Introduction: Globally, the high prevalence of burnout in healthcare workers (HCWs) is of the utmost concern. Burnout is a state of emotional exhaustion, depersonalization and a decreased sense of personal accomplishment. While the 2019 Coronavirus (COVID-19) exacerbated the burnout prevalence among HCWs, limited studies have explored this phenomenon using qualitative methodologies in the Eastern Cape Province and South Africa generally. This study explored how frontline healthcare workers experienced burnout during the COVID-19 pandemic in Mthatha Regional Hospital. Methods: Ten face-to-face in-depth interviews were conducted with non-specialized medical doctors and nurses who directly cared for COVID-19-infected patients during the pandemic in Mthatha Regional Hospital (MRH). In-depth interviews were digitally recorded and transcribed verbatim. Data were managed through NVIVO 12 software before being thematically analyzed using Colaizzi’s analysis method. Results: Four main themes emerged from the analysis. These themes were burnout manifestation , precursors of burnout , alleviating factors of burnout , and the last theme was every cloud has a silver lining (improved infection prevention and control (IPC) measures, learning to be more empathetic, the passion remains and confidence grows). Conclusion: The COVID-19 pandemic brought about a rapid change in the work environment of healthcare workers who are the backbone of efficient healthcare services, thereby rendering them vulnerable to increased burnout risks. This study provides strategic information for policymakers and managers on developing and strengthening welfare policies to promote and protect frontline health workers’ well-being and work functioning. Since the discovery of the concept by Freudernberger in 1974, burnout has gradually been recognized as a psychological phenomenon with personal, professional and organizational consequences, which affect both the quality of services rendered and personal well-being ,3. In hiPredominantly, burnout is assessed using Maslach’s Burnout Inventory (MBI), a questionnaire that measures the three dimensions of burnout ,5,6. MasDue to the nature of healthcare workers’ (HCWs) work, they are at increased risk of burnout , as showThe 2019 coronavirus (COVID-19) pandemic created conducive conditions for burnout to thrive among HCWs, given substantive changes in their usual practice and the delivery of services to patients . As of 1Frontline HCWs’ health and safety are of the utmost importance, given their role in patient care, more so in such time as the COVID-19 pandemic . Few stuA study using exploratory qualitative design was conducted to gain deeper insights into the manifestation of burnout in HCWs during COVID-19 from the participants’ perspectives.The study was conducted in MRH, Oliver Reginald (OR) Tambo district in Eastern Cape, South Africa. The MRH has specialist departments, such as internal medicine, family medicine, obstetrics and gynecology, surgery, anesthesia and pediatrics. However, for this study, we recruited nurses and doctors who had been assigned to COVID-19 wards, as they were most likely to be severely affected by intimate and sustained exposure to caring for patients diagnosed with COVID-19. Notably, during the COVID-19 pandemic, specific areas were turned into COVID-19 specialized wards, as the rapid spread of the disease could not have been anticipated. Using purposive heterogeneous sampling, we recruited doctors and nurses who had been displaced from their original departments to COVID-19 wards. The heterogeneity nature of our sampling enabled us to ensure a good mix of participants in terms of occupation, experience, gender and age. Lunch breaks were used to conduct in-depth interviews, and this arrangement had been cleared by the facility management. The sample size was determined through data saturation, which was reached at ten in-depth interviews, a point where no new themes emerged from the in-depth interviews. The literature asserts that data saturation can be reached at ten in-depth interviews with information-rich participants ,29,30.What had happened?”; “How did you handle the situation?”, were also used. The interview was concluded by soliciting the participant’s socio-demographic information. For confidentiality purposes, participants were de-identified during the analysis.Using the interview guide approach, between 23 March 2022 and 4 May 2022, we conducted in-depth face-to-face interviews in English with ten participants, at a time (lunch breaks) and place convenient for them. The interviews lasted an average of 26 min (14 to 49 min). All participants signed informed consent before being interviewed, and the interviews were tape recorded (with the participants’ permission). The in-depth interview explored how burnout manifested in those involved in caring for patients with COVID-19 (covering different elements of burnout), the effects of burnout on their health and patient care, as well as the effects of burnout on how they perceived their professions. To enhance the depth of the data, probing and practical questions, such as “Data collection and analysis were performed iteratively. The audio recordings of the interviews were transcribed verbatim by the lead researcher and were then analyzed using Colaizzi’s method of analysis . The proTo ensure the trustworthiness of the study, we followed Lincoln and Guba’s  guidanceThe study participants comprised six doctors and four nurses involved in caring for COVID-19-positive patients during the pandemic, with the ages ranging from 26 to 46 years and the majority (70%) being females. These participants were recruited from their original departments of work, including family medicine (three), internal medicine (three), gynecology (one), labor ward (one), general surgery (one) and high care (one). Eight and two participants were single and married, respectively. By designation, among the nurses, three were professional nurses and one was an enrolled nursing assistant compared to five medical officers and one family medicine registrar. The duration of working with confirmed COVID-19 patients ranged from 1 month to 24 months. Notably, the results of this study are analyzed without any emphasis on the specificities of the professionals interviewed (doctors vs. nurses). During data analysis, four main themes and sixteen sub-themes emerged from the analysis. These themes were burnout manifestation, precursors of burnout, alleviating factors of burnout, and lastly, every cloud has a silver lining .The main themes and sub-themes captured the strains and learning opportunities presented by the COVID-19 pandemic.The first sub-theme under burnout manifestation was the emotional strain, detachment and irritability attributable to the high number of critical patients, the number of deaths, feeling inadequate to help the sick, dealing with panicking patients and grieving patient relatives, as well as infected colleagues, and generally, the change in the nature of their practice. As a result of the high rate of mortality, resource constraints and concern for their own well-being, participants eventually developed some emotional detachment from their patients. This increased their irritability, thereby failing to react diplomatically in situations, and this irritability also affected family members in home settings.“it’s been hectic for all of us and most of us we’ve been hands-on, have been complaining majorly of the emotional strain that comes with it… It involved a lot of uhm- in fact long working hours and the high number of patients that we were seeing. So, it was involving mostly all of the aspects of our being. So, it came with emotional stress.”(D1)“You definitely experience the emotional exhaustion ‘cause you are losing patients. So that definitely takes a toll on you ‘cause [because] you feel like why am I even here if I can’t save the patients?... Patients are not the same, like, I mean, you’ll have a patient that will come in well, and then the next day patient has demised. Like that patient will affect me emotionally, more than someone who’s been unwell since the beginning.”(D2)“yeah It’s emotionally draining, it’s emotionally exhausting, because sometimes you would think I wonder what happened to the patient, because when I left, she was like this and this and this. And then when I come back… and that thing you would think about it for even a week.”(N4)“Uhm Because some of those patients were panicking it was emotionally exhausting, because we’d try to explain to someone uba (that) you have to do this and this and people were panicking, they’d take out the oxygen”(N3)“And it’s not just, it’s not just about the work itself, per se, during the second wave, it’s about the fact that you are not only dealing with the patient, you’re also dealing with their families, right. So, you are dealing with families, you’re also dealing with colleagues, colleagues with relatives that are also having severe form of COVID. So, there is a lot of emotional, I mean, you have- passing through a lot emotionally in terms of seeing your colleague losing their own relative, losing their own parent, losing your own colleague.”