Readiness for return to work model-based analysis of return-to-work perception of young and middle-aged colorectal cancer patients with stoma: A descriptive qualitative study

doi:10.21203/rs.3.rs-2460105/v1

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Research Article

Readiness for return to work model-based analysis of return-to-work perception of young and middle-aged colorectal cancer patients with stoma: A descriptive qualitative study

https://doi.org/10.21203/rs.3.rs-2460105/v1

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published 23 Jun, 2023

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Purpose: With an increase in the number of young and middle-aged colorectal cancer (CRC) patients with stoma, understanding their perception about return to work (RTW) can guide medical professionals to provide appropriate rehabilitation strategies, which can eventually improve patients’ readiness for RTW and enable them to achieve final rehabilitation. The present study aimed to investigate the RTW-related perceptions of young and middle-aged CRC patients with stoma after surgery.

Methods: From 2021 to 2022, we conducted a basic interpretive qualitative study involving semi-structured interviews with 17 CRC patients with stoma in two grade 3A hospitals in China. This study was based on the readiness for return to work (RRTW) model. Data collection was continued until data saturation was reached, and all data were transcribed verbatim and analyzed by Colaizzi’s phenomenologicalmethod.

Results: The following three key themes were identified: (1) self-efficacy; (2) decision balance; and (3) change process. Eight subthemes were formulated that were included within the respective main themes.

Conclusion: In light of the current low self-efficacy and unsatisfactory willingness of patients with stoma about RTW, we suggest that medical staff should implement cognitive intervention and supportive intervention to improve self-efficacy and actively enhance the motivation of patients for RTW and simultaneously resolve the pertinent difficulties; this could help patients to accept the positive change process and enable their successful transition from a change process to RTW.

Return to work

Colorectal cancer

Stoma

Self-efficacy

Decision balance

Change process

Colorectal cancer (CRC) is the third most common malignant tumor globally after lung cancer and breast cancer[1]. The incidence of CRC has been increasing steadily in recent years. In 2022, approximately 151,000 individuals are expected to be diagnosed with CRC, and nearly 52,580 are expected to die due to this disease[2]. Moreover, by 2030, approximately 15% of patients with CRC will be younger adults; this estimation implies that an increasing number of people of working age will be diagnosed with CRC[3].

Stoma remains the primary mode of treatment despite advances made for treating CRC. Ostomy is classified into permanent stoma and temporary stoma. Permanent stoma requires the removal of the anus and creation of a permanent stoma in the abdominal wall; this could severely damage the patient’s body image, physiological function, and quality of life[4]. Temporary stoma involves alleviation of the intestinal pressure; it prevents the occurrence of anastomotic fistula and contamination of the intestinal content. The intestinal tube is lifted to the level of the abdominal wall, and the stoma plays an important role in clearing waste. After the healing of the anastomotic stomach or closure of the fistula, the bowel function recovers, and the intestinal tube lifted to the abdominal wall level is eventually incorporated into the abdominal cavity; consequently, the patients can lead a normal life after closure of the fistula [5]. However, regardless of the use of permanent stoma or temporary stoma, CRC patients continue to experience inconvenience in their daily living and work life because of the stoma.

Given that many patients with stoma are in their most productive working years, return to work (RTW) has become an important aspect of their rehabilitation. A previous study reported that the RTW rate for patients with CRC was 70.3%[6]. Work is one of the most common means for people to stay in touch with society. For many patients with stoma, having a job has perceived advantages, including strengthening their sense of professional identity, improving mental well-being, and providing financial stability. RTW can also provide these patients with a sense of normality and control over their lives as well as a sense of social belonging [7, 8]. This is also consistent with the highest level of need in Maslow’s hierarchy of needs—the pursuit of self-realization[9]. In contrast, the inability to RTW or prolong absence from work due to illness can cause financial burden for these patients and their families and hinder the process of returning to social reintegration and interpersonal interaction; this will also increase stress on caregivers who are more prone to be affected by fatigue and negative emotions, which is not conducive to family harmony[10], while the loss of labor force is not favorable for social development[11]. Therefore, RTW is crucial for patients, their families, and society.

Patients of working age and with stoma may, however, not be considered fit to perform the required work. Because of low self-efficacy, they may be in a long-term self-negation mood and think that they cannot RTW. Moreover, low levels of social support and low social acceptance may influence the decision of these patients[12]. It is crucial to understand the RTW profile of patients after colostomy, which can guide medical professionals to provide them with appropriate rehabilitation advice and eventually promote their overall physical, psychological, and social rehabilitation.

