This qualitative study was a part of the development phase of a complex intervention following the updated Medical Research Council framework [40] regarding work-oriented rehabilitation. A qualitative interview design was chosen to gain an in-depth understanding of stakeholders’ experiences and perceptions of cancer survivors’ RTW process. Semistructured interviews were conducted with 25 stakeholders representing various roles in the RTW context during spring 2023. The qualitative interview approach provided flexibility and allowed participants to elaborate on issues of personal and professional relevance [41].

Sample participants were recruited using purposive sampling to ensure variation in characteristics, geographic locations, and work settings (specialized care, primary care, and public and private sector). Purposive sampling involves the intentional selection of information-rich cases to capture diverse experiences related to the studied phenomenon [42]. The sampling aimed to capture variation both between stakeholder groups and within groups comprising multiple roles. For example, the health care professional group included several relevant clinical disciplines (physicians, nurses, occupational therapists, and physiotherapists). The sampling strategy also reflected the stakeholders commonly involved in RTW processes for cancer survivors, resulting in higher representation of health care professionals and representatives from the Swedish Social Insurance Agency, while representation from Employment Agency officers was more limited (n=1). Rehabilitation coordinators were included as one of several stakeholder groups; however, the study was not designed to specifically examine their role but rather to explore facilitators and barriers to RTW across multiple stakeholders.

Participants represented 3 regions in central Sweden, involved in a larger research program developing an intervention to support cancer survivors’ RTW. Stakeholders included health care practitioners (registered nurse, occupational therapist, physician, counselor, and rehabilitation coordinator), social insurance officers, employment service agency representatives, and first-line managers from private and public employers. Selection was based on experience supporting cancer survivors in maintaining or returning to work during cancer treatment. Inclusion criteria were employment within a stakeholder group relevant to RTW processes (ie, health care professionals, social insurance officers, employment service officers, social workers, or first-line managers) and experience of supporting cancer survivors in RTW. No specific exclusion criteria were applied; however, all participants were required to be able to participate in an interview conducted in Swedish. The study followed COREQ (Consolidated Criteria for Reporting Qualitative Research) [43].

The study was conducted within the Swedish RTW system, a tax-funded framework involving health care services, employers, and the Swedish Social Insurance Agency. Employers provide sick pay during the initial 2 weeks of sick leave, after which the Swedish Social Insurance Agency assesses work capacity, administers benefits, and coordinates rehabilitation in collaboration with health care providers. Employers are also responsible for workplace-based rehabilitation, while additional support, such as rehabilitation, may be provided by the Swedish Public Employment Service (Act no. 2019:1297).

RTW processes typically involve ongoing interaction between these stakeholders, where health care providers assess work ability, employers implement workplace adjustments, and the Social Insurance Agency coordinates measures and monitors eligibility for benefits. For individuals with cancer, the system includes specific regulations and coordinates efforts intended to support a gradual and individualized RTW process, although the level of coordination may vary.

A study coordinator recruited participants in 2 stages. First, brief study information was emailed to key organizational contacts relevant to the study, who were asked to forward the invitation to potential participants. Interested individuals contacted author SLF for further information. Subsequently, comprehensive information was provided, eligibility criteria were verified, and participants were informed about the purpose of the study. Initially, 26 individuals expressed interest in participating; however, 1 participant withdrew prior to the interview due to personal reasons, resulting in 25 completed interviews. Participants provided informed consent and, immediately before the interview, completed a brief web-based survey describing their demographic characteristics (Table 1). Participants’ age ranged from 39 to 65 years, and those who were employers had between 8 and 46 employees (median 43).

The authors SLF, LE, PF, and MF interviewed the stakeholders individually, one-on-one in a video meeting. The interviewers comprised a district nurse, an occupational therapist, and 2 oncology nurses; 3 were women and 1 was a man. The interviewers had both professional experience in clinical cancer care and experience in conducting qualitative interviews. A semistructured interview guide was followed (Textbox 1), asking follow-up questions as needed to deepen or expand responses, in line with qualitative interview methodology [41]. Interviews were audio-recorded, lasting between 20 and 71 minutes (median 42 minutes).