(D3)Emotional strain also affected how HCWs cared for the patients, given that health outcomes were usually poor.“Because many times we know as health workers our aim is to salvage as much as possible of life as we can. But then during my COVID ward cover, many times, I had really little emotional attachment towards patients, and whatever the outcome I was not even moved. So, it was more like I’m just a robot doing work, I don’t really care much about the outcome because many times most of them will die. So, I think, personally, the main manifestation was my attitude towards patients, which is not yeah, ideal.”(D5)The emotional strain and detachment had a ripple effect on HCWs, as they increasingly became irritable, even in circumstances where they would normally react diplomatically. This irritability affected family members in home settings as well.“A part of you empathizes and sympathizes with the patient right. But if- when there’s nothing else, you’ve given them salbutamol nebs and oxygen, sometimes they do not feel the oxygen it goes up to 15 up to 20 You feel like there’s nothing more I can do you feel like a bit irritated and tired as to, but there’s nothing else I can do, everything that was prescribed and above that I’ve done, but there’s nothing the patient is still in distress.”(N4)“So, you will, I think I had even myself personally noticed there was a time my wife said, “You know what, now you are, you no longer talk to the kids, you shout at them all the time… you get home you are tired physically, let alone emotional-emotional tiredness, you are physically tired. There’s emotion, there’s a child that does not understand what is going on. They just want their father’s love. So, you will, for a small thing, you will find shouting at the kids because you are tired... I was at that point of burnout.”(D6)“… and there are times you would even become irritable for no reason because we were going through a lot. There are times that you would find yourself not as receptive to the relatives of the sick one as much as you supposed to be and even towards colleagues because we would all be irritable at different points in time. So, it brought up characters we never thought we would be demonstrating to people around us.”(D1)The infectivity of COVID-19 and the mortality rate thereof induced fear and anxiety on HCWs. The fear of contracting and possibly dying from the disease while caring for patients was an overriding feeling, to a point of distrusting the personal protective equipment (PPE).“Mmh ok, I think a whole lot of us just had anxiety, like a lot of anxiety, ‘cause you’re doing so much but your patients are still dying so you feel like you’re not doing enough, but at the same time, we have our own anxiety with regards to- just like COVID, in the beginning anyway, with regards to COVID because you don’t know am I gonna get it? Did I sanitize correctly? Is my PPE—like did I wear my PPE correctly? Did I take it off correctly?... But I always was like thinking at the back of my mind, the smallest thing “I have a headache- do I have COVID?” “I have a scratchy throat- do I have COVID?” You know. So, I just walked around with a whole lot of anxiety so I didn’t actually actively do anything about it.”(D2)“You’re feeling unsafe for yourself and especially the people you live with at home, if you’re someone who lives with people, if it’s elderly people, if it’s kids. And every new wave brings a new characteristic or things like that. So, you’re always nervous you’re feeling unsafe, you’re unsure if you’re gonna make it that’s, I think that’s the biggest worry, unsure if ok I’m gonna work because it’s my job, but if I get it again, am I gonna be safe again?”(N1)“And patients are also anxious, the doctors are also anxious about what’s gonna happen, am I gonna get COVID and all that, yet you still have a lot of patients to see.”(D3)HCWs also experienced physical exhaustion imposed by increased workload and work demands and long working hours; yet, there was no sense of job accomplishment, given their inability to save COVID-19-infected patients. “But then there’s also just like the physical fatigue ‘cause now you have so many more patients, even working in casualty uhm like you have so many more patients than you would normally, and your patients are so sick, so you like doing much more.”(D2)“And it was just feeling tired, working overtime. I remember some other days we would go out at 10 midnight because we had so much to do and the night staff would come late and there were few people to work around with, so personally it was very hard”(N2)However, hard work did not match health outcomes, thereby creating a low sense of job accomplishment, and the fact that patients were indulging on information from the media platforms did not make things any better.“Now that patient will not have confidence in you… and now you will find yourself in the back foot in winning a battle with the patient. How is he gonna trust you about any other thing now that we’re gonna say. So, COVID will make you feel you are smaller when it comes to treating patients, especially if you treat someone who’s current with news and what is going on”(D6)D2 added: “And the other thing about COVID, especially the first wave is that you sort of didn’t know what to do. So, you felt like you are powerless. It literally felt like you are powerless and… you were just standing there watching the patient die… I felt like I have no idea what I’m doing. And I’m just completely useless being here. Like, I felt like I’m just here for my patients to think, Okay, we have a doctor, but actually, this doctor doesn’t know what he’s doing, so yeah”N1 further attributed her inability to perform her duties efficiently to resource constraints. “You know what, if you have patients that are dying on your watch and you know there’s something you could’ve possibly done had the facility had such uhm treatment maybe, equipment maybe, that could’ve helped a patient at least, you go home feeling like a failure because you know “I studied this in the book, I could’ve done this if I had this to work with.”(N1)D5 further expressed that not being able to achieve what you were called to do yields zero accomplishment. “I think the time I was covering COVID ward personally, the death rate, was more than 80%. So being a doctor, knowing that your call is to save lives, but then you’re not saving any. So, I don’t feel like I’m accomplishing anything, anything during the COVID Ward cover, because patients kept on dying, no matter what we tried to do. And so, it was like, zero accomplishment, just being there as a robot to certify deaths actually than to save lives.”The difficult period created a dreadful climate, took away HCWs’ enthusiasm about their work, but they still felt that they had no choice but to show up and fulfil their duties.“We cope, we push as much as… as hard as it was. But you had no choice, you wake up the following day you still come to work even though you know that it’s hard.”(N2)“And every time you have to wake up and come to work, it would be a struggle, because we were so exhausted. The interest in coming to work was almost zero. But because we had to push through, we didn’t have a choice we went on.”(D1)Occupational exposure to high COVID-19 mortality rates imposed emotional exhaustion on HCWs in a manner that ultimately culminated in burnout. “So, because of the toll of seeing people dying every day, so initially, every time you get home, [you are] very emotionally exhausted. But then over time, like, I don’t really feel anything towards whatever’s happening to my patient… So the number one cause was the rate of death. So, there was a high mortality rate, and at the same time, not being able to do anything for the patients, there’s no medication, the hospital is poorly equipped. So, there’s nothing much we could do. So, the rate of death was so high that and at the same time not being able to intervene. So, I think that was the number one moral killer in a way… So, it was the first experience where by yes, you are a doctor and ahhh you have more deaths than people living. So, it was the first experience whereby, like, you see death left, right, and centre in a day, like that. So, I think it was- I had no previous encounters of such high death toll.”(D5)“And eh-eh during first wave and second wave there were lot of deaths as well, so that created a lot of emotional burnouts. It was not easy.”