Interprofessional education in cancer care – a scoping review

Abstract

Background

Comprehensive cancer care requires effective collaboration by interprofessional healthcare teams. The need to develop educational initiatives to improve interprofessional collaboration is increasingly recognised. However, there is no agreement regarding the interprofessional competencies required for effective cancer care leading to much variation on the focus of research, planning and managing change. A scoping review was conducted to identify the current status of IPE in cancer care and to summarise the results of previous research in order to guide the development of interprofessional education in cancer care.

Methods

The JBI Scoping Review guidelines were used to guide the process of the review. A search of the available literature was conducted in CINAHL, MEDLINE (Ovid), PubMed, PsycInfo, Scopus databases from January 2012 to March 2023 to investigate IPE for health professional clinicians working in cancer care.

Results

Of the 825 initial references and 153 studies imported for screening, a total of 28 studies were included in the final review. From those studies, seven focused on the need for IPE and interprofessional competence for oncology healthcare professionals, four reviewed existing IPE programs and 17 described the development and evaluation of interprofessional education. Findings show variation and lack of concept definitions underpinning research in IPE in cancer care settings. Variation also exists in the range of research activities in IPE, most notably related to communication, teamwork and the development of interprofessional practice. The evaluation of impact of IPE is mainly focused on health care professionals’ self-evaluation and general feedback. Impact on patient care was only evaluated in one study.

Conclusions

Based on the results, interprofessional education research in the field of cancer care is limited in Europe. Thus, there is a significant increase in publications in the last five years. A more systematic focus on the theoretical framework and definition of concepts would be of value. Research and programme development should be based on a shared understanding on what constitutes the interprofessional competences and IPE. Programmes to develop interprofessional practice should be developed and implemented systematically with inclusion of validated assessment methods, and evaluated and improved regularly.

Background

Over the last decade, there has been increased interest in developing educational initiatives to improve interprofessional collaboration and practice in the cancer care setting [1,2,3,4,5,6,7]. Non-communicable and life-style related diseases, including cancer, are among the biggest challenges facing EU health systems and countries, causing illness, premature death and associated social and economic costs. The number of cancer cases is expected to increase in Europe by 24% by the year 2035 [8]. As the demand in cancer care continues to increase, health systems require a workforce of educated oncology specialists and professions to provide continuity and sustainability of care. Current educational systems have yet to match all the requirements needed in cancer care [9]. Furthermore, quality cancer care requires effective collaboration by an interprofessional healthcare team [10, 11]. People with cancer benefit when the health care professionals caring for them, not only collaborate, but strive to learn from each other [12].

Interprofessional collaboration can be defined as collaborative interaction among experts with different professional backgrounds involved in care of people with cancer and who share common goals [13]. Models vary across cancer units [14] and can involve professionals from different oncology specialties (radiation, medical and surgical oncologists) and disciplines (such as pathology), professionals from nursing and social affairs and allied health professions such as physiotherapists, psychologists, nutritionists and speech therapists [15]. Professionals from varying disciplines and professions have different knowledge bases, premises and competences for cancer care and interprofessional collaboration [10, 11]. Interprofessional healthcare teams need to understand how to optimize the skills of their members, share case management and provide better health services to patients and the community. Such collaboration results in a strengthened health system and leads to improved health outcomes [12]. Furthermore, effective communication is important not only for patients but for the well-being of all healthcare professionals (HCPs) [16]. Thus, interprofessional practice requires effective leadership,administrative support [17, 18] and continuous evaluation [18].

According to The Centre for the Advancement of Interprofessional Education (CAIPE) interprofessional education (IPE) concept can be defined as occasions when two or more professionals learn with, from and about each other to improve collaboration and the quality of care [19]. The primary goal of IPE is to improve patient care by better interprofessional collaboration [6]. This concept should be reflected in the training of cancer care workforce. In oncology, the concept of multidisciplinary care is an established part of the clinical practice [20]. Training of oncology specialists and professions needs to recognise the value of interprofessional care. Interprofessional collaboration has been seen as necessary for example in precision oncology [21] and radiation oncology [22], but IPE programmes vary substantially across countries [23]. In Europe, many professional societies provide opportunities for post graduate training for medical professions. The existing training curricula of ESTRO (European Society for Radiotherapy and Oncology), ESSO (European Society of Surgical Oncology and ESMO (European Society for Medical Oncology), all recognise the importance of interdisciplinary knowledge and understanding among specialists in radiation oncology, cancer surgery and medical oncology. Yet, gaps exist in mutual understanding among the three disciplines on interprofessional practice [24]. Very few training programmes in the European curricula for oncology specialists involve formal interdisciplinary attachments or integrated interprofessional approach on cancer care. These deficits limit both the scope and the value of interdisciplinary collaboration and the drive for better care. Interdisciplinary dialogue also drives standards and improves communication [24].

