Until recently, there was no guidance for oncology nurses and other health care professionals on various components of the return to work (RTW) journey for patients post stem cell transplantation (SCT). Post-SCT survivors have lower RTW rates because of numerous conditions, such as fatigue, anxiety, physical limitations, and graft-versus-host disease (GVHD) complications—particularly chronic GVHD. Oncology nurses have a crucial role in all phases of the SCT continuum in facilitating conversations and helping survivors develop an RTW plan.
American Society for Transplantation and Cellular Therapy (ASTCT) RWT Guidance
In a study of 45 national and international SCT centers, 87% of respondents agreed that RTW was a problem for most of their post-SCT survivors, and only 36% of the centers have an RTW program. To develop RTW guidance, the ASTCT formed an interdisciplinary guidance committee. Critical members included a physical therapist who had developed international PT guidelines for post-SCT survivors and an occupational therapist who was instrumental in developing the Anthony Nolan Foundation’s extensive RTW support in the United Kingdom. As a result of the committee’s work, they offer RTW recommendations in each phase of the SCT process. In addition, since nurses in all areas of SCT spend the most time with survivors, they can advocate for the patient along their RTW journey.
- Pre-transplant Phase
Oncology nurses can learn about patients’ jobs or those of other household wage earners. They can encourage patients to discuss their concerns with the clinical social worker about how the SCT may affect their ability to work or provide for their family. Oncology nurses can encourage patients to discuss their RTW goals with their referring oncologist and transplant physician. Evidence suggests that these discussions help cancer survivors successfully return to work.
Furthermore, oncology nurses can empower patients by connecting them with the interdisciplinary team member (often a clinical social worker or financial counselor) who can help patients understand their disability benefits. For example, cancer survivors often need assistance understanding their legal rights, short-term or long-term employment benefits, and other benefits.
Of utmost importance is for patients to optimize their physical fitness during the pre-transplant phase. Good pre-SCT fitness levels are associated with better post-SCT physical fitness and less fatigue. Since decreased physical strength and fatigue can hinder RTW, oncology nurses can do an overall assessment with early intervention to facilitate a referral to PT and OT.
- Transplant Phase
During the transplantation period of Day 0-Day +100, oncology nurses are vital in helping the patient maintain physical activity. Many transplant centers integrate PT early in the SCT process with a best practice example of integrating physical medicine and rehabilitation (PM&R) professionals into the SCT team.
To establish a baseline, PT/OT assesses the patient before admission to the hospital and then begins therapy upon admission. PT, OT, and therapeutic recreation professionals may be part of the PM&R services. If patients have no signs of bleeding, they can modify therapy during thrombocytopenic precautions or changes in their condition, such as GVHD complications.
During the first 3 months, regular communication with the employer and coworkers is critical, as patients who communicate more frequently are more likely to RTW and return to their previous position. In addition, oncology nurses can encourage patients to ask if anything has changed that might affect their status as an employee on medical leave, including any changes to their health insurance. Coach them with wording like, “I am unsure of my RTW, but I can keep you updated. How often do you want me to update you?”
- Post-transplant Phase
The post-SCT phase (Day +100 and beyond) can be the most challenging for RTW decisions for patients with GVHD. Oncology nurses can collaborate with the interdisciplinary team to help determine patients’ physical, cognitive, and emotional readiness for RTW. The ASTCT RWT guidance suggests an extensive, comprehensive team evaluation of patients’ work readiness. Relying on patients’ self-reports of preparedness may result in an unsuccessful, too-early RTW.
In addition to the survivors’ readiness, the assessment must include the workplace’s preparedness to ease the RTW transition. Since the Americans with Disability Act stipulates that “employers are required to make reasonable accommodations” to support cancer survivors’ RTW, oncology nurses can encourage patients to discuss specific details with the social worker.
Although there are no specific RTW guidelines for patients with GVHD, there are now RTW recommendations from ASTCT. The key to success is ensuring that patients dealing with GVHD know that their health and circumstances may change, so their RTW plan must remain flexible. Early RTW conversations are vital when assisting patients in examining their work goals and considering work modifications for successful reintegration into the workforce. In this way, oncology nurses can support patients throughout the different phases of the SCT journey.
Return-to-Work Guidelines and Programs for Post-Hematopoietic Cell Transplantation Survivors: An Initial Survey
American Society for Transplantation and Cellular Therapy Return to Work Guidance Committee Recommendations for Health Care Providers Who Take Care of Hematopoietic Cell Transplantation Patients