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A Conceptualisation of Resilience Among Cancer Surviving Employed Women in Malaysia

This study examines the experiences faced by employed female cancer survivors when developing resilience. We used a phenomenological approach to understand these experiences and challenges. A total of ten participants with different types of cancer participated in this research, which was carried out using semi-structured interviews. Social media was used for triangulating the data collected. The meanings of resilience were monitored through the particpants’ social media accounts (namely, Facebook and Instagram) from the time of diagnosis until they returned to work. Data were analysed using thematic analysis. Five themes emerged from the data collected: (a) resilience through painful experience, (b) resilience through acceptance, (c) cognitive resilience, (d) emotional/psychological resilience, and (e) behavioural resilience. From our participants, we gained insight into the meaning and conceptual definition of the cancer journey. The study is based on the authentic experiences of the participants. The findings are intended to create awareness among other employed women to aid the development of their resilience. The study results provide family counsellors and practitioners in the Malaysian context with guidelines to help women have positive lives in the future.


Introduction
Lifestyle-related diseases such as cardiovascular disease and cancer have become more prevalent worldwide (World Health Organization, 2020) and in Malaysia (Ministry of Health Malaysia, 2020). As of 2020, cancer was a leading cause of death worldwide, with ten million deaths from the most common types of cancers: breast, lung, colon, rectum, and prostate (World Health Organization, 2020). Cancer is the second leading cause of death in Malaysia, following that caused by heart attacks (Ministry of Health Malaysia, 2020). The Ministry of Health Malaysia (2017) reported that cases of cancer are increasing every year, with breast cancer (the most frequent type of cancer reported) rising at a rate of 17.7% for women. In Malaysia, there are almost 10,000 unreported cases of cancer per year (Ministry of Health Malaysia, 2017). Many cancers can be cured if treated effectively and detected early. However, late cancer detection is attributed to delays in recognizing early signs of cancer and inadequate screening among Malaysians (Meikeng, 2019). Malaysian women perceive cancer as taboo, so they often delay screening and diagnosis. As such, this denial, in many cases, leads to a lifethreatening disease. Hence, late detection has contributed to the increase and unreported numbers of cancer incidents. Even with late detection, women's chances of cancer being diagnosed are higher than men's; there would be one case for every nine women (Azizah et al., 2015, Meiking, 2019. This is a picture of the current phenomenon of our society. What is important is that this impact is significant not only to the cancer patients, but also the families, the communities, and the country. growth can be modified. Promoting resilience and post-traumatic growth are significant components in cancer care (Seiler & Jenewein, 2019).
Employed cancer-surviving women may conceptualize their resilience experiences by having significant supportive working family environments (Grunow, 2019;Lawson et al., 2019) in their daily lives. Resilience is connected with other parts of the individual's life with cancer, such as work, health, family, and economic status (Abdullah, Rozita et al., 2013;Armstrong et al., 2011;Bentur et al., 2014;Kobau et al., 2011).
Historically, the term "resilience" has come from mental health, as coined by (Germazy, 1991), a clinical psychologist. The word "resilience" connotes the ability to bounce back after adversity (Hart et al., 2014;Wagnild, 2009). Resilience is derived from the Latin word that means an element's flexibility. Resilience is defined as the process of adapting well in the face of adversity, trauma, tragedy, threats, or even significant sources of threat (American Psychological Association, 2012).
In this research we studied the resilience associated with a diagnosis of cancer, particularly for those women who continue working as they engage in treatment. For the past few years (2015)(2016)(2017)(2018)(2019)(2020), an inadequate amount of research has been conducted in Malaysia regarding the conceptualisation of resilience among employed cancer-surviving women. Researchers focused on how cancer surviving women attained resilience and gave meaning to it. We focused on how these women give meaning to their resilience experience. Recent studies have focused on the coping mechanisms among Malaysian cancer surviving women Sharif & Khanekharab, 2017) and quality of life after twelve months of using effective coping mechanisms . In the Malaysian context, each woman's view of her cancer journey may influence her relationships with the group. For instance, even as a multicultural country, Malaysia still has collective beliefs and norms in many aspects of life, including healthcare. We used a qualitative approach, particularly, phenomenological study by applying Interpretative Phenomenological Analysis (IPA; (Smith & Osborn, 2015), to understand and explore the meaning of the experiences of women as cancer-surviving individuals who have returned to work with many responsibilities and the illness.

History of Resilience
In early resilience work, the central issues were related to children and adolescents facing extreme stress. The longitudinal study, known as the Kuaia study, examined children with chronic crises, divorce, and parental psychopathology (Werner, 1993). The study suggested that a minority of the children with family issues developed resilience in their later years. For the last two decades, studies on resilience have shifted towards different disciplines such as education (Gu & Day, 2007), business (Riolli & Savicki, 2003), leadership (Ledesma, 2014), and community (Brennan, 2008).
Resilience work has extended as the number of suicides increases globally, and the most affected individuals are those with mental health issues caused by impulsive life stress such as financial issues and life-threatening disease, which has grabbed the world's attention and is extensively debated (World Health Organization, 2019). Hence, the study of resilience has emerged drastically as one of the contributing factors leading to the issues of suicide. Several studies mentioned that resilience results from individuals' personalities, environments, and cognitive acceptance of adversity.