Phenomenology is the branch of science devoted to the understanding of social phenomena from the perspective of the object and to describe their world in the way that the subjects have experienced. For patients with CRC, whether to RTW or not depends on their perceptions of the stoma and its effect in the real world. Hence, on the basis of phenomenological research, we can accurately determine the common essence of stoma patients’ wishes and views on RTW. Therefore, in the present study, we aimed to investigate the perceptions of CRC patients with stoma regarding RTW.

Theoretical framework

In 2002, Canadian scholars Franche[13] et al. proposed a new Readiness for Return-to-work Model that focuses on the interpersonal context of work-disabled employees. In this model, employee interactions with the workplace and the healthcare and insurance systems are considered as they affect the three primary dimensions of change: decision balance, self-efficacy, and change process. The model also has the potential to consider individual variations in the optimal stage-specific timing of interventions based on an individual’s readiness for RTW (RRTW). Therefore, we assume that patients who have undergone colostomy also follow the decision balance-self-efficacy-change process trajectory when they RTW. Hence, we also focused on these aspects to conduct this interview with an intent to use this model as a theoretical guide to deeply explore the influence and effect of the three dimensions of decision balance, self-efficacy, and change process on the willingness and view of patients who undergo colostomy.

Ethical approval

Prior to the interview, all participants were provided information orally about the objectives of this study. After all the patients were made fully aware of study design and objectives, they were asked to sign the informed consent form. The study design and procedures were approved by the Ethic Committee of Guangzhou Medical University prior to conducting the research (approval number: 202201012).

Design

A qualitative, interpretive, and exploratory phenomenological approach was used to determine the perceptions of young and middle-aged CRC patients with stoma with regard to RTW. Qualitative data were collected by semi-structured interviews and analyzed by the phenomenological method proposed by Colaizzi[14].

Participants

From 2021 to 2022, a purposive sampling method was used to recruit participants from the Affiliated Cancer Hospital and Institute of Guangzhou Medical University and TCM-Integrated Hospital of Southern Medical University in Guangzhou, China. The sample was selected such that the key general demographic data are balanced. These data were considered saturated when no new themes or new information emerged in subsequent interviews. The inclusion criteria were as follows: (1) diagnosis of CRC; (2) completed one month or more since surgery; (3) age 18–60 years, (4) employed at the time of diagnosis, (5) able to read text and has good communication skill, and (6) voluntary participation and provided informed consent to participate. The exclusion criteria were as follows: (1) presence of other organ malignancies or other major organic lesions, (2) tumor recurrence, or (3) mental illness or difficulty in understanding the questions.

Procedure

First, on the basis of the analysis of the available literature on this topic, the research group conducted a brainstorming session based on the RRTW model and designed a preliminary outline of the interview. Subsequently, two rounds of expert consultation were conducted, each of which comprised five experts with extensive clinical and teaching experience. The eligibility criteria for the experts were as follows: (1) master’s degree or above, (2) senior designation; and (3) more than 10 years of experience in the field of gastrointestinal nursing or psychology (Appendix A) Based on the RRTW model and the results of brainstorming and two rounds of expert consultation (Table 1), the pre-interview outline was preliminarily formulated. Next, 2 patients with stoma who met both inclusion and exclusion criteria were selected for pre-interview. The final interview outline was created after making some modifications based on the results of pre-interview. In the final interview outline, the second and third questions of the pre-interview outline were merged into the current second question (Appendix B).

Table 1 Results of the analysis of expert consultation

Round	Positive coefficient of experts			Authority coefficient of experts			S-CVI^d
Round	Number of distribution	Effective recovery (%)	Advice presentation (%)	Ca^a	Cs^b	Cr^c
1	5	100%	60%	0.90	0.74	0.82	1
2	5	100%	80%	0.88	0.70	0.79	1

^aCa: Judgment coefficient; ^bCs: Familiarity coefficient; ^cCr: Coefficient of expert authority; ^dS-CVI: Scale-level content validity index

Data collection

Semi-structured face-to-face interviews for data collection were conducted at the appropriate place and time as agreed by the two sides. The interview process was best conducted in quiet, secluded places (e.g., in an office or in garden downstairs). The process included two interviewers, one of whom conducted an in-depth interview with the participants by referring to the interview outline, and the other interviewer was responsible for recording, noting down the required details, and re-questioning when necessary. To establish trust and effective communication between the interviewers and the participants, the interviewer asked some general questions at the beginning of the interview. Next, according to the interview outline, the interviewer asked several open-ended questions. To obtain rich data, probing methods (e.g., asking for details, examples, and related reflections) were used. Each interview lasted approximately 30 min. All interviews were recorded, and the important details were noted; moreover, subtle facial expressions, vocal tone, body movements, and emotions of the participants were recorded during the interview. To ensure anonymity, interviews were conducted privately, and a random number was assigned to each participant. After the seventeenth interview, data saturation was reached as no new data were identified, and the data collection process was terminated.