In 2010, the World Health Organization issued a report Framework for Action on Interprofessional Education and Collaborative Practice stipulating that teamwork is the first among interprofessional learning domains in a clinical setting, the others being roles and responsibilities, communication, learning and critical reflection, understanding of the needs of the patient, and ethical practice [12]. Interprofessional learning (IPL) has become a more prominent feature of health professional education at both pre-qualification and post-qualification levels. While the terms interprofessional learning (IPL) and interprofessional education (IPE) may relate to differing processes, with IPL focusing more on micro learning processes and IPE being more strongly reflective of an overarching educational framework, they tend to be used interchangeably in the existing literature [25].

Recent research relates to collaborative practice skills within clinical oncology [2] and radiation oncology [6] in determination of the impact and value of interprofessional learning [26] and interprofessional communication [27]. Among the barriers to successful implementation on interprofessional education, are the variations, both in definition and in concept, underlying research on IPE. Commonly used concepts are ‘interprofessional learning’ and ‘interprofessional education’. However, recently, the European Commission has launched the concept of ‘inter-specialty training’ to combine education and training of medical, nursing and allied health professionals in the cancer care setting [28]. The concept was defined later by McInally et al. (2023): “Inter-specialty training in oncology occurs when two or more specialties within professions collaborate by learning and interacting with each other during training in order to provide high quality cancer care” [29]. However, in order to understand the context of previous studies and to inform both training programmes and future research it was considered that a scoping review was required.

The objective of this scoping review was to describe the extent and type of evidence regarding interprofessional education (IPE) in oncology. The aim was to identify how IPE has been defined, how methodology underlying the research and implementation of the IPE has been utilised, describe the state of IPE in oncology. This review is part of a European collaborative project on inter-specialty training with the intention of providing useful training programmes across Europe and beyond (INTERACT-EUROPE).

Methodology

The current review followed the scoping review methodology. This type of evidence synthesis aims to systematically identify and map the breadth of evidence available on a particular topic, field, concept or issue. Scoping reviews can clarify key concept definitions in the literature and identify key characteristics or factors related to this concept [30]. The scoping review involved five stages: 1), Development of a scoping review protocol including research questions, and the purpose of the study; 2) Literature search on CINAHL, MEDLINE (Ovid), PubMed, PsycInfo, Scopus data bases [3], Selection of studies, 4) Data extraction, 5) qualitative analysis and presentation of results.

The questions guiding the scoping review were:

• 1. How has IPE been defined in previous research in cancer care?

• 2. What competences have been used to guide the curriculum development of IPE in cancer care?

• 3. What teaching, learning and assessment methods have been used in previous studies?

The PRISMA checklist extension for scoping reviews (PRISMA-ScR) was used to guide the process of the review. A detailed scoping review protocol was produced including databases and subject headings [31]. MESH terms, when applicable, were used to capture all the relevant literature. In consultation with a librarian, initial search titles and abstracts (N = 825) were reviewed by one researcher. All 153 items identified in this way were then downloaded into Covidence Systematic Review software (r) for further screening by three researchers. This process was followed by full text screening by the same researchers to identify articles that met the specified inclusion criteria.

Data retrieval protocol

Databases: CINAHL, MEDLINE (Ovid), PubMed, PsycInfo, Scopus

The PCC that featured the search: P(articipants) = oncology medical professionals (medical oncologist, radiation oncologist, oncology surgeon) and nurses, C(oncept) = inter-specialty or interprofessional education or interprofessional learning, C(ontext) = Cancer care setting

Criteria

Inclusion: Quantitative, qualitative studies and systematic reviews; papers with focus on IPE/IPL, development of interprofessional collaboration and teamwork through IPE; teaching, learning and assessment methods of IPE in the context of oncology.