Resilience and Cancer Surviving Women
Within the scenario of cancer patients, after the treatment is completed and they return to work, physical stress and emotional disturbances are prevalent as women recognize significant life changes (Allen et al., 2009;Dewi et al., 2020). In addition, numerous emotional and physical challenges are experienced by women with cancer during the transition period of treatment and follow-up examination. Resilience is connected with other parts of the individual's life with cancer such as work, health, family, and economic status Armstrong et al., 2011;Bentur et al., 2014;Kobau et al., 2011).
A study conducted on breast cancer in Malaysia and Singapore showed that these women face financial matters, misconceptions from relatives, misleading information from health-related websites, and perceived less effective health care services (Lim et al., 2015). In Asian countries, most of the literature and research discussed are quantitative studies regarding women and cancer issues. For instance, Chan et al. (2015) and Chan et al. (2018) discuss the enduring physical and psychological effects women experience after the cancer regime treatment. However, there is a lack of evidence on the resilience and well-being of cancersurviving individuals' experiences in Malaysia, especially for employed women. Schroevers and Teo (2008) found that many researchers have focused on positive psychological changes among Western cancer survivors compared to non-Western countries.
We were motivated to conduct our study because of the lack of evidence from other studies exploring women's actual experiences in their resilience journeys and coping with their new situations as cancer individuals returning to work. As women always focus on unfitted demands and different responsibilities, many studies show that it is necessary to explore and study resilience among employed women. For instance, upon returning to work with cancer treatment, employed women have to fulfill different responsibilities and expectations at home and work which demand their commitment Our study examines differentiated conceptualisations of resilience shared by participants, especially those cancer-surviving women who have returned to work. Most families in Malaysia are recognised as dual-income families in which women have multiple responsibilities at home and work. Therefore, this study provides an in-depth understanding of how employed women in Malaysia give meaning to their resilience experiences. The conceptualisations based on these findings may benefit future programs and modules designed for cancer support group counselling interventions provided by counsellors and social workers. Hence, this study aims at answering the question: how do employed women with cancer conceptualize their resilience experience after returning to work?

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Positioning Ourselves in the Study
The researchers had different roles in this research. Sumari and Ab Razak have diversified roles as researchers and supervisors of students and therapists in the university, setting specializing in women, marriage, and family counselling. Mohd Kassim is a counsellor with many experiences handling counselling sessions related to women and resilience. Green and Johnson (2015) delineated the importance of interprofessional collaboration with two or more professions working together to achieve common goals and solve various problems and complex issues. With the diversified background from academic and counselling settings in this research, we can benefit women with cancer.
Knowledge of researchers' personal experiences was relevant in this study as this influenced the need to carry out this project. Furthermore, it assisted readers to appreciate what unfolds in the inquiry. As Curtis et al. (2017) mentioned, translating research findings and knowledge into clinical practice is essential to safe, transparent, effective, and efficient healthcare provision and meeting the expectations of patients, families, and society. As the researchers recollected our previous experiences as counselling practitioners and academicians, several relatable questions arose from the counselling session we encountered. Among those are (a) how is resilience defined by thee cancers surviving employed women? (b) how do these women with cancer describe their resilience experiences? (c) how does resilience change the lives of these employed women? (d) how do these women develop new coping skills? and (e) how do they go about their future plans? In an attempt to answer these questions, the researchers came to the realization that we could explore the experience through exploring the journey of resilience of women with cancer as they return to work. This starting point prompted research questions and confirmed the method of inquiry. Despite its importance, translating research into clinical practice is challenging. The study aimed to dwell on lived experiences to explore the conceptualization of resilience among employed women with cancer in Malaysia.

Theoretical Framework
We used three theories in this study; namely the Wheel of Wellness (Myers et al., 2000) (Myers 1998), Model of Resilience (Wagnild & Young, 1993) (Wagnild & Young, 1993), and Stages of Resilience (O'Leary & Ickovics, 1995;O'Leary & Ickovick, 1995). The Wheel of Wellness model (Myers,1998) has five main life tasks: spirituality, self-direction, work and leisure, friendship, and love. This wellness model has been widely used in counselling and could be practised by counsellors and social workers in addressing individuals' physical concerns in counselling disciplines. In addition, this study is also based on the model of resilience (Wagnild & Young, 1993), which includes meaning, self-reliance, equanimity, perseverance, and existential aloneness. The last theory is Stage of Resilience by (O'Leary & Ickovics, 1995) O' Leary and Ickovic (1995). The four stages of resilience are survival (how we respond), adaptation (how we adapt), recovery (how we bounce back), and thriving (how we grow), which consider how the dimension of resilience is achieved by different individuals. We defined conceptualization of resilience among women with cancer with the following elements derived from the above-mentioned models: self-reliance, perseverance, existential, spirituality, self-direction, love, survival, and adaptation. However, we uphold the conviction that the characteristics of human wellness and resilience could serve as a metaphor for what goes on when women with cancer attempt to understand their experiences of resilience. In summary, all the theories are significant and influential in this research's methodological choices and decisions, especially in data collection and analysis.

