2.1 Study Design

This study employed a qualitative design, utilizing descriptive phenomenological methods to explore the lived experiences of people who have experienced a stroke in relation to their RTW process. Data were collected through semi-structured interviews, enabling an in-depth exploration while allowing participants the flexibility to comprehensively express their perspectives.

2.2 Ethical Considerations

This study was approved by the Ethics Committee of Henan University School of Nursing and Health (HUSOM2021-288) and conducted in strict adherence to ethical guidelines and regulations, ensuring research integrity and participant rights.

2.3 Sampling Strategy

This study employed purposive sampling to recruit young and middle-aged stroke patients in the recovery phase from three communities in Zhengzhou City between December 2022 and July 2023. To ensure diversity, a maximum variation sampling strategy was also applied. According to WHO guidelines, stroke survivors with stable vital signs, consciousness and nonprogressive conditions are eligible for early rehabilitation, typically starting 10–14 days posthemorrhagic stroke. For this study, based on literature and expert consultations, the rehabilitation period was defined as ≥ 6 weeks from the most recent stroke event.

2.4 Participant Selection

A purposive sampling method was used to select young and middle-aged people who had experienced a stroke from three communities in Zhengzhou City, all of whom were in the rehabilitation period. A maximum variation sampling strategy was adopted to ensure a comprehensive and enriched understanding of the RTW needs of young and middle-aged stroke survivors. Inclusion criteria are (i) age range from 18 to 59 years, classified as young and middle-aged adults [20]; (ii) patients diagnosed with stroke confirmed by cranial CT or magnetic resonance imaging [21]; (iii) patients employed before the stroke who have not yet successfully returned to work; (iv) patients with adequate communication skills who voluntarily agree to participate in the interview. Patients who were unable to communicate or had other severe comorbidities were considered ineligible for inclusion in the study.

2.5 Data Collection

The interviewer served as the primary research instrument, utilizing audio recording equipment for documentation. The interview outline was developed based on a review of domestic and international literature and consultations with experts in cerebrovascular nursing. The questions included the following: (1) What does work mean to you? (2) What do you think is the impact of the stroke on your ability to work? (3) What factors do you believe will affect your RTW? (4) Do you need support in preparing for RTW? (5) What expectations and needs do you have from individuals, family, healthcare organizations or society? (6) What kind of support (informational, psychological, rehabilitative) would you like to receive, and from whom, in preparation for your RTW? What does work mean to you?

Face-to-face semi-structured interviews were conducted by two experienced researchers, each with over 10 years of expertise. Interviews, lasting 25–40 min, were held in hospital interview rooms or participants' homes. Recruitment was facilitated through study information posted on a community bulletin board, with interested participants contacting the researcher via phone or WeChat. Eligibility was assessed, and those meeting the criteria received an information sheet detailing the study's purpose, procedures and confidentiality assurances, with voluntary consent obtained. Interviews were flexible, guided by participant responses, and enriched by observations of non-verbal cues. Audio recordings ensured accuracy. Data collection continued until meaning saturation was reached, defined as no new themes emerging from additional interviews, aligning with Hennink et al.'s recommendations [22]. This iterative approach ensured a thorough understanding of the study's themes.

2.6 Data Collation and Analysis

Interview data were transcribed verbatim within 24 h and double-coded by two independent researchers to ensure reliability. Using Colaizzi's seven-step approach [23], the data were repeatedly reviewed to extract meaningful statements and generate codes. Core themes were synthesized by integrating patients' statements and identifying connections between themes. Credibility was enhanced through iterative comparison of coded data with original recordings and validation by some participants, incorporating their feedback to refine findings. Ambiguities were resolved through group discussions, ensuring consensus and consistency in the final results [24].

2.7 Rigour

To ensure study rigour, interviews were conducted by two experts with over ten years of interviewing experience, while two-stroke nursing specialists coded and analysed the data. All researchers contributed to developing the interview guide and refining coding results. Credibility was enhanced through member checking, allowing participants to validate identified themes and subthemes. Group discussions facilitated reflection on interview conduct and data analysis approaches. Additionally, all researchers received rigorous training in qualitative research methodologies, ensuring reliable execution and valid results.

3.1 General Information of Interview Subjects

The study included a total of eleven people who have experienced a stroke, comprising eight males and three females, with a mean age of 43.27 ± 7.79 years. Most participants had attained a high school education or higher, and the majority were married. The demographic details of the study population are summarized in Table 1.

3.2 Interview Data Analysis Results

The researchers conducted semi-structured interviews with 11 young and middle-aged people who had experienced a stroke. They organized, coded and extracted meaningful statements from the interview data to identify themes. Based on the results, the researchers summarized four main themes and 13 sub-themes regarding the work return needs and expectations of these patients: (1) self-management needs; (2) social support needs; (3) need for information related to returning to work; (4) personal development needs. The coding process and thematic framework diagram are shown in Table 2 and Figure 1, respectively.

