2019 Volume 1 Issue 2 Pages 31-38
Objectives: The purpose of this study was to develop a guidebook to be used in “promoting the balance between cancer treatment of workers and continuation of their work”. The guidebook was developed to promote collaboration among cancer survivors and employers, human resource personnel, supervisors, colleagues, and health providers, with the aid of occupational health nurses (OHNs). Methods: The guidebook is based on our previous survey and discussions with seven researchers who had experiences in occupational health nursing practices. The guidebook focuses on secondary and tertiary preventions aiming at promoting the smooth return to the workplace and continuing sound working lives of cancer survivors. Also, the guidebook includes primary prevention, such as promoting a good working culture. The tentative guidebook was evaluated for its usability and then further developed into a final version. Results: The guidebook we developed consists of four sections: 1. Introduction; 2. Twelve practical checkpoints for improved support in balancing cancer treatment and work; 3. Preparedness for cancer survivorship; and 4. Appendix, which include hypothetical support cases and practical information. Practical checkpoints are described with action phrases, which included four aspect: support for individual workers with cancer; support for supervisors and colleagues; collaborations with human resources staff; and collaborations with stakeholders inside and outside of the company. Conclusions: The authors believe that the use of this guidebook will contribute to improving the quality of occupational health services and promote balance between cancer treatment and continuation of sound working lives.
Cancer survivors often face challenging issues during their working lives, such as difficulties in returning to work and balancing their cancer treatment and employment1). Takahashi2) indicated that work-related issues for workers with cancer are highly individualized. Cancer survival can be affected by many factors, including type and stage of cancer, treatment modality, demographic background, physical and cognitive condition, psychosocial adaptation, type of occupation, and position held. Workers can also be influenced by organizational factors, such as employment regulations and workplace culture. In promoting a balance between cancer treatment and working life within a company, it is important to establish a return-to-work support system for cancer survivors, similar to other programs aiming to improve worker’s self-care abilities2,3). Occupational health professionals have important roles and function to play in this process, as they are well placed to provide concrete advice and health guidance from the viewpoint of both business persons and medical professionals4,5,6).
The Japanese Industrial Safety and Health Act of 1972 states that a business that employ over 50 regular employees must contract with an occupational physician. However, occupational health nurses (OHNs) have not been officially recognized in the Industrial Safety and Health Act as being necessary in the workplace. This is despite more than 10,000 OHNs working in Japanese companies in 20157). Kanamori et al.8) and Kono et al.9) pointed out that there are many instances where OHNs play an important leading role in providing health care management and health promotion for employees suffering health problems. However, few articles are available that show the importance of OHNs providing practical support for facilitating the balance between cancer treatment and continuing the working life of cancer survivors or organizational approaches at their workplace5,10). As OHNs have not been recognized in the Industrial Safety and Health Act, their work role is defined by the company that employs them in Japan11). Adding to this, is the issues that Japanese OHNs have differing educational backgrounds12,13) and licenses7). Because of these issues, it is necessary to develop a guide to ensure the high quality of programs for cancer survivors in the workplace by OHNs.
The purpose of this study was to develop a guidebook for “promoting the balance between cancer treatment of workers and continuation of their work”, which should be a priority of OHNs in collaboration with working cancer survivors, employers, human resources personnel, supervisors, colleagues, and allied health providers.
The guidebook was developed based on discussions with seven researchers who had experience in occupational health nursing practices. From February 2012 through March 2014, we met with seven researchers 11 times to develop this guidebook and conducted an evaluation meeting of the guidebook in September 2013. From the first meeting to the fifth meeting, we discussed the target and framework of the guidebook. During these meetings, we developed a tentative guidebook. During the next four meetings, we planned the evaluation meeting. At the last two meetings, we revised the guidebook to become the final version.
In the development of the guidebook, we referred to the findings of our previous studies, focus group interview (FGI)14) survey, and questionnaire survey15). The results of our previous studies indicate that OHNs play important roles and function as coordinators for the workplace environment, as well as providing health services for workers with cancer. The OHNs also provided health education to prevent injuries or worsening health conditions for workers with cancer in the workplace. Furthermore, OHNs provided ongoing nursing practices involving collaboration with stakeholders inside the company during the support process following the diagnosis and after returning to work14,15). On the other hand, OHNs were found to experience difficulties collaborating with hospital staff and family members of cancer survivors15). This was also added to the practical checkpoints of the guidebook.
