Abstract
BACKGROUND:
The number of survivors of head and neck cancer (HNC) has steadily increased due to major advances in cancer care. However, cancer survivors who experience job loss face different challenges regarding return to work (RTW). Relatively few studies have integrated the experience encountered by patients.
OBJECTIVE:
This mixed-methods study aimed to explore the experience and challenges of RTW in patients with HNC.
METHODS:
Data were collected with structured questionnaires (n = 120) and semi-structured face-to-face interviews (n = 12).
RESULTS:
Relationships were found between patient’s physical status, perceived stress, and social support. Patients who continued work, or not, had significant differences in reported physical function and stress. Four themes emerged from the qualitative data, including the perceived meaning of work, challenges for RTW, preparing for RTW, and social support. After diagnosis and treatment, patients perceived the meaning of work, such as personal value, responsibility, and financial need. They faced many challenges to RTW, including declining physical strength, workload, schedule rearrangement, speech difficulty, and changed appearance. In order to RTW, they prepared extensively and needed support from family and friends.
CONCLUSION:
This study revealed the experiences and challenges of RTW patients with HNC. The results allowed us to identify patients’ concerns and ways that healthcare providers could improve the RTW process. Future studies may develop tailored approaches for RTW in healthcare and government policies.
Introduction
Globally, head and neck cancer (HNC) accounts for more than 650,000 cases and 330,000 deaths annually, and it is the seventh most common cancer [1]. In the United States, HNC accounts for about 3% of all cancers. An estimated 51,540 people will develop head and neck cancer every year [2]. In Taiwan, HNC is ranked fourth in male cancer incidence. Due to significant advances and treatment efficacy, the 5-year survival rate is around 47.1–64.6% by subtypes in Taiwan [3].
In Taiwan, HNC patients are mainly men, due to the habits of smoking, drinking and eating betel nuts, and they are mostly diagnosed at working age [3], which is an important stage in the development of business and work and most are the main source of the family’s income and need to maintain living standards [4]. The main treatment of HNC cancer, including surgery, radiation, and chemotherapy, may require 2–3 months in general [5]. As a result, many patients face suspension of work [6]. The disease and treatments cause physical and psychological distress, such as communication and eating difficulties, general fatigue, visible changes in appearance, and mental adjustment, and may result in barriers to RTW [7–9]. Many HNC patients cannot continue their work; previous studies found that about half of patients with HNC changed their occupational status within one year [8, 10].
Return to work (RTW), which is considered as an important indicator of cancer recovery, and Isaksson and colleagues represents that the patient has recovered from the disease and can return to a normal life [11]. Work provides a financial income and a structure for normalcy in everyday life, and working adults develop a self-identity and can participate in social relations [12, 13]. Nevertheless, working HNC survivors are a very heterogeneous group of workers with very different kinds of work. The variety of occupations, workloads, and work environments may affect the patients’ consideration of RTW [14, 15]. As far as, relatively few studies have examined the experiences of HNC patients in their working situations.
The barriers related to RTW of HNC patients have been mentioned in previous studies [7–9, 16], such as disfigurement, physical decline, mental adjustment, and psychosocial dysfunction, but each study extracts partial perspective and could not see the individual patient as a whole to state the comprehensively experience and difficulties encountered by these patients, as well as their feelings and considerations in life. Relatively few studies have explored and integrated the difference in RTW on a physical, psychological, or social domains. Thus, further study is needed to facilitate the subsequent support and assistance for patients to RTW. Therefore, these divergences point to the need to develop mixed-method studies, which have potential to reveal new findings related to the experience and challenges to RTW in HNC patients. The purpose of this study was to explore status and difference of physical function, perceived stress, and social support in different work status; and further to explore the experiences and challenges of RTW in HNC patients.
Methods
Design
A descriptive concurrent mixed-method study was utilized in this study. Data was collected using a cross-sectional survey together with semi-structured interviews [17] to obtain a deeper understanding of the experiences and challenges of RTW of the patients with HNC.