3.3 Self-Management Needs

3.4 Social Support Needs

3.5 Need for Information Related to Returning to Work

3.6 Personal Development Needs

4.1 Provide Continuous Rehabilitation Care Guidance to Improve Disease Management

This study found that patients' ability to perform daily activities was significantly impacted by their residual symptoms, which in turn reduced their work adaptability and confidence in returning to work. These findings are consistent with previous research [25]. However, the majority of patients exhibit a positive attitude towards returning to work and actively strive to re-enter the workforce, demonstrating a strong need for effective self-management of their condition throughout the process. Post-stroke disease management requires comprehensive symptom monitoring and targeted guidance to enhance self-management skills. This includes the use of memory aids, strategies for fatigue management and functional limb exercises [26].

Some patients encountered interruptions in their rehabilitation programmes due to insufficient continuity of care guidance following discharge or challenges in personal adherence. Prior research has demonstrated a high demand for continuity of care among individuals who have experienced a stroke, which includes comprehensive disease education, medical rehabilitation training and access to professional support through community resources [19, 27]. Continuity of care services enables patients to receive consistent, high-quality rehabilitation guidance post-discharge, crucial for correcting adverse emotions and behaviours and improving health outcomes [28]. Zhou et al. [29] found that self-management programmes significantly enhance the social participation of stroke patients, particularly by encouraging active involvement in social, occupational and leisure activities. This, in turn, fosters greater independence and self-confidence. These findings suggest that well-designed self-management programmes can help patients regain functionality in their daily lives, thereby improving their quality of life and reinforcing their social roles. Furthermore, Lo et al. [30] proposed a nurse-led, community-based self-management programme aimed at supporting stroke patients in managing their rehabilitation process more effectively. By providing personalized health guidance, functional training and psychological support, this programme facilitates a smooth transition from the inpatient phase to community-based rehabilitation, thereby preparing patients for a successful RTW. Thus, patients require comprehensive and continuous nursing guidance to enhance disease management. Healthcare professionals should provide regular, intensive education and management post-discharge to maintain high levels of patient compliance [31].

In China, stroke patients face unique socio-cultural and systemic challenges, including limited access to continuous rehabilitation services and varying levels of health literacy. developing and implementing culturally tailored self-management programmes that address the specific needs of Chinese patients is of paramount importance. Such programmes can bridge gaps in rehabilitation services and significantly improve long-term outcomes. Therefore, advancing the development and application of self-management programmes in stroke rehabilitation—particularly those adapted to the cultural and systemic context of Chinese patients—has the potential to positively impact long-term recovery and reintegration.

In this study, with a focus on the RTW process for stroke patients, there is increasing evidence highlighting the potential of integrative medicine in post-stroke rehabilitation. Integrative medicine, which combines the strengths of both Western medicine and traditional Chinese medicine (TCM), has been shown to promote comprehensive rehabilitation through individualized treatment plans, thereby facilitating a successful RTW. Systematic reviews and meta-analyses have demonstrated that the integration of Western and TCM approaches, particularly in motor function recovery, pain management and emotional regulation, can effectively assist patients in overcoming the physical and psychological challenges associated with returning to work [32]. Given that returning to work is a complex, multi-stage process, further exploration of the application of integrative medicine is warranted to enhance the quality of care and long-term rehabilitation services for stroke patients. This is particularly relevant in helping patients adapt to the work environment, improve their work capacity and manage occupational stress. investigating how integrative medicine can be more effectively incorporated into clinical practice may ultimately facilitate a smoother and more sustainable RTW journey for stroke survivors.

4.2 Foster a Supportive Social Environment to Enhance Emotional Support

The interview results indicated that patients seek support from multiple sources, and external social support can foster positive emotions and encourage individuals who have experienced a stroke to adopt a positive outlook, thereby facilitating their RTW, This aligns with prior research findings [33]. Given the prolonged nature of the rehabilitation process and the diverse emotional needs of stroke survivors, it is advisable to enhance the integration between patients and various support systems. This approach will maximize the benefits of external social support and increase patients' motivation to RTW. In the prolonged process of returning to work, Family members and friends should actively engage in the patient's preparation for returning to work by offering encouragement, supervision and reminders, helping the patient better navigate the challenges encountered during the process. Providing primary caregivers with a systematic understanding of post-discharge care and guiding them to ensure the patient adheres to their rehabilitation exercise programme on schedule can significantly accelerate recovery and facilitate a return to normal life. Medical staff should maintain timely communication with patients to understand their internal needs and provide essential emotional support and assistance. Tailored to individual needs, healthcare professionals can deliver disease education, rehabilitation care and strategies for symptom management to both patients and caregivers, while establishing a multi-platform care service model to enhance the continuity and effectiveness of care, promoting a smoother and more comprehensive recovery process.