According to Elo and Kyngäs [45], the interviews were transcribed verbatim and analyzed using qualitative content analysis. Initially, transcripts were read several times by authors SLF, KW, and MF to gain familiarity. No dedicated qualitative analysis software was used. Instead, data were managed in Microsoft Excel to organize transcripts, track codes, and collate categories. Data handling followed strict standards of integrity and confidentiality.

Transcripts were evenly distributed among these authors, who independently extracted meaning units relevant to the study aim and generated initial categories and subcategories. Subsequently, these authors collaboratively reviewed their analyses, refined categories and subcategories, and reached consensus on findings. All 25 interviews were analyzed as a single dataset. No separate analyses were conducted by stakeholder groups; instead, themes were developed based on patterns identified across the entire material. During coding, sector-related nuances were noted and considered in the interpretation, but no formal comparison between stakeholder groups was performed. An example of the analytic structure is illustrated by the data unit “Most people want to work. I have to say it’s an extremely exciting experience working with people, that everyone is so eager to get back to work. I think so.” which was coded as “Most people want to work,” grouped into the subcategory “Desire to work,” and further abstracted into the category “Emotional significance of work.” Trustworthiness was ensured through analyst triangulation to enhance credibility and reduce interpretative bias [42]. Dependability and confirmability were supported through transparent documentation and regular discussion within the research team [46]. Reflexivity and methodological transparency were emphasized to strengthen credibility and transferability, in line with qualitative research standards [41]. The research team included members with backgrounds in nursing, health-related research, and occupational therapy, which contributed to multiple professional perspectives during data interpretation. Reflexive discussions throughout the analytic process increased awareness of potential preunderstandings and supported interpretative rigor.

The study was approved by the Swedish Ethical Review Authority (registration numbers 2022-03686-01, 2023-05671-02) and conducted in compliance with the Declaration of Helsinki (World Medical Association, 2013). Informed consent was obtained from all participants. Participants did not receive any financial or material compensation for their participation.

Barriers and facilitating factors regarding RTW were identified not only in the individual adaptations made by cancer survivors but also in cooperation among stakeholders. Structural issues, including financial obstacles and sick leave regulations, also influenced RTW outcomes. Highlighted factors promoting work-related well-being were flexibility and personalized adaptations. Categories and subcategories are presented in Table 2.

The interviews revealed not only a strong desire for more developed and improved collaboration among stakeholders but also a lack of awareness about available support and confusion over roles and responsibilities. Stakeholders emphasized the need for a structured collaboration plan to clarify roles and enhance teamwork. This, according to them, would facilitate collaboration and ensure that each party had a clear understanding of their respective roles and responsibilities.

The stakeholders reported that a flexible RTW approach was required to facilitate cancer survivors’ RTW process during and after cancer treatment, where tasks were adapted to cancer survivors’ abilities and needs. They said the process can be compared with a balancing act that requires continual adjustment in how it is set up.

One area the interviewees felt had worsened concerned the structural barriers that could arise in connection with RTW. Among other things, they thought that regulation of working hours for RTW was a problem. They also pointed to the financial situation that could arise when employees wanted to return to work but for various reasons were unable to perform their regular tasks, as this could lead to increased costs. Furthermore, they stressed that lack of qualified access was an obstacle to creating a “smooth” RTW process.

In the interviews, stakeholders on the labor market emphasized that, in several respects, individual conditions affect RTW. They said that this was a matter of providing support, having empathy, and calibrating when a push is needed to help the individual summon up the strength or courage to return to work. It is also about helping the individual feel included in the social interaction that a workplace can provide.

In several interviews, stakeholders on the labor market described how individuals’ experiences and attitudes toward returning to work are, in many respects, based on emotions. This included the feeling of wanting to work and the social interaction that work can provide. Several concerns were also raised, such as the fear of working or not having the strength to do so.

