J Occup Rehabil DOI 10.1007/s10926-013-9465-6 Return to Work Following Breast Cancer Treatment: The Employers’ Side Corine Tiedtke • Peter Donceel • Angelique de Rijk Bernadette Dierckx de Casterlé •  Springer Science+Business Media New York 2013 Abstract Purpose Research on employers’ experiences with return to work (RTW) of employees with breast cancer is lacking. Employers seem to be the key people to create good working conditions. Our aim is to explore how Belgian employers experience their role and responsibility in RTW of employees with breast cancer. Methods Using a qualitative design (Grounded Theory) 17 employers from the public (7), private (5) and non-profit (5) sector, directly involved in the RTW process, were interviewed. The analysis was based on the Qualitative Analysis Guide of Leuven (QUAGOL) with constant data comparison and interactive team dialogue as important guiding characteristics. Results RTW of employees with breast cancer is experienced by employers as an intangible process that is difficult to manage. This was expressed in (1) concern, referring to the employer’s personal and emotional involvement, (2) uncertainty about the course of illness and the guidance needed by the employee and (3) specific dilemmas in the RTW process (when does one infringe on employee privacy; employee vs. organization interest; employers’ personal vs. professional role). The degree to which this was experienced related to variety in organizational, employer, and employee factors. Conclusions The findings of this study confirm the importance of the employer’s involvement in RTW of employees with breast cancer and contribute to a better understanding of its complexity. The employers did their best to grasp the intangibility of the RTW process. Further research is needed to refine these findings and to discover the specific needs of employers regarding supporting RTW of breast cancer patients. Keywords Return to work
Breast cancer
Qualitative research
Employer perspective Background C. Tiedtke (&)
P. Donceel Department of Public Health and Primary Care, Occupational, Environmental and Insurance Medicine, Katholieke Universiteit Leuven, Kapucijnenvoer 35/5, 3000 Leuven, Belgium e-mail: corine.tiedtke@med.kuleuven.be P. Donceel e-mail: peter.donceel@med.kuleuven.be A. de Rijk Department of Social Medicine, Faculty of Health, Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands e-mail: angelique.derijk@maastrichtuniversity.nl B. Dierckx de Casterlé Department of Public Health and Primary Care, Centre for Health Services and Nursing Research, Katholieke Universiteit Leuven, Kapucijnenvoer 35/4, 3000 Leuven, Belgium e-mail: bernadette.dierckxdecasterle@med.kuleuven.be Breast cancer is the most prevalent cancer type among women in the Western world and most women are diagnosed with breast cancer when they are of working age. In 2004, Belgium was ranked first for the incidence rate in Europe. The rates for the 35–49 and 50–69 age groups (working age) were 172.1 and 390.2 per 100,000 females respectively and for all ages combined 110.2 per 100,000 females. In 2006, for the Flemish region the incidence rates were 167; 360.2 and 105.5 respectively [1]. In 2008, the breast cancer incidence rate in Belgium (for all ages) was 109 [2, 3]. Breast cancer is usually coupled with long periods of sickness absence because of medical treatment. In the Netherlands it was pointed out that between 2001 and 2005 2,259 women out of nearly half a million workers had 2,361 episodes of sickness absence due to breast cancer [4]. 123 J Occup Rehabil Swedish investigators found that nearly half of the employed women in the study (N = 511) reported physical (breast and arm) problems shortly after surgery [5]. Others focused on the impact on women’s work ability after breast cancer treatment [6–9]. However, after treatment accompanied by short or long periods of sickness absence, many employed women wish to go back to work. Employers have to decide how to respond to the return to work (RTW) issue. As far as we know, there is hardly any research on employers’ experiences regarding supporting RTW of employees with breast cancer [10]. In a focus group with various stakeholders, we found that employers have to balance the interests of both the business and the employee. Moreover they see obstacles to an early RTW of employees with breast cancer [11]. There is some research on how employers treat employees with cancer in general [12, 13]. Employers seem to be willing to support employees with cancer, but tend to worry about the employee’s ability to meet the demands of the job [12, 13], in terms of quality and quantity due to the employee’s medical condition [13]. Moreover, employers do not know how to retain qualified employees with chronic health conditions and express the need for assistance on these matters [13]. Studying social isolation among disabled persons, Vornholt et al. [14] discussed variable factors influencing the acceptance of employees with disabilities: characteristics of the person with disabilities, the co-workers, and the employers. However, the authors were not entirely sure how acceptance of disabled persons related to their employment. Generally, the literature shows the importance of workplace support for the RTW issue of more or less able-bodied employees with cancer [13]. According to a qualitative study by Holmgren and Ivanoff [15] employers seem to be the key people to create good working conditions before and after sickness absence. Aas et al. [16] endorsed this role and identified the leadership qualities that should be displayed to an employee following cancer treatment, according