(N2)All participants conceded that staff shortage contributed to their feeling of burnout. The family medicine doctors were further stretched thinly because, even though they had their allocated time in the COVID-19 designated wards, they would still have to find the means to capacitate the casualty and outpatient departments. “Uhm there was one time that I was working with only one other category of nurse that was the lower category. And we had about 13 patients, just the two of us, 13 patients, majority of them were on oxygen and oxygen on respiratory distress, and others are very confused, trying to jump out of bed. “Nje” [So] it has been very hectic, it’s been made worse by a shortage of staff, because we do not have staff at all, at all. If you’re lucky, you’ll be like five in a team. And nurse-patient ratio is just not adding up, does not add up at all.”(N4)Over the course of the pandemic, the hospital contracted nurses to meet the staff demands, and N2 shared how, during the times when there were no additional nurses, the burnout was more. “One may say that coz [because] in the beginning there was no one employed specifically for COVID, so we had to extract employees from the other wards to come and work in the COVID ward, so that created so much eh-eh-eh confusion and more of burnout, because people didn’t wanna [want to] come and work here, so we had short staff. We were so short staffed… So, imagine the staff that used to work in one ward having to be split into three wards and some of us are on quarantine. So, it was- there was that time though I’m not specifically sure was it wave 3 or wave 2. But I think it was wave 2, because it was most hectic of them all… But after we got our contract workers it became more easier as we got more staff to work around and uh-h things got better”(N2)The COVID-19 era caused a rapid increase in patient volume in the hospital, thus increasing the workload and the number of hours for the personnel, particularly during waves 1 and 2 of the pandemic. COVID-19 exacerbated the distress experienced by HCWs prior to the pandemic.“The high number of patients that were coming were not easy to manage. So, we would get very large numbers, I would say more than 6 or 7 times the number of patients we would normally find before COVID or in between the waves. So, the major factors were the shortage of staff and the number of patients that were affected and needed that medical attention.”(D1)“You find that the workload now is too much on the people who are on the ground and the numbers would be quite high. So, I think during the second wave, it was just too much.”(D4)The rapid development and evolution of COVID-19 posed a certain level of uncertainty with regard to the knowledge of the disease, the required care and even the adequacy of personal safety precautions. “So, I think, during the first COVID wave, when- so obviously, none of us was really like, well up to date with COVID and how it works, except just seeing people dying a lot.”(D5)“So, it makes you feel like I don’t have- immediately feel like that’s what could easily have could have triggered people to go to burnout and even depression because who do you talk to, who knows better in this? There’s no one else. It’s you and what you read. Everybody is reading the same thing, it’s new every day. There’s something that is released. So, it makes you feel like you don’t- you’re isolated -you’re on your own. If you die, you will die and no one is sure how to treat- a definite treatment for the condition. It caused a lot of stress.”(D6)Not knowing when one is protected enough from contracting the disease increased uncertainty, asserts N4:“No matter how much precaution you thought you took, the mask, the gowns, gloves, shoe covers, head covers, but there’s always that eish, maybe it’s I don’t know, because firstly, … when the disease was, was here first, it was said it was transmitted through droplets. So, we needed to wear mask. … now you kind of feel like, what if it’s airborne now? It’s no longer about droplets to need to be in a certain distance away from the person. What if it’s airborne now? So, a part of you feels like maybe the air can leak into the mask.”(N4)The unfamiliar rapid disease progression left HCWs wondering about the constant experience of such catastrophic events, the deaths due to unclear pathologies. Dealing with grieving relatives left them with emotional strains beyond work environments, to a point of having dreams and nightmares, hearing the screams of relatives.“Because, at times, I would be sitting in my room thinking “how did we lose so and so?” or thinking; when I called a certain family, how a person reacted. Or maybe you would be sleeping, and then you wake up in a dream hearing a person crying. So, it does, like affect you as a person emotionally.”(N2)“No, no, no, definitely not. The- more than the patient dying in front of you, that has COVID, what-what-what, you-what would ehh remain something ringing in your mind is what the relative say, when they felt like as health professional, we didn’t do enough for their patients.”(D6)The doctors took rotational time off among themselves as a strategy to decrease exposure to COVID-19 infection, reduce burnout and also alleviate physical exhaustion.“Ok we also did like rotations, and we took weeks off so I think that also helps, ‘cause you’d come back from your week off think “ok I’m good, I can do this” Uhm and then you start the week and by Tuesday afternoon you “ok I need to go again”. So, it wasn’t always that bad, I think the breaks and the rotations made a difference.”(D2)“We tried to take time off, but it was not always possible. Sometimes you find that you, with the person that you’re working with, you may be in for two days, then the other one is off then when you come back, when the other one comes back. You take off just to relax. But it was not always possible that we will get off.”(D4)HCWs also revealed that the psychological support they received from the hospital helped them cope better, and simply knowing that it is accessible was reassuring.“So, there’s so much emotion involved during the second wave. So that you felt that at the point that some of us will be needing counselling and the hospital actually provided avenue for those that felt that they needed counselling themselves, needed the support, they had that opportunity to get counselling, and so… I feel that the fact that you have that opportunity, that service available for you, the fact that you know that it’s available, so it’s already reassuring that okay, at a point, I may need to go there myself. Others went there, so, I definitely believe that it helped. The fact that it’s even available, is helping in that regard.”(D3)“I quickly tried to adjust the mind and it’s I think it’s also the time they tried to bring the psychologists to talk to us about the ways of coping and what the way how we can get help in getting our minds putting our minds at ease with the COVID. I think that played a crucial role, because it came in the first wave. So therefore, once we got there, and then you start to think, and then you come at peace, then you could cope unless you don’t have even that support-nyana [small support] from the psychology psychiatry side of things to be able to put things in patterns for you and do what you can.”(D6)The periods of low mortality and morbidity reduced burnout.“For-the- I think the fourth, third-fourth waves, the patients that we were seeing, what makes me feel like burnout was not as maximum as it was on the second wave, the number of patients that we were seeing was lesser and uhm the patients that we were seeing were not in very bad conditions. We would have the patients who are symptomatic, but quite stable, that wouldn’t need prolonged attention or mmh a long number of interventions to do. So, I think that’s what made us relax a bit, because the patients that we would be seeing were not in a severe disease, if I may put it that way, and the numbers were not many.”(D1)The recruitment of additional nurses to meet the COVID demands meant that the workloads were fairly distributed, and the load became a little lighter.“But after we got our contract workers it became more easier as we got more staff to work around and uh-h things got better”(N2)“Oh, the contract and then was renewed at the end of January. So that how it was somewhat by remedial but it was only about two people that were added. So, it wasn’t that much of a help but it was not the same as only two people on duty with that number of patients.”(N4)Even though the pandemic had been a very challenging time in the practice of these HCWs, causing them burnout, some good came out of it, in line with the saying “every cloud has a silver lining.” The COVID-19 pandemic brought some important lessons.The COVID-19 pandemic reinvigorated the basic infection prevention and control (IPC) measures, which had been neglected in the pre-COVID-19 era.