2.1 Participants and study design
This cross-sectional descriptive correlational study was conducted between December 2021 and May 2022 in a tertiary care hospital in Henan, China. Participants were recruited through convenience sampling. The inclusion criteria were patients who: (i) Met the World Health Organization's definition of young and middle-aged people aged 18–59 years14; (ii) Were diagnosed with stroke on imaging; (iii) Did not have mental illness or cognitive impairment; (iv) Were involved in work before the illness and have not retired. Patients with a combination of other serious illnesses or other cerebrovascular disease and the presence of severely impaired vision and hearing were excluded from this study. Subjects provided written informed consent.
According to the cross-sectional sample size survey formula, N=(Z1-α/2+Zβ)2/[P1(1-P1)]b2,15 Z1-α/2=1.96 and Zβ=1.28; furthermore, the literature review yielded P1=0.507 and b=0.51,16 which when incorporated into the formula yielded: N =162. In total, 203 young and middle-aged stroke patients were included in this study.
2.2 Research instruments
2.2.1 Self-generated general information questionnaire
This scale was designed by the researcher and covered socio-demographic information such as age, gender, place of residence, housing status, education level, marital status, monthly income, and mode of payment for medical care. Disease-related information included the type of stroke, whether it was the first-onset stroke, the timeframe of the diagnosis, at what point rehabilitation exercises were started, and whether any residual functional impairment existed. Work-related information collected included the type of occupation and nature of work prior to illness.
2.2.2 Return to Work Readiness Scale (RRTW)
Developed by Franche et al.17 and translated and revised by Cao,18 the RRTW is mainly used to evaluate the level of a patient’s readiness to return to work. The scale includes 6 dimensions and 22 items and is divided into two parts. The first part comprises 4 dimensions (13 items in total) for patients who have not returned to work, including a pre-intention dimension, intention dimension, action preparation-self-assessment, and action preparation-behaviour. In the second part, there are two dimensions (9 items in total) for patients who have returned to work, namely, uncertain maintenance and active maintenance. Each item is scored by on a five-point Likert scale. The total score is not set in the scale, and the sum of items in each dimension is the score of this dimension. The dimension with the highest score represents the preparation stage of the patient; the higher the stage, the higher the level of readiness of a patient to return to work, and the more fully prepared they are to return to work. If the final score of the two dimensions is the same, the respondent will be classified as the stage at a low level in the two dimensions according to the patient's filling results. If three or more dimensions with the same score are obtained simultaneously, the questionnaire will be deemed invalid. This study targeted patients who did not return to work by using only the first part of the scale. The Cronbach's α coefficient of the questionnaire in the formal investigation of this study was 0.728.
2.2.3 Social Support Rate Scale (SSRS)
Formulated by Xiao19 in 1994, the SSRS includes 10 items spread across three dimensions: objective support (items 2, 6, and 7), subjective support (items 1, 3, 4, and 5), and utilization of social support (items 8, 9, and 10). The total score ranged from 22–66, with higher scores indicating higher levels of social support. Since its establishment, the SSRS has been widely used in 20 disciplines and majors in China, and the associated Cronbach's α coefficient was 0.941.
2.2.4 Stroke Self-Efficacy Questionnaire (SSEQ)
Developed by Jones et al.,20 Li et al.21 translated the SSEQ into Chinese and applied it to patients with first-episode stroke to measure functional performance and self-management confidence levels during the recovery period of stroke. The Cronbach's α coefficient of the scale was 0.969. The scale has 13 items in total, divided into two dimensions: activity function (8 items) and self-management (5 items). A Likert 10-level scoring method is used. The higher the total score, the higher the rehabilitation self-efficacy of the tested patients. The Cronbach's α coefficient of the questionnaire in the formal investigation of this study was 0.947.
2.2.5 Fatigue Severity Scale (FSS)
Compiled by Krupp et al.22 in 1989, Wu and Wang23 translated the FSS into Chinese and applied it to evaluate the fatigue severity of stroke patients. The scale is a single dimension including 9 items, all of which are scored using a Likert 7-level score. The total score is the average or sum of the 9 items. A FSS score of ≥4 or ≥36 indicates fatigue, and the higher the value, the more serious the degree of fatigue. The Chinese version has good reliability and validity, with a Cronbach's α coefficient of 0.932 and intra-group correlation coefficient of 0.742,24 indicating that the FSS is a reliable and effective tool for measuring post-stroke fatigue. In this study, the Cronbach's α coefficient of the questionnaire was 0.938.
2.3 Data collection procedure
Regarding the pre-designed questionnaire, Questionnaire Star software was used to fill in the questionnaire online or distribute the questionnaire in person to collect data. The purpose and benefits of the study were explained to the patients before filling in the questionnaire, and the patients were asked to complete in the questionnaire themselves as much as possible. If the patient's education level, physical function, and other aspects could not be filled in by the patient, the patient's family members or researchers were allowed to assist them to complete the questionnaire. All questionnaires were collected and checked by researchers, and those with incomplete information were excluded. A total of 218 questionnaires were distributed and 203 were recovered, with an effective recovery rate of 93.1%.
2.4 Statistical analysis
SPSS 26.0 software (IBM Corp, Armonk, NY, USA) was used for the statistical analysis and processing of all data. Means ± standard deviations were used to describe the measures, and counts were expressed as number of cases and rates (%); univariate analyses were conducted using rank sum tests such as the Mann-Whitney U test or the Kruskal-Wallis H test: Spearman's correlation analysis was used to explore the relationship between readiness to return to work and self-efficacy, social support, and fatigue severity scales and the dimensions. Ordered multiple logistic regression was used for multifactor analysis, with P<0.05 being considered a statistically significant difference.
2.5 Ethical approval
The study was approved by Ethics Committee of the College of Nursing and Health of Henan University (HUSOM2021-288), all methods were carried out in accordance with relevant guidelines and regulations. All patients in the study gave informed consent before the questionnaire began