Sample and recruitment
Participants were recruited from an HNC ward in a medical center in central Taiwan from November 2018 to November 2019. All participants met the following criteria: (a) received the anti-cancer treatment (e.g. surgery, chemotherapy, radiotherapy), (b) were at least 20 years old and (c) could communicate in Chinese or Taiwanese. A quantitative study was conducted by convenience sampling which eligible participants were referred by their doctors in the outpatient department and interviewed by structured questionnaires. The minimum sample size was calculated using G-power with alpha = 0.05, power = 0.8, and based on data from previous research on RTW among HNC survivors in Taiwan [16], giving a suggested minimum sample size of 111. A total of 120 patients met the inclusion criteria and completed the questionnaires. A qualitative study by purposive sampling in the hospital was applied to invite patients to explore the experiences and challenges of RTW. Initially, fourteen HNC patients who were recommended by the healthcare professionals were invited to participate in this study, but two refused to take part because of the pain of surgery and physical discomfort. Consequently, 12 patients participated in this study to share their experiences and challenges of RTW.
Data collection
Quantitative measures
Structured questionnaires, including background information, perceived stress scale, and social support were used and those were in order to further understand the patient’s physical, psychological and social aspects.
Background information
Patients’ demographic information, including gender; age; education level; marital status were collected through a background information form. Disease and physical information, such as diagnosis, stage and Karnofsky Performance Scale (KPS) indicated physical function status, were collected by a research assistant face-to-face.
Perceived stress
Perceived stress scale (PSS) developed by Cohen, Kamarck and Mermelstein [18] is a widely used psychological instrument for measuring the perception of stress. The 14 questions ask about feelings and thoughts in daily life during the last month. Each item scored by Likert scale (0 = never, 4 = very often), some items (item 4,5,7,8) scored reversely and added up for each item to get a total. PSS can range from 0 to 40 with higher scores indicating higher perceived stress. PSS has a good reliability (Cronbach’ α was 0.88) in the study.
Social support
Medical Outcome Study Social Support Survey (MOS-SSS) was developed by Sherbourne and Stewart [19] and 19 items were designed for evaluation of multidimensional, self-administered, and social support survey for patients. MOS-SSS covers four functional support scales, including emotional/informational, tangible, affectionate, and positive social interaction. Each item scores by Likert scale (1 = never, 5 = always), and for each of the subscales and overall scores were transformed from 0 to 100, with higher scores indicating more support. MOS-SSS was widely used in cancer research and appropriate Cronbach’ α was 0.95 in this study.
Qualitative collection
Qualitative data were collected via face-to-face semi-structured interview at the bedsides of the HNC wards by the coordinating author, who had many years of experience in caring for HNC patients. All interviews were audio recorded with the consent of the participants. During the interview process, the caregivers (mainly the participant’s wives) naturally joined the interviews and helped to clarify the ideas expressed by the participants.
Data analysis
Quantitative analyses (descriptive statistics, t tests by analyzing the difference between two group means and Pearson’s correlation by analyzing continuous variables) were conducted to examine the distributions of physical status, perceived stress, social supports in different work status and overall relationships. The qualitative interview data were transcribed verbatim and analyzed using qualitative content analysis, as suggested by Graneheim and Lundman [20]. The interview transcriptions were read and reread several times to obtain a sense of the whole of the participants’ experiences and challenges of RTW. The textual content identified by the authors as related to the experiences and challenges of RTW was divided into meaning units and labelled with codes. The various codes were compared based on the similarities and differences and sorted into 14 subthemes and 4 themes. During the data analysis, the three authors analyzed the interview data separately and compared and discussed the codes until consensus was reached. All authors discussed the themes and shared their opinions to verify that the themes represented the participants’ experiences and challenges.
Trustworthiness
The four aspects of trustworthiness in qualitative research, namely, credibility, transferability, dependability and confirmability [21], were used to enhance the trustworthiness of this study. The qualitative interviews were conducted by the coordinating author, who had extensive experience in caring for HNC patients. The participants were asked questions with semi-structured open-ended questions that allowed the participants to share freely as much as they wished about their experiences of healing and thinking about the issues regarding RTW. Most of the participants had family members present during the interview. Their family members helped to reword what they said when the participant’s expression was unclear or directly joined the interview to describe the situations that the participants confronted. The interviewer also asked for clarification of the narratives to achieve credibility. The study recruited the participants from a range of backgrounds and extracted thick descriptions from the interviews to achieve transferability. To accomplish dependability, the coordinating author’s rich experience was combined with that of the other two authors, who were trained and experienced qualitative researchers. During the data analysis, the team members asked one another, “Were these participants’ experiences representative of HNC patients in RTW?” The interviews were recorded and reflexive notes were kept to establish confirmability. The results were discussed several times with peers to confirm that the data coding and themes and patterns could be substantiated by the data. All the processes of data analysis were carefully and clearly reported by the authors to ensure that the findings and conclusions could be applicable to other situations and populations to support transferability.