to employers and employees, which included being understanding and empathetic, considerate and appreciative. Others investigated which factors may influence the giving of workplace support. Hinman [17], for instance, found that employers were willing to adapt the workplace for breast cancer employees, when specific information about their limitations was available. It is also suggested that employers often postpone actions to support RTW [18]. One of the reasons for postponing supportive actions might lie in the employer’s concerns. Employers have to watch the finances in their organizations [19]. Looking at the various stakeholders’ perspectives, it is also suggested that employers want to make a profit at the least possible cost [13, 19]. However, if employers are made responsible for rehabilitation, they seem to be more interested in taking early 123 RTW action [20]. Possibilities for employers vary depending on the legislation, structure of RTW organization and informal norms [11, 21]. It is therefore important to study the specific case in its context. This article focuses on breast cancer in Belgium, where a compensation policy exists. Belgian employers only have to pay sick pay for the first 2–4 weeks and there is no legal obligation for them to actively support RTW. Since 2004 employers have been obliged to inform employee’s about their right to contact the occupational physician during sickness absence to discuss their work load beforehand. After contacting the treating physician (approved by the employee), occupational physicians may discuss work adaptations with the employer, but the employer can decide whether to offer these arrangements. Generally few organizations have organizational policy or protocols for RTW. Internationally, there is thus fragmented and limited knowledge about the employers’ side on the RTW process, let alone on the RTW process of women with breast cancer. The aim of this study is to investigate how Belgian employers experience their role and responsibility in RTW of employees with breast cancer. Methods Design A qualitative design was used, based on a Grounded Theory approach [22] to better understand the employers’ perspective regarding their role and responsibility in the RTW process of employees with breast cancer. Setting and Participants To select employers (or their representatives) with a wide range of views and perspectives we searched for small and large companies from the public, private and non-profit sector. Interviewees were selected using various methods. We started with volunteer employers, recruited from a symposium (4) and they were supplemented with new participants through Human Resources Manager (HRM) networks (2); occupational physicians (5); online questionnaire posted via twitter and LinkedIn (3); and finally an open question to four hospitals and twelve social organizations in Flanders (3). At the start we formulated three inclusion criteria for the employers (c.q. departmental managers or HR managers): direct involvement in the RTW process, recent experience (\5 years) with 3–5 cases, and willingness to discuss reallife cases regarding the RTW process of employees with breast cancer with the interviewer. Difficulties regarding recruitment and non-response compelled us to deviate from J Occup Rehabil developed by CT including analytically meaningful concepts and identified common messages. The overall scheme was again discussed and refined with the co-authors and used to develop a list of essential concepts. The actual coding took place by using this coding list and linking significant transcript passages to the (sub) concepts using the QSR Nvivo 9 (QSR International Pty ltd, 2011) program (CT). During the coding process interviews and schemes were (re) read as many times as necessary to refine the concept list or adapt the linked passages in interactive dialogue with all authors. First the concepts were integrated and described with their meaning, dimensions and characteristics and finally, the authors were able to reconstruct an integrated story of the data of all respondents at an abstract, conceptual level. We presented and discussed these final findings with seven external experts, including six social scientists, experienced in qualitative research and one occupational physician. The involvement of an interdisciplinary research team (career counselor, insurance physician, psychologist, and nurse) in the process of analysis (researcher triangulation) and the review of the results by external experts (peer debriefing) contributed to the trustworthiness of the findings. Informed consent was obtained from all participants. Moreover neither the identity of the employer, nor the organization to which he or she belongs is reported in the paper. these criteria. We accepted former experience ([5 years) with \3 cases. All participants who were eligible, available and willing to be interviewed were included (17). Interviewees were chief executive officers (1), departmental managers (3) and HR managers (13) from the public sector (7), private (5) and non-profit sector (5). All male (7) and female (10) interviewees were directly involved in the RTW process of one (9) or two (8) employees with breast cancer (Table 1). Data Collection Seventeen face-to-face in-depth interviews (with a mean duration of 62 min) were conducted at the employer’s place of work. The interview guide consisted of questions related to the employer’s experiences with ‘sickness absence’ and ‘diagnosis disclosure’, ‘work disability’ and ‘RTW’. We asked them, for instance, how they experienced their role during sickness absence, work disability and RTW; how