Data analysis

The processes of data collection and data analysis were conducted simultaneously. We used a seven-step Colaizzi’s phenomenological method to analyze the data. All audio-taped semi-structured interviews were anonymized and transcribed verbatim in Chinese. The total transcription duration was approximately 6.9 h, and the average interview time was approximately 30.3 min, with a total of 92,545 words. Names and other personal identifiers were removed to protect the confidentiality of the participants. One researcher performed transcription, and another researcher assessed the transcripts to ensure content accuracy. Before coding, the two researchers independently read full text of the transcriptions to familiarize themselves with the data. All the interview data were then coded using Nvivo12plus, and significant statements were distilled. On the basis of a theoretical framework, the researchers formulated general meanings for significant statements until two researchers reached a consensus. The researchers then arranged these statement meanings into clusters of themes to find common significant concepts, which were prototypes of themes. Subsequently, the researchers developed exhaustive descriptions and defined each early theme by inserting three or four typical statements against the theme. Similar themes and descriptions were compiled and compared against each other to extract common viewpoints, which formed the emerging themes. Finally, these emerging themes were organized into major themes and subthemes. All themes were discussed among the research team and modified if required.

Participant characteristics

Seventeen semi-structured interviews were conducted. The participants included 6 women and 11 men, with an age range of 32–59 years (average: 45.6 years). Table 2 shows the sociodemographic and clinical characteristics of the participants.

Table 2 Sociodemographic and clinical characteristics of the participants

No.	Gender	Age (years)	Education level	Marital status	Occupation at the time of diagnosis	Diagnosis	Types and properties of stoma
1	Female	39	Junior middle school	Married	Office staff	Rectal cancer	permanent colostomy
2	Male	47	Junior middle school	Married	Self‐employed	Rectal cancer	Temporary ileostomy
3	Male	50	Primary school	Married	Workers	Colon cancer	Temporary ileostomy
4	Female	36	Junior middle school	Married	Workers	Rectal cancer	Temporary ileostomy
5	Male	49	High school	Married	Administrative staff	Rectal cancer	Temporary ileostomy
6	Male	42	Junior middle school	Married	Driver	Carcinoma of sigmoid	Temporary ileostomy
7	Female	43	Primary school	Divorced	Hotel attendant	Rectal cancer	Temporary ileostomy
8	Female	32	Junior middle school	Married	Workers	Rectal cancer	permanent colostomy
9	Male	34	Junior college	Married	Airport security	Rectal cancer	Temporary ileostomy
10	Male	43	High school	Married	Driver	Colon cancer	Temporary ileostomy
11	Female	48	High school	Married	Administrative staff	Rectal cancer	Temporary ileostomy
12	Male	48	Junior middle school	Married	Self‐employed	Rectal cancer	Temporary ileostomy
13	Male	46	High school	Married	Chef	Rectal cancer	Temporary ileostomy
14	Male	51	Primary school	Married	Workers	Rectal cancer	Temporary ileostomy
15	Male	59	Junior middle school	Married	Logistics manager	Colon cancer	Temporary ileostomy
16	Male	56	Technical secondary school	Married	Office staff	Rectum adenocarcino-ma	Temporary ileostomy
17	Female	52	Primary school	Married	Workers	Colon cancer	Temporary ileostomy

Three major themes emerged from our data analysis. These themes and the associated subthemes are described in the following sections. The framework diagram of the results (Figure 1) was obtained based on the three dimensions of the RRTW model and the research results, and illustrative quotes are provided in Table 3.

Theme 1: self-efficacy

Irrational cognition of CRC and stoma

Regarding CRC and stoma, most patients responded that they had never developed such disease earlier and that they were only aware of the name of the disease as CRC; however, they had no knowledge regarding the cause of CRC and the reason why surgery is required for enterostomy. During disease recovery, some patients began to take more interest in their role and started focusing more on their recovery.

Ability to interact socially was reduced

Objective disease factors lead to a reduced social interaction

The decrease in patients’ social interaction is partly caused by objective factors. The physical function and physical strength of the patients are affected to a certain extent during the recovery period after the surgery. Because of the treatment approach, some patients need to carry drainage tubes even after discharge and require continuous chemotherapy, which causes them inconvenience while performing their daily activities. The patients believe that it is not suitable to venture outside during recuperation; consequently, the scope of social activities is narrowed down between families and relatives, which is not favorable to restore interpersonal relations after returning to society. For some patients, social relationships were mainly restricted to their work colleagues before they underwent surgery; however, after surgery, they were largely divorced from their social relationships.