“So, I think that’s one thing that it’s changed for me, it has made like, protecting myself so much more important, you know, now I work with “could this patient have TB?”, cannot really come close to him or her without wearing a mask. Like now it’s not just about COVID. And these are things that we should have been worried about even before. But we’re just very chilled about it… now I must always wear a mask when I come close to a patient, I must always wear gloves when I touch a patient, I must always sanitize like, before I touch a patient, after I touch the patient, like I literally go home at the end of the day, and my stethoscope is sticky, because after every patient I examined, I’ll clean it with the sanitizer.”(D2)“Uhm, I think more than anything, COVID has made us aware of any other things that we were not paying attention to like your cleanliness, your coughing and sneezing etiquettes and things like that. And now, I feel like we are trying, we are far from the end, but we are now trying to practice more of safer ways more cleaner ways, hygiene, and things like that. Ahh ja I feel like now we are more aware of such things than before, as practitioners and myself personally really.”(N1)Some participants reported having returned to being empathetic again to their patients after COVID-19 caused emotional numbness. “So, it got us to be more receptive to our patients to be more empathetic to our patients. I think it’s- it’s out of, I don’t want to say it’s out of guilt for having not done it or for having been unable to do it during uhm the peak waves, but it has taught me specifically that, it has taught me how important it is to interact on an empathic level with the patients. It improves- it’s got eh-an impact on their healing on their way to healing, it’s got an impact on their way to disease resolution, as much you find that we attending to clinical conditions, but there is always an emotional and a psychological aspect of things. So, I feel like we are now more receptive to patients when it comes to their emotions and their psychological aspects in disease, specifically.”(D1)“Now a COVID patient doesn’t feel like just a patient with a diagnosis. Now, I want to understand cause my relative when he had COVID I mean, he was calling me all that he didn’t say he was scared because grownups, but like, I understood that, Ok, so as a doctor in the family, he feels like I’m someone that he can, someone that he can call and be asking questions about his condition and all that. So, I think I think now I’ve understood patients more. Yeah, or better, rather.”(D2)Some participants shared the zeal that they still have for the work they do, despite their burnout experience, while others recognized that the unusual COVID-19 experience presented an opportunity for learning new skills and growing their patient care experience. “Uhm, sheez..uhm, I feel like a soldier really (laughter). I feel like a soldier. I soldiered through a pandemic and contracting COVID three times and still coming to work and still not have quit my job. I feel like I am- I came out stronger. Obviously, there was burnout, there was things like that, but I feel like I came out strong. I came out more willing; want to know more, obviously do more with the employer’ support or the facility support because the most demotivating thing is wanting to do more and know more and not have the resources to do all that.”(N1)“So, in a way, because opened up my, my mind, professionally as to how to tackle and better intervene and better manage the patient. Because from past experiences as to how it was managed, so now you’re like, okay, this is how it was managed. Maybe if I try it like this, it might help.”(N4)“So, on my side when I see a severely ill patient I go with motivation because most of the management principles and the skills for managing these patients have improved a great deal. So, there is a lot of improvement of how we manage- on how I manage the patients that I see, especially now that we are in a relaxed environment. Taking from the experience that we would have to work under pressure and be in a hurry, so now that we are in less pressure it’s easier to be precise and it easier to be proper in managing our severely ill patients. I would say the positive part about it is that we developed, or we fine-tuned a lot of skills in managing these patients.”(D1)“But I can say now it has made me stronger, more independent, more eager but also more cautious of how I do things because anything can happen at any time.”(N1)The results of this study revealed how the COVID-19 pandemic rendered HCWs in MRH vulnerable to burnout, which manifested as emotional strain, physical exhaustion, anxiety and fear, low sense of job accomplishment, emotional detachment, irritability and dreading work, but without neglecting their responsibility. High COVID-19-related mortality, increased work volume, staff shortage and constant feelings of grief affected HCWs in COVID-19 wards. Psychological support from the hospital and the additional personnel mitigated the impact of COVID-19 on HCWs and improved their resilience.Due to the COVID-19 morbidity and mortality, high workload, long working hours, resource constraints and feelings of job-related inadequacy related to poor recovery rates of patients, all participants experienced emotional strain. This was consistent with the literature, which posits emotional exhaustion as the central construct of burnout ,34. SimiThe impact of emotional strain and detachment led to irritability, which extended to home settings, a phenomenon congruent with the results of self-reported observation by Malaysian front-line HCWs who experienced burnout , frontliCOVID-19 created fear and anxiety among HCWs, a phenomenon not unique to this study , as theyOur study participants reported high levels of physical exhaustion, thereby threatening HCWs’ resilience at MRH. The high volumes of patients, increased job demands, long working hours in unfamiliar conditions and caring for critically ill patients with poor treatment outcomes were pervasive across the entire health system ,24. ThisThe fact that hard work put in by HCWs in caring for their patients did not match the outcomes created a feeling of inadequacy and powerlessness. Patients’ overindulgence in information from the media disempowered HCWs who did not have extensive knowledge of the disease. Their inability to save patients’ lives in their care created a sense of low accomplishment, which is one of the three dimensions of burnout discovered by Maslach and Freuderberger in the 1970s . This isThe working conditions during the COVID-19 pandemic were so strenuous and unbearable, to the extent that HCWs dreaded going to work but held their heads above water to uphold their professional responsibility. This reluctance to work was also reported in a scoping review by Robertson et al. . The SouIn our study, although not always possible, doctors made internal arrangements for rotational breaks to limit exposure to COVID-19 infection and reduce burnout and physical exhaustion. To meet the increased workload demands, which imposed a significant strain on HCWs, the government recruited additional nursing staff. These strategies are supported by the evidence, which suggests that long working hours are associated with poor inter-shift recovery, leading to more work stress and exhaustion, with the inverse being helpful in alleviating burnout during pandemics ,36, and Psychologist intervention was another important government intervention identified in our study. HCWs were provided with the option of psychological counselling sessions in order to equip them with pandemic coping and protective strategies. The knowledge of the availability of this option was soothing for HCWs, a strategy that had been used in China  and in oOn the brighter side, and without downplaying the devastations of the COVID-19 pandemic, participants reported high awareness of IPC measures, such as screening patients, maintaining hand and respiratory hygiene, and wearing masks and PPE, because of COVID-19. These IPC measures had been neglected in the pre-COVID-19 era, negating the WHO recommendations on protection measures against viral outbreaks ,48. ConsDespite undergoing an experience of emotional detachment towards their patients, the participants in our study eventually regained empathy and compassion, as COVID-19 affected their close relatives. This shift compelled HCWs to recognize the suffering of their patients and understand that they are treating the person and not the illness, noting that empathy goes with listening, respecting, communicating well and understanding. These are the backbone of effective medical care .Qualitative studies are important in order to complement quantitative studies and create a holistic picture of all the challenges underpinning burnout, especially within the context of COVID-19. As a strength of this study, the rigorous method of data analysis employed illuminates the deeper level of HCWs’ shared real-life