Abstract
Objectives
Due to its complexity, the management of cancer-related fatigue (CRF) is best based on an interdisciplinary care approach. Thus, we examined the preferred and the actual distribution of responsibilities from the perspectives of healthcare professionals and patients.
Materials and Methods
An online survey was conducted among physicians (N = 148), nurses (N = 184), and psycho-oncologists (N = 144) in Germany. The participants evaluated a series of statements and selected the professional disciplines that they deemed most responsible for specific tasks in CRF management. Data were complemented with the patient perspective. Experiences of cancer patients (N = 1,179) were assessed by questionnaires. Data from the healthcare professional and patient perspective were analyzed descriptively. For comparisons between professional groups, Kruskal-Wallis H tests and subsequent Dunn-Bonferroni tests were used.
Results
Healthcare professionals and patients agreed on a lack of interdisciplinary collaboration on CRF. Professionals valued the necessity of addressing CRF and educating patients, which was not mirrored in patient experiences. Physicians in aftercare and rehabilitation were overall perceived as main actors in CRF management. Nurses and psycho-oncologists frequently considered their own discipline as responsible for most of the tasks.
Conclusion
It is necessary not only to define task-related responsibilities in standardized operating procedures but to foster interprofessional collaboration in the management of CRF.
Keywords: cancer-related fatigue, supportive care, interdisciplinarity, interprofessional collaboration
Implications for Practice.
As recommended in clinical practice guidelines, the implementation of standardized operating procedures could be a relevant measure to clarify roles and referral pathways in cancer-related fatigue management. Clarified roles would be expected to facilitate the interprofessional collaboration. Yet, to benefit from such determination, the interprofessional confidence needs to be enhanced, for example, within interprofessional communication skills training. It might not be sufficient to increase professionals’ confidence in their (own) knowledge and skills within training but also to address their attitudes regarding other professions’ ability to manage cancer-related fatigue. Accordingly, other professions, but physicians, that is, nurses and psycho-oncologists, need and wish to be involved. To realize this interprofessional care approach in cancer-related fatigue management, structural support from healthcare institutions (eg, time and premises made available for training and administration systems) is necessary.
Background
Defined as “a distressing, persistent, subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion related to cancer and/or cancer treatment that is not proportional to recent activity and significantly interferes with usual functioning”,1 cancer-related fatigue (CRF) is one of the most impairing sequelae in cancer care.2–4 Despite applicable recommendations of clinical practice guidelines on how to manage CRF efficiently,1,5,6 it is at the same time one of the most common unmet supportive care needs.1,7 In one-third of cancer patients, symptoms persist years after diagnosis and hinder those affected from managing daily life and returning to work.2,8,9
Taking into consideration the multidimensionality of CRF and its complex diagnostics, clinical practice guidelines call for an interdisciplinary approach based on standard operating procedures (SOPs) to meet patient needs.10,11 If successfully realized, interprofessional collaboration in healthcare in general has the potential to increase the competence of healthcare professionals (HCPs) and evidence-based treatment decisions.12 Moreover, if multiprofessional HCPs collaborate efficiently, patients perceive the quality of patient-professional communication to be positively affected.13 Regarding CRF, however, international studies have identified a lack of interprofessional collaboration and lacking SOPs as barriers currently impeding its effective management.14
This is supported by results from the LIFT project (Longitudinal Investigation of Cancer-Related Fatigue and Its Treatment; Clinicaltrials.gov, identifier: NCT04921644). In focus-group discussions with HCPs working at a Comprehensive Cancer Center in Germany, participants described an uncertainty regarding their professional responsibilities in CRF management, as well as interprofessional communication barriers.15 Leadership and roles seem not to be clarified in CRF management, which might lead to misunderstandings and missed opportunities.15 This unanswered question of responsibility in CRF management could at least partially explain the apparent knowledge-to-practice gaps in an associated survey among HCPs in Germany. Some HCPs stated not to recommend promising treatment options to patients regularly despite their awareness of the evidence-based effectiveness.16-18 Knowledge of CRF-related guidelines was overall scarce among physicians, nurses, and psycho-oncologists.16-18
As the clarity of roles has a major impact on interprofessional collaboration in healthcare,19 we aimed to explore how HCPs working in the field of oncology do allocate responsibilities in CRF management among professional disciplines.