they communicated during the various phases and how they supported the employee. Participants were also asked to share additional concerns or experiences with the interviewer. In the course of the study the interview guide was adapted according to meaningful themes that emerged from the data. Analysis Results After transcription of the audio taped interviews, a Grounded Theory qualitative analysis took place, using the Qualitative Analysis Guide of Leuven (QUAGOL) [23]. The QUAGOL is a theory- and practice-based structured guide to help researchers analyse qualitative data, using a Grounded Theory approach. The constant data comparison and interactive team dialogue about reflections, schemes and concepts are important characteristics of the guide. To prepare the coding process, a thorough (re) reading of the transcripts took place, using only paper and pencil. To understand and phrase the interviewee’s story, transcripts were summarized in narrative reports and/or schemes per interview in answer to the research question (CT). These were discussed repeatedly with the other authors and adapted and refined during the research process. After constantly testing and comparing the individual schemes [with (sub) concepts per interview] with the co-authors, an overall scheme was The analysis appears to show that employers perceive the guidance and return of an employee with breast cancer as an intangible process. The entire RTW process is experienced as difficult to manage. …you have to be able to integrate that rollercoaster of an organization… [8] …it’s a mixture of: one moment you are subjective and the other you are objective… [11] …and the rest is management, but that goes in different ways: it goes upwards from the bottom and comes downwards from the top… [13] They admit that there’s not much support, and they mainly follow their own judgement. The decision-making was often ad hoc. Some of them felt there should have been a Table 1 Participant characteristics (N = 17) Age Sex Sector Function Experience (RTW br.c.) \40 8 Male 7 Public 7 Ch ex off 1 One 9 40–50 2 Female 10 Private 5 HR manager 13 Two 8 50–60 [60 5 2 Non-profit 5 Dept. manager 3 123 J Occup Rehabil RTW policy within the organization or guidelines; others liked being able to make their own decisions and thought their role and responsibility concerning an employee with an oncological disorder was not something you could perform by the rules. …it’s like this: as an employer you must be allowed a certain amount of flexibility. If there are too many rules, you’re no longer flexible; because you have to stay within the rules… [4] The intangible part of this RTW process also appeared to have something to do with the specific diagnosis of breast cancer and the accompanying uncertainty in terms of duration and prognosis. This unpredictability of the course of the illness and the absence of the employee was a difficult concept for employers to get to grips with. The way in which employers dealt with RTW of employees with breast cancer on a personal and professional level appeared to stem from their own insight. Although they applied the general sickness leave regulations as correctly as possible, employers admitted to waiting it out, trying to get a sense and feeling about things. In this respect they felt isolated because there were few opportunities to discuss it with other fellow employers or doctors. This also made them feel that there was little way of testing out their management of the process. …you never actually get the time to see each other and exchange views and look at the matter together and say: what’s the best way to approach this matter (…) what are they doing and what are we doing, and how do they see it and how do we see it… [3] Approaching the issue on the basis of personal insight and without any real guidelines gave rise to a whole range of activities, from express incorporation of their instrumental role to sympathising, supporting and supervising the employee as best they could in their view. The intangible nature of the situation was expressed in a certain (1) concern of the employer as a person, in (2) uncertainty throughout the whole process and in (3) a number of specific dilemmas in the RTW process. Below we look in more detail at these core findings and their underlying factors. Concern During the interviews it was very noticeable that the employers were concerned when learning of the ‘breast cancer’ diagnosis and the possible unfavourable prognosis and when hearing or realising what the employee would have to go through. They reported being very affected by the confronting message, especially if the woman was close to the employer. Some employers found it very difficult to 123 deal with and even became emotional when recalling the moment. …hearing about someone you know personally, who suddenly has something so life-threatening, out of nowhere, yes, you don’t get over that… [3] The concern also prompted them to offer support during the entire duration of the illness, to show real interest and to give encouragement to the employee. …I tried to have as much contact as possible with her (…) from my position, that’s not a policy here or anything like that, I wouldn’t have done it every week or two weeks, but because of my own involvement… [15] Some employers said that this experience made them think about their own mortality and helped them understand that it was an emotionally challenging and upsetting situation for the employee. They tried to sort everything out on the technical and administrative level during and after the illness. The personal concern was perceptible in all the interviews, but there