Whilst the interview findings suggest that patients wish for employers to demonstrate understanding and support for stroke survivors by proactively adapting the work environment and workload or identifying suitable job roles, implementing these measures in practice can be challenging. This process often requires support from multiple sources, including greater awareness, organizational commitment, and access to external resources. To overcome these challenges, strategies such as targeted workplace education, training programmes and the development of support networks can help employers and colleagues better understand and address the needs of stroke survivors, fostering a more inclusive and supportive work environment [34]. Additionally, stroke survivors can benefit from peer support; establishing patient exchange meetings can offer a platform for collective emotional release, communication, peer encouragement, information sharing and the provision of role models from individuals who have successfully returned to work [35]. The state and society should also increase their attention to stroke survivors by enhancing public awareness and promoting the disease, thereby enabling patients to access more welfare resources and support through various public welfare platforms. Therefore, establishing a comprehensive social support network is essential to address the emotional support needs of patients and to assist them in returning to work more effectively.

4.3 Provide Abundant Information Support to Enhance the Ability to RTW

It was found through the interviews that the participants expressed a desire for information regarding retraining, such as the optimal time to RTW, retraining programmes, job search opportunities and legal and welfare policies, accessible through various channels. Currently, most domestic discharge guidance for patients recovering from stroke focuses on disease-related health education and lacks vocational retraining content [36]. Given the individualized variations in information needs among stroke survivors, the internet represents an effective medium for acquiring information related to job searches, legal matters and welfare policies. However, considering that some patients may face challenges in utilizing digital technology, it is advisable to employ a combination of electronic and nonelectronic means [37]. Healthcare professionals can offer information support in various forms, including reinforcing verbal education, providing manuals on job search skills, evaluating the ability to RTW and offering guidance via video and telephone. Furthermore, inadequate communication and coordination among hospitals, rehabilitation units, employers, communities and social insurance companies have been identified as factors reducing the rate of patients' RTW. These stakeholders often lack understanding of patients' health conditions, making it challenging to accurately assess their ability and need to work, aligning with the findings of the interviews in this study [38]. Hence, it is essential for stakeholders to enhance cooperation to maximize the use of existing resources. This can be achieved by consolidating patients' illnesses and occupations for unemployment registration, establishing a comprehensive and systematic information platform for returning to work, regularly disseminating recruitment information and publicizing re-employment policies and regulations. These efforts can help patients stay informed about the latest job opportunities and policies, enable stakeholders to understand patients' situations, and meet their diverse information needs. This approach facilitates the connection of information, management and relationships among hospitals, communities, families and employers.

4.4 Acquire New Job Skills to Enhance Self-Worth

Most patients perceived work not merely as a means of earning a livelihood but as a platform for social engagement and a means of demonstrating their self-worth, particularly for younger individuals. Some patients proactively sought to enhance their employability by acquiring new skills or exploring career paths better aligned with their post-stroke capabilities. This often involved participating in vocational training, learning to utilize assistive technologies, or commencing with part-time employment to gradually acclimate to the demands of the workplace. These findings suggest that stroke survivors view the process of returning to work as a pivotal step in re-establishing their independence and self-esteem, an enhanced sense of self-worth appears to play a critical role in fostering their motivation to reintegrate into the workforce. Research indicates that involving people who have experienced a stroke in volunteer activities can be mutually beneficial for patients and service recipients [39]. This engagement can help patients gradually rebuild their work skills, develop teamwork and communication abilities, and prepare for full-time or part-time employment while also contributing to society and discovering their own value. However, implementing this practice necessitates addressing practical challenges, such as organizing volunteer opportunities, providing adequate training and encouraging patient participation. Additionally, negative public attitudes toward individuals who have experienced a stroke can adversely affect their willingness to RTW [25]. To counteract these issues, it is essential for the government, in collaboration with the media, to educate the public about the needs of stroke survivors. Efforts should be made to enhance understanding, shift public perceptions, foster a societal culture that is supportive and respectful of stroke survivors, and ensure equitable employment opportunities for them. Additionally, some patients may be unable to resume their previous jobs due to physical limitations post-stroke, necessitating the acquisition of new skills. Community rehabilitation centres play a crucial role in this process. Communities should enhance their organization of employment guidance, allocate dedicated employment guidance personnel, offer diverse vocational rehabilitation skills training and provide tailored skills training courses for patients with varying needs. To further improve re-entry rates, community support services can be integrated with medical rehabilitation centres to streamline services.

4.5 Limitations

This study has several limitations. First, the exclusion of individuals with aphasia limits the understanding of the specific needs of this group. Second, despite efforts to ensure sample diversity, a gender imbalance persisted, particularly with a lower representation of female participants, which may have influenced some of the study's conclusions. In traditional Chinese culture, men are typically viewed as the primary breadwinners, which may contribute to a higher likelihood of men returning to work after illness. Conversely, women are often expected to assume primary caregiving roles within the family, which may explain the underrepresentation of female participants in the study. Additionally, the perspectives of employers, family caregivers and healthcare professionals were not incorporated, which may have affected the comprehensiveness of our understanding of care needs. Finally, since the study was conducted in Zhengzhou, the capital city of Henan Province, the fast-growing economy and high cost of living may exert considerable pressure on patients to RTW sooner. However, Zhengzhou's well-established healthcare and rehabilitation resources may provide greater support, thereby enhancing patients' confidence and increasing the likelihood of their RTW.