Methods
Study design and participants
Within the LIFT project, a cross-sectional online survey was conducted among physicians, nurses, and psycho-oncologists working in oncology in Germany. Participants were recruited in a variety of ways, using convenience sampling in the first step and snowball sampling in a second step to extend recruitment. Physicians, nurses, and psycho-oncologists from the in- and outpatient care, who saw at least one cancer patient per week for at least one year and had sufficient German skills to follow the survey, were qualified to participate. Detailed recruitment information has been published elsewhere.16-18 Data collection took place from December 2021 until September 2022. Ethical approval was granted by the Ethics Committee of the Medical Faculty of Heidelberg University (S-526/2018). The here presented study results are complemented by the perspective of 1,179 cancer patients, which we investigated via survey within the LIFT-project. Patients with ≥ 18 years of age, (newly) diagnosed primary tumor, recent or current chemotherapy, radiotherapy, hormone therapy, targeted or immune therapy, and the ability to understand and follow the study protocol could have been included in the survey. This resulted in a mean time after initial cancer diagnosis of approximately 5 months within the sample. The mean age was 63 years (SD = 12.5) and 56% were female. Cancer types were most commonly breast cancer (26%), colorectal cancer (16%) and prostate (14%). Details of the recruitment process, sample characteristics, and selected survey results reflecting the patient perspective have been published by Milzer et al.20
Study questionnaire
The survey was devolved in alignment to an Australian questionnaire.21 Items were pre-tested with representatives from all 3 investigated professions in oncology. The pilot study revealed neither unclarities during completion nor necessary additions to the content, and it was considered satisfactory. Self-report survey questions, which are of interest for the present study, covered the perspectives of HCPs regarding the current state of CRF management, the distribution of responsibilities in interdisciplinary CRF management, their personal involvement in current CRF management, as well as sociodemographic and professional characteristics (eg, age, gender, workplace, work experience, etc.).
To assess the perspectives on the current state of CRF management, HCPs were asked to indicate their agreement with statements regarding the interdisciplinary exchange on CRF, patient education on CRF, and screening of CRF, such as “Every patient should be routinely and repeatedly asked about CRF,” on a 4-point Likert scale.
To describe how responsibilities in CRF management are distributed, participants had to choose one or more professional disciplines following the question “Who do you think should be responsible for the following areas in cancer care?”. Disciplines to choose were “general practitioner,” “practitioner (acute care),” “practitioner (aftercare),” “practitioner (rehabilitation),” “other medical specialists,” “nurses,” “psychologists (eg, psychotherapy, psycho-oncology),” “further supportive services (eg, social medical services, supportive piloting, nutritional counseling, physical activity, and exercise training),” or “none/not necessary.” CRF-related management tasks were “Routine education on CRF,” “Routine screening on CRF,” “Counseling on preventive measures for CRF,” “Comprehensive assessment by means of anamnestic interview, physical examination and, if necessary, laboratory tests,” “Counseling regarding treatment options for CRF,” and “Provision of service points for CRF patients, eg, for exercise programs, psychosocial interventions, etc.”
Additionally, participating nurses and psycho-oncologists were asked to rate to what extent they feel involved in the management of fatigue in cancer patients on a 4-point Likert scale (“not at all,” “slightly,” “fairly,” and “very much”). They were further asked to indicate, if they perceived their current involvement to be adequate, with the answer options “no,” “yes,” “most of the time yes,” “I’d rather be less involved,” and “I’d rather be more involved.”