was a difference in the degree of concern. Some employers were deeply affected. …what I found most difficult was the fact that here is a woman who was then 40 with children aged 13, 11 and 8, who knows at a certain moment that she’s not going to make it and that she’s going to leave behind her husband with his three children, and this is a terrible loss for the work colleagues and for this department… [2] Also the fact that employers were reminded of people within their own circle of friends and family who had died, and this contributed to their concern. Some employers even had breast cancer themselves and so were even more affected. Uncertainty The specific diagnosis of breast cancer resulted in a lot of questions for the employer. The interviewed employers related how from the moment their employee was absent, they were faced with a number of uncertainties about the diagnosis, the treatment, the prognosis and the guidance needed by the employee. This uncertainty also seemed to be related to the employer’s lack of experience. What they most wanted was information. For reasons of privacy, employers were often not aware of the reason for the absence. When they did find out about the diagnosis, they were then faced with questions about the disease progression and how long the employee would be absent. J Occup Rehabil …we knew she had to undergo an operation, but we didn’t know when and we didn’t know whether there would be post-operative treatment, and how long that would all take… [3] The interviews revealed that employers wondered what the employee was going through, what the future held for her and how serious the situation was. How should they help the employee? What questions were they allowed to ask, what not? Should they stay in contact with the sick employee and if so, how? How would the employer know whether the employee appreciated his/her questions and concern? …yes, maybe the first contact, or the number of times you visit her (…) should I ask that or not? Of course I do ask how she is doing, but I didn’t ask any detailed questions like: ‘what are they doing to you right now?’… [14] At a later stage of the disease employers wondered when and if the RTW could be broached, without seeming pushy. If there was no consultation with the company doctor, how would the employer know whether the employee was in a position to fulfil her tasks and cope with the rhythm, pace and content of the job? In addition, many employers said that they didn’t have enough information about the legal options concerning RTW, which contributed to their uncertainty. So as not to make any mistakes, they had to go and find out from the HR department. …progressive employment, what does that mean exactly, and how am I supposed to arrange it (…) you mustn’t let anyone work for too long at a go or too many hours, it has to be just right or else you’d be hearing from the health insurance, it’s simply not allowed… [1] Virtually all the employers interviewed experienced this uncertainty and relayed the message that a broader picture of the disease would help them to be able to understand and offer help. However, among employers with more knowledge and experience with employees with (breast) cancer this uncertainty was less central to their experience. Dilemmas The interviews reveal that being involved in the RTW of an employee with breast cancer involves being confronted with a number of dilemmas. The employers reported struggling with questions of employee privacy, conflicting interests (of the employee concerned, other employees or the organization) and conflicting roles as an employer. If employers were made aware of the diagnosis by the employee herself or indirectly, they were faced with the question of how to stay in touch with the employee without intruding in her personal life. Should they stay in the background, or intervene and support the employee? …you’re constantly treading that difficult line between respecting people’s privacy. You shouldn’t actually ask: ‘‘what have you got’’ and yet you want to remain in touch during the period of sickness. So it’s not straightforward… [8] They also wondered whether they were supposed to replace the employee in the organization by someone else or leave her position open. Wherever possible the work was divided among colleagues. Some employers thought it was almost unethical to replace an employee suffering from breast cancer. …there are limits as an employer, but life does go on (…) at some point you’re left with no choice but to look for a replacement (…) but we were well aware that she would be thinking: see, they’ve replaced me already… [3] Another dilemma was defending the rights of the employee against the rights of the colleagues. According to the employers, there was only so long you could ask colleagues to support the returning employee. To avoid problems among the remaining staff (‘‘…if you allow any exceptions, there’s a lot of jealousy…’’ [16]), the adapted tasks have to be performed again by the employee herself eventually. …so you have to build it up gradually, but there has to come a time when she can work normally again and do the same as her colleagues (…) if she for example said: I really can’t do any heavy work and I can’t handle that pressure anymore, well, then she really can’t work for us anymore… [1] The employers sometimes found it difficult to combine the interests of the employee with those of the company. They saw the internal and external pressure in the company increasing all the time, making it more difficult to find a balance between the interests of both parties. They tried to approach it conscientiously but did note that it would