A subjective strong sense of stigma leads to the refusal to socialize

On the subjective level, although enterostomy saved the lives of the patients to some extent, it completely altered their perception of natural excretion. The patients found it difficult to accept that the stoma existed on the abdominal wall. Therefore, most of the patients we interviewed had varying degrees of shame, and they were more resistant to social interaction. During the stoma-carrying period, most patients experienced very negative psychological feelings about communicating with other people, and they even took the initiative to refuse to communicate with people other than their families. Some patients admitted that their nature had gradually become worse, their mood was easily affected, and they became impatient. Their cognition of the stoma also reflects the group values of their social circle, and it was observed that the acceptance of the stoma by their friends was also relatively conservative and generally on the low side.

The level of stoma-related self-efficacy was polarized

Active thinking to solve the problem of stoma care

Some patients had a positive attitude toward nursing of their stoma. They were willing to actively learn the relevant knowledge and participate in and undertake the nursing activity for their stoma; they even conducted some work, such as pocket replacement, independently or with assistance of their families. They exhibited strong confidence in stoma self-care. These patients were good in thinking and summing up their nursing experience. They actively managed issues such as fluid leakage and dermatitis in stoma to effectively reduce the occurrence of stoma-related complications.

Evading the responsibility of self-care and relying entirely on family care

Some patients lacked confidence to take adequate care of their stoma and relied entirely on the help of their families. Some patients thought that the position of stoma leads to a certain degree of difficulty in nursing and that it is not easy to perform nursing care. Other patients believed that their stoma is temporary, and they were eagerly waiting for it to be placed back into the abdominal cavity 3–6 months later; hence, they thought that their family members should take care of the stoma during this short period of time, and it is not necessary for them to master nursing skills.

Theme 2: Decision balance

Motivation to RTW

Working can promote physical and mental health and realize one’s self-worth

Some patients thought that RTW can be regarded as exercise for themselves, which can not only alleviate their boring life at home for a long time but also help to recover from the disease and promote physical and mental health. Moreover, some patients not only liked their careers but also had strong professional ethics. They believed that the stoma will not prevent them from realizing their self-worth at work.

Economic needs

Because of illness, surgery, and other reasons, the financial situation of most patients’ families had declined to a certain extent, and economic pressure prompted them to take the decision to RTW. In particular, male patients and single mother patients felt that RTW was inevitable to restore the main source of income of the family.

Robust social-family-workplace support system

A tolerant social environment, adequate family support, and good understanding of work-related colleagues had a positive impact on the patients’ willingness to RTW. Most patients responded that they received good care from their families and financial support and care from their friends and work-related colleagues during their illness. The nature of the work of the participants also had an impact on their willingness to RTW.

Difficulties in RTW

Inconvenience while dressing and poor image

Because the stoma is located in the abdominal wall, some patients thought that this awkward position made it very inconvenient for them to dress properly for the occasion. Because of their nature of work, some patients were required to wear uniforms with belts during work; this was a difficult issue for patients with stoma. They felt that they have to abandon wearing tight clothes because it will suppress the stoma and cause discomfort; this was especially problematic and restrictive for women who liked to wear such clothes to appear beautiful.

Decrease in physical function

Long-term illness, surgery, and chemotherapy had affected the physical function and psychology of the patients. Most patients showed physical weakness, decreased resistance, memory loss, etc. Moreover, after the surgery, it was difficult for the patients to meet the work requirements in terms of work intensity and working hours, which they could manage before the illness. Therefore, they first wanted to wait at home to recover from their illness and then consider whether to RTW.

Problems of stoma such as continuous excretion and odor

Undoubtedly, stoma and defecation are a great physical and psychological challenge for patients. In particular, most temporary stoma cannot store feces; consequently, stoma excretion will be continuous or irregular. The patients need to frequently visit the toilet and perform timely cleaning; otherwise, feces accumulation would easily lead to stoma leakage and odor. This not only makes it very inconvenient for patients to move and work but also places high psychological pressure on them while interacting socially with others. Consequently, the stoma problem may prevent them from RTW.

Decision-making to RTW

Looking forward to RTW and plan to overcome the difficulties

Although the stoma had some negative effects on the patients’ quality of life, such as inconvenience during daily activity, dressing restriction, and nursing difficulties, some patients maintained an optimistic and positive attitude toward the stoma. They believed that the effects of CRC can be overcome and the issue can be resolved, and they were awaiting RTW.

Negative response and abandon the thought of RTW decisively

While deciding whether to RTW, half of the patients chose to abandon the thought decisively. Most of them refused to rework because of the existence of stoma. They insisted that they will reconsider this decision after the stoma has been placed back and they have fully recovered from the disease.