Exclusion: Editorials, discussion papers, focus on other healthcare professionals outside oncology setting, non-oncological professionals, only on pre-registration students, conference abstracts and proceedings.

Limits: English language, 2012–2022 original search, updated search – to April 2023.

The main search terms: clinical oncology [MESH], medical oncology [MESH], radiation oncology [MESH], surgical oncology [MESH], oncology nursing [MESH], interprofessional training, interprofessional education, interdisciplinary education, interprofessional learning, interspecialty training, inter-specialty training.

Any conflicting screening results were discussed and decisions were made collaboratively. Full-text articles were filtered and reviewed. A data extraction sheet was pre-planned to extract the key information of the studies and reviews including authors, year, country, purpose of the study or review, study or review type and method, concept used, definition of concepts, interprofessional learning or education focus and/or competences, programme characteristics, teaching, assessment, and evaluation methods used and the main results.The data were extracted by three researchers and analysed with narrative content analysis. The process, analysis and summary of results were further discussed with the full research group including all the authors.

Results

Characteristics of the studies

A total of 28 studies were identified through database searching, of which one study was identified by reviewing reference lists (Fig. 1). There were fourteen quantitative studies, four reviews, six mixed methods studies and four qualitative studies (Table 1). The articles reported interprofessional educational programmes in United States (n = 15), Canada (n = 7), United Kingdom (n = 3), Denmark (n = 1), Germany (n = 1) and Switzerland (n = 1). Articles were published between 2012 and 2022. Nineteen of the articles were published in the last five years. From the included papers eight focused on describing the need and competences of oncology healthcare professionals [3, 4, 6, 9, 32,33,34,35], three reviewed existing IPE [1, 36, 37] or the development and evaluation (n = 17) of oncology interprofessional training [2, 5, 16, 22, 26, 38,39,40,41,42,43,44,45,46,47,48,49]. The target groups of the IPE included nurses, pharmacists, physicians (medical oncology, surgical oncology, radiation oncology and palliative care), radiographers, technicians and staff with healthcare backgrounds such as psychology, occupational therapy and other support workers (such as social workers, chaplaincy, or administration staff in contact with oncology patients).

Fig. 1

Data retrieval

Table 1 Summary of the reviewed papers

Collaborative care in cancer

In oncology, medical, nursing and allied health professionals provide complex care in an interprofessional context [33, 37, 41, 45]. To provide the best treatment and care for people with cancer, healthcare professionals are required to collaborate [1, 37]. According to Head et al. (2022) interprofessional collaborative practice is an essential component of quality healthcare in oncology [42]. Effective interprofessional care was seen as necessary to provide optimal care for patients [16], improve the safety of care delivery [38] and better outcomes of patient care [16, 32, 38].

Terminology

Eight of the papers [3, 6, 26, 32, 34, 35, 37, 44] reported using the concept of IPE or IPL with reference to existing definition in literature. One study used the concept of “Interprofessional clinical training “ [38], one “Interdisciplinary education and training”, and one “Multidisciplinary education and training” [49], however no definition of these concepts were provided [36]. None used the concept of ‘inter-specialty or interspecialty education or training’. Nine of the included papers had some concepts described but did not include clear definitions and eleven had no mention or definition of IPE or IPL. (Appendix Table).

The concept of interprofessional education (IPE) can be seen as a means to improve health system function and delivery of care [34]. In order to achieve positive transformations in healthcare delivery, healthcare professionals (HCPs) must develop skills in interprofessional collaborative practice [42]. The principles of IPE should be embedded into every aspect of programs [36]. IPE would ideally result in greater understanding and improved communication between disciplines and professions [22, 32, 36], improved coordination [32, 36, 39], enhance team-based care management [32] and optimize more culturally affirming care [46]. Desired outcomes from IPE include also articulating one’s professional role as well as those of other professions, mutual respect, trust and willingness to collaborate [5].