If the participant was unable to rate, there was the option “unable to judge” for some questions. The survey was conducted online via LimeSurvey (LimeSurvey GmbH, Hamburg, Germany). Survey completion took 15 minutes for HCPs and was remunerated with the sum of €15.
The complementary patient perspective on current CRF management is based on another survey within the LIFT project. Patients were asked to rate their agreement to the statement “My responsible healthcare professionals (physicians, nurses, psycho-oncologists, social workers) work well together on CRF,” on a 4-point Likert scale. Furthermore, patients had to answer the binary question “Have you been asked during your cancer treatment whether you feel exhausted?” for 5 professional groups in cancer care (treating physician, nurses, psycho-oncologists, general practitioner, during rehabilitation). Likewise, the question “How well were you informed about fatigue during your cancer treatment?” had to be answered by patients for the 5 mentioned professional groups in cancer care respectively, with the answer options “not informed,” “poorly informed,” “rather informed,” and “well informed.”
Statistical analyses
We used SPSS 29.0.0.0., with P ≤ .05 (2-sided) considered statistically significant. Descriptive analyses were conducted for the main variables in the HCPs and patient sample. Additionally, Kruskal-Wallis H tests and, if significant, subsequent Dunn-Bonferroni tests were performed to compare professional groups in their ratings of the statements regarding current CRF management. Effect sizes were calculated using Cramér’s V, with V = 0.1 indicating small, V = 0.3 moderate, and V = 0.5 large effects.
Results
Sample
Informed consent was provided by 209 physicians, 162 psycho-oncologists, and 260 nurses. Incomplete survey questionnaires were excluded, resulting in a final sample consisting of 148 physicians, 144 psycho-oncologists, and 184 nurses. Most of the psycho-oncologists and more than one-third of the physicians were directly invited to the survey by study personnel via mail after having been systematically drawn from outpatient care registries. One-third of the physicians and more than half of the nurses were aware of the survey through talking to colleagues. Moreover, another third of physicians and one-third of nurses was invited through newsletters and mailing lists of (training) institutions. Descriptive statistics of the study population are displayed elsewhere.16–18
HCP and patient perspective on current CRF management
The HCP perspectives on current CRF management are presented in detail in Table 1. The majority of physicians (65.5%), psycho-oncologists (56.3%), and nurses (65.8%) strongly agreed that the interdisciplinary exchange regarding CRF is neglected. Professional groups did not differ significantly in their estimations (H (2) = 4.43, P = .11).
Table 1.
Healthcare professionals’ attitudes regarding current CRF management.
| Strongly disagree | Disagree | Agree | Strongly agree | Not to judge | |
|---|---|---|---|---|---|
| n (%) | n (%) | n (%) | n (%) | n (%) | |
| The interdisciplinary exchange with regard to CRF is neglected. | |||||
| Physicians (N = 148) | 3 (2.0) | 7 (4.7) | 41 (27.7) | 97 (65.5) | 0 |
| Psycho-oncologists (N = 144) | 0 | 8 (5.6) | 52 (36.1) | 81 (56.3) | 3 (2.1) |
| Nurses (N = 184) | 0 | 6 (3.3) | 49 (26.6) | 121 (65.8) | 8 (4.3) |
| Educating patients about CRF before starting cancer therapy unnecessarily worries them. | |||||
| Physicians | 83 (56.1) | 50 (33.8) | 13 (8.8) | 1 (0.7) | 1 (0.7) |
| Psycho-oncologists | 59 (41.0) | 57 (39.6) | 18 (12.5) | 5 (3.5) | 5 (3.5) |
| Nurses | 83 (45.1) | 71 (38.6) | 16 (8.7) | 10 (5.4) | 4 (2.2) |
| Every patient should be routinely and repeatedly asked about CRF. | |||||
| Physicians | 1 (0.7) | 19 (12.8) | 51 (34.5) | 77 (52.0) | 0 |
| Psycho-oncologists | 1 (0.7) | 11 (7.6) | 45 (31.3) | 86 (59.7) | 1 (0.7) |
| Nurses | 4 (2.2) | 4 (2.2) | 53 (28.8) | 118 (64.1) | 5 (2.7) |
| Routinely screening every patient for CRF is a major effort. | |||||
| Physicians | 14 (9.5) | 39 (26.4) | 44 (29.7) | 50 (33.8) | 1 (0.7) |
| Psycho-oncologists | 41 (28.5) | 47 (32.6) | 25 (17.4) | 22 (15.3) | 9 (6.3) |
| Nurses | 32 (17.4) | 56 (30.4) | 55 (29.9) | 30 (16.3) | 11 (6.0) |
Abbreviations: N, n, number of cases; CRF, cancer-related fatigue.