This study underscores that the RTW process for cancer survivors is a complex and multifaceted challenge, requiring coordinated efforts across the health care, insurance, and employment sectors. The interview findings reveal several key factors that act as either facilitators or barriers to successful RTW. Notably, the significance of interdisciplinary collaboration, clearly defined roles and responsibilities, and flexible support structures emerged as critical areas with considerable potential for improvement. However, these areas also pose challenges due to the different perspectives and priorities among stakeholders.

Building on this overall complexity, the findings underscore the need for enhanced collaboration and clearer role definition within the RTW process for cancer survivors, and in the planning of future RTW interventions. Despite a shared consensus among stakeholders to support individuals in their transition back to work, systemic barriers such as siloed organizational structures, ambiguous responsibilities, and insufficient communication were perceived to impede effective coordination. Similar challenges have been noted in other contexts. Svärd et al [38] observed that stakeholders in RTW processes for individuals with common mental disorders often operate under competing goals and ambiguous mandates, leading to fragmented efforts. In this study, stakeholders expressed expectations of other actors while remaining uncertain about their own responsibilities. This finding is noteworthy given Sweden’s rehabilitation coordinator role, designed to support individuals on sick leave and facilitate coordination among stakeholders, including health care professionals, employers, and social insurance officers. Strengthening the mandate and visibility of these coordinators may therefore improve coordination outcomes, and comparable roles could be valuable in other national contexts. Désiron et al [39] likewise emphasized that such coordinators can provide tailored support, maintain continuity, and help bridge gaps between stakeholders.

The reported lack of coordination and cooperation between stakeholders may be linked to how rehabilitation coordinators have been implemented in Sweden. Although such functions have been introduced and are present in many settings, previous research has indicated that their role is not yet consistently established or fully integrated into RTW processes [32,33]. Barriers such as unclear mandates, variable recognition among stakeholders, and limited resources may restrict their ability to fulfill their intended coordinating function [32,33]. This may partly explain why participants in this study continued to describe persistent gaps in coordination.

More broadly, previous research has emphasized the importance of facilitators in changing processes [1]. Strengthening collaboration and clarifying the division of responsibilities among stakeholders are essential for ensuring a smoother RTW experience. For instance, Lau et al [36] highlight that siloed health care systems impede information exchange and collaborative evidence generation, ultimately undermining patient outcomes and system efficiency. The lack of integration among health care providers, social insurance agencies, and employers results in duplicated efforts, delayed interventions, and increased frustration among professionals. In our study, participants consistently emphasized the importance of teamwork and interprofessional collaboration. This statement aligns with findings from Désiron et al [39], who advocated for a dedicated RTW coordinator to improve work-oriented rehabilitation interventions. In a previous interview study by Bilodeau et al [37], employer representatives’ perspectives on supporting breast cancer survivors in their RTW process were explored. These findings closely align with stakeholders’ perceptions in our study, reinforcing the notion that collaboration challenges, unclear responsibilities, and communication barriers are prevalent across contexts. The highlighted issues of stakeholder collaboration reflect our observations regarding fragmented efforts and unclear mandates.

In addition to these coordination challenges, stakeholders perceived that structural barriers, such as financial challenges and sick leave regulations, must be addressed when promoting cancer survivors’ RTW. Financial constraints often discouraged employers from accommodating employees who were not fully productive, reflecting the findings of Fitch and Nicoll [47], who identified reduced income as a significant adverse consequence for cancer survivors. Financial difficulties are often associated with increased psychological distress and reduced quality of life [48].

Employers frequently struggled with balancing economic considerations by providing suitable workplace adjustments, resulting in conflicts, redeployment, or even unemployment for cancer survivors. The complexity and inflexibility of sick leave regulations were also identified as critical issues. Cancer survivors faced significant administrative burdens when adjusting their sick leave arrangements, particularly regarding rules that mandated even distribution of working hours across the week. Such rigid regulations often discouraged survivors from attempting gradual RTW, potentially prolonging full-time sick leave unnecessarily. To address these barriers, simplifying sick leave regulations and providing clear, adaptable guidelines are essential. Additionally, introducing financial incentives for employers who facilitate flexible and partial RTW arrangements could encourage greater inclusivity and reduce economic pressures. These measures could significantly enhance the feasibility of accommodating cancer survivors in workplaces, promoting healthier, sustainable RTW.