Competency domains

In the field of oncology, increasing and building on a set of foundational knowledge, skills, and attitudes within physical, psychological, social/cultural, and spiritual domains, and collaborating with other HCPs, an early learner/novice practitioner will move towards an identity as an expert interprofessional practitioner. A competence framework on the shared set of competencies can bring professionals together, while recognizing the individuality of each profession as possessing distinct and complementary skills [9].

Of the papers describing competence framework development for interprofessional education, one focused on finding consensus on shared interprofessional competences in oncology [9], one on teamwork competences [32], one on integrative oncology [35], one on communication skills [36], one on cultural competence [46], two on paediatric oncology [1, 37], one on palliative care in oncology [42], two on psychosocial training needs in oncology [4, 33] and three papers described the specific needs of radiation oncology professionals [3, 6, 34]. Development of frameworks considered the challenges to effective coordination and the impact on patient and clinical outcomes as essential to optimal, high-quality care [32].

Four of the papers reported development competences for IPE. The development process was informed by guidance from an expert advisory panel with a Delphi study based on a literature review in two of the studies [9, 35]. Both Esplen and colleagues [9] and Wells-Di Gregorio and colleagues [33] started from domains proposed by an expert subgroup, Esplen and colleagues [9] incorporating also focus group interviews. In the Warsi et al. (2022) study the focus group was used to determine intervention objectives [49]. The expert panels all involved oncology professionals, and one [35] included patient and public representatives. All included shared competences divided into the domains of knowledge, skills and attitudes.

Participants

Target groups included in six of ten studies multidisciplinary professionals working in general oncology [16, 38, 39, 45,46,47], four in radiation oncology [2, 22, 26, 44], one in gynaecology-oncology [43], one in paediatrics [48] and four in different departments within the hospital or in primary care [5, 40, 41, 49]. Focus on the programmes varied. Thus, interprofessional collaboration and practice in general was included in the learning goals of the IPE in six papers [3, 6, 9, 25, 35], communication in five papers [9, 16, 26, 35, 39] and teamwork in [2, 3, 22, 26, 39, 46] representing the main areas of interest of IPE in the cancer care setting.

Five studies described existing IPE education [6, 36, 37, 42, 46], while two focused on paediatric oncology [1, 37] and one on interdisciplinary education [36]. Three of the studies used literature reviews to identify IPE [1, 37, 49] and one [36] got the information from a survey carried out by oncology physicians from different specialties.

Teaching methods

Teaching methods varied in methods and usefulness and included face-to-face and web-based didactic content such as lectures, workshops, educational sessions, role play and reflections. Three papers concluded that there is a lack of interdisciplinary education in oncology and also highlighted the value of IPE to professionals. (Table 2). Teaching varied in time from a one hour-long discussion group session accompanied by online modules [48] to a year-long course [44]. The mode of delivery also varied including simulated cases and scenarios (n = 5) [2, 16, 22, 26, 40] some specified having standardized patients [2, 16] and others were cases discussed and developed in teams [22, 26, 40] and/or by use of self-reflection [16]. Five of the studies included e-learning modules [5, 16, 38, 41, 48] alone [38, 41] or in combination with face-to-face training [5, 16, 48]; in the case of the other nine, all the training was face-to-face [2, 22, 26, 38, 40, 43,44,45, 47] All but one of the studies were focused on learners. One exception was based on a train-the-trainer model [39].

Table 2 Characteristics of interprofessional education for oncology healthcare professionals

Evaluation

Of the 18 papers which described the evaluation of IPE programme (Table 3), 11 described also the development process [5, 22, 26, 38,39,40,41, 44, 46, 48, 49].

In the evaluation of education programmes, ten used pre- and post-programme evaluation methods [5, 16, 22, 26, 38, 40, 41, 45, 47, 48], two had mixed methods with observation and surveys [2, 39], one used qualitative evaluation with semi-structured interviews [45] and one compared the professionals participating with participants from other education activities [44]. General feedback surveys with participant satisfaction were the most common programme evaluation surveys developed for the studies.

Studies included samples of between four [44] and 1,138 participants [41]. Three of the studies included three-month follow-ups [38, 43, 48] and three studies, six-month evaluation follow-ups [43, 48, 49] indicating that gained intervention outcomes were sustained in the long term.

