Work after breast cancer: Identification of cognitive difficulties using the Perceive,Recall,Plan,and Perform (PRPP) System of Task Analysis

Abstract

Introduction

Few ecologically valid assessment tools are available for occupational therapists to evaluate the cognitive demands and performance of women with breast cancer in the workplace. This study aims to identify difficulties in work-related cognitive strategy use experienced by women with breast cancer using the Perceive, Recall, Plan, and Perform (PRPP) System of Task Analysis.

Method

Deductive content analysis was used to code secondary data from 10 interview transcripts involving women who had breast cancer and experienced difficulties in everyday cognitive functioning after treatment. Thirty-four PRPP cognitive strategy items were used as pre-determined codes in a secondary analysis to identify and quantify specific cognitive difficulties described by the women.

Results

The 10 women experienced problems with work tasks that required the cognitive strategies related to the ‘programming’, ‘continuing’, and ‘attending’ processing categories of the PRPP system. In addition, the women demonstrated strengths in their capacity to evaluate their own thinking and performance.

Conclusion

This pilot study indicated the need for further research to determine how cognitive impairments which may occur after breast cancer treatment impact on occupational performance in a complex work environment. The PRPP System of Task Analysis was identified as a potentially useful measurement and interview tool for this purpose.

Keywords

Breast cancer cognition return to work

Introduction

Resuming work is seen as a crucial milestone after breast cancer (Duijts et al., 2014; Munir et al., 2010). However, many women report ongoing cognitive problems which impede return to work (Player et al., 2014). Associated self-confidence and job security issues arise when work performance is impacted by cognitive impairment (Becker et al., 2015). There are few ecologically valid assessment tools (Nelson et al., 2014) which occupational therapists can use to evaluate the cognitive demands of women with breast cancer during work performance (Newman, 2013), enabling return to work interventions to be planned. This pilot study used the Perceive, Recall, Plan, and Perform (PRPP) System of Task Analysis (Chapparo and Ranka, 2014) to identify difficulties in work-related cognitive strategy use experienced by women with breast cancer.

Literature review

Breast cancer and work

The survival rate for women with breast cancer is now 5 to 10 years, making the ‘survivorship’ phase an important consideration in the continuum of return to everyday activities. Women with breast cancer have identified returning to work as a significant stage in their recovery (Munir et al., 2010). While it is estimated that 60% of cancer survivors are of working age (Oberst et al., 2010), there is little information about how cancer and related treatments impact on return to work. Diminished quality of work, as well as a reduction in quantity of work, have been suggested, leading to absenteeism, presenteeism, performance management, problems working with colleagues, early retirement, and termination of employment or resignation (Boykoff et al., 2009).

Despite research showing that breast cancer survivors score significantly lower in the cognitive domains of executive functioning, working memory, and divided attention, than non-cancer controls (Lindner et al., 2014), female breast cancer survivors report frustration at the lack of acknowledgement that they receive from many health professionals when they report cognitive difficulties (Becker et al., 2015; Player et al., 2014). They report that their work performance is affected by physical (fatigue, reduced upper limb function, and sensory discriminations) (Tager et al., 2010), psychological (anxiety, distress, and depression), and cognitive difficulties (Boykoff et al., 2009). Specific cognitive difficulties include reduced attention, memory, concentration, multi-tasking, organising information, and processing speed in their everyday and work tasks (Becker et al., 2015; Vardy and Dhillon, 2011). Some studies have shown these cognitive difficulties to last months and years after treatment has ceased (Oberst et al., 2010).

Possible causal factors of cancer-related cognitive changes

Several hypotheses have been associated with cancer-related cognitive changes (CRCC) in breast cancer survivors (Ahles et al., 2012). Two assumptions form the foundation of studies exploring the causality of CRCC. First, women with breast cancer have normal cognitive functioning prior to any treatment. Second, that chemotherapy has been the agent responsible for cognitive changes noted by women, neuropsychological tests, and imaging studies (Ahles et al., 2012). Studies which have been able to obtain pre and post chemotherapy cognitive testing on women with breast cancer indicate 20–30% of women had lower than expected cognitive performance, based on education level and age, before commencing any treatment or having surgery, and was not correlated with psychological factors such as depression or anxiety (Castellon et al., 2004; Wefel et al., 2004). This would suggest that factors other than drug therapy (such as chemotherapy) be considered as causal factors. Other possible factors may include ageing, genetics, and hormone drug therapies (Vardy and Dhillon, 2011).