The results of the FGI survey showed the role of OHNs in each support process, such as pre/post diagnosis, during sick leave, and returning to work14). Based on the FGI survey, the questionnaire consisted of four parts to determine if the OHNs support workers with cancer, supervisor/colleagues working with cancer survivor, human resources staff, and inside/outside medical stakeholders15). The practical checkpoints of this guidebook were compiled by focusing on nursing support that OHNs categorized as good practices in the FGI survey14) and the support items with a high implementation rate in the questionnaire survey15).
The goal and readers of the guidebookThe goal of this guidebook is to provide practical checkpoints and strategies that provide better supports for workers with cancer, the workplace and companies employing OHNs as members of an occupational health team.
The intended readers of the guidebook are OHNs employed by companies. The guidebook mainly focuses on secondary and tertiary prevention, such as nursing support for promoting the return to work and a continuing work life for cancer survivors. Also, it includes primary prevention and the promotion of a good working culture by utilizing the strengths of OHNs as health promoters8,9). In addition, we decided to present hypothetical cases and useful information resources providing an easy linkage to concrete nursing practices and for deeper understanding of the contents of the guidebook.
The procedures of usability evaluationThe tentative guidebook was presented to 18 OHNs, with the aim of seeking their comments and evaluation. During a 1-hour evaluation meeting, we explained the contents of the guidebook and how it should be used for 30 minutes. Participants then had group discussions about the guidebook for 20 minutes, after which they answered an anonymous evaluation sheet in 10 minutes. They were from diverse backgrounds working as OHNs; for example, with regard to level of expertise or employment in a large-, small-, or medium-sized enterprise. OHNs had a mean of 8.8±7.7 years of experience. Of the 18 participants, 7 (38.9%) of them belonged to a company with over 3,000 employees, 5 (27.7%) of them belonged to ta company with 1,000–2,999 employees, 3 (16.7%) of them belonged to the company with under 999 employees, and the other 3 participants did not report their company affiliation. The types of industries were also considered, such as manufacturing, chemicals, electric appliances, and information technology and financial. The main purpose of the evaluation was to obtain comments from the OHN practitioner about the usability and the ease of understanding the contents and structure of the guidebook. The descriptive questionnaire items were: 1) comments about support for individual workers with cancer and support for supervisor/colleagues, 2) comments about collaboration with human resource department and inside/outside medical stakeholders, and 3) comments regarding the use of this guidebook by young OHNs with less than 3 years of experiences. Participants were asked to answer these question items regarding viewpoints: ease of understanding, ease of use, validity of description, sufficiency explanation, and upgrading of nursing practice. Based on the comments from 18 OHNs, we revised and developed the guidebook to make it a final version.
Ethical considerationThe ethics review board of the School of Health Sciences in Tokai University approved the study procedures (No.11-16), including our previous research14,15). Participants of the evaluation session were given written and oral explanations of the study objectives and of the ethical considerations. Consent was obtained from each participant when completing the anonymous evaluation sheet.
The guidebook consists of four sections (Table 1). First, the “Introduction” contains the statistical data for cancer survivors of the working generation. Also, the current society changes for cancer survivors are discussed as basic topics for promoting balance between cancer treatment and work life. In particular, we introduced how treatment systems are changing, noting that it should be possible to continue working while undertaking cancer treatment, adding that the image of cancer is also changing from a disease leading to death to now being seen as one of the chronic diseases2).
| Section | Contents |
|---|---|
| Introduction | Scope and aim of this guidebook |
| Current status of cancer survivorship at workplace | |
| Twelve practical checkpoints for better support of cancer survivorship | Supports for cancer survivor workers |
| Supports for supervisor and colleagues working with cancer survivor | |
| Collaborations with the human resources staff members | |
| Collaborations with stakeholders inside and outside of the company | |
| Preparedness for supporting cancer survivor workers and workplace | Supports for individual workers, workplace and company from viewpoints of primary prevention |
| Additional information: Case study and practical information | Hypothetical support cases study of support for balancing cancer treatment and continuing working life by Occupational health nurses |
| Practical information: web-site, research papers, and books |
Second, we addressed 12 practical checkpoints that allow for better support for balancing between cancer treatment and work life. These practical checkpoints were developed based on the good practices that OHNs had already practiced from the results of our previous survey14,15). Five practical checkpoints of supports for individual workers and two practical checkpoints of collaborations with the human resources staff members were extracted. These practical checkpoints employed from nursing support indicated high implementation rates, as demonstrated in the results of our previous questionnaire survey15). Two practical checkpoints were: 1) promote a workplace culture of mutual support and caring; 2) examine and adjust the necessity and method of collaboration to hospital or clinic. These practical checkpoint items were those to which young OHNs admitted difficulties in the FGI survey14). Three other practical checkpoints were also derived from OHNs good practices in the FGI survey14).