Ethical considerations
The study was approved by the institutional review board at a medical center in central Taiwan. Written informed consent was obtained and the participants’ rights were described by the interviewer in person in the hospital before each qualitative or quantitative interview. If there is any unwillingness, participants can withdraw from the study at any time. All participants were guaranteed that the experiences they provided and the data would be handled confidentially.
Results
Quantitative results
Participant characteristics
Participants consisted of 120 HNC patients (94.0% male), with a mean age of 59.7 years (SD = 9.3). Of the participants, 82.5% were married, 35.8% had junior high school education, 60.0% were unemployed or sick leave. 65.8% of the participants the tumor site was in an oral cavity and 42.5% of the patients were at disease Stage IV (Table 1).
Background information (N = 120)
Background information (N = 120)
Patients who continued work reported better physical function (mean = 83.5, SD = 9.3) than patients who were unemployed or receiving sick leave (mean = 72.9, SD = 12.1), and was significantly different (t = 5.46, p < 0.01). Patients who continued work had lower perceived stress (mean = 13.0, SD = 8.7) than patients who were unemployed or receiving sick leave (mean = 17.8, SD = 8.8), and was significantly different (t = –2.94, p < 0.01). Patients who continued work had better overall social support, emotional/informational support, affectionate support, positive social interaction, and lower tangible support than patients who unemployed or sick leave on average (Table 2).
Distributions of physical status, perceived stress, social supports in different work status and overall correlation
Distributions of physical status, perceived stress, social supports in different work status and overall correlation
A correlational analysis showed that physical function was associated with perceived stress (r = –0.63, p < 0.01), overall social supports (r = 0.29, p < 0.01), emotional/informational supports (r = 0.29, p < 0.05), tangible supports (r = 0.18, p < 0.05), affectionate supports (r = 0.30, p < 0.01), and positive social interaction supports (r = 0.23, p < 0.01). Perceived stress was associated with overall social supports (r = –0.43, p < 0.01), emotional/informational supports (r = –0.44, p < 0.01), tangible supports (r = –0.32, p < 0.01), affectionate supports (r = –0.40, p < 0.01), and positive social interaction supports (r = –0.37, p < 0.01) (Table 2).
Qualitative results
Twelve participants consented to participate in this study. Five participants worked as construction workers, three participants were farmers, three participants worked in business, and one participant was an elected public representative. All participants were males aged between 34 and 65 years, with an average age of 52 years. Most of them (n = 11; 91.7%) were diagnosed with oral cancer and one with nasopharyngeal cancer. All participants had received tumorectomies and some had received radiotherapy or chemotherapy. The majority of participants (n = 9; 75%) were married. The majority of participants (n = 8; 66.7%) were within 1 year since their diagnosis at the time of interview (Table 3). The four themes that emerged from the data were as follows: the perceived meaning of work, challenges for RTW, preparing for RTW, and the support of family and friends (Table 4).
Overview of the participants
Overview of the participants
Themes and subthemes
The personal value change: Living like a parasite
Work perceptions varied among the participants, one being the sense of personal value. They felt that, if a man loses his job, his life may become meaningless. Before they made the decision to have surgery, the participants experienced the process of seeking out suitable doctors and the diagnosis process. They were on sick leave from work. The participants even described being on sick leave as like “living like a parasite”. Being on sick leave made them feel like a “useless person”. They desired to go back to work, and they hoped that their families could return to normal.
I hope I can go back to work as early as possible. I stayed at home… just like a parasite and doing nothing the whole day. … My father told me that I can just resign, and he would provide me money. But I am an adult, do you know how old I am? I still have daughters to raise. It is impossible to rely on him to provide money to me. My family and my wife’s family all really support me. Now, they are trying to cook meals for us. This is what I feel about fortune. My wife also takes care of me and tells me, “Don’t do this, don’t do that.” And I told her, if I do nothing, then I am a useless person. They comfort me that I don’t have to think so much; all I have to do is eat and sleep. But I can’t just live like this. (Participant 1)
Responsibility: Cannot let go
The participants described feelings of being unable to let go of their work. Work represents a kind of commitment and responsibility and cannot suddenly stop just because of illness. Some participants would go to their workplaces to take a look and viewed the process as an exercise. Some had their children take over their work, but they were still worried about it and visited the workplace to have a look or tried getting help. They also worried about how the treatment would affect their customers. The participants could not let go of their work and wanted to get things done.