Neuroanatomical changes

Magnetic resonance imaging (MRI) and positron emission tomography (PET) studies carried out during the performance of selected neuropsychological tests (such as short-term verbal memory tasks) have shown specific functional and structural changes of the brain that occur with CRCC. First, there is decreased neural function in frontal (Ferguson et al., 2007; Inagaki et al., 2007; Silverman et al., 2007), hippocampal (Inagaki et al., 2007), and cerebellar structures (Silverman et al., 2007) which contribute to language, planning, memory, and coordination. Second, these studies also showed breast cancer survivors had wider recruitment of neural activity during such simple cognitive tasks when compared to those without breast cancer. Researchers hypothesised that women breast cancer survivors may recruit additional brain regions to perform specific cognitive tasks in an attempt to compensate for subtle changes in cognitive ability (Ferguson et al., 2007), increasing the cognitive load, and therefore the overall performance effort for even simple everyday tasks.

Measurement of cancer-related cognitive changes

The two forms of measurement commonly used to identify CRCC in women with breast cancer are neuropsychological testing and self-report measures (Newman, 2013), of which there have been inconsistent correlations (Moore, 2014; Tager et al., 2010). Castellon et al. (2004) reported that individual perception of CRCC appeared worse than objective neuropsychological assessment results for women breast cancer survivors.

A meta-analysis by Lindner et al. (2014) found that breast cancer survivors performed more poorly on neuropsychological tests, compared to norms and health, age, and education matched women. It is estimated that 15–25% of women experience cognitive impairments for months or years after treatment (Ahles et al., 2012); however, some estimates are as high as 60% (Vodermaier, 2009). While some women report profound cognitive deficits, for most, the effects are subtle or mild. Many of the neuropsychological tests used to detect CRCC in women with breast cancer were intended for assessment of individuals that had sustained traumatic brain injury, stroke, or dementia, where the impairments are likely to be moderate to severe.

The ability of neuropsychological tests to detect subtle or mild changes in everyday performance is poor in community functioning people with other mild neurocognitive disorders similar to CRCC (Aubin et al., 2014; Bootes and Chapparo, 2010). Conditions required for standardised neuropsychological test administration do not reflect real life everyday environments and the events in which women have reported difficulty. CRCC experienced in normal everyday occupations may not be reflected and evaluated in these standardised assessments. Women with breast cancer report problems with complex tasks such as driving or multi-tasking at work (Reid-Arndt et al., 2009). Such tasks require dynamic use of cognitive strategies in ‘real time’. A persistent but subtle cognitive impairment appears to make a significant impact, particularly in the workplace.

There are a variety of self-reported measures issued to women breast cancer survivors to rate their cognitive limitations and abilities. For example, the functional assessment of cancer therapy – cognition (FACT-Cog) (Ottati and Feuerstein, 2013) tests immediate and delayed verbal memory and executive function and, while demonstrating good concurrent validity with other neuropsychological measures (Von Ah and Tallman, 2015), lacks applicability to a complex work environment. Ottati and Feuerstein (2013) developed a brief 21-item measure of the cognitive symptom checklist-work-59 (CSC-W59), asserting it can be used to quickly assess work-related cognitive problems for breast cancer survivors. While Moore (2014) suggests a current need for standardised self-reported measures of cognitive function for use in daily practice, they are viewed as somewhat subjective and lack credibility among some health professionals as well as health funding schemes. The need for data collection methods and assessment tools that are simultaneously objective, reliable, and ecologically valid is required for this sensitive area of practice.

The PRPP System of Task Analysis

The PRPP System of Task Analysis is a process-orientated, criterion referenced assessment that uses task analysis methods to identify problems with cognitive strategy use (Chapparo and Ranka, 2014). The assessment targets everyday functional tasks performed in the context of the person’s natural home and work environment (Bootes and Chapparo, 2010). An underlying assumption of the assessment is that a person’s capacity to process the cognitive demands inherent in everyday tasks can be observed, identified, and used to determine the need for occupational therapy (Chapparo and Ranka, 2014).