Theme 3: Change process

Experience Change

Change the social interaction

A small number of patients slowly began to re-contact people they were familiar with, while showing an evasive attitude toward contact with strangers, unless they choose to communicate offline to avoid possible embarrassing situations.

Plan to adjust work intensity or work type

Some participants responded that easy work is also a good option to return to society. If they RTW, they may plan to change their jobs or adjust their work frequency, duration, and intensity to best suit their health.

Regain a new life and feel life

Almost all the participants re-examined their lives after suffering from the disease and felt that they gained new life and new insights regarding life. They now believed that life is most precious and decided to relax themselves and avoid getting trapped by the opinions of others. They gained confidence to overcome the disease and actively cooperated with the treatment regimen. They were also very grateful for the love of their family and friends and decided to cherish their lives as a reward.

Behavior change

Pay careful attention to the situation of stoma and timely nursing

Some patients undertook some measures to prevent stoma-related issues to overcome the difficulties that may arise when they RTW, such as slowing down the speed of their activities, making preparations before going out, carrying stoma care materials, and paying attention to and changing stoma feces in time.

Increase exercise and nutrition as well as strengthen physical and mental rehabilitation

To promote physical recovery and RTW as soon as possible, some patients made changes in their nutrition and exercise. They began to increase their nutritional intake of proteins and vitamins and performed appropriate activities and exercises to increase their physical recovery.