The following instruments were used to evaluate the impact of the IPE: (i) Readiness for Interprofessional Learning Scale [3, 22, 26], (ii) UWE Entry Level Interprofessional Questionnaire [22], (iii) Trainee Test of Team Dynamics and Collaborative Behaviours Scale (CBS) [22], (iv) Assessment of Cultural Competence using the Intercultural Development Inventory [40], (v) Frommelt Attitudes Toward Caring of the Dying [40], (vi) Attitudes Toward Health-Care Teams Scale [3], (vii) Attitudes Toward Interdisciplinary Learning Scale [3], (viii) Self-Efficacy for Interprofessional Experiential Learning Scale and End-of-Life Professional Caregiver Survey [1], (ix) Cultural Competency Assessment (CCA), Lesbian, Gay, Bisexual, and Transgender Development of Clinical Skills Scale (LGBT-DOCSS), (x) Interprofessional Socialization and Valuing Scale (ISVS) [46].

Other studies included in the review describe Delphi methods [9] and focus group interviews [4, 6, 9, 33, 39, 45] and instruments developed for the purpose of the study [5, 38, 39, 43].

Participants had positive reactions to the programmes indicating them as a promising strategy in improving cancer care [38]. They reported high levels of satisfaction [26], including improved relations within the team [22], the acquisition of new skills [41] as well as cross-cultural competence [40]. Confidence among the participants also increased [41]. Participants reported that they would highly recommend these programmes to their colleagues [2].

Participants considered that these educational events were valuable. They helped in areas such as consolidating communication, improving dialogue [5], valuing leadership [42, 44] and better understanding of spiritual needs [48]. These programmes also improved understanding of specific issues such as the effects of therapy on patients, the place of palliative care, management of pain and other symptoms and quality of life [47] and also a comprehension of the legal issues surrounding cancer [43].

There was statistically significant improvement in knowledge of teamwork principles [39] developing shared mental models, cross-monitoring situational awareness and effective conflict resolution, agreements about roles and responsibilities [22], and behaviours. Participants valued the opportunity to gain the perspective of other professions, connecting with colleagues from other disciplines practising crisis response in a simulated environment [2], and demonstrating lower levels of concern and anxiety when communicating with other professionals [44]. Some participants incorporated meditation into their daily routine by involving other family members and making it part of a “family routine” [45].

Significant improvement was also noted in increased comfort when discussing survivorship issues with patients. Significant increase in knowledge of survivorship care for five types of cancer, more confidence in ability to explain a Survivorship Care Plan (SCP), and increased comfort in discussing late effects of cancer treatment [47] were all reported. The main challenges were “breaking down the walls and being more comfortable with vulnerability” [45], and in being more open-minded after training [43]. Training increased IPE recognition of participants’ home institutions [42].

Table 3 Evaluation methods, description and outcomes of the IPE

Discussion

To the best of our knowledge, this work is the first scoping review summarising the existing research on interprofessional education and learning in the cancer care setting. We identified 28 articles published between January 2012 and March 2023 with a significant increase in publication in the last five years. The results indicate growing interest of interprofessional education in this setting. Interestingly, most of the studies and reviews identified were from US and Canada, showing the need for further research and collaboration in Europe.

This highlights and strengthens the need for collaborative initiatives and projects such as INTERACT-EUROPE, launched in 2022. The project is based on the EU Beating Cancer Plan 2021 in which the concept of “inter-specialty training” was launched to combine education and training of medical, nursing and allied health professionals in the cancer care setting [27]. This extends the use of specialty to also include different professionals, not only specialties among one profession [29]. The EU Beating Cancer Plan is a key strategy document for cancer care development across Europe, including the training of cancer care workforce. The concept will be used in the European training programmes. Therefore, it was important to understand its similarities and differences with most used concepts, especially, interprofessional education (IPE). One important aim of the review was to identify the concepts used in research and IPE development in the field. We found that interprofessional education [3, 4, 6, 9, 16, 22, 26, 33, 36, 38,39,40,41,42,43, 45] is the most common term used. However, it seems that, in the oncology setting, there is need for improving the theoretical underpinnings of education research on interprofessional education. Inter-specialty training and interprofessional education are very similar. Thus, inter-specialty as a concept could refer to education including only specialities of one profession. To enhance the interprofessional practice it is, however, important to be inclusive for all professionals of the multidisciplinary teams. From 11 studies and reviews using the IPE or IPL, only eight studies defined or described the concept. In the McInally et al., (2023) study, medical doctors and nurses from the oncology field, expressed lack of understanding of the inter-specialty training as a concept [29]. IPE may have been more familiar to participants; however, the results of the study and our review indicate that conceptual clarity is needed in future studies and development of inter-specialty training.