In the third section, we showed how OHNs can provide primary prevention for workers and staffs within the workplace. This is achieved by providing information that would reduce the risk of cancer and contribute to creating a diverse workplace culture. This section followed the same viewpoints as the 12 practical checkpoints: support individual workers with cancer, support supervisors and colleagues, collaborate with the human resource staff, and collaborate with stakeholders inside and outside the company.
Fourth, for the last section of this guidebook, “Additional information,” we included hypothetical support cases and practical information. The three hypothetical support cases are employed so that readers of the guidebook can easily understand important points of nursing support for balancing cancer treatment and work. Furthermore, practical information was introduced about web-sites and books that show available information promoting balance between cancer treatment and work life.
Modification by the usability evaluationThe 18 OHNs who participated in the usability evaluation reported a total of 20 positive comments about this guidebook. Of the 20 positive comments, 6 of them were regarding support for individual workers with cancer and support for supervisor/colleagues, 7 of them were regarding collaboration with human resource department and inside/outside medical stakeholders, and the rest 7 were comments asking if this guidebook was to be used by young OHNs. These comments were, for examples, “I want to use this guidebook for promoting balance between cancer treatment and working life”, “it is useful for understanding how to support cancer survivor in the workplace”, and “I would like to recommend the guidebook to inexperienced OHNs”.
On the other hand, comments suggesting some amendments were received. About support for individual workers with cancer and support for supervisors/colleagues, we received two comments asking for additional explanations. Regarding the collaboration with human resource department and inside/outside medical stakeholders, we received one comment requesting additional explanations. Regarding comments about possible usage by young OHNs with under 3 years of experiences, we received 3 comments requesting additional explanation and modification of the format and structure of the guidebook. These comments related to additional explanations in accordance with the corporate structure and situation of the workplace and modification of the structure of the guidebook for promoting practicality. The guidebook was modified after getting consensus in the discussion with seven researchers. The revised part of the results based on feedback from the usability evaluation is shown in Table 2.
| Comments | Summary of modification | |
|---|---|---|
| Comments on additional and supplementary explanations | ||
| It is necessary to specifically show how we manage the cooperation with supervisor/colleaguesa | Added procedures for promoting cooperation among the workplace in checkpoints 7 and 8 (“support to formulate and enhance support systems for cancer survivor in the workplace” and “promote creation of the workplace culture of mutual support and caring for each other”) | |
| It is necessary to add how to explain and promote mutual support a | Added a short column about cancer workers contribution for promoting supportive workplace and also added the importance of expressing self-esteem, impartiality, and gratitude | |
| It is necessary to indicate specific examples or points in the collaboration with the human resources staff members b | Described concrete support cases and examples of advice in the checkpoints of the collaboration with the human resource staff members | |
| It is necessary to add viewpoints of primary prevention *3 | Added content that clearly indicates that the content of this section is primary prevention in the section of preparedness for supporting cancer survivor workers and workplace | |
| Comments on the format and structure of the guidebook | ||
| It is necessary to devise a way for readers to consider the next actions necessary while reading the hypothetical case c | Insert questions such as “what support is possible next?” and “what preparation should the OHNs have?” on the way of description | |
| Introduce the main points of the support in the final page | ||
| It is unclear as to what to do at each practical checkpoint c | Revised each practical checkpoint by using the same format of “why important”, “how” and “points to remember” following the format shown in Ergonomic Checkpoints | |
The 12 practical checkpoint items are shown in Table 3. The practical checkpoints consisted of four separate viewpoints. Viewpoint 1 consisted of five items, viewpoint 2 consisted of three items, and viewpoints 3 and 4 consisted of two items each.