Research Question
The question of inquiry for our study is the following: how is resilience defined by these cancer-surviving employed women?

Research Design
In this study we explored how resilience is defined by these cancer-surviving employed women. We learned of their experiences through in-depth interviews and data triangulation. Using theory and methodology of interpretation to understand life's text is known as hermeneutics (Alase, 2017;Merriam, 2009). We used Interpretative Phenomenological Analysis (IPA) in this study (Smith & Osborn, 2015), as it is idiographic in focus. IPA offers insight into how a given person in a given context makes sense of a given phenomenon.

Participants
In this research project, we recruited participants from the Cancer Support Group in Malaysia using snowball techniques. Out of 25 potential names, only ten women fulfilled the required criteria. The inclusion and exclusion criteria were explained to all participants as we communicated with them personally before the interview sessions.
The inclusion criteria were cancer-surviving employed women who have returned to work but are continuing with treatment. These women have endured an operation, chemotherapy, radiotherapy, and/or medication. The diagnosis and prognosis must be at least five years prior to being pronounced as survivors. Research shows that 90% of cancer rate survivors after five years of diagnosis survived due to early screening and treatment (Swanberg et al., 2017) and that the overall survival rate is generally stated as a five-year survival rate, which is the percentage of people in a study or treatment group who are alive five years after their diagnosis or the start of treatment (National Cancer Institute, 2022).
Of the participants, nine women were Malays and one was Chinese, with diversified cancer types ranging from stage one to four. Their ages ranged from 32-59 years old. The majority were breast cancer-surviving women. One was self-employed, two worked in the private sector, and the rest were government servants. Two of these women had been diagnosed during their early pregnancy. One woman is a widow, and the rest are married. These women were similar in that they all possessed dual responsibilities at home and work. In summary, the participants come from similar backgrounds as they observed their healthy living lifestyle by having good nutrition intake, regular exercise, and yearly medical health examinations. The majority of the participants did not take a long time before deciding on the cancer treatment. They started the cancer treatment following advice from doctors beside doing the complementary and alternative medicine (CAM). They started having challenges as the treatment started, both physical and emotional, as well as expectations from family around them. Participants not only gained support from the support groups they joined after being diagnosed with cancer, but they are now also able to offer their support to other women with cancer. Because of this, they are able to resume working and stay resilient even though they are not pronounced as survivors.
The research participants volunteered and signed the informed consent form during the briefing of the interview protocol. We also explained the significance and implications of the interview sessions. As this research is affiliated with the University of Malaya, the University Malaya Research Ethics Committee's approval was observed before the interview sessions.

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Data Collection Procedure
We used in-depth interviews and social media documents analysis in this research. In line with IPA, which has an idiographic focus, we conducted interviews and made sense of the phenomenon of resilience, which has an idiographic focus. We conducted interviews and made sense of this phenomenon; that is, how resilience is defined by these cancer-surviving employed women.

Interviews
We conducted three phases of interviews: beginning, middle, and end phases (Seidman, 2006). These phases are covered in only one session for participants C-J; however, for participants A and B, two interviews were conducted.
We prepared interview protocols to guide the interview sessions and achieve the research objectives (Merriam, 2009), and for probing purposes: to hear the experiences of cancer-surviving employed women in order to come to know how they define resilience. In the first session, we asked, "What is your definition of resilience in your cancer journey?" and "What is your cancer experience?" These questions were intended to outline the resilience and the meaning given to the experiences. The second stage consisted of questions describing their lives as surviving women with dual responsibilities. We asked, "What is your experience as surviving women with dual responsibilities?" This stage explored the meaning-making they made on the resilience journey. They elaborated on the coping mechanisms they used in their "new" life. The third stage reflected on the participants' plans after returning to work. For example, "What is your (and family) plan in regard to cancer awareness and prevention action?" Eventually, they were encouraged to share their thoughts regarding the meaning of resilience they gained through previous experiences.
The interview sessions ranged from 35 to 90 minutes. We produced the transcription immediately after the interview. The interview sessions took three months to complete. All interviews were audio recorded and we observed and recorded the participants' non-verbal observable communication (e.g., facial expressions and voice intonation) during the interview sessions in our reflective notes.

Social Media Documents
The advancement of technologies allows participants to highlight their experiences and advise the public via social media. Hence, we monitored and analysed participants' social media updates (Facebook and Instagram) from the first diagnosis. We used this information to triangulate information between what the women wrote and their interview sessions. For this research, only six participants actively updated social media content regarding their cancer journey through Facebook and Instagram. The remaining four participants chose not to post such updates, but they told us they shared their resilience experiences face-to-face with relatives and friends.

Significant Pictures
To further help us capture the world through the participants' eyes, we used several techniques. We used an auto-photography technique (Glaw et al., 2017), where we asked participants to take photographs of their environment and then use the pictures as actual data. We asked them for visual resources like photos, videos, paintings, drawings, collages, or any artworks are used to understand and interpret images in the qualitative study. Finally, we asked for captions, pictures, and videos from their social media which are triangulated in discovering their resilience meaning-making experiences.