Furthermore, the majority of physicians (89.9%), psycho-oncologists (80.6%), and nurses (83.7%) (strongly) disagreed that educating patients about CRF before starting cancer treatment worries patients unnecessarily. Despite this, there were significant group differences (H (2) = 7.24, P < .05, V = 0.1). Physicians seemed to be more likely to see in education the risk of worrying patients than psycho-oncologists were (z = −2.552, P < .05).
The majority of physicians (52%), psycho-oncologists (59.7%), and nurses (64.1%) were further strongly convinced that every patient should be asked about CRF routinely and repeatedly. Despite this, professional groups differed significantly in their estimations (H (2) = 8.35, P < .05, V = 0.2). Less physicians than nurses (z = −2.888, P < .05) seemed to support regular and repeated consultation of CRF. Accordingly, the majority of physicians (63.6%) (strongly) agreed to the statement that routinely screening every patient for CRF is a major effort. Professional groups differed significantly in their ratings (H (2) = 30.42, P < .001, V = 0.2). Seemingly, routine screening on CRF was perceived to be an effort by less psycho-oncologists (z = 5.463, P < .0001) and nurses (z = 3.430, P < .01) than by physicians.
The level of involvement in current CRF management perceived by psycho-oncologists and nurses is displayed in Table 2. Sixty percent of nurses, as well as 40% of psycho-oncologists felt slightly involved in current CRF management or not at all. Psycho-oncologists tended to feel more involved than nurses did. Estimations of the current level of involvement differed significantly between nurses and psycho-oncologists (H (1) = 8.11, P < .001, V = 0.2). However, both psycho-oncologists (33.6%) and nurses (51.6%) would rather be more involved. Regarding the adequacy of current involvement, nurses and psycho-oncologists did not differ significantly in their estimations (H (1) = 2.245, P = .13).
Table 2.
Psycho-oncologists’ and nurses’ perspective on their current involvement in CRF management.
| To what extent do you feel involved in the management of fatigue in cancer patients? | ||||||
|---|---|---|---|---|---|---|
| Not at all | Slightly | Fairly | Very much | Not to judge | ||
| n (%) | n (%) | n (%) | n (%) | n (%) | ||
| Psycho-oncologists (N = 144) | 22 (15.3) | 37 (25.7) | 35 (34.2) | 39 (27.1) | 11 (7.6) | |
| Nurses (N = 184) | 36 (19.6) | 74 (40.2) | 43 (23.4) | 28 (15.2) | 3 (1.6) | |
| Do you think your current involvement is adequate? | ||||||
| Yes | Most of the time yes | No | I’d rather be less involved. | I’d rather be more involved. | Not to judge | |
| n (%) | n (%) | n (%) | n (%) | n (%) | n (%) | |
| Psycho-oncologists (N = 144) | 22 (15.3) | 37 (25.7) | 35 (34.2) | 39 (27.1) | 11 (7.6) | |
| Nurses (N = 184) | 36 (19.6) | 74 (40.2) | 43 (23.4) | 28 (15.2) | 3 (1.6) | |
| Psycho-oncologists (N = 144) | 25 (17.4) | 42 (29.2) | 7 (4.9) | 1 (0.9) | 49 (34.0) | 20 (13.9) |
| Nurses (N = 184) | 16 (8.7) | 38 (20.7) | 26 (14.1) | 1 (0.5) | 95 (51.6) | 8 (4.3) |
Abbreviations: N, n, number of cases; CRF, cancer-related fatigue.
