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thank you for the introduction and thank youall for joining today. what i hope to is actually get through the presentation in 20 minuteto half an hour, and open it up for us to have further discussion. for me the wholearea of cancer is fairly new and i feel that from the discussion i can learn a lot fromall of you with regards to the cancer piece of it all.just to start off, i will give just a little bit of the presentation outline. what i amgoing to start with doing is just give you a brief introduction to some of my interestsand program of research, and how i think about work. i am then going to tell you a littlebit about some of the projects that i am interested in with regards to cancer and work, more specifically.i will finish off the presentation with some

more detailed discussion about qualitativemetasynthesis research i was involved in leading, with a group of other researchers, where welooked at survivor’s work experiences with a goal of really being able to develop strategiesthat facilitate return to work. so how we could use what we already know to developstrategies to facilitate return to work. in the next slide what i wanted to illustratewas a little bit about where my research interest and research goal come from. so i am actuallyan occupational therapist by profession and i had worked as an occupational therapistfor 15 years before coming back to do my graduate studies. most of my clinical experience hadbeen in the area of brain injury rehabilitation, and probably half of my clinical career ispecifically worked on helping individuals

return to work; so most of the focus was onvocational rehabilitation. what i then wanted to do was expand on that and came back todo my graduate studies, to develop some research expertise. most of my research expertise includesqualitative and a little bit of quantitative expertise, guideline development, i had donesome work on consensus building, knowledge translation and a little bit of work lookingat work from a clinical evaluative perspective. so what my overall aim is is to use that clinicalexperience, and i think a lot of my questions or a lot of my work was driven by the experience/questionsthat came up with clinical practice, combine it with my research expertise. so essentiallydevelop practical strategies and tools that would facilitate work re-integration. i thinkthe over-arching kind of push or drive for

me is this whole idea of enhancing inclusionof individual, cross rehabilitation populations within the context of workplace.when i think about enhancing work or work re-integration, i often view work as somethingthat happens in a continuum. so there is a sense of, you know, what’s happening withindividuals when they are off of work, what happens to individuals during the initialkind of return to work or when people are back to work; and then what might happen orwhat might be relevant to their ability to actually maintain their work or maintain theirengagement within the workplace. what i have done in terms of thinking about that is thinkingabout, while people are off work, some of the most important questions that we can oftenask is, “how we help evaluate their work

readiness?”, “how we help evaluate theirpotential to return to work?” once they are back at work, what i found was what tendsto be the most significant piece of the puzzle is being able to assess how they actuallythey are managing at work and what their work performance is like. the workplace supportsaccommodations that are put into place, especially from work maintenance or a long term perspectiveof how the supports may be relevant, and any issues that might be at the workplace froma health and safety perspective that needs to be considered.when i did my phd. work, most of my work was focused on the whole idea of what types oftools might be necessary to facilitate individuals, their ability to re-engage in work again.so the types of things that will help them

off-work and as john had said in the introduction,i have developed a couple of guidelines and professional guidelines that look at specificallyaround the evaluation of work readiness determination, and traumatic brain injury and the secondone is severe burn injuries. in relationship to work habits, to explore the idea of employmentsuccess and the role that workplace accommodation can play in that. we also looked at issuesfrom gender around workplace health and safety. just go a little bit into some of my interestsmore specifically in encountering cancer survivorship; we have just started a study where we willbe looking at cancer survivorship and successful return to work, specifically looking at therole of workplace accommodations. in this particular study, it’s a qualitative studyand what we are looking at is understanding

the idea or concept of returning to work andworkplace accommodations from three key stakeholder’s perspectives: survivors, health care or vocationalproviders, as well as employers, with the eventual kind of goal of developing some sortof guidance or strategies for best practicing in relation to accommodations, and the processesthat may be most relevant to successful employment outcomes. what we are doing is interviewingsurvivors and asking them questions around their experience with return to work, howthey decided when they were ready to return to work, how they went about requesting accommodationsand asking for accommodation; and whether those were successful or not. we will alsobe interviewing health care providers and vocational service provider. this may includehealth care workers such as ots, physiotherapists,

psychologists, perhaps physicians as well.it will work with rehabilitation counselor to work within the context of insurance companies,and also anybody who is officing work from a community type of context; and try to findout from them how they support return to work decision-making, how they go about requestingor putting around accommodations or recommending accommodations, and putting them into placeand to learn a little bit about the successes and challenges within those process. lastbut not the least; we would like to be able to interview some of the employers to geta sense of their experiences with supporting individuals with cancer and return to work.we will ask them what some of the challenges may have been and what they did to ensureaccommodations were put into place.