Table 3 Illustrative quotes related to themes

Themes and subthemes	Illustrative quotes
Theme 1: Self-efficacy
Subtheme 1: Irrational cognition of CRC and stoma		Quote 1: At first, I couldn’t accept that I couldn’t use my anus to defecate any more, and I felt like I was going to be a patient all my life (wry smile). I also don’t know much about stoma, so I thought it is easy to cause problems with stoma defecation. (P1) Quote 2: I carry this thing (stoma) as a patient, so how does the patient go to work? (P16) Quote 3: Now that I have this disease, I dare not visit my relatives and walk around, let alone travel. I even dare not go out and eat anything I really want to eat. (P11)
Subtheme 2: Ability to interact socially was reduced
-Objective disease factors lead to a reduced social interaction	Quote 4: Because I haven’t been out since my operation and its only been a month after surgery, where can I go? Now is also the period of recovery. (P2) Quote 5: Because my previous social contacts are all about work. Now I’m sick, I can’t participate in work. After temporarily recuperating at home for such a long time, I just occasionally say hello to others. (P5) Quote 6: During chemotherapy, I didn’t go out to play. (P8)
-A subjective strong sense of stigma leads to the refusal to socialize	Quote 7: I won’t tell normal people about my stoma. I seldom go out now, and I don't even go to the square, but take a walk in a place where there are few people. (P12) Quote 8: Actually, I can't accept stoma, [...] there must be obstacles in my heart (to get along with others face to face). [...] (weeps after being silent for 12 s) I’m afraid of being rejected. [...]I definitely don’t want people to know that I have a stoma. I will avoid as much as I can and hide as much as I can. (P4) Quote 9: I feel like this thing (stoma) is a bit of a burden. […] I'm afraid that it will be full or leak before a thing is done. How humiliating it would be if it leaked out in a public place! (P15) Quote 10: I had a temper that flared up easily in the early stage of CRC, and if I tell something to my family once or twice but they still don’t understand, I will lose my temper with them. So, I communicated less with my family after I got sick. (P5) Quote 11: It’s not my psychological effect, if my friend is sick and I’m not sick, I must have some scruples about him in my heart, everyone will do so, this should be very normal. (P10)
Subtheme 3: The level of stoma-related self-efficacy was polarized
-Active thinking to solve the problem of stoma care	Quote 12: I think experience is very important about colostomy care. You have to slowly accumulate experience from a lot of failures. The most important thing is not to let fecal water seep into the skin, which is the most important point. (P5)
-Evading the responsibility of self-care and relying entirely on family care	Quote 13: Anyway, I don’t take care of the stoma. It’s all my husband’s work. I don’t usually do it myself, and I don’t want to do it. (P8) Quote 14: Now there is no way to take care of this stoma. Next time I will come back for a recovery operation, then my defecation will return to normal. (P3)
Theme 2: Decision balance
Subtheme 1: Motivation to RTW
-Working can promote physical and mental health and realize one’s self-worth	Quote 15: If the company approaches me, I will definitely go to work, which is a work ethic. […] I haven’t reached the retirement age yet; as long as my health permits, I must do something because I like my job. (P5) Quote 16: It is not good to stay at home every day, and it is better to take work as exercise, which is helpful to the course of the disease. (P12)
-Economic needs	Quote 17: I am the main force of the family, and if I don’t go to work to make money, the pressure on my family will be greater. (P3)
-Robust social-family-workplace support system	Quote 18: My friends came to visit me, let me express some feelings, and also understand some of the situation in the work industry. (P5) Quote 19: My leader also said that the post was still reserved for me, and he told me to take good care of my illness, and when I was healed, I could go to work at any time. (P15) Quote 20: Family affection and friendship are reflected in my difficult time, and my family, friends and unit leaders all called to greet me. With regard to financial issues, I can also apply for subsidy from the union. (P16)
Subtheme 2: Difficulties in RTW
-Inconvenience while dressing and poor image	Quote 21: Women love to be beautiful, but I can't wear beautiful clothes anymore. If the clothes are tightly tied, they will press against the stoma, causing stoma pain and discomfort. (P7)
-Decrease in physical function	Quote 22: I have just had surgery; my physical strength will definitely be much worse, which will affect my working time and labor intensity, and my memory will certainly not be as good as it used to be. In the past, I had to remember a lot of data, but now I can only remember some special things. (P5)
- Problems of stoma such as continuous excretion and odor	Quote23: If the stoma discharges stool and produces gas, it will arch the stoma bag, which makes me uncomfortable, so I can’t work with the stoma.... It is not like normal excretion that is drained all at once, but slowly and continuously, which is very troublesome. (P7) Quote 24: First of all, I don’t think it’s good to go to the toilet often, and I’m afraid that the stoma has a bad smell. Second, since it takes me more than an hour to go to work by car and transfer, I am worried about accidentally bumping into my stoma. (P16)
Subtheme 3: Decision-making to RTW
-Awaiting RTW and plan to overcome the difficulties	Quote 25: I asked the doctor to operate on me quickly so that I could go back to work as soon as possible. (P13) Quote 26: I still want to go back to work, since I have nothing now, how to survive if we don't work? (P7)
-Negative response and abandon RTW decisively	Quote 27: I feel that it is very inconvenient for me to carry a stoma because I have to go to the toilet very frequently. I still want to take care of myself and think about work after I recover. (P11) Quote 28: I don’t think it’s necessary to go to work when carrying a stoma, and I won’t go to work anyway. After the stoma is put back, if I return to normal diet and activities after chemotherapy, and I can go to work then. Otherwise. How can I go to work when my body is very hard? (P14)
Theme 3: Change process
Subtheme 1: Experience Change
-Change the social interaction	Quote 29: I’m sure I won't get in touch with strangers anymore, but I can get in touch with people I know slowly. (P4)
-Plan to adjust the work intensity or work type	Quote 30: I plan to recover for a while first. But if I go back to work, the labor intensity should not be as strong as before. (P5) Quote 31: I will do more work when I don’t go to the toilet because if I do the same amount of work as my colleagues, then everyone is balanced. (P13)
-Regain a new life and feel life	Quote 32: When I first came to the hospital, I was in a terrible condition and couldn’t meet the surgery conditions. Now that the operation has been done, it is a good turnaround for me (laughter). I think stoma is really a great invention. […] I have also made a psychological transformation myself and felt great now. Later, when I had more contact, I found that there were more people with a stoma, not just me. (P1) Quote 33: Although I married far away, my parents were not around, and my husband and I often quarreled before I got sick, and I also regretted marrying him, but now I actually had no regrets after this illness. (P4) Quote 34: I usually don’t pay attention to my body, but after the operation, I feel that my life is very expensive. (P11) Quote 35: When I was sick, I felt that my family and friends were fine. I think I should fight against the cancer and give back to them. I have parents, husband, and sons, and I think my responsibility has been not fulfilled yet. (P17)
Subtheme 2: Behavior change
-Pay careful attention to the situation of stoma and timely nursing	Quote 36: Since I am worried that my ostomy bag will fall off or need to be changed, I have to carry care items with me just in case. Just like girls bring cosmetics (laughs), after getting ready, there should be no other problems. (P1) Quote 37: Usually, I need to pay more attention; if the excretion reaches half, I need to open the bag and pour out the excrement. (P15)
-Increase exercise and nutrition and improve physical and mental rehabilitation	Quote 38: I think there are two aspects for recovery, one is to supplement nutrition, and the other is to keep up with exercise. (P5) Quote39: In order to maintain my body, I ate fish soup gradually, ate greens, and began to exercise. (P13)

Implement cognitive intervention and support intervention to improve self-efficacy