be difficult to meet the demands of the employee if there were many with such a diagnosis. …I approach it according to my conscience. But I work in a free space, the space I get between the interests of the individual and that of the employer. Some people say to me: ‘‘you’re far too easy-going, you have to be tougher’’. So I’m stuck between a rock and a hard place… [2] The interviews revealed that employers sometimes wrestled with the different roles they had to combine in dealing 123 J Occup Rehabil with this problem: the human, empathetic role and the more distant, professional role. …I still see the two roles combined. You have to be human in any case, but in the end I’m still ‘the boss’, I haven’t suddenly become a friend. Later she’ll return to a role where you have that relationship… [17] The above experiences about concern, uncertainty and dilemmas came up in all the interviews, but were not experienced to the same extent by all the employers. These variations seem to be related to differences in (a) organizations, (b) employers and (c) employees (Table 2). Organizational Factors Employers admitted that their personal experiences regarding RTW of an employee with breast cancer were influenced by the nature of the organization and more specifically the culture and procedures that applied there. Some employers described their culture as people-oriented. That was a culture where there was ordinarily a lot of respect and regard for each other and where people were very concerned about the fate of sick employees and wanted to make sure people could find their place again. Employers sent the message that such a culture did play a role in their view of the employee with breast cancer and prompted them to maximise RTW possibilities. …people here get quite a lot of chances. In that area I think we are fairly social as an employer, sometimes maybe too social (…) there is rarely any dispute about giving someone a chance to come back… [2] This applied not only for care institutes where ‘respect’ was a key value and giving care was self-evident. Such people-oriented values were also present in factories and public companies. …one of the basic principles here is respect for the people standing ‘on the line’. That policy is the be all and end all for me. I live by the grace of the people standing on the line (…). That is our capital, they are our sources, those are the people who ensure our output… [5] Other employers described their culture as performanceoriented: a culture in which the emphasis was more on performing and making a profit. By way of an example, employers indicated that this sort of culture was less likely to make changes to the work situation to help the employee. …I was sick for three weeks and I know how busy and fast it is here. They take into account that you’ve been absent, but actually they expect pretty much the same (…). It’s quite difficult in a culture where everything has to be done fast and now… [8] In organizations where there were protocols for discussions with the company doctor within the organization, employers felt less uncertain. They thought these protocols were useful and felt supported as a result of the discussions because arrangements could be made, for example, about tasks and adaptations for the re-integration of an employee. …what happens very often in this organization, is that we see people before they come back to work, so we can determine together with them, often also in Table 2 Employer’s RTW experiences Organisational factors Culture / Policy Concerned as a person Understanding Empathy Employer factors View / Role / Experience Uncertainty Course of illness Guidance RTW options Dilemmas Employee factors Attitude / Employee Employer Relationship 123 Privacy Employee / Organisation Employee / Colleagues Personal / Professional RTW as intangible Difficult to manage Nothing to base it on Ad-hoc decisions J Occup Rehabil consultation with the GP, what the situation is: look, what are the options in the work package… [10] there are companies where that would not work… [11] The existence of specific agreements within the organization, for example about coming back part-time, was seen as a support when weighing up the organizational interests against the employee’s interests. Furthermore the extent of their experience with (breast) cancer appeared to play a role in their approach (‘‘…my wife also had breast cancer and then I began to realise what it all means…’’ [6]). Sufficient general expertise and an open attitude as manager, resulted in their view in them feeling less uncertain about their supervisory role. …we really start from the principle that it is gradual and not permanent (…) then we stand by that and try and organise the work so it’s possible. The rule is one year, but if we really see that there is progress, we deviate from that, and say: okay, if you still need another year, then you can have it. But if we think it looks like it will turn into a permanent system, we stop it (…) That’s the vision; I don’t always agree with it either (…) but that’s the internal arrangement here… [3] Employer Factors The interviewed employers also referred to themselves as a person, when it comes to their role and responsibilities in the RTW process. …you can’t just be thrown into this if you are 25 years old and just out of college. You need a certain level of maturity to develop, to gain insight, to earn respect, acceptance, well-being and appreciation in all those areas… [5]. It was clear from the interviews that what sort of person they were, what sort of life experiences they’d had, played a role in their approach. …not every supervisor is the