Data Analysis
We used Atlas.ti. software version 8.4.24 to organise and analyse the transcribed data and to inductively code the transcripts in more effective and reliable ways. We followed the seven IPA steps for analysis coined by Charlick et al. (2018). Those steps include reading and re-reading, initial noting, developing emergent themes, searching for connection among the emergent themes, migrating to the next case, searching for patterns across the themes, and lastly, taking interpretation to a deeper level.
Step One The first important step in IPA is to have a process of reading and reading again. This step helped us to familiarize and immerse with the original raw data. We personally went through the data by reading it multiple times to capture and understand the lebenswelt or essence of meaning and actions by these women with cancer. As we read, we added comments into the left-hand margin as suggested by Langdridge (2007). Primarily we asked ourselves and identified "what is going on in the text." We focused on content (what was being discussed), language use (features such as metaphors, symbols, repetitions, pauses), context, and initial interpretative comments. Some comments associated with personal reflexivity were also generated (e.g., how might this affect personal characteristics of the interviewer, such as gender, age, social status, affect rapport with the participant). It was helpful to highlight distinctive phrases and emotional responses.

Step Two
Step 2 of initial noting is also known as initial coding. We coded the transcripts based on what we saw repeated in the interviews. The coding started with the first participant until the last in the sequence. For instance, we begin with noting and labelling the respondents' definitions of "resilience." In this process of initial noting, we included descriptive, linguistic, and conceptual comments. In our descriptive comments we identified vital phrases, explanations, descriptions, and emotional responses, such as, "I never thought I would have cancer." For linguistic comments we noted pauses, tears, pronoun words or repeated words, tone, and metaphors used. For conceptual comments, we focused on the participants' dominant understandings based on the essence they are discussing. The researcher needs to do a lot of reflection in this conceptual comment stage. For instance, we reflected on, "What would I do or how would I react if I was in their shoes?" and "How do these participants react when receiving the diagnosis?" Table 1 below shows initial noting based on interview transcripts, observation during an interview, significant picture, and social media documents. The descriptive comments (DC) are indicated as normal text, conceptual comments (CC) are written in red, and linguistic comments (LC) are blue. CC: Hence, she feels more open to talking about cancer and resilience as she trusted the friend (researcher was initially wondering whether she could find the actual support as she indicated to be accepting more critics than support in subsequent interviews).
LC: The word selections are clear and straightforward, reflecting her emotion of having somebody who belongs to the same group; that is, cancer patients. Words used connote her inner feeling and spirituality of wanting to be near God.

Step Three
In this stage we worked with transforming our notes into themes. This stage is signified by developing questions on meaning. The questions indicate a key concept we may feel as emerging themes in the next level of themes development. The common themes reflect a shared understanding of the phenomena of the participants of this study. Table 2 below explains the development process of themes from the interview transcripts. The descriptive comments (DC) are indicated as normal text, conceptual comments (CC) are written in red, and linguistic comments (LC) are blue. We engaged the same process for social media data and photos. Step Four Next, we looked for connections between emerging themes, grouping them according to conceptual similarities, for direct answers to our research question, and by manner of abstraction and providing each cluster with a descriptive label. We compiled themes for each transcript before looking for connections and clusters. Some of the themes were dropped at this stage, if they did not fit well with the emerging structure or because they have a weak evidential base. For instance, some sub themes (conceptual similarities) such as healthy lifestyle and engrossed in hectic lifestyles are grouped in one superordinate theme, lifestyles, as the similarities concept emerged. A final list comprises of numerous subordinate themes and subthemes is shown in Table 3. Step Five We repeated the same process from stages 1 to 4 for each transcript. The next participant's transcript needed to be treated on its independent terms of merit. Hence, researchers practiced bracketing (epoche), in keeping with IPA's idiographic commitment. We have to focus more on the case and participants to avoid prejudice and influence from previous and later cases. Hence, it was significant for us to bracket any pre-conceived pieces of information arising from the previous case/participants' analyses to ensure a smooth process for the next case to align with the third axis of IPA that is idiography that pays attention to the particular. We diligently observed the systematic steps presented above to remain objective and ensure this study's rigour. The data analysis process ceased several times as the researcher felt influenced by previous cases.

Step Six
The patterns among the emergent themes were identified in this step. This process is essential to differentiate how a theme from a case or participant can help to be a highlight to other issues or themes. This stage also involved examining similar or different themes across cases.

Step Seven
The interpretation of themes is taken to a deeper level at this stage. In this step, we deepened the analysis by utilizing metaphors and temporal referents and importing other theories as lenses to view the research (Langdridge, 2007;Smith & Osborn, 2015). We also refer to the theoretical frameworks used in this study at this stage to understand a deeper level of these women's experience of resilience. Hence, the interpretation is based on the Wheel of Wellness (Myers 1998), Model of Resilience (Wagnild & Young, 1993) (Wagnild & Young, 1993), and Stages of Resilience (O'Leary & Ickovics, 1995) (O' Leary & Ickovick, 1995). For instance, since this study uses IPA with limited sampling, there is room to compare and contrast the voice of employed women, as this sample consists only of women among the professional category of employee. Hence, there is room to explore the experience of cancer women from another side of the working sector; for instance, the paraprofessional and non-professional category. To further explain, the participants involved at least have a bachelor's degree (from different disciplines), as it may influence their level of awareness about cancer. In addition, this step allows deeper interpretation by bringing in the criteria not mentioned in the operational framework of research participants. The inclusion criteria are: working women, resume work with follow up cancer treatment, and having multiple roles at home and work. Hence, it will enable more possibility and more probability in terms of their resilience experiences.