The illustrates the multidisciplinary context of cancer care settings and the need for professionals to work together for people with cancer to achieve optimal care outcomes [10, 11, 50]. Interprofessional education, bringing the professionals together, can improve interprofessional practice and collaboration. According to our results, participants evaluate IPE positively and improving the collaboration. To support the development of interprofessional practice in oncology, as described in the WHO Interprofessional Collaborative Practice framework, describing and defining the common competences for inter-specialty training programme is important [12].

The shared set of competences in oncology practice included interprofessional collaboration, recognition and understanding or needs and experiences of a person affected by cancer, person-centred care and service approach, communication skills, use of technology in care delivery and understanding of one’s own limits and ability for self-care. James et al., (2016) also highlighted the values and ethics, roles and responsibilities [2] and Koo et al., (2014) attitudes towards interprofessional collaboration, in addition to communication competences and teamwork capabilities [3]. The above-mentioned are also key elements of interprofessional education. The aim is not for learners to master all the disciplines and professional expertise, but more about understanding the expertise of different professions and what they need to know about the specialty or the profession to work efficiently together [2]. Thus, our review provides information also on the common foci of the programmes in addition to more general interprofessional practice and team work focus; care and symptom management [2, 22], paediatric oncology (1, 36, 47 ), safety [38, 39], psycho-social oncology and psycho-oncology [4, 5, 33, 43], palliative and end-of-life care [1, 40, 43], spiritual care [48], integrative oncology [35], survivorship [41, 47] and well-being at work of healthcare professionals [45]. Although, our review focused on oncology, findings on theoretical underpinnings of the studies and programmes, teaching methods and evaluation of IPE could be used on other specialties also.

A variety of methods was used on the IPE. The content and focus and learning goals of IPE, and what constitutes interprofessional education varied between the studies and reviews. This has been highlighted also as common to IPE by the Committee on Measuring the Impact of Interprofessional Education on Collaborative Practice and Patient Outcomes (2015) [51]. Programme evaluation was mostly limited on participant satisfaction and feedback on delivery of the education. The evaluation methods mostly used in evaluation of the impact of education interventions were knowledge tests, behaviour change, confidence, comfort, intention to change practice and self-assessment of preparedness, Previously validated instruments were used in five studies [3, 22, 26, 40, 46], but it was common to use survey instruments developed for the study. Impact on patient care was not often measured. In one study patient incidence reports were included [14]. This result demonstrates a need for more systematic use of previously developed evaluation and assessment methods when appropriate, but also extent the evaluation of impact on care.

Limitations

A limitation of this study is that only publications in English were included. Neglecting the potential data of studies from non-English speaking countries can have an impact on the results. Furthermore, we used broad subject headings with Boolean operators in search of literature, but it is possible that we did not find all the papers published. To decrease this risk, a professional librarian was consulted in the literature search process. We did not include studies focusing only on one specific cancer type, and this also needs to be seen as a limitation. As is common in scoping reviews, the quality of publications was not assessed, and we included papers with a variety of methods in the review. This needs to be recognised in interpreting the results. Thus, this review approach produced more rich data for describing the current state of IPE in cancer care.

Conclusions

Based on the review, research on interprofessional education in the field of cancer care is limited. The need for interprofessional education is well recognised, yet provision and research in this field needs to be increased to enhance quality, person-centred care for people affected by cancer and efficient delivery of cancer care. In the future research would benefit from a more systematic approach to underpinning the theoretical framework on IPE. The evaluation of impact of IPE is currently mainly focused on HCPs perspective. Further research is needed to evaluate the impact on patient care. It is also evident that research and IPE programme development is very limited in the European context and therefore research is needed to strengthen the IPE development in Europe.