| Viewpoints | Items of practical hints |
|---|---|
| Supports for individual worker with cancer | Confirm health conditions and work situations at regular intervals |
| Respond to consultation for trivial troubles or problems immediately | |
| Approach to support self-decision-making | |
| Support for mental and emotional aspects | |
| Handle personal information including health information while considering privacy | |
| Supports for supervisor and colleagues working with cancer survivor | Confirm and coordinate workplace environment and work conditions for balancing work and cancer treatment |
| Support to formulate and enhance support systems for cancer survivor at the workplace | |
| Promote creation of the workplace culture of mutual support and caring for each other | |
| Collaborations with the human resources staff members | Give advice about appropriate assignments in placing as Occupational Health Nurses |
| Confirm and coordinate available in-company systems and flexible shift | |
| Collaborations with stakeholders inside and outside of the company | Allocate role with occupational physician and exchange information at regular intervals |
| Examine and adjust the necessity and method of collaboration with hospital or clinic |
Each practical checkpoint in the guidebook includes descriptions of “why important”, “how”, and “points to remember” following the format shown in Ergonomic Checkpoints16). Each support by OHNs was expressed in a short sentence, called an action phrase. The “why important” section addressed the necessity of the action phrase and the “how” section listed procedures of practice as a concrete content of support. The final “points to remember” section showed the summary of each practical checkpoint. The “how” clause constitutes the main portion of each practical checkpoint, which describes easily applicable measures. In the description, special focus is placed on covering easily implementable measures in 3 to 6 items. In “confirm health conditions and work situations at regular intervals”, for example, easily understandable measures are listed (confirm symptoms and physical conditions, decide timing and procedures of health interviews, and advice for promoting self-care abilities) depending on the situation that exists in the workplace (Figure 1).
Example of 12 practical checkpoints
In addition to the 12 practical checkpoints, this guidebook also includes health promotion and primary prevention activities that can be delivered by occupational health nursing support, as health professionals who are familiar with the workers and workplaces. In other words, because OHNs are considered front-line staff, it is possible for them to provide these nursing practices. These nursing practices represent integrative support for establishing systems of sharing information promptly and for arranging the workplace environment or workplace culture when workers have cancer.
The section of preparedness for supporting cancer survivor workers and workplace addresses an action phrase similar to that of 12 practical checkpoints from three viewpoints of supports for individual workers, workplace, and company. Support for individual workers includes various approaches, such as the provision of information about healthy lifestyles and self-care to prevent cancer; use of medical checkups as an opportunity for health guidance; and recommendations for detailed testing when necessary and education related to cancer-causing toxic substances and high-risk work. Examples of support for the workplace include providing facilities for and publications about health consulting services; awareness-raising campaigns to prevent cancer; management of workplace environments and control of work that has cancer-causing risks; and encouragement of communication with responsible managers. Suggestions for supporting companies include setting up counseling systems for workers with cancer, preparing flexible work shifts, and creating a workplace culture that promotes diversity.
This section emphasizes how OHNs play an important role in strengthening social support in workplaces for individuals or organizations by being prepared for opportunities to engage in health support activities. Through daily occupational health nursing practices, OHNs contribute to create better workplace cultures, in which all workers can continue to improve the quality of their working life, whether they are suffering from a disease or not.
Hypothetical support casesThis section presents three hypothetical support cases designed based on the FGI research and the practical experiences of the researchers. The specifics of the support cases are as follows:
Case 1: A case in which a female worker diagnosed with uterine cancer refused to acknowledge her cancer in a workplace dominated by male workers.
Case 2: A case involving a male salesperson, in which the working conditions after returning to work were modified to suit the changes in his physical conditions, as a result of an OHN’s intervention in the company’s management to reorganize the workplace support system.
Case 3: A case involving a globally active manager, in which the changes were made related to overseas travel permission after the manager returned to the workplace.
A broad range of nursing practices for OHNs working under various conditions and with various support processes is demonstrated in these cases. Each support case is described using four pages in the guidebook. The first three pages give background information about the OHNs and the company or health management department to which the OHNs belong. This is followed by details, such as the age, gender, and work content of the cancer survivor who is receiving support, and chronological details of the support provided by the OHNs. The cases are summarized in such a way as to make it possible for the reader to think about the support provided by the OHNs and to consider the direction of the support while continuing to read. This is also encouraged by the insertion of questions such as “What support is possible next?” and “What preparation should the OHNs have?”. The final page introduces the main points of the support provided by the OHNs, with the intention of making it possible for the reader to review the direction of the support given by the OHNs.
The 12 checkpoints for better support have been prepared in terms of the four support perspectives: of the worker him/herself; of the supervisor and co-workers; of collaboration with the human resources department; and of collaboration within the occupational health team and with outside medical institutions. These four support perspectives were clarified in our previous studies14,15). The studies suggested that OHNs do not only provide individual care of cancer workers, but also act as coordinators to enhance workplace support, such as cooperating with supervisors and co-workers. This involves the human resources department for organizational support, creating work environments where workers with cancer can work comfortably5). It was also made clear that, as a member of the occupational health team, OHNs in small- and medium-sized enterprises (SMEs) share the responsibilities with occupational physicians and are expected to play a central role in cooperating with outside medical institutions9,17,18). In fact, OHNs face some limitations, such as lack of opportunities for receiving supervision and professional advice in the company, because they often work as the only one health professional in Japanese SMEs19). This guidebook particularly will be useful to maintain and improve quality of occupational health nursing in SMEs.