Our findings underscore the importance of tailoring work conditions to cancer survivors’ individual needs during RTW. Key supportive factors were flexible, personalized arrangements; gradual workload increases; remote work options; and adaptable schedules. Limited, nonpressured testing of work capacity was particularly valued for balancing health and rebuilding confidence. Stakeholders across professions emphasized individualized support, reflecting the complexity of recovery. This aligns with López-Faneca et al [35], who highlight the value of personalized RTW programs, and Bilodeau et al [37], who emphasize humanistic management and flexibility. They also stress the importance of addressing unclear responsibilities and expectation gaps, as these may hinder coordination. Together, these findings underscore the need for structured measures such as clear communication, emotional support, respect for privacy, and tailored interventions. Overall, our findings reinforce the need for individualized, flexible, and coordinated RTW approaches to promote recovery, sustainable employment, and workplace inclusion.

Beyond workplace adaptations, stakeholders considered cancer type, health status, treatment duration, and family circumstances as influential for cancer survivors’ motivation and ability to return to work. Personal attitudes, expectations, and the emotional meaning of work were also emphasized. A workplace where individuals feel included and not defined by illness was viewed as essential, and encouraging workplace contact and inclusion was seen as an important aspect of stakeholder support, aligning with reviews indicating broad consensus that RTW should be encouraged when health permits [49]. Stakeholders further highlighted health-promoting factors, such as social belonging and adjusted workload, as important for sustainable RTW. This is in line with a previous review evaluating the importance of personal and social factors to sustainable RTW after ill health due to mental disorders or musculoskeletal disorders [34]. Furthermore, stakeholders stressed the need to gently give cancer survivors a push back to work, always with the cancer survivors’ well-being in mind. One study showed that strengthening people’s self-efficacy regarding RTW is an important factor for successful and more rapid RTW [50]. Earlier research has also shed light on the perceived importance of maintaining contact with work during sickness absence [51]. However, uncertainty about when to initiate communicating with employees and the fear of exacerbating cancer survivors’ condition by making contact were described by stakeholders in earlier research and perceived as barriers to RTW [51].

Extending these findings, the results showed that stakeholders clearly perceived that RTW can promote multiple dimensions of well-being for cancer survivors on sick leave. Social benefits include reestablishing connections with colleagues, a sense of belonging, and receiving collective support, while economic benefits involve transitioning from sick leave benefits to earned income. This multifaceted value of RTW is an important finding in this study. However, stakeholders may need to consider that RTW can serve as a coping mechanism for managing existential reflections associated with a potentially life-threatening illness. The transition back to work can help survivors regain a sense of normalcy and control [52], yet it may also mask underlying emotional distress [53]. Research shows that cancer survivors often experience heightened anxiety and depression after treatment ends, partly due to reduced contact with health care providers and lingering fears of recurrence [13]. These psychological challenges can be exacerbated in cases where recovery is delayed or complicated, increasing the risk of emotional setbacks. Therefore, RTW interventions must address both physical and emotional dimensions of recovery [35] and involve stakeholders not only from the health care and the Social Insurance Agency but also from employers, who are generally not involved in developing RTW interventions [54].

Taken together, these findings are in line with previous research on RTW across a range of chronic conditions [7,25,34], which consistently highlights the importance of coordination, communication, and role clarity among stakeholders involved in the RTW process [20,38]. Similar barriers, such as fragmented responsibilities, limited collaboration between organizations, and challenges in navigating complex systems, have been described in studies of other chronic disorders [36,50,54], suggesting that many of the identified themes reflect more general structural and organizational challenges in RTW processes.

At the same time, some aspects appear to be more specific to cancer. These include the unpredictability of the disease trajectory [9,53], the impact of treatment-related side effects such as fatigue and cognitive impairments [13,20,52], and the need for flexible and individually adapted RTW processes over time [10,21]. Such factors may place additional demands on both coordination and workplace adaptations and highlight the importance of addressing cancer-related needs within RTW interventions. Taken together, these findings suggest that while several barriers and facilitators are shared across diagnostic groups, effective RTW support for cancer survivors also requires attention to condition-specific challenges [22,34].