The PRPP conceptual model used as the framework for analysis in this study is based on four information processing typologies used during task performance. Termed ‘quadrants’, these are based on information processing theory and reflect sensory perception (perceive), memory (recall), response planning and evaluation (plan), and performance monitoring (perform) (Chapparo and Ranka, 2014). These four processing quadrants are illustrated as the inner layer of the PRPP System model (Figure 1).

Figure 1.

The perceive, recall, plan, and perform system model (Chapparo and Ranka, 2014).

The four PRPP quadrants are divided into a further 12 sub-quadrants (middle layer Figure 1) and 35 cognitive strategies (termed descriptors) form the outer layer of the PRPP System model, and are considered cognitive strategy behaviours that can be observed by the assessor. Stage 2 of the PRPP analysis involves rating the participant’s performance on a three point scale, indicating how effectively the person applied each cognitive strategy (3 = effective for task performance, 2 = questionable, 1 = not effective).

The PRPP is administered through the use of ‘occupation sampling’, where specific tasks and routines nominated by the client or others in the client situation are used as examples of cognitive strategy application difficulties generally experienced in daily living (Chapparo and Ranka, 2014). This general and specific information is obtained by using three data collection methods, each of which has demonstrated reliability and validity. First, observation of task performance yields a description of cognitive strategy use strengths and weaknesses that can be scored by a therapist observer. Second, questionnaire formats have been developed for use at school (Chapparo et al., 2013) and work (Bootes and Chapparo, 2013) that generate information about specific cognitive difficulties as conceptualised by stage two of the PRPP conceptual model. Third, interview formats can be used in situations where observation is not possible (Bootes and Chapparo, 2010, 2013). In an interview format, general information is sought about the difficulties experienced by the client, with follow up probes to obtain descriptions of examples of task performance where these general difficulties are experienced. From the descriptions of general and specific instances of reduced cognitive strategy use, a score can be derived to represent the extent of difficulties perceived by the interviewee. This third method of PRPP data collection was utilised in this study.

The PRPP has demonstrated reliability and validity for identifying cognitive strategy application deficits in adults with acquired brain injury (Nott and Chapparo, 2012), HIV-related dementia (Ranka and Chapparo, 2010), and schizophrenia (Aubin et al., 2014), but not for cancer patients. Studies (Calvio et al., 2010; Nelson et al., 2014) have called for more research into appropriate cognitive assessment methods for women with breast cancer that offer alternatives to current neuropsychological test methods and are work focused. Therefore, this pilot study sought to use the PRPP System of Task Analysis to identify specific cognitive strategy strengths and difficulties experienced by women with breast cancer when returning to work.

Method

Design

This study adopted a qualitative approach using deductive content analysis of secondary qualitative data which had been collected for a previous study and which described difficulties with everyday function experienced by women with breast cancer (Player et al., 2014). Qualitative inquiry was employed for this study because: (a) the focus was on the subjective experiences of women with neurocognitive disorder who returned to work after breast cancer; (b) subjective experience is time and context dependent and the purpose of the study was to discover how women experienced cognitive strategy disorder in their particular work contexts at the time of task performance; (c) the purpose of the research was not to discover generalisable ‘truths’ about CRCC, but to develop working hypotheses for further research; and (d) this inquiry was not concerned with causal relationships, but rather with the ‘mutual shaping’ of variables. This study sought to describe the subjective experiences of cognitive strategy use of women who returned to work after breast cancer.

Data collection

Secondary data were generated from transcribed narratives about women’s experiences of ‘chemo-brain’. The original interview questions did not focus on pre-determined cognitive assessments, but used a broad ethnological approach to explore the meaning that cognitive changes had on their daily lives. While the women were not asked directly about the impact of cognitive changes on their productivity, almost all voluntarily disclosed the impact of CRCC on their work tasks and their productivity role.

Participants

The participants in this study were previously recruited through methods utilised in a previous study (Player et al., 2014). The Player et al. (2014) study recruited women aged 40–70 years at time of diagnosis of breast cancer and who were undergoing or had completed chemotherapy, as they represented women of working age. Women were invited to participate in the study if they self-identified cognitive difficulties, were fluent in English, and lived in New South Wales.