Ensuring the Rigor of the Study
This research highly observed reliability and validity issues. Among the triangulation processes used were member checking and peer review. The triangulation process is described as a continuous process in data analysis. The triangulation occurred when the researchers diversified the sources and used multiple triangulation sources to ascertain an in-depth understanding of the data.

Member Checking
We practised member checking in this research to ensure the reliability of the data collected. Member check functions as participants' validation to identify the credibility of the results. For instance, after the interview, we requested clarification from the participants on the information shared in the previous interview. Participants were asked to give feedback on the earlier information they had shared. Researchers in the medical area connote the term member check as post-interview comments. This post-interview aimed at assisting the participants in noting the feelings, interpretations, and comments during the interview. We do member checking with the respondents during the follow-up interview session to ensure that the information gained earlier really reflects the meaning of their shared experiences.

Peer Review
This research used peer review conducted by two experts in qualitative research. This review was undertaken to ensure the study's reliability, accuracy, credibility, and validity. The peers validated themes and sub themes emerged from the interview sessions. This research was validated by experts in the qualitative field, validating the themes that emerged. Theme validation by the experts is significant to ensure the themes emerged to reflect the research questions and objectives.

Bracketing
We applied bracketing throughout this research process to avoid leading with our preconceptions of the phenomena. The bracketing process started before the research by listing any personal inclinations, prior inputs, and previous understandings of the concept of resilience among cancer surviving women.

Results
From the data collected and analysis conducted, five themes emerged. The themes are: (a) resilience through painful experience, (b) resilience through acceptance, (c) cognitive resilience, (d) emotional/psychological resilience, and (e) behavioural resilience. Hence, the quotes were used according to related themes in answering the research questions. The illustration of how employed women in Malaysia defined their resilience experiences was derived from this study.

Painful Resilience
Most participants related how they conceptualized the resilience experience derived from the painful episodes, both physically and mentally. Regardless of how they struggled, they managed to resiliently handle the painful process. The researcher does not use the word resilience directly, but the participants were asked about their experience as cancer surviving women. Participant B's interview captured the greatest of painful experiences as she has had a fourth relapse and still bounces back.
Interviewer: As a woman, I do understand you are wearing a different hat, you mentioned about your work demands and responsibilities as a wife and a mother. How do you define your resilience? Participant B: Initially, it was very painful. Even though it looks like no stress. In a while, it will be fluctuating between OK and not. Moreover, during that time, cancer patients were not as many as nowadays. About the awareness and treatment.
Interviewer: What do you mean by awareness and treatment? Participant B: As I do not know who to refer to. As I don't have anybody around me who are also cancer patients. I gained much information on cancer based on my own readings. When I asked my doctor, the answers to my questions are also not convincing me. So, my resilience experienced I got from painful experience in terms of physical and emotion. It causes me a lot of emotional stress.
Participant B's account emphasized the distress she felt as she struggled to manage or comprehend her situation. Throughout the treatment, she faced several challenges. As she had several relapses, she started to initiate with certain complementary and alternative medicines due to dissatisfaction with the doctor's explanation. She started to consume alternative medication to avoid relapse. The medication affected her physical health and financial condition. This relapse, insufficient information, and alternative medication have led her to experience resilience in painful and challenging ways.
She could adapt well to the situation once she returned to work as she gained full cooperation with colleagues and superiors. She took another initiative in facing the mental challenges once she resumed her work. She got involved with work, social connection with colleagues, and house chores. When she felt that her health condition did not permit, she might opt for work from home since her company allows so. She said: So, when you are busy with other things, busy with your work, house chores, meeting friends and many more. Actually, …you don't have time to mourn. You will tend to forget about your health condition.
Other quotes from participants showing their painful resilience are: Interviewer: How do you define your resilience through painful experiences? Participant G: Sometimes, I felt weak in front of my kids. I always mentioned dying. But I know I have to be strong for them.
Participant H: So, when I was diagnosed with cancer, I was thinking, "eh, I had the worst experience before this and it affect my emotions badly.