(Wife) He went to the construction site to take a look. He would not be relieved; he just went to look around and then came back. He went to the construction site to see how the work was progressing. He is a responsible person; when he takes a project, that becomes his responsibility. (Participant 5, Wife)
(Wife) [I told him] All your children have grown up; you have to share your responsibilities with your children. He has worked very hard all his life, it is enough. The children should be able to take his job well now. The only concern is that he will not let go. (Participant 7, Wife)
Financial need
For some participants, work also met the financial needs of their families and themselves, especially when their children were still in school.
I need to work. If I stop working, how can I keep the family running routinely? My kids are still studying. Two are in university, and another will become a freshman this year. Although they don’t need me to take care of them, they do need money to study. (Participant 2)
Theme two: Challenges to return to work
Physical strength declining
For HNC patients, any treatment, whether surgery, chemotherapy, or radiotherapy, may change the patient’s appearance or affect other functions. Participants noted that their physical strength after surgery was not as good as before they were diagnosed. They described it as “a huge difference”. Some of them even noted that their physical strength had declined by 30%. Especially for those needing physical strength in their work or labor, less body strength was one of the challenges in returning to work.
My physical strength is worse than before the surgery, and it is nearly 30% worse. The doctor reminded me to exercise more . . . but my physical strength is not as good as before. (Participant 12)
Adjusted job role and workload
For some participants, RTW requires good physical strength, so their strategies were to adjust their work roles, such as being relegated to the second line to let their sons take over.
My son was doing it with my wife. I just went to help them. I help to collect blankets when he delivers the eggs. My physical strength is worse than before. I just do some chores, like a little helper. (Participant 11)
Most of the participants adjusted their working conditions, but participant 10 changed his career from a manufacturer to a poultry farmer because his original job required physical strength and he could not bear the workload.
Schedule rearrangement
Participants also mentioned the problems regarding time management. Because of the unpredictability of the disease progress and treatment outcomes and the long course of cancer treatment, they had to adjust their schedules for the treatment. For example, participants 1, 3 and 4 were on sick leave when interviewed.
(Working abroad) After completing my rehabilitation program, I still need to do radiotherapy. . . . When I need to visit my doctor every two months, I will come back and take a rest. (Participant 3)
Speech difficulty
The participants mentioned that after surgery, the structure of their mouths had changed. It became difficult to open and close their mouths and their speech was slurred. This change made daily life more difficult and affected their options in choosing and doing jobs.
[When I was talking,] It was a huge difference. The mouth became so dry and slurred. I could easily feel it. My second operation removed part of my tongue. When I was talking, sometimes [other people] couldn’t understand me. I needed to say it again and again. (Participant 12)
Although only participant 12 mentioned slurring as a problem in communicating with other people, most of the participants had the same problem with clear communication. Therefore, when family members were present in the interviews, the family members would always try to help them to express what they wanted to say.
Changed appearance
Regarding changes to their facial appearance, one participant stated that he was unsatisfied with his appearance, but most of the participants seemed to feel that they could accept the changes and that their recovery was better than expected. They did not mention the influence of their facial appearance on their work during the interviews.
Some participants said they were annoyed by the change in appearance, especially after the operation. The difference in skin color was not aesthetically pleasing, and they hoped to use cosmetic surgery to repair the damage. After returning to the community, they used masks in the early stage to cover the scars from the surgery.
Although I am 65, I still care about my facial appearance. I feel that I don’t look good. The skin color isn’t right and feels flat. When I first looked in a mirror, my emotion was . . . so bad, I felt depressed. I wear a mask for this reason. It doesn’t really matter to me, because I got used to it. One time, my friend asked, “Why do you look so bad?” I knew that it didn’t look good in the beginning. If someone said that, I just ignored it. I sunbathe when I am at home, and I get different skin colors in different spots. I will turn to the beauty industry in two or three years to get it done. (Participant 8)
Theme three: Preparation for RTW
Nutrition supply
Once they were diagnosed with HNC, and throughout the treatment processes, the participants faced challenges, such as declining body strength, reorganization of their schedules to fit treatment programs, or adjustments of their working times to reduce their working hours in the future. As the participants felt that their physical strength had declined, they made various adjustments to their diets and medicines, and they also expressed their willingness to conform to professional arrangements. Some participants followed their doctor’s advice and then adjusted their behaviors in their own ways.