experiences of burnout. To our knowledge, there are no COVID-19-related burnout studies on HCWs in the Eastern Cape Province, and contrary to other studies, our study showed that despite the dark cloud imposed by COVID-19, there is a silver lining.Although the study produced important findings, especially for MRH management, the transferability of the findings would be limited, given that the study was conducted in one health facility and confined to nurses and doctors, thereby excluding other healthcare workers involved in the care of COVID-19 patients. Although we contend that data saturation was reached, additional insights may have emerged with a larger sample size. Secondly, the study did not make comparisons between the two professions (nurses and doctors), as that fell outside the study objectives. Future studies should consider incorporating other healthcare professionals involved in patient care using mixed methods.Healthcare workers are the backbone of effective healthcare services, but the nature of their work predisposes them to burnout. The COVID-19 pandemic increased HCWs’ susceptibility to burnout, given that they had to work under highly unbearable conditions, where the job demands increased unexpectedly and rapidly. In this study, HCWs experienced various burnout symptoms, including emotional strain and detachment, uncertainty-induced fear and anxiety, physical exhaustion, low job accomplishment and dreading work while maintaining professional responsibility. The conditions created by COVID-19 pushed the government and HCWs alike to think outside the box and be creative in mitigating COVID-19-induced burnout. These creative ways included rotational time off work and psychological support.Most importantly, although the COVID-19 conditions initially threatened HCWs’ resilience, this subsequently improved HCWs and their adherence to IPC. The burnout phenomenon, which has evolved over the years in terms of what it entails and its evocative power to capture the realities of people’s workplace experiences, has made it both important and controversial in the research field . Outbrea


Interventions to support work participation in cancer survivors (CSs) have shown limited effectiveness. Applying a behavioral change framework  could make work participation interventions for CSs more timely and tailored. We aimed to explore the application of the stages of change framework to work participation support for CSs and to generate stage-specific intervention content.n = 6, n = 5, n = 4) were conducted. Data were analyzed along the six work-related behavioral change stages purported by the readiness for return to work framework, which is based on the stages of change.Eighteen experts  were individually interviewed, and three focus groups with CSs (The following themes were identified: (1) pre-contemplation: emotional support and staying connected—encourage contact with the employer/colleagues; (2) contemplation: considering return to work is stressful—facilitate the deliberation process; (3) preparation self-evaluative: assess current capabilities—seek guidance from, e.g., occupational physicians; (4) preparation behavioral: planning return to work—allow for personalized solutions and encourage supervised return to work; (5) uncertain maintenance: guard against overload—train self-efficacy strategies and communication tactics; and (6) proactive maintenance: accept and prepare for the long term.Our results support the potential utility of tailoring CSs’ work participation support along the stages of change.We provided recommendations for intervention content and developed a stage-specific work participation intervention for CSs, the effectiveness of which will be evaluated in an upcoming randomized controlled trial.The online version contains supplementary material available at 10.1007/s11764-022-01196-x. While cancer incidence continues to rise, improvements in screening, treatment, and survivorship care allow cancer survivors (CSs) to live longer, with better quality of life , 2. Due Various  professionals are involved in the RTW process, e.g., medical specialists, occupational therapists, physiotherapists, general practitioners, occupational physicians, insurance physicians, and supervisors/employers. However, central to the RTW process are CSs themselves, who often wish to receive guidance throughout this complex trajectory , 13. AltRecently, researchers have started to apply concepts from behavioral psychology to the RTW/work retention process of CSs. Duijts and colleagues  suggesteBy identifying CSs’ behavioral change stages related to RTW, interventions to support work participation are assumed to be better able to tap into CSs’ stage-specific circumstances and support needs , 19. In The current qualitative study is part of the STEPS project (SusTained Employability of cancer Patients and their partnerS), i.e., a combined randomized controlled trial (RCT) for CSs and cohort study for partners of CSs. Within the STEPS RCT, we will evaluate a behavioral change-based intervention program to support RTW and work retention in CSs . The curExperts in the field of cancer and work  were eligible to participate in an individual interview if they had experience with work participation support for CSs. Experts were recruited via the professional network of the research team  and invited for participation via e-mail or telephone. Hence, a professional relationship between most authors and experts existed prior to study commencement. Upon response to the invitation, experts received an information letter, informed consent form, and a brief questionnaire indexing sociodemographic information and relevant work experience. After signing the informed consent form and completing the questionnaire, an interview was scheduled to take place at the expert’s workplace, at Amsterdam UMC, or via telephone.CSs were eligible to participate in a focus group if they were between 18 and 65 years of age at the time of inclusion, had been diagnosed with cancer a maximum of 2 years ago, had received chemotherapy or radiotherapy, were currently employed, and had been on sick leave at least some time during the past 2 years. Convenience sampling was applied, as CSs were recruited via various  platforms, including those of the Dutch Federation of Cancer Patient Organizations (Dutch acronym: NFK), and patient panels of “kanker.nl” and the Antoni van Leeuwenhoek hospital. Using a recruitment flyer, CSs were invited to contact the research team, whereupon they received the digital information letter and a link to a digital informed consent form and screening questionnaire, indexing sociodemographic and disease-related information. Eligible CSs were contacted by telephone to schedule a focus group at Amsterdam UMC. Due to this recruitment strategy, no information on non-response is available. No relationship was established with CSs prior to study commencement, excepting two: one participant who was a family member of author PC and one participant who was known to the research team due to her participation in previous psychosocial oncology research projects conducted by the team.Expert interviews were held between August and November 2019 and had a mean duration of 68 min per interview. Interviews were primarily led by one author , with one or two secondary interviewers present to supplement and take notes . A.Z., S.D., and P.C. have experience in conducting qualitative research , 26. IntFocus group interviews were held between November 2019 and March 2020 and had a mean duration of 114 min per interview. Focus groups consisted of a maximum of six participants per group and were led by an experienced moderator (SD). Two observers were present during each focus group , to take notes on non-verbal behavior and ask additional questions. A research assistant was present at all focus groups to observe and take notes. Focus groups were semi-structured and followed an interview guide , which wExpert interviews and focus groups with CSs were held until data saturation was reached themes were identified from the data in the absence of new information). Expert interview data were not analyzed thematically as expert interviews were held to inform the focus groups with CSs. Main points from expert interviews were collated per behavioral change stage and were presented as a preamble to stage-specific focus group results. Grounded in realist epistemology , focus To assess inter-coder reliability, one focus group transcript was independently coded by two authors . Afterwards, codes were discussed to reach consensus and to build the final coding tree (Supplementary File 3). A.Z. coded the remaining focus group transcripts, using this coding tree. Any coding ambiguities or additional codes were discussed with a second author (P.C.). Themes were identified from the codes by A.Z. and discussed in a consensus meeting (with P.C. and S.D.). Participants’ quotations were selected from the focus group data to support findings. Quotations were translated to English by the research team. As expert interviews were not transcribed verbatim, expert quotations are not presented in the n = 4), reintegration coach specialized in oncology (n = 3), psychologist specialized in oncology (n = 1), rehabilitation physician (n = 1), oncological surgeon (n = 1), occupational therapist specialized in oncology (n = 1), cancer patient advocate (n = 1), national policy advisor (n = 1), scientific researcher (n = 2), and AYAn = 3).Eighteen experts participated in the interviews . Three experts did not complete the brief questionnaire due to lack of time resulting from their heavy workload. Thus, excluding the three missing cases from the descriptive analysis, the mean age was 49 years (SD 11), and the mean years of experience with work-related guidance of CSs were 15 years (SD 10). Experts had a wide variety of, and sometimes multiple, occupations. Primary occupations were occupational physician, some of which specialized in oncology  or full-time  employment contract, while at time of the focus groups, most participants were on sick leave . Although information on job type was not collected via questionnaires, focus group data showed that most participants had white or pink-collar jobs.Fifteen CSs  with a mean age of 47 years  participated in the focus groups Table . ParticiYou see very clearly that this [RTW/work retention] process is made up of stages, and all of us here are in different stages. .Experts and CSs were able to relate their experiences to, and organize their experience along, the behavioral change stages.I would’ve been happy with a program like this [points at the worksheet]. I’m already happy that I’ve got this [stage overview] on paper; I’ll be able to look at it from time to time. .Both experts and CSs talked about the potential utility of having a stage overview, as it could validate and normalize CSs’ stage-specific experiences and provide them with a future perspective.[In response to above] Each time you’re in a stage, you feel like you can’t look beyond that stage. I still get that feeling now [that I’m back at work]. .Experts stated that CSs often appeared to be in Pre-contemplation when they were still undergoing treatment. As for stage-specific intervention strategies and tools, experts advised to focus on the emotional needs of CSs and to gently raise awareness of the RTW trajectory and related laws and regulations. Experts suggested that the first professional point of contact in this stage could be e.g., an oncology nurse or a clinical occupational physician.I think it really depends on your circumstances in this stage. I was in this stage when I was literally sick to death of chemo. […] I think if someone initiated a conversation about work, the only thing I could’ve done was cry. .CSs emphasized that in Pre-contemplation, the physical and mental burden of cancer treatment precluded any thoughts about work. CSs stated that the treatment trajectory and its related effects were often unclear and unpredictable, preventing them from thinking beyond the present moment.They [colleagues] came over for a cup of coffee. […] When you’re still in the [treatment] stage, you’re like: ‘Work is over there. Let it be. This is my world now.’ But that changes when – without talking about work – colleagues come over. Then you start thinking about work and how you had a good time with your colleagues. .Keep in contact a bit. Because at a certain point you’re back at work, and I notice now that because of my hair, people don’t recognize me. And that’s of course because my appearance has changed. But I don’t recognize people anymore either, because so much has changed over time. .According to CSs, if work was to be mentioned in this stage, it would have to be done with great delicacy, informally, and without pressure to RTW. CSs reported that as work had faded into the background of cancer and its treatment, informal contact with colleagues and employers was considered helpful for emotional processing and gently re-igniting an interest in work. This informal contact helped CSs to slowly progress to another behavioral change stage. Not being contacted by a supervisor or colleagues was considered hurtful and confusing: CSs expressed that during this time, they needed to feel part of the team, but not be pressured in any way to RTW within a certain timeframe.I’d suggest discussing legislation about work, because I always felt that the law was breathing down my neck. […] I had to go to the occupational physician and he told me about the law and that I had to go to work now, because I was nearing two years of sickness absence.After a year [of sickness absence] I started to look into it [sick leave legislation], because I […] heard stories about reintegration at a different employerIn both the pre-contemplation and contemplation stage, a need for early information provision concerning relevant legislation was mentioned by CSs.ought to RTW, needs to RTW, wants to RTW, can RTW, and what is needed to RTW. Experts mentioned that, to facilitate this deliberation process in this stage, various intervention strategies could be applied. First, experts advised using motivational interviewing techniques to elicit CSs’ natural curiosity about RTW, their colleagues and workplace. Furthermore, experts suggested encouraging CSs to talk through their expectations regarding RTW and to address anticipated practical and emotional barriers that might hinder RTW. This would also allow CSs to divide RTW into manageable steps and provide an opportunity to address barriers collaboratively with the intervention provider. Furthermore, experts advised that relevant information should be provided and misconceptions should be gently corrected, e.g., information concerning the independent role of the occupational physician and his/her duty of confidentiality, CSs’ and employers’ legal rights and obligations, and the effects of cancer and its treatment on (long term) work ability. According to experts, this information could be provided by, e.g., a reintegration consultant or a  occupational physician.6Experts characterized the contemplation stage by feelings of confusion, anxiety, and overwhelm in CSs. According to experts, these feelings could be caused by an internal deliberation process related to RTW, e.g., considerations regarding whether the CS For me, it [chemotherapy] was four to five months of hell and I didn’t know if I’d get out of it. And how I would get out of it. And what would happen after the last one [round of chemotherapy]. […] When the last one was injected, that was the worst one. But after that, I felt like: ‘Okay, I’m starting to feel better and better, and I can think about the next steps.’ .CSs described that thoughts and questions about RTW emerged when they started to physically recover from cancer and its treatment, leading to feelings of confusion, worry, and anxiety.I thought, you know: ‘I’m done [with treatment] now. Everything’s done and I need to be well again.’ But you’re not [well], at all. You don’t know what you’re capable of at all, really. Because not only does your work continue, but the rest [of your life] continues too. […] I panicked. I thought ‘How?! How am I ever going to be able to function at work for a whole day again?’ .If important questions regarding RTW remained unanswered, CSs described that they could potentially stay in contemplation for a long time. According to CSs, guidance from  professionals would help them in making informed decisions about RTW, and progressing to another behavioral change stage.I think the occupational therapist can – in this Contemplation stage – help you weigh the pros and cons [of RTW]. .It’d be good if someone said that to you, like ‘No, you’re not going to work. You’re first going to think about these questions. And when you’ve thought about them, and you’ve come up with some of your own answers, then we’re going to talk about that [RTW]. .Not all CSs recognized themselves in the contemplation stage. Some reported to have skipped this stage altogether, which could be due to personality  and/or coping strategies .I think I skipped this stage. I’m not much of a contemplator. .In my mind, I was already between stage four [Preparation Behavioral] and five [Uncertain Maintenance]: we’re just going to do it [RTW]. .how to RTW. Regarding intervention content, experts suggested using worksheets and diary exercises to gain insight into CSs’ current daily schedule, energy levels, and work-related capabilities and to compare those to  RTW goals. According to experts, RTW goal setting should be done in line with the occupational physician’s advice and input from the direct supervisor where applicable. Work tasks should be discussed with the aim of subdividing these tasks into more manageable, buildable ones that could be prepared for, for instance, occupational therapy. Next, experts mentioned that CSs should be encouraged to build on their current capabilities, instead of focusing on capabilities that might have been lost or (temporarily) diminished due to cancer treatment. To be able to RTW over time, experts advised that CSs’ capabilities, such as physical fitness and emotional resilience, should be expanded progressively at home . Other recommended strategies included information provision , verbal encouragement, and emotional validation. Experts emphasized the effort and energy it takes for CSs to (plan) RTW and the feelings of frustration and grief that this can bring about.In Preparation—self-evaluative, experts explained that CSs appeared to have made a favorable decision regarding RTW and to have focused their attention on gaining information on Am I still able to [work] – am I still the same? Do I still have the same amount of energy to do that in the same way as before? It’s quite nerve-wracking to do it [work] again. Like: ‘Can I still do it?’ And, of course, I still can […] But can I still do it in terms of energy? Can I gather the courage? Can I still deal with all of that input? […] I’ll have to experience that myself. No one can predict this for me. .In preparation—self-evaluative, CSs described seeking information to evaluate whether they were able to RTW and what RTW would look like . This evaluative process was often hindered by a lack of input from  professionals regarding the work-related impact of cancer treatment, confusion about where to find guidance, and fluctuating energy levels.Because work does fit [in your daily/weekly schedule], but then the rest [of daily life] doesn’t fit anymore. .Work on that very consciously: your energy levels. Not at work, but just at home. Like, what are you doing? Take a moment of rest. Then do something again. […] You have some instability, at least I do. Like on one day it’s okay, and then the other day it’s crap. […] That’s hard too. .CSs discussed the importance, in this stage, of gaining insight into their current activities, energy levels, and moments of rest, and to adjust their habits and schedule slowly, at home, to make space for future RTW.Guidance from supervisors, occupational physicians, and occupational therapists was thought to be helpful in gaining insight into the abovementioned aspects and in planning future RTW:Unravel the tasks that make up your job. Which elements are in that? .[In response] And also mirror that to where you’re at right now. […] If I can’t read at home, it’s realistic to assume that I can’t read at work either. […] But I am able to do other things. So […] you have to dissect and filter: I can do this, but I can’t do that yet. […] I think you mainly have to look at the possibilities, if you even get this far. Otherwise, you get completely discouraged. .With your supervisor, look at what’s possible regarding the tasks that you are able to do. […] What you’re aiming to take on [in terms of tasks]: are you able to do that? For that, I think you definitely need an occupational therapist. Because he can give you a bit more insight into your [energy] balance. .According to experts, CSs in preparation—behavioral sought practical guidance to plan and try out RTW. Experts noted that CSs had a tendency to aim for RTW too quickly in this stage , which was identified as a risk factor for sickness absence recurrence. Regarding intervention content, experts suggested collaboratively developing a concrete, yet flexible, RTW plan in this stage. This RTW plan should consider the needs and suggestions of the CSs, and, if applicable, the occupational physician’s and supervisor’s input. According to experts, CSs should be encouraged to plan their RTW in detail: how to prepare for their first day/week back at work, how to respond to colleagues, how (often) to communicate with their supervisor, which tasks to take up, for how many hours per week, and so on. Experts warned that trying out the RTW plan might lead to CSs encountering obstacles and setbacks. Therefore, experts suggested that RTW planning should be flexible that employers should be made aware of the necessity of this flexibility, that CSs need to be coached throughout the obstacles and setbacks, and that CSs’ successes should be celebrated. Finally, experts proposed that CSs get help or support to build their work-related self-efficacy, by learning and practicing various skills  that could be taught by, e.g., occupational therapists.Even though I had a very good relationship with my direct supervisor, well [he said]: ‘Look around a bit, have some coffee.’ Um, yeah, after a month of having coffee and looking around I thought ‘And now?’ .CSs described preparation—behavioral as a turbulent and energy-consuming stage in which they often RTW without the appropriate guidance. CSs described that employers and colleagues often had a well-intended “anything goes” attitude towards their RTW: CSs were welcome to determine their own working hours and work tasks. Although this was experienced as welcome freedom when initially returning to work, CSs mentioned that the continuance of this attitude led to stagnation in their RTW process, confusion about expectations, and frustrations due to the performance of menial tasks.I didn’t want any stupid little tasks. No. I did everything I could to get back to work and then to come back and do menial tasks like copying? [Indignant] Well, yeah, no. Absolutely not. […] I need a challenge to recover. .I told him [occupational physician] that I thought it was time for me to get back to work, or that I thought it’d be good for me. But for months now, we’ve been looking for things that I’d be able to do. […] I think he [supervisor] keeps looking for tasks that are similar to the work that I did before. And I’m thinking it’d be nice if that’s the end goal, but the first steps can be different. […] I just notice it’s so hard to explain how complex it actually is. .CSs expressed the need for concrete and personalized RTW planning. CSs experienced that  professionals involved in the RTW process often assumed to know what was best for them. CSs’ own perceptions of the situation, however, could differ greatly.He [occupational health expert7] said to me: ‘Maybe it’s too ambitious to go back to work now, but apply for volunteer work, have coffee with the elderly for one or two hours a week.’ With all due respect – because there’s nothing wrong with that – but we [supervisor and CS] walked out of there and my supervisor said: ‘I saw your face in there: we’re not going to do that. We’ll find another solution, because this way you’re actually taking another step back.’ .You notice it [work-related support] is very dependent on the person. I was also offered support from an occupational psychologist because I wanted to go [back to work] too fast. But I also think there are plenty of people who maybe need that little push. .The question is the same for everyone: ‘How do I develop a realistic [RTW] plan?’ That’s similar. The answer to that is just different for everyone. .Experts noted that CSs had a tendency of wanting to do too much, too quickly when they were recently back at work, e.g., working too many hours at once and taking on too many tasks. According to experts, this can lead to CSs getting frustrated, burnt-out, and relapsing into sickness absence. When CSs were recently back at work, experts explained that both CSs and their employers could struggle, because (1) a structured RTW plan might have been missing, (2) the plan needed continuous assessment and adjustment, and (3) the instability of the CS required open and strategic communication. Experts said that the “anything goes” approach mentioned in the previous stage is noticeable in uncertain maintenance too, as employers might be careful not to exert any pressure on the CS. In uncertain maintenance, experts recommended various intervention strategies to prevent sickness absence relapse: first, as in the previous stage: acknowledging and validating CSs’ efforts in RTW and being back at work and, next, allowing CSs to trial their RTW plan and assess and adjust it periodically. Related to this, experts mentioned educating the employer on the importance of their flexibility in the RTW and work retention process, and maintaining awareness of CSs’ energy expenditure and work/life balance, for instance with the help of an occupational therapist or reintegration consultant. Finally, teaching communication strategies to CSs and their employers to communicate expectations, needs, and support during this fluctuating time.You want this [being able to work] so much. But of course, you’re limited in what you can do. But you don’t want to admit that, at all, right? […] I really thought like, ‘Yeah, I can’t do anything anymore. I don’t know anything anymore.’ […] And that makes you very insecure. […] I thought I just had to be able to do and know it all immediately again. .In uncertain maintenance, CSs described a turbulent state of getting to terms with their “new normal” regarding reduced work ability and also wanting to do too much at once. CSs often wanted to prove that they were still a valuable employee that they could still do the work and contribute to the organization and their team. According to CSs, this could result in feelings of insecurity, guilt towards colleagues, work/life imbalances, fatigue, burnout symptoms, and sickness absence relapses.I thought I was ready to start doing things again physically, but cognitively I wasn’t feeling quite right yet. I was dealing with a lot of stress. […] The moment I felt a bit better physically, I thought I was on top of the world. […] I just wanted to do something. […] Someone should have said to me: ‘Slow down for now, you have to process some things and deal with that stress’. .During chemotherapy […] I worked on therapeutic basis.8 […] As per January 1st, I’m fully back at work. And it’s harder than I thought. A lot harder. .CSs suggested celebrating small successes to stay motivated during this turbulent time. They often felt they lost sight of how far they had come regarding RTW and needed an external party to remind them of their successes.Small wins, you know, your confidence builds through that and then you get into a more positive flow. At least that’s what you want. And that takes time. For me, that took a year before I was fully back at work. .[Your supervisor can say to you] ‘I’m so happy you were able to come today, you did well and I’ll see you the day after tomorrow.’ Like that. Clarity. .CSs also suggested utilizing collegial supervision to ensure they maintained their RTW and work retention plan, including limitations set on working hours and work tasks.My colleagues know that I always work overtime and at one point I said to them ‘Guys, it’s half past one, tell me to go home’. […] And they do. […] Before I relapsed [into sickness absence] I didn’t do that [listen to colleagues]. After I relapsed, […] I do listen to it. .According to CSs, informing colleagues of their current abilities, limitations, instability, and work-related needs was seen as necessary to align mutual expectations. However, CSs also noted that colleagues could feel anxious and uncomfortable around them. CSs suggested that by clearly communicating about (the consequences of) cancer, this discomfort could be alleviated. Both the CS and the employer could play a role in this communication.They [colleagues] didn’t have all the information and yeah, then I felt a certain resistance [from them] or something, like: ‘She’s there [at work], but actually we can’t count on her [to do the work].’ […] They [colleagues] often feel it’s [cancer] scary as well. .Experts described that CSs in proactive maintenance seemed to have found their foothold at work, though work retention could still be hindered by continued instability, changing energy levels, and long-term consequences and late effects of cancer treatment. For intervention content, experts suggested supporting CSs and their employers by providing information about the long-term consequences and late effects of cancer treatment on work ability , strategizing for when CSs might recognize these consequences and effects , maintaining awareness of energy expenditure and work/life balance , and maintaining periodic work assessments and long-term employer flexibility.CSs mentioned that they often felt unstable at work for a long time and that they often struggled to maintain a healthy work/life balance. According to CSs, learning to accept cancer-related changes in their lives, including changes in their work ability, characterized the shift from uncertain to proactive maintenance.With regards to cancer, how long does a process like that take? To feel like you can turn the page, instead of being in the middle of the chapter? I think that takes years. It’s a mourning process that isn’t just finished within a year. And your fear isn’t gone within a year. And your family also deals with cancer. That’ll all last for a while. .It’s only now [being back at work long-term] that you realize: ‘Oh right, I can’t do that anymore. Or, I do things differently. .[In response to above] Yeah, that’s part of the ‘old me’. .Accepting cancer survivorship as part of one’s identity was not important for every CS.It’s not for everyone. For instance, I’m still aiming to become my old self again. That’s just my goal. .Last, when CSs were back at work long term, they said lasting instability and changeable work ability needed to be evaluated and discussed periodically. According to CSs, aspects that should be discussed during these evaluations included, for instance, working hours, work tasks, energy levels, work/life balance, work satisfaction, and collegial communication.Periodic evaluations, I think, with the occupational physician. Just to ask how you’re doing along the way. […] You need room to still be instable. And boundaries […] when you want to go too fast, other people will [have to] hit the brakes for you. .[Interviewer in response to above]: How long do you think you’ll need that [kind of support]?When you’re back at work a little longer, [let] employers know that you can experience concentration problems and lack of energy in the long term too. .[In response to above] Lack of sleep. .[In response to above] Acknowledge the late effects. .[In response to the interviewer] My whole life, I think. .In exploring experts’ and CSs’ perspectives on the application of the behavioral change stages , 22 to wAlthough RTW and work retention of CSs have long been referred to as a complex process, only recently have researchers started to look deeper into and describe CSs’ progression through this process. It has become clear that this progression is stage specific , 18, 34 Another example concerns the managing of anxiety, overwhelm, and ambiguity towards RTW in the contemplation stage. Prior research has shown the complexity of making decisions regarding RTW , 13, 35.Although there are common factors characterizing each stage, in the current study, we highlighted the importance of personalized guidance. Within the TTM , there aTwo stage-overarching difficulties emerged from our Moreover, we learned that employers, occupational physicians, and colleagues play a crucial role in various stages of the RTW/work retention process. However, both experts and CSs indicated that supervisors often lack the know-how to guide CSs through this process confidently and appropriately. This is in line with prior research showing the impacts of supervisor support on successful RTW , 41, 42,To our knowledge, this is the first study explicitly applying behavioral change theory to the creation of concrete, stage-specific, intervention content for CSs seeking support in the RTW, and work retention process. Our Third, as occupational therapists and reintegration consultants have been chosen as intervention providers within the STEPS intervention program, our results may have been biased towards the role of these professionals in the RTW and work retention process of CSs. However, in all interviews and focus groups, the authors asked open-ended questions and encouraged participants to think of any  professional that might be suitable as an intervention provider.Conceptualizing work participation support for CSs along the behavioral change stages allows for (1) developing intervention strategies that address predictable stage-specific needs, barriers, and facilitators Table ; (2) addThe behavioral change stages provide a flexible framework along which to organize RTW and work retention support for CSs and allow room to further tailor intervention content to, e.g., cancer diagnoses, treatment modalities, prognoses, risk factors for unsuccessful RTW, and personal circumstances of CSs. Future research should evaluate the effectiveness of intervention programs that offer stage-specific support for CSs aiming to RTW or retain work. Our research team will do this in an upcoming randomized controlled trial: STEPS .Our results support the potential utility of organizing work participation support for CSs along the behavioral change stages. From expert interviews and focus groups with CSs, we have distilled stage-specific needs, barriers, and facilitators, which can be used to develop intervention content. Recommendations for such intervention content are presented. Organizing work participation support for CSs in this way provides a clear framework for  professionals involved in the RTW/work retention process of CSs and allows further tailoring based on, e.g., cancer diagnoses, treatment modalities, and personal circumstances of CSs.Supplementary file1 (PDF 171 KB)Supplementary file2 (PDF 17 KB)Supplementary file3 (PDF 352 KB)Below is the link to the electronic supplementary material.