At present, our research reflects a common situation, that is, many patients have a severe lack of correct cognition of CRC and the stoma they carry; moreover, they have formed irrational cognition, that is, people’s absolute demands and beliefs about themselves, others, and their surroundings, which lead to false, distorted, and destructive self-evaluation[15]. This may be related to the fact most patients involve their families to communicate with doctors during illness and treatment, rather than acquiring relevant knowledge and health education directly from the medical professionals. The patients lacked theoretical knowledge and experience in dealing with stoma and did not develop effective self-coping strategies. Because of irrational cognition and to prevent uncertain behaviors from causing harmful consequences to the recovery of CRC, the patients tend to close themselves and lose interest in most things even if they can participate [16]. To analyze the reasons, patients choose to indulge in patient role[17] and focus excessively on their disease recovery. Moreover, low psychological acceptance of stoma leads to low self-efficacy[18], and the patients begin to rely on the care and help provided by family members and medical staff. This situation severely affects their confidence to face life, and it then becomes difficult for them to return to a normal life. Because of the stoma, they also tend to avoid socializing, stay away from previous social relations, and refuse to make new friends. This inevitably results in a low level of social adaptation, which makes it more difficult for patients to resume normal life, work, and other social activities; this drastically affects the overall rehabilitation of patients’ social function[19].

Therefore, to alleviate negative psychological feelings and improve their self-efficacy and self-nursing ability, some targeted suggestions should be given to these patients. For patients with excessive concern regarding CRC or stoma who tend to form irrational cognition, we should help them correct their irrational cognition and adopt reasonable rehabilitation behavior[20]. For patients who lack the knowledge of CRC and stoma and professional guidance, medical staff should fully explain the disease course to patients and their families. Here, a critical aspect is that medical professionals should encourage patients to participate in health education programs and guide patients to correctly understand CRC and stoma, so that they become aware of the potential impact of this disease on their life and work[21]. Medical professionals should also actively promote patients’ transformation into positive behavioral changes. In particular, medical staff can provide professional guidance regarding actual behavior changes made by patients, such as improving nutrition and exercise. When patients have a complete understanding of CRC and stoma and master the basic nursing skills, they will have a certain sense of achievement and will gain confidence in addressing the issue of stoma; moreover, their self-efficacy will also gradually improve[22]. Finally, for patients who lack the experience of CRC and stoma, we suggest them to seek social support. Medical professionals should follow up and provide continuous nursing for postoperative patients to avoid the loss of contact between patients and professional nursing services after discharge. Simultaneously, family members should be motivated to be more enthusiastic to help patients solve their related problems. Appeal should be to the public to improve the tolerance of colostomy patients, advocate nondiscrimination against them, and give them due respect and honor.

Improve the motivation of patients with stoma to RTW and simultaneously solve pertinent difficulties

The results of the present study showed that most of the participants eventually expressed reluctance to RTW, which is different from that observed in previous studies^[23]. In the present study, however, the factors influencing the decision-making of RTW in patients with stoma were multifaceted. Among these factors, the motivation affecting RTW mainly includes the need to realize self-worth, family economic status, and social-family-workplace support. RTW is an important approach to repair the damaged identity, distract oneself from disturbing thoughts, escape from social isolation, and have access to financial resources[24]. Lower economic level can cause survival pressure on patients, and they are more likely to RTW to meet their financial needs. Therefore, economic demand has become one of the important motivations to affect the decision of returning to work after the surgery. Moreover, support from colleagues and employers also encourages the patients and improves their willingness to RTW; this finding highlights the importance of work adjustments, solid support systems, and flexibility at the workplace. On the other side, the difficulties mainly include damage to the external image, reduced physical function, and negative effects of the stoma. The most common complaint was physical issues, including decreased bodily functions, continuous defecation through the stoma, and foul odor production. Enterostomy surgery can cause long-term side effects such as altered bowel and sexual functioning, body image changes, and pain and fatigue, which can trigger lifestyle changes and inhibit participation in social activities, thereby affecting the quality of life and hindering RTW [25]. Additionally, decreased social communication skills and negative emotions were also considered as barriers[26].

Hence, the healthcare system and the relevant social insurance system should be improved as soon as possible. For example, nursing insurance should be formulated for colostomy patients, and public infrastructure should be improved, such as establishment of emergency service stations for special groups in public places and provision of stoma replacement-related materials. For RTW, we suggest that the motivation of patients should be actively promoted, and the role of the family-social-workplace support system should be highlighted; in particular, we recommend employers to adopt a flexible scheduling system for patients with stoma. Employers can reasonably arrange the work intensity of patients according to their physical status, create an inclusive and friendly working atmosphere, and identify with patients’ professional identity. We should encourage patients to return to the workplace to fully realize their sense of self-worth while relieving economic pressure and having normal interaction for improving their quality of life. To actively solve the difficulties that prevent patients from RTW, medical professionals can provide education to patients to eliminate their inferiority complex due to the stoma and encourage them to regain their self-confidence and choose their favorite clothes without affecting the stoma. Mastering nursing skills correctly and carrying stoma materials to workplace and changing them in time can avoid fecal leakage and odor to a great extent and solve patients’ worries regarding colostomy[27].