that’s one study that we are currently lookingat in terms of understanding workplace accommodation. the other thing that i am very interestedin and particularly even more so interested in, because in the last presentation abouta month ago that jennifer jones did, we had some discussion and issues that came up aroundthe fact that there are few guidelines that in this particular point in time that professionalscan use to determine somebody’s work readiness and actually evaluate and plan for their returnto work. so one of the things that i am interested in is looking at doing a literature review,synthesizing that literature review and developing a guideline with recommendations that willaid work evaluation and return to work planning. from what i have been able to gather, thereare quite a number of guidelines for screening

diagnosis and more medical treatment but notnecessarily comprehensive guideline that would specifically look at return to work.last but not least, in terms of being able to develop some understanding of how individualsperform within the context of the workplace because there are lots of studies that suggestthat performance can be affected following cancer for a number of different reasons.i have worked together with some other collaborators at the princess margaret cancer center, atmcgill, at ottawa, and we are eventually hoping to do is see if we can garner funding to beable to develop a tool that can measure work performance specifically at the workplace.i am going to step back a little bit. that was kind of the background information. iam going to share with you a little bit about

what we found was in the context of the metasynthesisthat we completed. this slide provides just some background information in terms of howi typically think about the elements or the factors that can actually affect return towork from any kind of complex injury or illness. i think for me i conceptualize cancer survivorshipas an example of that. so there may be personal factors within the individual that may impactsuccessful return to work, there may be factors within the occupation itself or the specificjob demands, and there may be factors from a support perspective and also support thatmay be provided by the community or personal support that individuals can bring in withthem. it is often important to understand the interaction between these factors andwhere they come together, more specifically,

using this venn diagram to that kind of understanding.when we look more specifically at some of the literature and cancer survivorship, thereare a number of personal and environmental factors that have been identified as beingrelated to successful return to work from cancer. on a personal level or on the levelof the individual, i think we can conclude demographic factors such as age, sex or gender,their education level, their pre-morbid health conditions and also co-morbid health conditionsthat an individual might have; and also the effect of persistent symptoms such as pain,fatigue, cognitive dysfunction, anxiety and depression on somebody’s ability to returnto work and perform at their return to work. from an environmental perspective, it caninclude things such as support, advice, and

services from health/vocational service providers.from a workplace supports perspective, it can often include a sense that an individualhas on whether they have been accepted back into the workplace. any feelings that theymight have had or experiences around discrimination and processes and relationship in how accommodationsmay have been or may not have been put into place.i am going to share with you a little bit about what we did in terms of the qualitativemeta-synthesis; and just for a brief little background on what qualitative metasynthesisis for individuals who may not be necessarily familiar with it. so essentially qualitativemetasynthesis is qualitative approach to pooling or bringing together findings and analyzingthose findings that we find across qualitative

studies. typically when we are pooling thesefindings, what we are doing is using methods consisting of more interpretive text sciences.so what we do in qualitative metasynthesis is move beyond the aggregation of findings,so a little bit less of that narrative review of the study found this, this study foundthat, etc., but to look at the links behind those particular findings and develop morehigher levels of kind of themes that we see are emerging from those studies. the wholeaim is really to, as opposed to just, gathering data from one study but to use interpretationsfrom variety of studies to give us new insights and develop new insights. so we are reallylooking at the findings or knowledge pieces from each of those studies.in this particular metasynthesis, what we

really wanted to do was kind of look at synthesizingor looking beyond synthesizing individual’s lived experiences. what we found when we lookedat the literature was that, some synthesis had been done understanding people’s experienceswith living with cancer and return to work process. then we identified the importanceof work following cancer. we were able to identify some of the support elements, butwe wanted to go a little deeper into looking at the data in more depth, and specificallybe able to identify some of the key points in the recovery trajectory where support andstrategies became more relevant to successful return to work. so now we could talk morespecially about recommendations for health and vocational service providers.our actual metasynthesis was guided by four

of the following related questions:how do cancer survivors describe their return to work processes?what strategies do they employ to return to work/maintain employment and navigate health,benefits and employment systems? what challenges do they experience? (e.g.cancer, work performance, work environment related)what supports do they report to be most relevant to facilitating positive return to work processesand outcomes? the method that we followed included firstidentifying what are synthesis questions, identifying exclusion/inclusion criteria (whatwe are going to include in the synthesis), developing search strategies, retrieving potentiallyrelevant articles, and based on those search