same; in the end the approach should be the same, but everyone has his own personality in these matters and so his approach is different… [5] The way employers regarded the employee and their own personal situation dictated the degree to which they were concerned. This was expressed in their underlying values (‘‘…you can’t do that, write someone off because of an illness, when she wants to come back…’’ [1]) or in the way they wanted to make efforts for the employee. The personal attitude or experienced behaviour was expressed in the feeling of responsibility for the re-integration of the concerned employee. …if I’d worked in a business where I knew that there was someone behind me wielding a whip, I would have said: go back home (…). I would have taken that liberty, I mean it (…) I really stood up to the management and said I find the humanity of such things (…) but, that’s me, and I know that …I think I’m definitely someone who can get on pretty well with people and can put people at ease because that’s one of my strengths (…) someone who is a bit more business-like or authoritarian (…) different in nature, would probably pay less attention to that… [14] Just as employers had a different vision of the reintegration process and their role in it, so too the expectations that they had of the employee returning or the trust they showed in the capacity of the employee differed. …you expect a healthy person to do their job, but with this person you’re first going to check to see: can she do the job? (…) And then even: what happened and what she can do, that’s accepted. It is said though that: the demands made of healthy people (…) you don’t make of these people… [4] Employers also differ in their feeling of responsibility towards the employee with breast cancer. Those with a concern that people should be given another chance in the company, for example, took initiatives to reach multidisciplinary agreement in order to ensure, from a more neutral role, that the return went as smoothly as possible. Employee Factors Finally, it could be deduced from the interviews that the variations in experiences of the employers also had something to do with the image that they had of their employees. This image of the employee as a person, her attitude (as regards her work, her illness and her colleagues) and her manner of communicating clearly influenced their experience regarding the employee’s RTW. The employers often presented a positive image of the employee concerned, and this dated from before the illness. Employers sometimes even talked about feeling a moral responsibility to help the employee that they, for example, qualified as someone who was loyal, social or had integrity. …she’s someone who takes her job seriously, very seriously, so I thought it was the moral responsibility of the company to have the same approach to her and her breast cancer, to explore what she must be going 123 J Occup Rehabil through? (…) Because if that woman had been very negative, I wouldn’t have allowed that in the company… [11] The quote below shows that the image that colleagues had of the employee can also be significant for the reintegration process, in particular for the way in which the employee is welcomed back into the team. …You have a history with the team you were part of. If you were somebody they could rely on, who was flexible, a good team player and then something happens to you, that’s human. That person is then handled differently within the team than someone who cut corners… [2] The way in which the employee communicated about her illness and her RTW also played a role in the employer’s experience. If there was lots of openness, the employer had fewer questions about the course of the illness and he/she felt more certain about his/her approach and in a better position to take the right decisions. … you do it from your instincts, but you don’t know if you’re doing it right. It all depends on the response of that colleague; for example, if you were dealing with a non-communicative person then I would soon think: ah, I’m not doing it well… [15] As is evident from the following quote, the personality of the employee (as perceived by the employer) really affected how the re-integration process went. The open attitude and communication enhanced the mutual bond of trust between employee and employer. This determined the extent to which the employer was concerned and the way in which he/she took responsibility for the re-integration process. …she was liked by everyone, she was very animated, she was always very friendly too, and well integrated in the team, which made it easier (…) her attitude was also a key factor. If she’d hidden herself away and not allowed us to stay in touch it would have been much more difficult for us… [1] Discussion To investigate the employer’s experienced role and responsibility in the RTW process of employees with breast cancer, a qualitative design was used to better understand the employers’ side in a Belgian context. The findings of our study show the conformity and variation of the employers’ involvement in the RTW process and allow us to describe it in its complexity. From the employers’ point of view RTW is an intangible process and difficult to 123 manage. Studying RTW from the employers’ side led to casting their personal involvement in a better light. As an answer to the intangibility of the whole RTW process the employers try to grasp the situation to the best of their ability, but their perceived role is not univocal. We found communality in the employers’ experience of being concerned as individuals, feeling uncertain, and having dilemmas. We also found variation, which