Participants were 10 women aged 39–67 years old and had stage II or III breast cancer. Two had recurrent breast cancer. One woman was still receiving chemotherapy; others ranged from six months to two years since completing treatment. Seven women lived at home in metropolitan areas and three in rural areas. Eight women were in paid (open) employment at the time of the interview, but two were unsuccessful in their attempt to return to work. The occupations of the participants were as follows:

Manager or administrator – 1

Professionals – 5

Associate professional – 1

Advanced clerical or service worker – 1

Intermediate clerical, sales, or service work – 2

Ethics approval for the original data collection and subsequent secondary analysis was received from the University of Sydney Human Research Ethics Committee.

Analysis of secondary data

Qualitative deductive content analysis was used to thematically re-code the 10 interview transcripts (Schreier, 2012). Deductive analysis starts with a preliminary conceptual model of the target of the research and generates probable explanatory hypotheses (Neuendorf, 2002). In this study, the target topic was cognitive strategy use during everyday task performance as conceptualised by the PRPP System of Task Analysis. Evidence of effective and/or ineffective cognitive strategy use was sought in the transcripts.

Three steps to deductive analysis were used in this study:

Conceptual units that represented cognitive strategy use during task performance were generated from the PRPP system of task analysis standardised terms (Chapparo and Ranka, 2014).

These analytic units were synthesised and ‘operationalised’ into 12 main themes or codes, representing the sub-quadrant cognitive processing units in the PRPP System (see middle layer, Figure 1).

The PRPP codes were matched to the body of data in the transcripts using the following process.

First, the content of all transcripts was read several times. Second, the data were scanned line by line for meaningful ‘chunks’ of information. Data were broken down into the smallest pieces of information that could stand alone and be ‘interpretable’ in the absence of any additional information (Guba and Lincoln, 2005). This ranged from a phrase to whole paragraphs. Repeated analysis of examples given by participants about procedural (task mastery) and strategy application (cognitive) elements of home and work tasks enabled the researchers to establish and validate text meaning in comparison to concepts contained in the PRPP conceptual assessment model. Third, the 34 PRPP descriptors were used as a coding system. Each characteristic representing cognitive strategy use was taken one at a time. This involved identifying any of the 34 PRPP cognitive strategy descriptors described by the participant in the interview. The data were individually combed for evidence of (a) the presence or absence of the cognitive strategy, and (b) how the strategy was expressed in the interview data (Table 1). This involved reading, comparing, and coding successive data units on a ‘feel-like’ or ‘look-like’ basis using the standardised definitions in the PRPP System of Task Analysis assessment manual (Chapparo and Ranka, 2014) (Figure 1). When statements were aligned with more than one particular cognitive strategy, consensus between the researchers and independent assessor was used to determine its analytical placement. Fourth, the nominated cognitive strategies for each participant were then scored using the 1, 2, 3, standardised scoring rubric on stage 2 of the PRPP System. Finally, after all 10 transcripts were thematically analysed, coded and scored, the stage 2 scores were entered into an Excel database for conversion into descriptive statistics and visual analysis.

Table 1.

Cognitive strategy expressed in interview data.

PRPP cognitive strategy items	PRPP standardised sub-quadrant definition	Quotation from transcript that fits the definition
Questions Analyses	Questions: verbally enquires about the location of missing items. Hesitates, looks at, or examines the task momentarily prior to making appropriate changes. Analyses: stops to evaluate a specific constraint.	‘I would go and do something that I knew how to do like use my food processor … I’d push the button and nothing would happen, I would look at it, and think “Why isn’t this working?” I’d take it all apart and put it together again and then think … oh I haven’t plugged it in … [therefore] things would take me ages.’ P8
Recalls steps	Performs the general and specific procedures and steps needed for known tasks and routines.	‘I would go and do something that I knew how to do like use my food processor … I’d push the button and nothing would happen, I would look at it, and think “Why isn’t this working?” I’d take it all apart and put it together again and then think … oh I haven’t plugged it in … [therefore] things would take me ages.’ P8
Contextualises to time	Remembers time. Performs at a known time.	‘Have to keep backtracking at the shops, because I had forgotten things. I don’t know what time, and I don’t know how long to take and I don’t know how I’m going to get there.’ P7
Contextualises to place	Remembers place. Performs in known place.	‘Have to keep backtracking at the shops, because I had forgotten things. I don’t know what time, and I don’t know how long to take and I don’t know how I’m going to get there.’ P7
Organises	Arrange objects and body to begin task. Re-arranges environment as task progresses.	‘My husband makes a lot of the decisions now … like “where do we want to be”, what do we have to do, what do we have to get done?’ P3