In accordance with the majority of HCPs, the larger proportion of patients (88.9%) (strongly) disagreed that their HCPs work well together on CRF, that is, perceived a lack of interprofessional collaboration (Table 3). Contrary to the affirmation of HCPs regarding the necessity of screening, less than half of the patients stated to be asked for CRF during cancer treatment by their treating physicians (46.2%), and even less by nurses, psycho-oncologists, their general practitioner, and during rehabilitation. The majority of patients had not been informed about CRF at any time during cancer treatment by any of the listed professional groups. Patients, if at all, were (rather) informed by their treating physician (19.2%).
Table 3.
Patients’ attitudes regarding current CRF management.
| My responsible healthcare professionals (physicians, nurses, psychooncologists, social workers) work well together on CRF. | |||
|---|---|---|---|
| Strongly disagree | Disagree | Agree | Strongly agree |
| n (%) | n (%) | n (%) | n (%) |
| 688 (67.6) | 217 (21.3) | 82 (8.1) | 29 (2.9) |
| Have you been asked during your cancer treatment whether you feel exhausted? | ||
|---|---|---|
| Yes | No | |
| n (%) | n (%) | |
| By treating physician (N = 1,142) | 528 (46.2) | 614 (53.8) |
| By nurses (N = 1,036) | 200 (19.3) | 836 (80.7) |
| By psycho-oncologists (N = 1,022) | 155 (15.2) | 867 (84.8) |
| By general practitioner (N = 1,062) | 291 (27.4) | 771 (73.6) |
| How well were you informed about fatigue during your cancer treatment? | ||||
|---|---|---|---|---|
| Not informed | Poorly informed | Rather informed | Well informed | |
| n (%) | n (%) | n (%) | n (%) | |
| By treating physician (N = 1,111) | 823 (74.1) | 74 (6.7) | 128 (11.5) | 84 (7.7) |
| By nurses (N = 1,004) | 930 (92.6) | 18 (1.8) | 38 (3.8) | 18 (1.8) |
| By psycho-oncologists (N = 1,001) | 898 (89.7) | 18 (1.8) | 49 (4.9) | 36 (3.6) |
| By general practitioner (N = 1,037) | 904 (87.1) | 37 (3.6) | 58 (5.6) | 38 (3.7) |
Abbreviations: N, n, number of cases; CRF, cancer-related fatigue.
Distribution of responsibilities in interprofessional CRF management
Figure 1 displays how HCPs allocate responsibilities in CRF management. HCPs’ estimation of the ideal distribution of responsibilities was independent of the current practice/involvement in CRF management. Being asked who they thought should (ideally) be responsible for different tasks in CRF management, physicians in our study primarily named their medical colleagues, mostly those working in aftercare (76%-93% per management area), in rehabilitation (73%-88%), and in acute care (53%-76%). Nurses, on the other hand, most frequently named their own discipline in 3 of the 5 management tasks (patient education: 89%; counseling on prevention: 87%; screening: 79%). Psycho-oncologists also saw their own discipline in 4 of the 5 tasks (except for diagnostics) among the 3 mainly responsible disciplines (patient education: 94%; counseling on treatment options: 92%; reference to contact points: 91%; counseling on prevention: 89%; screening: 76%).
Figure 1.
The 3 most responsible healthcare disciplines in the different areas of interprofessional CRF management according to physicians, nurses, and psycho-oncologists in our study. For every HCPs group (physicians, nurses, psycho-oncologists) participating in the study the 3 disciplines most frequently named to be ideally responsible are presented. The y-axis (%) represents the proportion of participants who have estimated a certain discipline to be (ideally) responsible for a certain CRF-related management task (A-F), that is, the higher the percentages are, the more participants from one HCPs group assumed a discipline to be ideally responsible in a certain area. Multiple choices were possible.