Acceptance Resilience
Resilience through acceptance appeared to be the central theme highlighted by all the participants. Despite the challenges, coping, and support gained in their cancer journey, all participants emphasized acceptance in developing their resilience. Upon the diagnosis, women with cancer had different feelings of denial, anger, and bafflement. Eventually, their early acceptance facilitated their resilience. Participant A, diagnosed with two types of cancer, repeatedly stressed her acceptance of her illness in allowing her to develop resilience.
Interviewer: When you said you came back to Malaysia immediately after 2 months, your cancer treatment ended, and you resumed working. So I believe that being in a challenging condition has just finished treatment and a new phase of a working environment. How do you manage everything? How do you see your resilience? Participant A: When there's no choice, and that's the only option I have. And I decided to take that choice. I think I have to set my mind. I mean, I know it's going to be difficult. First reason, I haven't worked for a long time and suddenly want to work. There are indeed many things. Secondly, my workplace is a kind of difficult place, a very busy hospital in town. So, I already have a mind setting because it's going to be difficult. Thirdly, because I came back as a patient who was on treatment. I'm still on medication right. I still need follow-up treatment at that time. So, when I have a mindset that I will indeed face a difficult, challenging phase, I plant early in my mind. I said, like, it's not going to be easy. It will be difficult. So, when it will be difficult, I think whatever happens, from the date of reporting back to work, until now, I think it's something that I can go through. I have to go through it myself, despite anything. Because people don't understand. It's only me.
Interviewer: How do you see your resilience after a second diagnosis of another cancer? The gap was only 2 years between the cancers. Participant A: Actually, I went back to work in May 20**. It was only 2 months after my thyroid surgery. The doctor removed my side thyroid (Hemithyroidectomy). Because there is no need to cut the two lobes as it did not spread to the other lobe, so only the right side was discarded. I had no choice because all these treatments were conducted overseas. At that time, I was continuing my PhD in Australia. So, I completed all the treatments while also undergoing my PhD. So, I said I had no choice. I have to accept it. The government sponsors me. So yes or no, I have to go back to work. Even though I had just had an operation at that time, I felt like I was eager to work. Because of that time, I feel like I'm done with my PhD. I don't want to do my PhD anymore. Secondly, I feel like I want to show that I'm healthy and I'm ready to work.
On her part, she only faced a condition where she had told herself that the situation would be challenging, especially once she resumed her work. Therefore, she could anticipate the issue of work-life balance and office crises. Furthermore, she holds that making people understand her health condition resulted in her limitations. For instance, the cold office condition affected her physically, especially in the Operation Theatre. Therefore, she discussed this situation with her superior before her returning to the office. This approach secured her physical and mental condition. Besides, this approach hinders stigma towards cancer patients.
So, it's important to discuss with your superior. My Head Unit is very understanding. Alhamdulillah.
Other quotes from participants showing their acceptance resilience are:

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Participant B: So, once you have gone through the third time, fourth time, you also have read a lot of research, you have found many possibilities, kind of treatments and means that you have already known much information. So, once you are positive, with all the information, you can handle it and will not down flat.
Participant D: So, once I got the news, I felt like … I don't know how to describe it; I did not cry. But, I was silent. I was thinking, was the news real, serious, or only a joke?

Cognitive Resilience
The result derived indicated that these participants have an excellent academic background with at least a bachelor's degree. Hence, the awareness and cognitive function facilitate the resilience experience, especially in attaining cognitive resilience. This type of resilience is highlighted most of the time by Participant F.
Interviewer: How do you see your resilience since you have completed the treatment and now resume working?
Participant F: I am OK. When it comes to working, I just work as usual. I don't think that I am sick. Why must I think that I am sick? As I believe my cognitive resilience/ functioning determines everything. If I have negative vibes, the condition will undoubtedly be negative. I never apply for medical leave, and I believe I am not sick and never falls ill. I go for cancer treatment based on an appointment.
Interviewer: How do you manage to have this condition after the cancer treatment?
Participant F: I cognitively set in my mind if I go to a clinic or hospital just for the cancer treatment appointment, and I am ok with it, no problem. What is important to me is to be happy and feel happy at my workplace, which helps me bounce back.
Participant F relies on her cognitive function from the diagnosis until she returns to work. In terms of feelings of resilience, she managed to cope with the diagnosis and treatment of cancer. She was pouring out her emotion on how she managed to control her mind over emotion. Even during the news of her positive cancer diagnosis, she was not sad.
I'm not ... no ... not sad, what for being sad? Everyone will die. It doesn't matter to me … that is how God wants to test us, right?
Other quotes from participants showing their cognitive resilience are: Interviewer: How do you think that you are cognitively resilient?
Participant H: Its your mental (cognitive), it has to be strong. As I believe mental control my body.
Participant I: I believe and think that I have to bounce back. I cannot be too emotional. Thinking 24/7. Asking why… why I become like this? No point of doing that.

Emotional/Psychological Resilience
Emotional resilience is related to cognitive resilience. The more the participants are engaged in cognitive resilience, the higher chance they have of showing the concepts of emotional/psychological resilience. These women vented and poured out their emotions with their circle of social support, and once they bounce back, they can help other women who are sharing the same shoes. Participant D is among other participants who shared the most resilience experiences developed through emotional/psychological aspects.
Interviewer: How do you describe your resilience?
Participant D: The source of my resilience is myself.
Interviewer: How does your resilience take place when it involves your emotions?
Participant D: But like me, when I was diagnosed with cancer. I knew that other people have cancer. I feel like I want to help them. I tried to guide them. I will feel very sad if I can't help. Recently, my friend, during my diploma she was diagnosed with cancer. She said chemotherapy is not good. I was trying to create awareness to her about this.
Participant D emphasized her resilience in terms of behavior. Even she was quite shocked by the result. She found herself able to control her emotions well and be resilient starting from the cancer treatment. At the peak of her achievement, she felt happy when she was able to help other cancer patients. She voluntarily helped them out in terms of preparation of mental, emotional, and physical in handling the treatment. She builds a connection with patients at the hospital regardless of their race, belief, and age. She said: And I am the open-minded type of person. I am open, and I can talk to other people like nothing happens as I can talk to you (the researchers).
Participant D was full of information and knowledge during the interview sessions. She shared a simple thing with the researcher. She wanted the information to be helpful for the research and cancer individuals. Her selection of words is proper and tactful. Verbal and nonverbal communication reflects each part of sharing. For instance, upon sharing the agony part of the effects of chemotherapy, her eyes were static, and she holds back her tears. She was delighted to share how she helped other individuals from her own juice recipe and collaborated with her cancer support groups with other cancer patients. Furthermore, based on her capacity, she voluntarily gives emotional and psychological support on tips and ways to handle cancer issues, regardless of religion, background, and career.
Other quotes from participants showing their emotional/ psychological resilience are:

Behavioural Resilience
Behavioral resilience is related to cognitive resilience. The more the participants are engaged in cognitive resilience, the higher chance of them having the concepts of behavioural resilience. These women engaged in certain behaviors and behaviour modifications allowing them to bounce back. Participant H is among other participants who reached resilience shortly as she believed that behaviour is important in many aspects of her life.
Interviewer: How do you relate your resilience with your behaviour?
Participant H: It's normal for a human being to be sad, and it is Ok, to be sad, but not too long. We have to wake up and focus on ourselves. To be healthy and recover from the illness. And we need to make some effort to recover. Regardless of alternative medication or hospital treatments.
Interviewer: Do you engage in a specific behaviour in developing resilience?
Participant H: Secondly, somehow, we have to go back to Him. To our Creator. Because, this thing, yes or no, he will surprise you. That is where you belong. That is, why you are here on earth. Go back to why we were created. I change my behaviour to be close to God. I leave all my interests related to worldly matters. For instance, I was a handbag and branded shoe collector before this. I didn't do that anymore. I engaged in submission to God, extra prayer, extra fasting and other supplication worship.
Interviewer: Yes, I understood. Is there any other behaviour that you always do that connotes your behavioural resilience?
Participant H: Enjoy yourself. Enjoy your companion. Enjoy your life. This behaviour helps me to understand my resilience experience.
Participant H highlighted the resilience experience gained through most of her cognitive and behavioural resilience. She rationalised the incidents in life as a cancer individual and manifested them through acceptable behaviour. She started her interview session by mentioning that this cancer journey is not as challenging as her first journey of an unsuccessful marriage. She said during the first trial of her marriage, and it jeopardized her emotionally and physically. By this second journey of adversity, she had mastered the skills. However, the test has its additional report when she was diagnosed with cancer when she was three months pregnant with her third child. Participant H expressed her battle and resilience experience a lot on many platforms. She had comprehensive support from family and close friends. She shared her resilience journey as a cancer surviving woman on a social media platform to share information and contribute to society. She actively gives tips, talks, and personal sharing coaching to women with cancer wearing the same shoes.
Other quotes from participants showing their behavioural resilience are: Interviewer: Do you engage in a specific behaviour in developing resilience?