PRPP: Perceive, Recall, Plan, and Perform

Findings

Findings are presented in two sections to answer the research aim, which was to identify the difficulties in cognitive strategy use experienced on return to work by 10 women breast cancer survivors who had undergone chemotherapy. First, difficulties as identified by the PRPP model and examples of accompanying narrative are given to illustrate three particular cognitive strategy application difficulties that were common to all the women. In this section, the women are identified by their participant number. Second, the group participant scores are presented and graphed visually, showing the minimum, maximum, and average PRPP sub-quadrant scores for the 10 participants (Table 2 and Figure 2). This mixed method approach is supported by constructivist researchers such as Mackenzie and Knipe (2006: 3), who stated that ‘quantitative data may be utilised in a way, which supports or expands upon qualitative data and effectively deepens the description’.

Figure 2.

Radar graph illustrating group average minimum, maximum, and average Perceive, Recall, Plan, and Perform sub-quadrant scores.

Table 2.

Minimum, maximum, average, and standard deviation scores for group PRPP (perceive, recall, plan, and perform) sub-quadrant scores.

Sub-quadrant	Facts	Schemes	Procedures	Mapping	Programming	Evaluating	Initiating	Continuing	Controlling	Attending	Sensing	Discriminating
Minimum % score^a,d	34	34	78	56	34	68	34	34	34	34	56	56
Maximum % score^b,d	100	100	100	100	89	100	100	100	100	100	100	100
Average % score^c,d	81.3	80.2	84.6	76	61.5	90.4	80.3	61.5	82.4	63.7	90.1	89
Standard deviation	19.4	24.2	9.3	15.3	15.8	15.5	27.8	21.5	20.2	28.4	15.1	15.6

Minimum % score: This is the lowest score achieved by any one or more participants in the group. These scores are plotted as the dotted line on the radar graph in Figure 2.

Maximum % score: This is the highest score achieved by any one or more participants in the group. These scores are plotted as the dash line on the radar graph in Figure 2.

Average % score: All participants score for the sub-quadrant divided by the number of participants (10). These scores are plotted as the bold line on the radar graph in Figure 2.

Expected performance is 90–100%.

Cognitive strategy use difficulties: Individual perspectives

All women gave examples of how they perceived CRCC to have reduced their self-confidence in their work ability. Participant 10, for example, stated that ‘the employer can’t see this underlying effort … it is difficult for them to understand … hard to explain why you aren’t coping … affects your confidence in ability to do job’. Worry and distress over their inability to ‘think straight’ when needed were apparent, with some of the women indicating: ‘I’m worried the cognitive problems will affect my ability to do my job’ (P4). An additional concern centred on the impact of CRCC on their relationships with employers and colleagues, illustrated by P6, who stated: ‘… it [chemo-brain] caused problems with my work mates’.

While all 10 women described individual amounts and types of deficits in cognitive strategy application difficulties, thematic coding using the PRPP sub-quadrant nomenclature indicated three areas received the most comment in the transcripts. These were ‘programming’ (chooses, sequences, calibrates), ‘continuing’ (flows, continues, persists), and ‘attending’ (notices, modulates, maintains) (Figure 1).

Programming

Programming is defined as the ability to choose an appropriate cognitive strategy based on the task requirement, then sequence and calibrate a plan of action and adapt this plan when required. Programming is responsible for being able to respond to novel and complex situations in a logical progression without unnecessary time to think (Chapparo and Ranka, 2014). Common programming difficulties experienced by participants in their work environment are described by Participant 3: ‘You think at the time you are doing something right, and then you’re not … then I can’t think how to go forward because I know I have made these boo-boos’, and Participant 5: ‘What was affected was my personal strategies for dealing with things that didn’t go my way.’

Specifically, these two quotations illustrate that while these women had knowledge about how to proceed with a known task, they were unable to change the plan and reformat performance when the situation demanded. They lacked flexibility in thinking strategies to enable rapid changes in response to a changing context.