I used to eat rice, noodles, or some seafood. Now I can’t eat anymore. I just drink it. I never ate beef before. Dr. X told me: You lack iron ions to produce blood cells, so you have to eat beef soup now. . . . I think that only by following the arrangements of professionals can the condition get better. (Participant 3)
Maintaining the connection with work
Despite still being in treatment and not having recovered their physical strength, some of the participants returned to their previous work fields and proceeded with work to the best of their physical ability.
Sometimes when my wife went to work at the construction site, I followed her to the place. . . . I helped them when I was okay. If I couldn’t, I just left it to them. Or I just did some light work, and then gradually increased the workload I could bear. (Participant 2)
Looking for information and resources
To obtain information they needed to prepare well for work, the participants sought information and resources in different ways. Some of their family members looked for information with search websites. Some asked doctors or medical professionals, or they even asked patients in similar situations how to take care of wounds or relieve symptoms.
One of his friends had the same doctor as him (my husband). The friend kept encouraging him that the process was okay; he just needed to trust the doctor. Then he felt more comfortable. (Participant 7, wife)
Protecting themselves from infection
To maintain a good enough condition to return to work, the participants tried to protect themselves from infection. The participants avoided contacting people while they were under treatment, and the family of the participants worried about the patient not having enough time to rest. They rejected the offers of the participants’ friends to visit. One participant’s wife noted the following:
When he was in the hospital, his friends all wanted to visit him. I refused. I told them that if you visit him, he will have less time to rest. You have to wait until he is discharged from the hospital, and I will invite you over for tea at that time. Actually, all of his friends were really concerned about him. (Participant 7, wife)
Theme four: Social support
Most of the participants described receiving support from their family and friends. Some of them stressed that their relationships with their wives improved after the diagnosis. The participants hoped that they could recover from the disease and share the responsibilities with their wives. Some of the participants knew that they did not have much time, so they cherished the opportunity to interact with their families. Some of the participants’ wives worried that their own emotions would influence the patients. They insisted on being optimistic and looking forward to the future.
I can’t influence his emotion. If he is pessimistic, I will be, too. It will be no hope at all. Actually, all of my unhappiness was just one day; I have things to do tomorrow. I know it is more important to look forward. Looking forward can make tomorrow better. (Participant 7, wife)
Participants’ friends visited the patients in their homes.
I couldn’t go outside, so my friends came to me. I was really happy. Some of my friends from the army, we hadn’t seen each other in so long. They knew I was sick. From the beginning of my admission till my surgery was done, they came to visit me one after another. (Participant 3)
Discussion
This study allowed an analysis of the subjective RTW experience and challenge in a sample of HNC patients by combining reports obtained during quantitative measures and qualitative interviews that express global RTW.
Struggling with the inability to let go was one important consideration. The meaning of work was described in previous studies as work or business being their “baby” [15], or as work playing a role in establishing the individual’s identity and maintaining a sense of normalcy or control [13]. In the study, patients described living like parasites or useless people while on sick leave, with participants visiting their workplaces to maintain contacts. Sometimes, they worried about others taking over their work and the effects on their customers. This finding is in line with those of previous studies, indicating that patients had motivation for RTW, such as not wanting to be a patient at home anymore, living up to societal expectations, and feeling a commitment to society at large [22]. Healthcare providers should be aware of the perception of work to provide patients emotional support and teach coping strategies for work adjustment.
Physical strength is a major consideration in RTW. Patients may feel tired easily, and this fatigue can influence their workload, total working time, or working hours. As described by the participants, their poor physical strength also affected many aspects of their lives. Several studies have noted that flexible work times are beneficial to patients in RTW [14, 24]. Moreover, a previous study mentioned that employers and/or colleagues had difficulty in dealing with cancer in the workplace; they did not understand the consequences of the disease and treatment, so patients experienced insufficient recognition from colleagues and disagreement about which work accommodations the patients could adjust to [25]. Torp and his colleagues further stated that self-employed individuals could adjust their workloads depending on their physical conditions [15]. We suggest that workplace and community health networks should be established to provide resources on health information, counseling, and guidance from healthcare providers.
This investigation showed that patients were concerned about changes to their appearance both pre- and post-surgery. A person’s appearance reflects his or her individual perception of his or her own body and is a multidimensional dynamic process [26]. Patients needed to cover up or take time to adapt to the changes after the surgery. Several studies have mentioned that appearance is positively correlated with depression, social contacts and quality of life [27], and a further study stated that the attitudes and feelings of appearance satisfaction will be reflected in emotion, behavior, and cognition, such as low mood, avoiding crowds, and self-denial [28]. Therefore, healthcare providers could play a role in assisting patients in maintaining their appearance and increasing their self-esteem and self-confidence to help them live more positively with cancer.