The guidebook describes the 12 checkpoints from four support perspectives. The format of action phrases, such as action checklists, has been used as a practical tool to cope with various health issues in the occupational health area20,21,22). This guidebook also introduces action phrases to answer questions specifically, such as “to whom” and “how” concerning their activities, to make their nursing practice easier.
Preparedness for supporting cancer survivor workers and the workplaceWith regard to preparedness for supporting cancer survivor workers and the workplace, the guidebook includes details of the approaches that can be used by OHNs before the diagnosis of cancer is made. Kono et al. mentioned that OHNs can obtain various kinds of information easily as frontline professionals because of their presence close to workers in their companies9). Taking advantage of this characteristic, OHNs could provide workers with direct health services, with an emphasis on prevention. It’s also useful in managing the casework of balancing cancer treatment and other work. In other words, OHN support is characteristically practiced not only after a worker is diagnosed with cancer (e.g., after taking sick leave or returning to work), but also before being diagnosed.
The OHNs should be prepared to take advantage of any opportunities by building a relationship of trust ahead of time through contact with workers and regular workplace visits and meeting at annual medical checkups9,17,23). It is also important to cultivate an organization culture that attaches importance to health and prevention using a population approach. It is suggested that a wide perspective of prevention is important to nurture a workplace environment and culture in which work continuation is feasible, even if an employee has severe disease like a cancer.
Utilization of support casesIn the 12 checkpoints, good OHN practices include direct supports for cancer survivors, preparedness for supporting them, and support for the workplace. Although these concepts were produced from our previous studies, the reader may have difficulty imagining the concrete support method. So, we described some simulated good practices in the guidebook in order to deepen understanding about practical support by OHNs. No matter how good an OHN may be at approaching individual workers with cancer, when the support is refused, it is difficult for the OHN to discuss the matter with the supervisor and the workplace and to cooperate with medical institutions. To discuss such difficulties in OHN support, it is suggested that, in addition to showing good cases, case study methods24,25) are effective if they also show how such difficulties have been dealt with chronologically. By inserting questions at appropriate times in the support cases section of this guidebook, we have tried to make readers think about how they would act in such situations. We have also added a final support point using some case management with simulated patients in order to promote the readers’ understanding of the characteristic support provided by OHNs.
LimitationWe actually held several training seminars for OHNs using this guidebook and investigated the effects of the training seminar on occupational health nursing practices26). However, we were not able to verify the effectiveness in increasing support activities using this guidebook in the occupational health nursing practice. In the future, it will be necessary to evaluate the effectiveness of learning from this guidebook when OHNs face a situation of providing support for a worker balancing cancer treatment and work. Hence, further research should examine the effects of OHN practice by utilizing the guidebook.
It will also be necessary to disseminate and promote the guidebook. Activities for broadly disseminating the guidebook (e.g., via websites, not just through training programs) are necessary to guarantee quality in the services of OHNs. Finally, support for balancing cancer treatment and work is a field in which many practices and research results are currently being announced, and information is updated daily. Therefore, it will be necessary to keep revising the guidebook to reflect the latest information.
For a worker who has been diagnosed with cancer to continue activities of work and life while being treated, it is necessary to construct a support system of organic collaboration among the worker who has cancer, the workplace, the human resources department, the occupational health team, and treatment personnel. For OHNs, whose roles and rules for assignment in various employment situations and company sizes are not yet clearly established by law, guaranteeing the quality of occupational health services is an urgent issue. In this research, we have presented good cases of balancing cancer treatment and work practiced by OHNs for workers and the workplace, and we have developed a guidebook to support the practice of OHNs. We expect that the use of this guidebook will contribute to improving the quality of the occupational health services provided by OHNs in promoting the balance of cancer treatment and work within companies.
The Research Ethics Review Board of School of Health Sciences, the Tokai University, approved the study procedures (No. 11-16).
Informed ConsentParticipants of the evaluation session was given written and oral explanations of the study objectives and of the ethical considerations. Consent was obtained from each participant when completing the anonymous evaluation sheet.
Registry and the Registration No. of the study/TrialN/A
Animal StudiesN/A
This research was supported by Health and Labour Sciences Research Grants, the Ministry of Health, Labour and Welfare (H22-ganrinshou-ippan-008), Japan.
All authors contributed to the design of the study and develop the guidebook. E.Y, N.N. and M.S. led the writing of this manuscript. All authors read, critically revised, and approved the final manuscript.
The authors declare that there are no conflicts of interest.