The findings also align with the model by Feuerstein et al [20], which emphasizes the need to tailor rehabilitation to the individual cognitive and emotional resources of cancer survivors and to the contextual demands they face. Although the analysis was inductive and not theoretically driven, the results underscore the importance of coordinated, individualized support across multiple systems. The complexity of the RTW process—requiring interdisciplinary collaboration, clearly defined roles, and flexible support structures—reflects the view of Feuerstein et al [20] that effective rehabilitation must integrate both personal and structural factors. Framed within this model, the study advances understanding of how rehabilitation practices and policies can better support survivors’ transition back to work.

Finally, the findings of this study have also informed the development of a planned intervention. In particular, the identified challenges related to coordination and communication suggest a need to strengthen structured collaboration between stakeholders. The importance of role clarity highlights the need to define responsibilities more explicitly within the intervention. Furthermore, the identified need for individualized and flexible support indicates that the intervention should allow for adaptation to individual circumstances and changing needs over time. Finally, the findings underline the importance of addressing both workplace-related and health care–related aspects within a coordinated framework.

The study has several strengths, including the methodological approach, which was considered appropriate for understanding and describing perceptions. In addition, a purposive sampling strategy and multiregional representation ensured broad stakeholder perspectives and increased contextual diversity and potential transferability. The sample size was considered sufficient, reflected in the rich interview data. One explanation could be the use of a fictional case during semistructured interviews. This may have helped the participants reflect on realistic scenarios, while the semistructured format allowed for depth in responses. One limitation of the study is that some stakeholder groups were underrepresented, which may have limited the diversity and comprehensiveness of perspectives.

The sample comprised fewer participants from the Employment Service Agency compared with other stakeholder groups, which may limit the depth of insights from this sector. However, this may reflect the limited involvement of this stakeholder group in RTW processes for cancer survivors within the Swedish system. Nevertheless, the sampling strategy was designed to maximize variation across key roles rather than to ensure equal group sizes, and we gathered substantial input from representatives in health care, social insurance, and employer organizations. Moreover, stakeholders were asked about cancer survivors as if they were a homogeneous group. This may be a limitation, because although rehabilitation and the conditions for RTW after cancer vary depending on the cancer diagnosis and severity, the tasks to be performed at work also vary.

A further limitation of the study is that the study did not specifically investigate stakeholders’ experiences of rehabilitation coordinators or their expectations regarding this function. Given the ongoing implementation of coordination efforts, future research should examine how rehabilitation coordination is perceived and how it can be further developed to support RTW processes.

In addition, cancer survivors were not included as participants. As key actors in RTW processes, their perspectives are essential for a comprehensive understanding. However, the study was designed to focus on stakeholders in working life, and the findings should be interpreted in light of this scope. Previous studies by our research group have explored cancer survivors’ perspectives, which complement the present findings.

Building on these findings, a clearer definition of roles and shared responsibilities among working-life stakeholders is essential to effectively support the RTW process among cancer survivors. Flexibility within the RTW process is crucial for enabling individuals to resume work at their own pace, facilitating their transition out of illness-related isolation, and promoting social interaction with colleagues. These are important aspects to consider in future policy development, interventions, and support measures. Additional research is needed to explore cancer survivors’ personal RTW experiences, with the goal of obtaining a more comprehensive understanding of the factors that influence the RTW process. To support interpretation and guide future research, Table 3 summarizes the implications of the findings for the Swedish RTW system.

This study highlights strategies that facilitate a successful RTW process among cancer survivors from the perspectives of working-life stakeholders. The findings underline the importance of individualized and tailored support, as well as the need for clear policies to guide stakeholders’ roles and responsibilities. Clarifying the rehabilitation coordinator’s role in improving stakeholder cooperation, and enhancing knowledge of cancer survivors’ specific workplace needs, can collectively facilitate a smoother and more sustainable RTW transition.