Physicians working in aftercare, followed by those working in rehabilitation facilities, were most frequently named over all tasks and by all 3 HCPs groups, that is, were thought to play or shall play a central role in CRF management. Having a closer look at the ratings regarding the disciplines of nursing and psycho-oncology (Figure 2), there are gaps between the self- and the external perception, respectively. For psycho-oncology, gaps are smaller, that is, the self-perception of psycho-oncologists toward a high responsibility of their discipline in CRF management was rather supported by how physicians and nurses estimated the role of psycho-oncologists. For nursing, gaps between self- and external perception were larger, that is, psycho-oncologists and physicians thought the discipline of nursing to be far less responsible than nurses themselves did. Regarding other supportive services, for example, nutrition-based counseling or exercise programs, participants allocated an overall sparse responsibility in CRF management, with the highest responsibilities of supportive services being assumed in referring patients to contact points and patient education. Psycho-oncologists attributed slightly higher responsibilities to supportive services than nurses and physicians did. Likewise, psycho-oncologists attributed slightly higher responsibilities to general practitioners than nurses and physicians did. Regarding general practitioners, however, participants agreed on a middle-sized responsibility in CRF management.
Figure 2.
Responsibilities in interprofessional CRF management attributed to nurses, psycho-oncologists, supportive services, and general practitioners from the perspectives of physicians, nurses, and psycho-oncologists in our study. The y-axis indicates the relative naming frequency (%) of the entitled healthcare discipline respectively (A-D), displayed per CRF-related management tasks (x-axis) according to nurses, psycho-oncologists, and physicians participating in the study. a Supportive services, for example, nutrition-based counseling or exercise training. Abbreviation: CRF, cancer-related fatigue.
Discussion
HCPs from 3 mainly involved professions in cancer care, medicine, nursing, and psycho-oncology, were surveyed regarding their perception of current CRF management in Germany and on how they would attribute task-related responsibilities in CRF management among professional disciplines. Survey results were complemented by the perspective of a broad patient sample.
There was strong agreement among HCPs and patients regarding a lack of interdisciplinary exchange and of interprofessional collaboration in the management of CRF. Previous international studies revealed similar findings for HCPs,14,21 as well as for patients.22,23 Accordingly, HCPs perceived the assumption that someone else was addressing CRF as one substantial, staff-related barrier to effective CRF management.21 Patients respectively were not able to clearly perceive roles of various HCPs22 and experienced the cooperation across sectors in supportive cancer care to be insufficient.23 Consequently, patients highlighted the coordinating role of general practitioners.22,23
Moreover, the majority of the HCPs in our survey were aware of the beneficial impact and necessity of routinely and repeatedly addressing CRF. However, this was not mirrored in patients’ experiences. Hence, it seems that many HCPs do not meet their own expectations for screening and education in clinical routine. Nevertheless, according to the patient perspective among the HCPs, it was the attending physicians who were most likely to address CRF and inform patients, if at all. Similarly, in a previous German study among cancer patients looking back at the last 2 years since diagnosis, physicians, in comparison to other HCPs, had been most likely to address CRF at least briefly.24
This is consistent with how HCPs themselves attributed task-related responsibilities in CRF management among professional disciplines in our study. Physicians in aftercare, along with those in rehabilitation, were among all 3 professional groups and all management tasks most frequently identified as (ideally) being responsible. Hence, taking into consideration how patients perceived the patient-physician communication about CRF,20 there might be a gap between the needs of patients and resources available among physicians. Accordingly, a third of patients affected by CRF did not feel taken seriously by physicians, and more than half perceived a lack of time to address CRF during medical consultation.20 While the awareness of CRF, as well as CRF-related knowledge and skills, should be further trained in physicians, other professions need to be involved and to take part in training to realize effective, interdisciplinary CRF management. Both knowledge and skills training, as well as the active involvement of other professions but physicians, need to be logistically supported by healthcare institutions, that is, by making time and premises available, offering suitable administration systems, as well as clearly defining referral pathways.14,24