might indicate the ad-hoc nature of dealing with the specific situation. During the process employers seem to be confronted with ‘sliding panels’ and they had no guidelines to act. Furthermore this study helped us understand that besides the intrinsic complexity of the RTW process, other factors play a role in the employers’ perceived role and involvement: characteristics of the organization, of the concerned employer and the employee. The interaction between these three factors (organization, employer, and employee) related to the RTW process of breast cancer employees has not yet been thoroughly analysed before. That employers have to balance the interests of both the business and the employee, was found in an earlier study of stakeholders’ experiences [11]. Recently McKay et al.’s [24] findings also confirmed managers’ lack of knowledge on how to respond to their employees with cancer. The authors agreed on the complexity of the RTW process and also on the revealed dilemmas regarding (1) supporting the employee and overstepping the privacy line and (2) the need to balance organizational and individual matters [24]. We found that all employers showed their emphatic involvement and did not operate purely from the standpoint of efficiency. We do not know whether we can consider their behaviour as accidental, arbitrary and/or intuitive, or whether we can characterize their decisions as tailormade. Given the fact that employers are not ‘robots’, they might wish to tailor RTW solely to the needs of the employee. Some employers even felt a moral duty to support the employee’s RTW, especially in terms of appreciating or even admiring the employees’ attitude during sickness absence. In their Norwegian study and starting from the assumption that employers play a key role in facilitating an effective RTW for long-term sickness absentees, Aas et al. [16] discovered that the most valued leadership qualities among employers and employees included ‘being understanding’ and ‘being considerate’, ‘being appreciative’ and ‘being empathetic’. Regarding most valued leadership types, employers valued ‘responsibility makers’ and ‘problem solvers’ most often [16]. Our findings also show that the employers felt responsible, and that they understandingly and empathically searched for an RTW approach adapted to the situation and context. However we did not study the relationship between what the employer did and RTW effectiveness. J Occup Rehabil Adding to these findings Vornholt et al. [14] reported the importance of person-related factors (e.g. behaviour) in accepting an employee with disabilities in the workplace [14]. We found that not only employee factors, but also organizational factors (people- or performance-oriented culture) and employers’ personal attitudes (being concerned) played a certain role in the RTW process, but we do not know if any factors were dominant and how they interact. In some cases the employers’ personal and emotional involvement led to leaving the employee alone or making no demands on the employee’s competence after RTW. However, according to the findings of Amir et al. [12] employers do actually indicate specific productivity concerns regarding people with disabilities while expressing the need to change the culture ‘‘so that it is more accessible and accepting of individuals with disabilities and chronic health conditions’’ [12, p. 79]. The authors agree with the finding that little is known about employers’ perspectives on the RTW experience of cancer survivors and on the effects of organizational level variables [12]. We found that employers were in a dilemma concerning productivity and the results strongly suggest that this was of minor importance in health care or people-oriented organizations. In the workplace the specific character of the breast cancer diagnosis, with its life threatening and mutilated character, might lead to excitement and suspense [24]. Yet, it can be debated whether the employers’ emotional involvement and various uncertainties are specific to breast cancer. These experiences might also occur with regard to other cancer diagnoses or severe illness. McKay et al. [24] found that colleagues of employees diagnosed with cancer were emotionally in shock [24]. The managers interviewed in the McKay study were uncertain about how to talk about cancer and they also felt distressed [24]. Employers confronted with RTW of an employee after a stroke faced complex emotional and practical issues. They also felt that they lacked knowledge and experience of how to handle the situation [25]. Emotional involvement of the workplace and employers being unsure or lacking experience in supporting employees might be part of the RTW process for employees with cancer. Amir et al. [12] concluded that employers as well as employees (with chronic illness or cancer) face many challenges in the complex RTW process [12]. Furthermore, the employer’s narratives on the intangibility of the RTW process might be coloured by the specific Belgian legislation, e.g. long-term sickness absence policy in Belgium. Some employers in our study mentioned that they treated breast cancer patients in the same way they would with any long-term sickness absence patient. Further, several employers, who were not HR managers themselves, also mentioned that they were not familiar with RTW legislation and that they had to consult their personnel department about the RTW options. A Belgian stakeholder study [11] showed that the RTW process was unstructured and complicated and employers felt confronted with practical barriers with regard to the part-time return of breast cancer patients. Although not