Helping patients perfect the positive change process and achieve RTW

The present study showed that even though none of the participants returned to work, they had varying degrees of experience or behavioral changes after the surgery. Some patients learned new life insights after surgery for treating CRC and began to love and cherish life more. They believed that CRC is similar to a hurdle in life, and they should be brave enough to overcome this hurdle and feel the new life in another way. This kind of open-minded attitude toward life was felt by most participants. However, a mere change in thought process or behavior is not sufficient to constitute a complete change process, which requires agreement on thought and behavioral change[13], as advocated by the Acceptance and Commitment Therapy (ACT), a new cognitive behavioral intervention therapy. Here, psychological flexibility is created through the process of acceptance and mindfulness as well as through the process of commitment and behavior change. This also implies that after completing the process of acceptance and mindfulness, you need to choose a valuable direction and finally take action[28].

At present, some participants have achieved varying degrees of experience and ideological change, and only a very few people have simultaneously achieved behavioral change. According to the ACT theory, the core root of human psychological problems originates from four aspects: fusion, excessive goals, avoidance of discomfort, and remoteness from values[28]. Thus, people may behave in a way that is inconsistent with what the environment offers relevant to their chosen values and goals. In the present study, this aspect can be understood by the observation that the experience change of some patients was not comprehensive and deep enough, and the rigid mental state of the past was not completely transformed into better psychological flexibility, that is, the capacity to continue with or change behavior, guided by one’s valued goals, in the context of interacting cognitive and direct noncognitive influences[29].

For patients with mild experience changes, we recommend the application of the six core processes of ACT to increase their psychological flexibility: acceptance, cognitive defusion, flexible attention to the present, self-as-observer, value-based action, and committed action—this is more succinctly summarized as behavior that is open, aware, and active[28]. ACT combines acceptance and mindfulness, with an aim to improve the psychological flexibility of individuals, that is, being able to feel the present and accept their own inner experience calmly and flexibly, which will help them improve the process of experience change, master effective coping styles, and adopt behaviors in line with their own values, thereby transitioning to the process of behavior change[28].

Limitations

In the present study, only patients’ experiences were explored, and the experiences of other influential persons such as employers, family members, colleagues, and healthcare staff were not investigated. Therefore, further studies are recommended to determine the experiences of these influential persons about patients’ RTW. It should also be noted that the results might not reflect all the facts in this area. Hence, our future research will investigate RTW over different time frames with a larger sample size and range and compare the patients across different types of work.

The present study deeply investigated the current situation of young and middle-aged CRC patients with stoma with regard to RTW and analyzed their attitudes and perceptions on carrying the stoma to the workplace. In light of the current low self-efficacy and unsatisfactory willingness of patients with stoma to RTW, we suggest that in the future, medical professionals should implement cognitive intervention and supportive intervention to improve self-efficacy and actively motivate patients with stoma to RTW; medical professionals should also solve difficulties pertinent to RTW and help patients perfect the positive change process and achieve successful transition from a positive change process to RTW.

Author Contributions

All authors contributed to the study conception and design. Conception and design were performed by Qiao Wang, Xi Su and Yulan Ren. Material preparation was performed by Yulan Ren, Ying Zhou, Yao Yang, Rui Xia and Yuan Yang. Data collection and analysis were performed by Yulan Ren, Qiao Wang, Lingling Zhang, Hui Li and Di Tian. The first draft of the manuscript was written by Yulan Ren and Ying Zhou, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Funding:This work was supported by the Guangdong Provincial Department of Health Medical Research Fund (A2022280); the 2021 Guangdong Province Traditional Chinese Medicine Situation Project (20211266), the Education Science Planning Project of Guangzhou Education Bureau (202213957), and the Innovation Project of Postgraduate Education and Scientific Research of School of Nursing, Guangzhou Medical University(Q22153033)

Ethics approval The study design and procedures were approved by the Ethic Committee of Guangzhou Medical University prior to conducting the research (approval number: 202201012).

Consent to participate Informed consent was obtained from all the participants before their inclusion in the study.

Consent to publish Not applicable

Competing interestsThe authors have no relevant financial or non-financial interests to disclose.

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No competing interests reported.

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Readiness for return to work model-based analysis of return-to-work perception of young and middle-aged colorectal cancer patients with stoma: A descriptive qualitative study

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