Furthermore, psycho-oncologists as well as nurses rated their own disciplines among the most responsible ones. However, nurses and psycho-oncologists stated not to be involved sufficiently in current CRF management and called for enhancement. As nurses and psycho-oncologists seem to feel responsible on the one hand but lack involvement on the other hand, one could hypothesize that both do not perceive the allowance to take over certain tasks in CRF management. Regarding the collaboration of nurses and physicians, difficulties related to professional hierarchies and divergent attitudes were known for decades.25,26 Nurses often do not get requested nor find the space to share their opinion, whereas they are regarded as passive by physicians.26 However, as recommended in clinical practice guidelines1 nurses could indeed take over tasks in CRF management in in-patient care setting, such as patient education, screening, and counseling.17,27 Moreover, to facilitate the diagnostic process and to realize a multidisciplinary, patient-centered care approach, guidelines call for a higher involvement of psycho-oncologists in CRF management in the in- and outpatient care setting.1,16 While in particular the discipline of psycho-oncology could play a unique role during the process of diagnostics differentiating CRF from depression, psycho-oncologists in our study perceived their discipline’s least responsibility in diagnostics. Taking into consideration their potential in coordinating22,23 and given familiarity for a majority of patients, also general practitioners should be involved in CRF care. HCPs in our study attributed a moderate responsibility to general practitioners, with a slightly higher responsibility in referring patients to contact points.
Thus, according to our results, the barrier to interprofessional CRF management might not only be caused by the lack of defined responsibilities and guidance, as well as the general lack of time and resources in healthcare. In turn, the process of clearly defining responsibilities itself might be complicated due to considerable discrepancies in how professional groups attributed responsibilities. Accordingly, even if tasks would be clearly defined within SOPs, as recommended in clinical practice guidelines, HCPs probably still might hesitate to hand over tasks to other professions due to reservations and lacking interprofessional trust. Trust is a crucial factor for interprofessional collaboration aside of, for example, leadership and the exchange of information.22 Therefore, in accordance with Potosky et al.28, it is not sufficient only to increase HCPs’ confidence in their (own) knowledge of CRF - perceived knowledge and self-efficacy even tended to be rather high in our participants16-18 - but to address their attitudes regarding other professions’ strengths and competencies. As mentioned above, healthcare institutions are meant to support this by implementing respective trainings, as well as securing the spatial and timely frame.
Strengths and limitations
While this study shed light on the current management of CRF, there are several limitations to announce. Data on the perspectives of HCPs and patients were generated using a cross-sectional and observational design, not allowing causal conclusions about current management. To explore the perspectives of HCPs and patients, we created survey questions, for which, however, neither reliability nor validity measures were available. After piloting, these quality criteria were assumed to be satisfactory. While the answers of HCPs could be biased by social desirability, the answers of patients could be influenced by a recall bias due to patients’ retrospective. Moreover, our data regarding the distribution of interprofessional responsibilities describe how HCPs would distribute responsibilities in CRF management ideally, that is, as if they could formulate standard operating procedures themselves. However, and this is important to note, data do not provide information on whether HCPs think, for example, the current responsibilities of physicians in rehabilitation are perceived to be low and should be enhanced, or, if according to participants, physicians in rehabilitation are currently responsible and should keep their responsibilities. Nevertheless, we assume that the variety of disciplines that were reported to ideally be responsible are not yet involved sufficiently, as patients as well as HCPs remarked a lack of interdisciplinary collaboration in CRF management.