strategies identified, what studies were mostrelevant in assessing the study quality, and subsequently extracting ace data, analyzingthose findings and using what we call a meta-ethnography approach (it’s a three stage approach thati will describe later to synthesize and develop recommendations). because we are looking atqualitative research, we are only included studies that included a qualitative method,and we actually included studies that had something to say about the whole return towork process. so it may have been decisions initially relating to return to work, thecomfortability to return to work, the initial return to work process when they initiallyreturned to work, as well as any studies that may have been involved with employment maintenance.we included studies where there was cancer

survivors themselves that were sharing experiencesas well as service providers, so including those perspectives, and really because noneof us in the research team actually reviewed studies other than in english, we mostly focusedon studies that were in the english language. what we found initially with our search wasthat we identified 2409 articles using a specific search strategy, 40 of which we included inthe inclusion/exclusion criteria which were potentially relevant. when we looked at themin greater detail, in terms of the depth of the information, we were able to eliminatesome more studies and so there were 48 studies that were in the inclusion and exclusion criteria.following the quality appraisal, we removed some studies because we identified them aslower quality and 39 studies in total remained

from which we did the full data extraction,analysis and synthesis on. in this next slide, i just wanted to describeto you what the meta-ethnograph looks like in terms of analyzing and synthesizing thedata. so it involves three steps: in the first step what we do is identify first order concepts.these tend to be very concrete indicators of things we see in the literature. in thisparticular case, we identified 25 categories or themes of information that came out withregards to that return to work experience. these were then organized into four key categories,and what i will be sharing with you in the findings is basically some of the elementsof the four key categories. those were then interpreted in relationship to what they meantfor practice in the third order interpretation

stage.so there were four categories of dicussion related to returning to work following cancer.there was discussion in relationship to post-cancer experiences at work, there were discussionsin relationship to managing work decisions and planning return to work, there was discussionrelated to the factors associated with successful return to work, there was discussion relateddisclosure and challenges to disclose or not to disclose (decisions to disclose).in terms of experiences with return to work, what we found was two very interesting themesthat came out and to some extent what appear to be juxtaposed to one another. so the firstwas something that we read a lot about and i am pretty sure most people are familiarwith it: idea of the importance and significance

to work to cancer survivors. the significanceof work and the importance of it was identified from a number of different perspectives. firstand foremost, there is lots of discussions about how many people feel the financial needto return to work. the importance of work was also discussed along the lines of helpingindividuals to cope and to some extent be distracted from managing the patient role.there was a huge desire to return to work in order to return to normality and life toreturn to normality. for a lot of people, the work experience provided them with structureand relief from boredom. and for a lot of people for whom the work role was specificallyvery relevant was that returning to work allowed them to recap what their own identity as aworker. for lots of other individuals, there

was discussions of the importance of workfor a sense of social belonging. i think lots of the specific indicators around the importanceand significance of work is similar to what we find in a variety of other populations.so they are not really necessarily that different from what i actually read about, or heardabout or seen about in relationships to individuals who had traumatic experiences with brain injury.but what was interesting was that there was always a back-drone about the significanceof work but also the importance of being able to re-evaluate the role of work in one’slife. so there seems to be lots of discussions about the meaning of work can change followingcancer and the need to re-evaluate one’s life and one’s goal, to re-evaluate therole of paid work in one’s life, and for

a lot of people they indicated that they oftenseeked less stressful work. and for a lot people, even for individuals for whom themeaning of work was very important, some of the meaning in relationship to work couldbe tampered by the challenges that they faced. so for example, if i am doing my job and performingvery well in my job, it would be easier for me to find meaning; even though i still enjoymy job subsequent to return to work, maybe the increased challenges make the work muchless enjoyable and the struggle may not be necessarily worth it.in terms of managing work decisions and planning to return to work, there were three key factorsor processes that survivors indicated were particularly important. one was the importanceto time and determine when one was ready to

return to work. this involved someone beingable to self-assess their work, their health status in relationship to their ability toreturn to work. for some individuals, the timing and readiness and the decisions toreturn to work was also sometimes based on loyalty; their sense of loyalty to their employer.for others, it was sometimes in relationship to viewing work as the next natural step interms of that process; so why wouldn’t i return to work if i am better and am ableto go back to work? from an economic perspective, lots of discussion especially from individualswho had limited benefits or no benefits, the decision to return to work was often basedon the adequacy or the inadequacy of sick leave time, how many benefits they may have.and for some individuals who were self-employed,