Continuing

Continuing is defined as the cognitive strategies used to smooth out the sequenced response so that all the steps of the sequence are complete. Continuing is responsible for cognitive effort being produced in the face of obstacles that may arise so that performance persists (Chapparo and Ranka, 2014). Difficulty with continuing and persisting may be commonly misinterpreted as physical fatigue, but as Participant 10 indicates, cognitive fatigue may be a large component of the fatigue experienced by breast cancer survivors: ‘Fatigue from effort about thinking about everything, and then takes 1 or 2 days to recover … taking longer to do something that you’d normally do.’ Participant 7 similarly illustrates how this cognitive effort feels, stating: ‘It’s as though you’ve got glue in the system’, and goes on to further describe how she has ‘cut down the number of clients but still working as hard and as long’. Participant 9 describes how she would ‘last about half an hour then fall off the mental perch’. Without an adequate compensatory strategy, she indicated that as a result she ‘would go to work, but actually not do anything’. Participant 10 sums up the concerns voiced by some of the women when she recounted how she perceived her work performance to be different to pre-cancer work and having to ‘look like’ everything is alright in the presence of employers and work colleagues: ‘It looks like you are doing fine on the outside … But the cognitive effort required to do the task in the expected time requires so much more cognitive effort than before cancer.’

Attending

Attending is defined as using cognitive strategies to notice, switch, modulate, and maintain attention on body, task, and environment. Attending is responsible for deciding what to attend to and what sensory information is or is not central to task performance (Chapparo and Ranka, 2014). Many quotations demonstrated the attending difficulties experienced by participants in their work environment. For example, participants recounted situations where noticing things in context during driving was an issue. ‘I didn’t see the car’ (P2) and ‘I hit the rail in the garage several times’ (P10). Participant 7 found ‘challenges in car parks, traffic lights … and roundabouts’ while Participant 9 stated: ‘I wasn’t getting that “it’s all clear” kind of message from myself’.

Concentration (PRPP ‘maintains’) appeared to be a common attention issue. Participant 7 indicated: ‘I only read half the email message, then reply’, while others made remarkably similar statements: ‘Concentrating is hard … I feel agitated’ (P2); ‘I just can’t do the concentrating like I used to’ (P3); and ‘I just sit there staring’ (P1).

Cognitive strategy use difficulties and strengths: Group

The participants’ sub-quadrant scores were summed and converted into an average score for the group of 10 women. Table 2 shows the group average and standard deviation score. Additionally, to demonstrate the range of scores within the group, the lowest and highest score from within the group for each of the 12 sub-quadrants was plotted (Figure 2).

Difficulties in cognitive strategy use

As a criterion-related assessment, the PRPP measures what a person can do against the individual standards set by their situation (Linn and Gronlund, 2000). Expected performance on the PRPP sub-quadrant score for functional cognitive strategy use during everyday activities is 90–100% (Linn and Gronlund, 2000). The 10 participants reported cognitive strategy difficulties at work in three to 11 PRPP sub-quadrants. On average, the participants had deficits in 7.4 of the sub-quadrants.

As seen in Table 2 and Figure 2, the only sub-quadrant in which no participant scored 100% as a maximum score was the planning sub-quadrant, ‘programming’, indicating that, in this group of women, planning was perhaps the most vulnerable cognitive strategy grouping to be impacted during work tasks. The ‘programming’ sub-quadrant includes ‘chooses’, ‘sequences’, and ‘calibrates’ cognitive strategy behaviours. In all other sub-quadrants, at least one participant scored 100%, indicating no difficulty. The minimum score obtained from the 10 participants shows low (34%) scores obtained for the sub-quadrants of ‘facts’, ‘schemes’, ‘programming’, ‘initiating’, ‘continuing’, ‘controlling’, and ‘attending’, indicating that the type of cognitive deficit experienced by women during work tasks is variable in type and severity.