In the Chinese food culture, there is the concept that medicines and food are homologous or that diet cures better than medicine. This culture emphasizes diet and uses food with Chinese medicines to fight cancer and maintain health [29]. Although some patients may protect themselves from infection and get adequate rest by refusing to see visitors during treatment, they still need mental and practical support from others, such as relatives, friends, and care professionals, to look for information and resources. Therefore, following up and providing care information during recovery are important to patients.
Support from family, relatives and friends is important for mental adjustment. Also, several participants also encouraged themselves. Many studies have stated that social and emotional support from colleagues, relatives, or employers are facilitators for RTW [22, 30]. However, some caregivers pointed out that they needed to stay positive and encourage themselves and their patients. Therefore, the evaluation of caregivers’ needs is also important, for health professionals should provide proper support resources for both patients and family caregivers, such as emotional support, home management, transportation to and from medical appointments, and support with activities of daily living.
Many patients expressed concerns about financial problems. The HNC patients in this study were mostly males and manual laborers, and their jobs were physically demanding, similar to the previous statistical data, due to the habits of smoking, drinking and betel nut, HNC often occurs in this group [4]. Previous studies found that there were different considerations for RTW between employed patients and self-employed people [14]. Some HNC patients adjust their work to temporary or self-employment, and even if they return to work, their salaries are lower than they were before the cancer [31]. Previous studies also found that the income of temporary or self-employed workers was volatile, and median earnings fell [15]. In Taiwan, the law allows employees to take leave without pay for a maximum of one year because of illness, but there is no law to protect the jobs and incomes of self-employed people. Therefore, we suggest that the government and companies develop regulations to ensure that people with disabilities and cancer patients are included so as to protect the employment rights of cancer patients. Other studies have pointed out that more support from co-workers or supervisors and comprehensive legislation may facilitate patients’ RTW [23, 25]. This result highlights the importance of work adjustments, good communication, and flexibility in the workplace, so we suggest that governments should enhance working environment support and provide more health information [22].
Clinical implications
The strength of the present study is that it provides results in-depth details about the experiences and challenges of RTW in HNC patients. Some studies have found that, in Eastern countries, people are less expressive about their situations in the face of RTW, especially middle-aged men who have unclear oral pronunciation [32, 33]. The results provide a more comprehensive illustration of patients’ considerations in RTW. Healthcare systems and providers can improve the RTW experience and limit the challenges for HNC patients by, for example: (a) providing care information about what to expect during recovery; (b) integrating a dietician consultation into the care process; (c) referring patients to an occupational rehabilitation professional to assist with the dysfunctions of speech and eating; and (d) providing mental support and teaching coping strategies. Also, the results provide a reference for government policy, such as establishing the regulations of employment counseling and job matching to facilitate RTW.
Study limitations
Some limitations of this study are noted. HNC patients are mostly male in the study, and the views of female patients need to be studied in the future. The quantitative and qualitative data were not longitudinal; therefore, the actual situations when they changed jobs were followed up and recorded over time. Thus, further longitudinal studies and comparisons of the perceptions of RTW between different variable groups are needed.
Conclusion
This study provides valuable insights into the perceived challenges and experience faced by HNC survivors in RTW. The results allowed us to identify the patients’ concerns and ways that healthcare providers can improve the RTW process. The findings demonstrate that HNC survivors may face difficulties and challenges in balancing their mental, physical, and financial problems, and that social support is needed within the constraints of their RTW situation. Future studies should develop tailored approaches for providing support for RTW in both the healthcare system and government policies.
Funding
This study was supported by the Ministry of Science and Technology (MOST106-2314-B-212-001).
Conflict of interest
The authors have no conflicts of interest to disclose.
Ethics statement
Approval was obtained from the institutional review board of Changhua Christian Hospital (No: 170908). The procedures used in this study adhere to the tenets of the Declaration of Helsinki. Written informed consent was obtained and the participants’ rights were described before each interview.
Data availability
The data that supports the findings of this study is available from the corresponding author upon reasonable request.
Footnotes
Acknowledgments
The authors thank the patients who participated in the study.
Author contributions
YJC and LHL contributed to the design and conception of the research. MKC and MYH contributed to the implementation of the research and data collection. All authors contributed to the data analysis and interpretation. YJC, LHL, and CIY contributed to the drafting and critical revision of the article. All authors read and approved the final manuscript.