responsible, employers tried to be flexible with the law to effectively support RTW [11]. In other countries several more extensive formal approaches exist to support employers during the RTW process: e.g. RTW legislation in the Netherlands, which makes employers legally responsible for supporting RTW [21, 26] and RTW organizational policy in Canada [26, 27]. Even though, these studies show that actors also experience difficulties to handle the RTW process because the course of illness is often unpredictable. Moreover, legislation or policies can also have unintended consequences themselves, such as increase of distrust between employers and employees [26, 27]. With respect to the gender aspect, all 17 employers (ten female and seven male) shared their experiences with the interviewer about solely female employees with breast cancer. Supporting an employee with breast cancer might be more difficult or delicate for male employers. A clear gender difference did however not pop up in our Grounded Theory analysis. Methodological Considerations The uniqueness of the study is a strength. Interviewing Belgian employers on a delicate topic complicated by privacy matters is not easy. There are currently no thorough studies of employer perspectives in this area in the Belgian context. We had to use several methods (occupational physicians, HRM network, Internet) to recruit our sample and we were able to obtain saturation at the level of the main concepts, but more research is needed to refine these concepts. Against all expectations, recruitment only resulted into a restricted number of participants. To a limited degree we were able to select specific employers using the preliminary results of the first six interviews. Nevertheless an interesting variation in organizations was part of our study: homecare services, hospitals, public services and factories. We thus had to limit our sample to participants who were willing to participate, as employers in Belgium do not to typically know the diagnosis of their sick-listed employees and breast cancer is a sensitive topic. Giving consent to participate in an interview to talk about employees with breast cancer was therefore a difficult decision. Nevertheless, this selection of willing employers might have been selective and biased towards willingness to support their employees, and our study might thus not cover the experience of employers who neglected their 123 J Occup Rehabil employees with breast cancer or maltreated them on purpose. Within the various organizations, we interviewed different individuals, whom we defined as employers: chief executive officers, HRMs and departmental managers, who might have had different areas of authority. An HRM might for instance know more about legislation, while the departmental manager maintains direct relations with employees and the chief officer is allowed to change protocols [16]. There might thus be a relational difference between the interviewee and the employee concerned. Moreover, most participants (12 out of 17) worked in hospitals and other public sectors which might also have biased our results regarding for instance the absence of a dominant efficiency paradigm. Several employers talked about cases from 5 to 10 years ago. It was probably less precarious to talk about a past incident. Although the employers seemed well-informed about the woman in question (some even showed their emotions), it is possible that information and their experiences were lost or over time, which might also bias our results. On the other hand this retrospection provided some employer’s with new insights into how to manage RTW of current employees with breast cancer. A few participating employers shared their concerns regarding a structured RTW of long-term sick listed employees (including employees with breast cancer) and showed their motivation to evolve a policy or a leading RTW instrument for their organization. The choice for a qualitative design (Grounded Theory) [22] allowed us to describe important concepts that add to an understanding of the RTW process of employees with breast cancer from an employers’ perspective. After presenting the results and how they were analysed, experts commented on the findings in a peer-debriefing. Significant or meaningful concepts were integrated or fine-tuned after the investigators reached a consensus. The use of QUAGOL [23] for analysis and the peer-debriefing with experts undoubtedly contributed to the trustworthiness as well as to the theoretical generalizability of the findings. Recommendations Employers and other RTW stakeholders might benefit from our findings. Generally the complexity of RTW is well documented [e.g. 13, 15, 19, 28–30], but we add to the background by giving a more nuanced description of this ‘intangible’ process. To relieve the employers’ concerns regarding managing this process, it might be appropriate to study the specific employers’ needs regarding supporting RTW of breast cancer patients and to explore ways to support employers. To test whether our findings are typical for employers’ experiences with breast cancer patients or can be generalized to patients with other oncological or 123 non-oncological but severe disorders, further research among other populations is needed. As mentioned, most participants of our study were from the public sector (and therefore probably more peopleoriented). To add to our findings it would be advisable to interview a large number of employers from the private sector with similar positions of authority and recent experience in supporting employees with breast cancer. 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