The average scores provide more insight about the prevalence of difficulties across the sub-quadrants. Of these average sub-quadrants scores, ‘facts’, ‘schemes’, ‘initiating’, and ‘controlling’ all have averages of 80% or more, probably indicating that the majority of the group are processing well in these areas, with perhaps one or two participants experiencing significant CRCC with those strategies. Alternatively, the lowest average scores were demonstrated in the sub-quadrants ‘programming’ (chooses, sequences, calibrates), ‘continuing’ (flows, continues, persists), and ‘attending’ (notices, modulates, maintains). This may indicate that these cognitive strategies are more vulnerable to CRCC, and confirms the emphasis given to these strategies by the women in their narratives. Other planning strategies used for mapping (knows goal, identifies obstacles, organises) had a minimum score of 56% and an average of 76%. While this was not the lowest score, when the average score is considered with the standard deviation of 15.3 this may indicate another area of difficulty that has impact on a number of the women’s activities.

Strengths in cognitive strategy use

The PRPP was also able to identify cognitive strategy strengths. Strengths can be identified by findings which demonstrate PRPP sub-quadrants that have high percentage minimum scores, together with high percentage maximum scores, high averages, and low standard deviations.

For the minimum scores, Figure 2 shows high scores (greater than 50%) for: recalling procedures (uses objects, uses body, recall steps) (78%); evaluating (questions, judges, analyses) (63%); sensing (searches, locates, monitors) (56%); and discriminating (regulates, discriminates, matches) (56%).

The average for these sub-quadrants is 80–90%, which is in the range of what is expected of a criterion-related outcome. The standard deviation of 9.3 for ‘recalls procedures’, memory for how to do known activities, indicates it is the most common strength amongst participants in this study. The sub-quadrant ‘evaluates’, or the ability to question and analyse a situation and one’s own performance effectively, is the second most common strength in these participants.

Discussion

A major finding of this study was that ‘programming’ was a problem for all 10 women in their work environments. Programming is one of the executive functions enabling problem-solving and planning, functions that have been identified in other studies as an associated difficulty experienced by women after breast cancer intervention (Duijts et al., 2014; Munir et al., 2010). However, from a PRPP perspective, the programming strategy group (chooses, sequences, calibrates) in this study more specifically targeted women being able to cope with changing situations in the work context. While the women were able to programme predictable events, they had particular problems generating an appropriate and timely course of action ‘on the spot’. The ability to engage in this type of programming is critical to work in open employment, particularly professional and/or cognitively demanding work tasks, or situations where multi-tasking is required (Boykoff et al., 2009). These types of work situations are more likely to have duties and tasks that require workers to be able to cope with novel and complex situations rather than routine and repetitive tasks. It is possible that women who have occupations that are cognitively demanding, include many interruptions, or have challenging timelines are more likely to identify deficits in this area. Preliminary research indicating that doctors specify ‘high functioning women’ to be more likely to report cognitive changes (Smidt, 2014) supports this hypothesis. Further research would benefit from matching occupation classifications with particular cognitive strategy difficulties.

Deficits in the PRPP sub-quadrants of ‘attending’ and ‘continuing’ are supported by similar reports from studies using neuropsychological tests and self-reported measures (Duijts et al., 2014; Ottati and Feuerstein, 2103; Wefel et al., 2004). The findings from this study indicate that women spend more time and effort attending to tasks and re-programming a response to new stimuli, in comparison to pre-cancer performance. Participants likened the disturbance to ‘a hidden disability’ which was experienced by them but difficult to explain, and only observable to others by slow and hesitant work performance. The fMRI (functional magnetic resonance imaging) studies by Silverman et al. (2007) and Ferguson et al. (2007) support this finding. These studies, which showed increased neuronal activity during task performance in comparison to non-cancer women, could be indicative of increased cognitive effort. It is possible that although women who experience CRCC are able to do their work, they are working harder to complete a task that was previously perceived as easy. No doubt such persistent cognitive load would result in cognitive fatigue (Mizuno et al., 2011) and hence further errors in work performance. The impact on women who are not prepared for such an outcome, and who do not have compensatory strategies to assist with return to work, may be to conceal their CRCC symptoms for fear of losing their job.

The transcripts of the women clearly focused on their perceived difficulties with cognitive strategy use. While there were no specific questions relating to perceived strengths, it was clear from their narratives, and use of the PRPP model, that the women had definite strengths which they used to assist performance. Further research to investigate a strengths-based approach to inquiry in this area of practice would be beneficial to women and those who provide intervention for them.