Conclusion
HCPs (physicians, nurses, and psycho-oncologists) as well as patients clearly perceived a lack of interdisciplinary exchange and interprofessional collaboration in CRF care. While HCPs seemed to be rather aware of what is needed to effectively manage CRF, they did not act accordingly in daily clinical routine. This was also confirmed by the patient perspective. Compared to other professional disciplines, if any, patients experienced physicians to be involved most actively. Correspondingly, from the HCP perspectives physicians in aftercare and in rehabilitation were seen to play and/or shall play a major role in CRF management. Though psycho-oncologists and nurses likewise allocated high responsibilities to their own disciplines. Those resulting discrepancies within the attribution of responsibilities in the management of CRF might complicate the process of clearly defining roles and pathways. At the same time, it highlights the importance of interprofessional trust.
Acknowledgments
The authors would like to thank all the participants for completing the survey, Sabine Holzmeier for data management and support of study conduct, as well as Christian Bader and Marvin Chong for study support.
Contributor Information
Anna S Wagner, Department of Internal Medicine II, Section of Psychosomatics, Psychotherapy and Psychooncology, University Hospital Würzburg, Würzburg, Germany.
Marlena Milzer, Division of Physical Activity, Prevention and Cancer, German Cancer Research Center (DKFZ) Heidelberg, Heidelberg, Germany; National Center for Tumor Diseases (NCT) Heidelberg, a partnership between DKFZ and University Medical Center Heidelberg, Heidelberg, Germany.
Karen Steindorf, Division of Physical Activity, Prevention and Cancer, German Cancer Research Center (DKFZ) Heidelberg, Heidelberg, Germany; National Center for Tumor Diseases (NCT) Heidelberg, a partnership between DKFZ and University Medical Center Heidelberg, Heidelberg, Germany.
Senta Kiermeier, Department of Internal Medicine II, Section of Psychosomatics, Psychotherapy and Psychooncology, University Hospital Würzburg, Würzburg, Germany.
Truong D Nguyen, Division of Physical Activity, Prevention and Cancer, German Cancer Research Center (DKFZ) Heidelberg, Heidelberg, Germany; National Center for Tumor Diseases (NCT) Heidelberg, a partnership between DKFZ and University Medical Center Heidelberg, Heidelberg, Germany.
Martina E Schmidt, Division of Physical Activity, Prevention and Cancer, German Cancer Research Center (DKFZ) Heidelberg, Heidelberg, Germany; National Center for Tumor Diseases (NCT) Heidelberg, a partnership between DKFZ and University Medical Center Heidelberg, Heidelberg, Germany.
Imad Maatouk, Department of Internal Medicine II, Section of Psychosomatics, Psychotherapy and Psychooncology, University Hospital Würzburg, Würzburg, Germany.
Author contributions
Anna S. Wagner (Conceptualization, Formal analysis, Investigation, Methodology, Visualization, Writing—original draft, Writing—review & editing), Marlena Milzer (Conceptualization, Investigation, Methodology, Writing—review & editing), Karen Steindorf (Conceptualization, Funding acquisition, Methodology, Project administration, Writing—review & editing), Senta Kiermeier (Conceptualization, Methodology, Writing—review & editing), Truong D. Nguyen (Conceptualization, Methodology, Writing—review & editing), Martina E. Schmidt (Conceptualization, Funding acquisition, Methodology, Project administration, Writing—review & editing), and Imad Maatouk (Conceptualization, Funding acquisition, Methodology, Project administration, Writing—review & editing)
Funding
This work was granted by the German Research Foundation (Deutsche Forschungsgemeinschaft, DFG) under Grant No. 438839893.
Conflicts of interest
M.E.S., K.S., and I.M. received research funding for projects related to fatigue as institutional payment from the German Ministry of Education and Research (Bundesministerium für Bildung und Forschung, BMBF). K.S. received honoraria for lectures with some relation to fatigue. For the remaining authors no competing financial interests or personal relationships were declared that could have appeared to influence the work reported in this paper.
Data availability
Data can be requested from the corresponding author.
References
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Data Availability Statement
Data can be requested from the corresponding author.