrence some employees felt empowered by surviving the experience of breast cancer and made several life changes such as cutting down their work hours [
34].
In our study, vulnerability appeared to be an overarching, central concept regarding the mental preparation for RTW and has the potential to be used in RTW research in general. As the current research shows, the concept of vulnerability can be understood in two different ways: being vulnerable (individualised) or being made vulnerable (socialised). Further investigation is needed to elucidate this proposition.
Research on RTW focuses more on self-efficacy, a linked but narrower concept. Self-efficacy refers to people's beliefs about their capabilities [
35]. Relationships between high self-efficacy and (earlier) RTW are found in cardiac patients [
36] and workers with back pain [
37]. Loh et al [
38] found positive experiences of self-efficacy in the post-treatment phase of breast cancer survivors. Self-efficacy is an important concept in the motivational models used for studying RTW. The women’s mental preparation for RTW can be regarded as a ‘contemplation’ phase which is considered in the Readiness for RTW model [
8]. In the ‘contemplation’ phase a person is beginning to consider RTW somewhere in the future, thinking of the pros and cons and feeling ambivalent, but unable to initiate change. Several dimensions are involved in making progress during the various phases (precontemplation, contemplation, preparation for action, action and maintenance). Decisional balance, the first dimension, reflects the (cognitive) process of weighing up the pros and cons. The second dimension ‘self-efficacy’ refers to one’s confidence in engaging in RTW and activities maintaining RTW’. Thirdly, change processes are assumed to be ‘experiential’ (perceived need to change thoughts, feelings and attitudes including communication with others) and ‘behavioural’ (actual change, e.g. contacting the employer) ([
8], p.237).
Our study demonstrated a more complex picture. Women consider pros and cons, but the weighing-up process is ambiguous and confusing and not as rational as the Readiness for RTW model [
8] assumes. The women experience increased self-efficacy as they feel recovered and motivated, but at the same time they experience vulnerability and also feel dependent upon their social (particularly work) environment. Regarding the third dimension we did indeed find that some women contacted their employer as regards to RTW, but not as a result of a behavioural change. Another contraction to this model is that our study demonstrated that mental preparation is not a linear process of improvement. The women did not report that they felt more ready for RTW in due course. Our findings show that the women are indeed motivated to take up their professional activities, but feel vulnerable after recovery and in need of some understanding, and this interaction with the environment is not found in the different phase models.
Several theoretical models for RTW [
7‐
10] focus on conditional (behavioural) steps in the phases before RTW. Not following these steps is called recurrence or relapse. This conditional character of the Readiness for Change model [
10] has been criticised earlier [
28]. Another important point on which our study’s results add to these models regards emotions. We found strong emotions embedded in patients’ preparation for RTW. This might relate to the specific case of breast cancer; these women probably need another approach than just taking action or improving motivation. The experience of having cancer is traumatic and stress-related [
33,
39]. However, many experiences that were surrounded by emotions addressed issues that will also be experienced by other employees that prepare for RTW after major illness: leaving the sick-role and wanting to keep their job; considering pros and cons of returning to work; (financial) insecurity about the future; worrying about reactions from the workplace, as well as searching for strength and expecting support. Bowles [
40] tried to add negative emotions and developed the Adaptive Change model, which is regarded as an improvement to the Readiness for Change model [
10]. However, Bowles [
40] still conceptualises the preparation for RTW as a linear process and negative emotions are regarded as a barrier to improvement. According to Bowles ([
40] p.442) individuals can move more easily from planning to action “if they manage negative emotions, have inner drive, and have social support from others”. Although we did not explicitly analyse the effects of the emotions on RTW rate, our study suggests that emotions are a self-evident part of the process and not a particular barrier.
Our study might point to an issue that is much broader and to another conceptual level that the behavioural models cited above. The issue is that uncertainty and vulnerability might be characteristic for the experience of many employees who prepare for RTW after recovery from a major illness and that thoughts are often confusing rather than a reflection of a linear development towards RTW. This seems to be neglected in mainstream research on RTW. The current discourse (in particular in activating RTW programmes) emphasises self-management, empowerment (connected to expectations and achieving goals), self-responsibility et cetera e.g. [
9,
32,
34,
40,
41], but as a result might neglect other important experiences that point to issues of confusion, uncertainty and vulnerability. Using life narratives Van Hal et al [
41] demonstrated that work disability “changed [the life] to such an extent that life cannot be lived as it had been before” ([
41], p. 83). In-depth qualitative research among people on long-term disability benefit in the Netherlands revealed that a “pending process of identity work” ([
42], p. 89) takes place, which means that (injured) persons have to think about how to relate to their past, present and future, and search for a new basis in life. During this process they wish to be heard and supported.
Furthermore, the models discussed above seem to have a too individualistic focus, while the social environment in its broad sense also constitutes an important influence on the RTW process. Several studies, both qualitative and quantitative, demonstrate a lack of understanding from the work environment [
28,
43,
44]. Our study also demonstrates the importance of the social environment not only in terms of expected support but also in terms of the institutional environment. Most women in our study do not know prior to RTW whether they are allowed to adapt their employment contract. This is because, in Belgium, there is no legislation forcing employers to guide RTW [
39]. This might explain why the interviewed women on the one hand made strong statements regarding their wish to return to work and at the same time expressed feelings of dependence, vulnerability and uncertainty. The Belgian legislation not only seems to lead to a lack of support [
39] but also seems to reflect the implicit norm that employees are expected to handle their absence from work alone and take the RTW initiative themselves. This effect of the institutional context is different from what is distinguished as the interpersonal context in the Readiness for RTW model [
8].