Occupational therapists play a unique role in assessing the impact of CRCC on women’s ability to perform work tasks. While cognitive assessment and rehabilitation have often been considered the domain of psychologists and neuropsychologists, Nelson et al. (2014: 2) call for a broader range of psychological scientists to ‘bring their expertise’ to the area of CRCC to help address some of the challenges presented by standardised neuropsychological testing in an aim to help improve the research and outcomes for women with breast cancer. Calvio et al. (2010) state that rather than dismissing women’s reports of cognitive problems, a thorough exploration of the exact nature of the problems and active approaches should be taken to reduce cognitive problems at work. Calvio et al. (2010) further state that there is a need for a more sensitive index of cognitive function at work. Where neuropsychological testing is able to identify cognitive trait deficits in isolation, this study demonstrated that the PRPP System of Task Analysis can evaluate how cognitive strategies interact in the context of job demands and workplace environment to impact on participation. Therefore, it is recommended that occupational therapists consider using the PRPP within a workplace assessment to highlight problems that are affecting the person–occupation–environment fit (Shaw and Strong, 2008).

The hypotheses arising from this study target the extent to which use of the PRPP during a workplace assessment may:

Offer credible evidence to support women’s self-reported difficulties upon return to work;

Highlight how cognitive problems impact on a breast cancer survivor’s work ability; and

Provide justification about the type of workplace-based interventions that are needed to support women through other stakeholders, such as employers, private insurers, and government service providers.

It is possible that early workplace assessment and rehabilitation services, which target self-management of CRCC, may prevent instances of performance management, early retirement, and premature departure from the workforce, as described by other research (Boykoff et al., 2009; Duijts et al., 2014) and the women in this study.

Limitations of the study

The findings in this study relate only to those participating in the research. Other participants may have offered different data from those studied. It is likely that a larger number of participants would enhance the diversity of data obtained. Caution is suggested against generalising the findings to all women who experience CRCC who live in other geographical areas or who are of a different age range.

The data analysis was carried out on pre-existing information, and therefore is limited by the original data collection methods and questions. The questions did not focus on details of work performance to the level that purposeful PRPP interview methods suggest, and they were not asked directly about PRPP concepts. Consequently, detailed information about cognitive strategy use from an exploration of a variety of work scenarios was not obtained. However, the analysis was able to detect strengths and weaknesses experienced by this group of women in enough detail to generate scores, demonstrating the clinical utility of the tool and concepts. Further studies might achieve more robust triangulation and derive additional data from employing observation over time as well as interviewing.

The data were interpreted using a pre-determined model of cognition. It is recognised that interpretation of the data is, to a certain extent, affected by the perceptions of the researchers. It is possible that other researchers using either the same or another cognitive model may have focused on different data, or interpreted the data reported here in a different way. This study included women who were engaged in both paid (open employment) and unpaid (household and family management) work. Larger studies of women that have returned to paid work are needed to confirm the findings of this study.

Conclusion

This pilot study sought to use the PRPP System of Task Analysis to identify specific cognitive strengths and difficulties experienced by women with breast cancer when returning to work. Using the PRPP, it was found that all 10 women who participated in this study had difficulties with cognitive strategy use when participating in paid or unpaid work tasks. While cognitive difficulties were unique to each woman, all had cognitive strategy difficulties with ‘attending’, ‘programming’, and ‘continuing’. Occupational therapists are in a unique position to provide workplace assessments for women returning to work after breast cancer. This study indicates that assessments should include elements of cognition, using an occupation-focused tool such as the PRPP System of Task Analysis. Further research is required to confirm the findings of this pilot study.

Key findings

Women with breast cancer experience CRCC.

This study suggests that common CRCC may be in ‘attending’, ‘programming’, and ‘continuing’ with work tasks.

What the study has added

Occupational therapists need to use an ecologically valid tool, such as the PRPP System of Task Analysis, when assessing work-related cognitive function.

Footnotes

Research ethics

Ethical approval was obtained from the University of Sydney Human Research Ethics Committee, reference number 2012/2119.

Declaration of conflicting interests

The authors confirm that there is no conflict of interest

Funding

This research received no specific grant support from any funding agency in the public, commercial, or not-for-profit sectors.

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