while they discouraged in some cases moreflexibility around their return to work and a lot of people thought that they actuallyhad to return to work perhaps often before they were ready to run that particular companyor whatever business they might be involved in. last but not the least, there were lotsof discussions with regards to perceptions of support: workplace support, in terms ofemployment support from supervisors and co-workers, accommodations that may be put into placein terms of social, family, transportation came up as a big instrumental element to supportingthem and return to work. and from a professional perspective, one of the things they say isthe advice that professionals could give to them in relationship to work readiness andwhat job modifications needs to be made once

they returned to work.the factors that they associated with successful return to work included their personal level;it included their persistent symptoms that they may continue to exhibit, what they perceiveto be their work abilities, how they may be able to cope and how motivated they felt interms of the whole kind of idea of return to work. from an environmental perspectiveonce again, the workplace, the social/family, and professional support that they identifiedwas most important. and from an occupational perspective, they talked a lot about the typesof work and work demands, and the amount of control they might have over that job in termsof job flexibility. the job flexibility piece is very associated with the ability to implementworkplace accommodations.

and last but not least, there were discussionsaround issues related to disclosure of illness. this interplay between needing to disclosein some cases or in some cases the disclosure may have already happened, people alreadyknew why somebody was away from work; needing to disclose in order to be able to accessany of the benefits that they needed to request accommodations or feeling that they mightneed to conceal some of the elements of their challenges or not disclose at all becausethey were afraid of the comments that would come through and the way they may be lookedat or discriminated against and ostracized. so lots of discussion around the disclosureof illness also comes through. just to give you a sense and i think in thefinal metasynthesis, we did make some specific

recommendation and practice recommendations.just to give you a sense of the third order interpretations and subsequent needs recommendationsthat we developed, the importance of being able to identify great variability and theimportance of individuals actually put on returning to work following cancer. hence,there was a real need to explore the meaning of work following cancer and to develop individualgoals. this goal setting should be done fairly early in the rehabilitation process. thereseems to be a great need for assistance to navigate the cancer and return to work journey,and lots of survivors talked about the importance of creating awareness, especially around persistentsymptoms such as fatigue, lymphedema and cognitive issues. the need to have greater informationwith regards to income replacement benefits

and accommodations. there is also a need tounderstand to what extent the health issues might affect work performance. this was somethingthat both survivors and professionals identified as a challenge. there must be knowledge aboutaccommodation legislations and information about how to disclose. the need for healthprofessionals to actually help determine work readiness for survivors and the need for healthprofessionals to make appropriate recommendations regarding returning to work schedules andworkplace accommodations. just to give you a sense of the limitationsof how we interpret the evidence through review, so to a large extent most of the studies thatwe reviewed focused on middle=aged breast cancer survivors. most of the focus also tendedto be on personal issues versus workplace/employer

kinds of support. a lot of the focus morespecifically on early return to work experiences versus employment maintenance phases. i thinkthis is particularly important because what we do know from other bodies of literatureis that, while levels of impairment might be relevant to understand the initial returnto work, understanding what happens in the workplace or workplace support speaks to alarge extent the maintenance of work in an employment context and not in a health contextas much. it requires us to understand what happens at the workplace and we do not havemuch understanding of that. there seemed to be a limited examination of the role of occupationalhealth demands so there is personal elements and environmental elements that we talkedabout. but the job demand pieces an understanding

that we didn’t previously include. it alsohas little application of theoretical perspectives to assist with interpretation of study findings.recommendations for future studies that we came up with were being able to use longitudinalstudies designed to look at work experience. the whole idea of being able to increase diversity,so looking at the diversity to cancer diagnoses; diversity if individual socioeconomic statusbecause the financial aspect pieces in well together; the diversity of sex/gender andeventually geographical diversity that allows people access to certain types of servicesto individuals who vary in terms of the services people may get at an urban environment asopposed to rural context. the influence of job category and work demands was somethingthat we thought was important. and the other

thing we found was very interesting was thewhole discrimination behind cancer survivors. what we have actually initiated, we actuallyhave a couple of occupational therapy students here in the program and as part of their actualmsc ot program they actually need to complete a research project. two students are lookingat and scoping review of the workplace sigma and discrimination in working age cancer survivors.so we are hoping to learn a little bit about that.so i am actually formally done with the presentation. i thought i should open it up for questionsand any ideas that individuals might have for future research and if i am happy to talkabout even new studies that we have just started now and get a sense of people’s potentialinterests.