Discussion
Overall, the findings show the experience of employed women in Malaysia in attaining resilience facing their surviving journey. All participants reported that their resilience journey was achieved through acceptance and painful experiences. As such, the resilience materialised through cognitive resilience, emotional/psychological resilience, and behaviour resilience. Thompson et al. (2011) delineated that exposure to traumatic events combined with psychological adjustment supplement the traits of mindfulness and acceptance. Meanwhile, emotional disengagement, which includes persistent disassociation, experiential avoidance, and coping strategies, is related to PTSD syndromes and psychopathology. Concerning this statement, all participants eventually gained their resilience through acceptance. Although they were aware they might not be the same as before, they stated their health improved by accepting the fate and proceeding to the suggested treatments. Cancer individuals took cancer as a reward from God (Ahmadi et al., 2019). The conceptualisation of the participants was diverse, including resilience through acceptance, painful resilience, emotional resilience or psychological resilience, behaviour resilience, and cognitive resilience.
Generally, resilience is divided into three main categories: psychological or emotional, behavioural, and cognitive. Biological, psychological, social, and spiritual domains have been identified as protective resilience factors and barriers for women coping with cancer (Valenti, 2011). Numerous international research studies have shown that psychological distress negatively relates to resilience (Matzka et al., 2016;Min et al., 2013;Schumacher et al., 2014;Silvera et al., 2005). Results indicated a relationship between psychological resilience and religious beliefs among breast cancer patients. This relationship is manifested through the facilitation that religious belief signifies through social support to enhance the psychological adaptation of illness. In maintaining psychol, positive emotional expression is considered a medium. Hence, this approach should be recognised by health care professionals and the woman's social circle (Fradelos et al., 2018). This could benefit the counselling practitioners when dealing with women with cancer.
Among the characteristics covered in resilience is the possibility of challenges and changes with a high degree of commitment with the limits of control supported by others. Resilient women mentioned having inner peace and cultivating meaning in their lives by using positive emotional expressions and positive reappraisals (Manne et al., 2015). Furthermore, positive psychological effects are felt by cancer individuals who use positive reframing (Schroevers & Teo, 2008).
Similarly, the participants keep using encouraging and positive words towards themselves and stay surrounded by individuals who use the same approach and provide emotional, psychological, and physical support. Cognitive resilience is defined as individuals' ability to handle the stressful effects of events on cognitive functioning; in other words, the capability of the brain to cushion against disease or adversity and recuperate from trauma. Some of the participants reported using their brains to compensate for the traumatic events.
Participants admitted that their resilience was gained through a painful experience. As they stated, their cancer journeys' physical and psychological pain did not jeopardise their resilience experiences. Pain sometimes comes with or without symptoms. Typically, symptoms can lead to pain which later leads to depression, anxiety, nausea, and fatigue. Hence, this study found that high resilience individuals reported less depression, reduced fatigue, and higher quality of life. This result could be traced back to participants who reported using the pain of cancer treatment as a platform to build resilience and continue their lives like before. Thompson et al. (2011) delineated resilience through acceptance as the ability to be fully aware of one's current condition. Acceptance could be conceptualised in three activities: observational psychological events, desire to amend the incidents' occurrence, and distinguished psychological experiences from the actual events from outside circumstances (Follette et al., 2004). In medical conditions and psychological disorders such as generalised anxiety disorders and chronic pain, acceptance-based intervention and mindfulness were significant to individuals involved. In summary, acceptance is defined as experiencing psychological events as comprehensive and brief reactions towards external events rather than segregating it as agonising psychological individual distress, which should be shunned (Orsillo & Batten, 2005;Palm & Pearson, 2014). In relation to this study, a majority of the participants find that their resilience was gained through their high levels of acceptance. Regarding the participants' spiritual and psychological resilience, they claimed that humour, optimism, reframing, acceptance, and goal setting were among the psychological factors that eased them to attain resilience.
Exposure to traumatic events combined with a more significant psychological adjustment is supplementary to the trait of mindfulness and acceptance . Meanwhile, emotional disengagement, which includes persistent disassociation, experiential avoidance, and coping strategies, is related to PTSD syndromes and psychopathology. PTSD theory of acceptance shows that mindfulness and acceptance skills enhance the recovery process from the disorders' main symptoms. Concerning this statement, all participants eventually gained their resilience through acceptance. They confessed that their health condition was improving, even if not like before, by accepting their fate and proceeding to the suggested treatments.

Limitations
This study has some limitations. First, the participants were all mature and at the peak of their careers, influencing their experiences and responsibilities. Hence, the experience might be different for women from different backgrounds. Based on a report in the Malaysian National Cancer Registry Report 2012-2016 of the Ministry of Health Malaysia, cancer incidents in women, regardless of type, are most common at 70-74 years, the retirement age. Second, only women are included in this research, despite cancer incidents in men currently rising. For future study, more samples representing the multi races is required. Fourth, for methodology, even though IPA is using idiographic, the result cannot be generalized to other women population with cancer. Hence the significant remains in the said phenomena only.
In conclusion, their perseverance facilitated the conceptualisation of the resilience these employed women possess. The findings provide an in-depth understanding of how Malaysian employed women conceptualised their resilience experiences. Based on the model outlined, perseverance allowed them to conceptualise resilience and continue their lives. The sub-themes of "resilience through acceptance" is considered as binding the knot that connects the other sub-themes.
The use of social media in this research validated the information gathered through transcript interviews and verbatim. Social media is an influential mechanism for many people but does not apply to participants of this research. Overall, only six participants used social media actively for sharing information regarding their cancer and resilience experiences. Meanwhile, the remaining four participants purposely didn't share it publicly either on social media or face to face with acquaintances.
This study identified how Malaysian employed women conceptualised the term resilience, especially when they returned to work. The findings show that resilience gained through acceptance is widely used by employed women who are diagnosed with cancer. Furthermore, participants also conceptualised their resilience through cognitive and psychological/emotional resilience, giving meaning to their cancer journey. Therefore, this study suggests that the authorities should assist women from diagnosis until prognosis, which would help them on their journey to recovery.
In summary, throughout the research process, we feel the application of IPA is best suited in exploring the meaning of resilience among employed women with cancer. Among the importance of using IPA is through the application of epoché, where our bias has been put aside before establishing research and research objectives. Furthermore, we learnt the different meanings given by participants on their resilience experience. Secondly, reflecting on the characteristics of these participants, we found one similarity in their educational background. Participants were women with a good academic background, minimal qualifications, and a bachelor's degree. Hence, the researcher received an abundance of volunteer participation from them. The behaviour reflects their openness and willingness to share the significant parts of their journeys to benefit and guide other people, particularly women. Furthermore, some participants mentioned their enthusiasm for reaching out to other women and offering them emotional, information, physical, and spiritual support regardless of religion. In addition, they participated actively in social support groups.
Thirdly, the culture of these women with cancer show that the participants have high trust in the medical team's professionality in treating cancer. This fact reflected many cancer options, including chemotherapy, radiotherapy, and the latest types of medication provided in Malaysia with a higher survival percentage.
Lastly, regarding the resilience process, the participants mention that despite all of their resilience processes, they give the most meaning to involving themselves with the Almighty. This process involved an extensive reflection of self, beginning from what has been done in life and what to achieve in future as cancer surviving women.