Presentation of information.

“I like simplicity–I like all one stop shopping…one piece of paper [or] two at the most that says it all in less paper” (Pharmacist 3). Presenting the patient with written information was emphasized to be important by all HCPs, but ideally this should be provided in a condensed format. Participants identified patient education needs to be comprehensible. This included presenting drug information using patient-centred language and written material at a grade three or four reading level. “You know, I try not to use big words. Well I mirror actually; I mirror what they bring to me” (Nurse 3). It was identified that patient material is mainly available in English and this can be challenging when speaking to patients in whom English is not their first language. Participants identified that HCPs needed to be transparent when presenting information to patients. They felt the presentation of information should include quantitative values, so that patients are able to understand the risks and benefits of therapy.

Prioritization of chemotherapy drug information.

All participants emphasized the importance of providing patients with information about how to “troubleshoot at home” to manage adverse effects. This included providing patient education on symptoms related to adverse effects to prevent toxicities related to therapy. When discussing adverse effect information, HCPs prioritized the drug information delivered to patients by discussing “the common and the serious [adverse effects]”. It was identified by physicians that long-term adverse effects of chemotherapy, although discussed initially, are not readdressed again with the patient when they finish treatment: “We don’t do this at all, … where you sit down and you say, ‘so you finished your chemotherapy and these are some of the potential long term [adverse effects]’” (Physician 5). Pharmacists and nurses felt it was important for patients to have a general understanding about how chemotherapy works to kill or target cancer cells and this was mentioned as a component of their teaching that was done with the patient.

Modes of education delivery.

Participants felt it to be beneficial for patients to have educational material available in a variety of forms. To accommodate different types of learners, providing patients with online resources and videos was felt to be valuable. The importance of providing additional visual information such as medication calendars or showing patients the names of their medication and images of their medications for referral, were described as an essential part of the written and verbal information provided. Physicians discussed novel modes of education delivery that may engage the patient including the use of new technologies (e.g. internet, video) and applications. A participant explained that people “have apps that extract how many steps they’ve taken, you should drink this much water. If we had something like that for chemotherapy and the scheduling for supportive meds and that type of thing that might be helpful too” (Physician 3).

Timing of education.

Although there was not a clear consensus on this, participants felt that patients needed to have some education provided prior to the first cycle or “in advance of their treatment”. It was felt that patients needed to receive some information and education on the medications they would receive at the time they were being offered treatment. As Pharmacist 5 explained, “[Patients] need that baseline education so that they know–okay, they’re asking ‘do I want to get this chemotherapy…what does that mean?’”. Participants felt that education needed to be repeated for patients. As Physician 2 said, “I think you have to deliver [education] like we are, multiple times. I don’t think you can deliver it once because they don’t hear it.” However, it was also noted that the healthcare team needed to be conscious of the patient’s time and not expect them to return to hospital for more appointments. Nurses recognized that education was often provided to patients at the same time as the treatment was being given: “we teach as we do” (Nurse 1). Education during drug administration was felt to be important from a safety perspective, but was done also as a consequence of limited time.

Reinforcement of education.

“How many times I’ve heard [patients] say they would sooner hear [information] too many times than not enough. Too many times versus not enough is so much better.” (Nurse 2).

Reinforcing and introducing education by “filling in gaps” or “details” was described by many HCPs. This included asking questions about how medications were taken at home and assessing patient adherence. “A lot of times when [patients] say ‘I have this nausea’–‘Well did you take your anti-nausea pills?’–‘No’”. (Physician 2). To further engage patients, patient-centred teaching sessions were also proposed. “You almost maybe think that if [patients] had a session [where you] tell them—how are you going to take your anti-nausea pills again? or what are you going to do if you get a fever? just so that they—they really absorb the information” (Physician 4). Many HCPs emphasized that education needs “redundancy” and “never stops” for patients.

Reassurance.

“Sometimes [patients] are overwhelmed and sometimes they can’t hear anything, so we do encourage them to [bring] someone with them” (Physician 2). Participants identified that patients need adequate support during education sessions. Family member support was encouraged by HCPs as this support person could help understand the information discussed. Providing the patient with contact numbers so they could reach the clinic and “call with problems” was described as another way to provide reassurance. One physician participant also allowed patients the option of bringing “little recording devices” to appointments. Group education sessions were felt to be beneficial for patients to provide reassurance; patients with similar cancers could be grouped together in these sessions so they could exchange information and support each other.

Individualized education.

“I don’t know if there is kind of a one fit for everyone” in providing education (Pharmacist 4). Participants emphasized that education is personal and felt it was important to provide an approach that was “tailored to the patient”. Group education sessions were criticized as being very general and it was felt these could be “fine-tuned for a patient” (Physician 3). Healthcare professionals felt it was beneficial to have education provided as a one-on-one session as this allowed an opportunity to provide patient-centred education. However, costs associated with the provision of one-on-one education were felt to be a barrier to its implementation as this would require more staffing resources to provide individualized education to all patients.

Understanding patient needs.

“Any time you provide information that’s near the diagnosis it’s going to be overwhelming and needs repeating for patients” (Pharmacist 6). Healthcare professionals identified that patients need “time to digest” after the diagnosis. They acknowledged that the patient’s ability to absorb information needs to be assessed when providing education as “it depends on the patient how much depth you can go in” (Pharmacist 5). Participants also thought that developing a relationship with the patient was important for patients to feel comfortable. Physicians acknowledged that it was important to establish patient expectations at the time of diagnosis as this was essential to recommending chemotherapy for the patient.

Collaboration among healthcare professionals.

“I mean ideally it would be nice if there was more collaboration than there currently is. We kind of right now, we all kind of work in our own little silo and we all have different information to give [the patients]” (Pharmacist 4). Ideas for team collaboration involved including pharmacists in chemotherapy clinics as primary educators. Pharmacists felt strongly about being integrated with physicians and nurses in the clinic: “if there was a pharmacist available, [in a] multidisciplinary clinic, then they would have a role, maybe a specialized role, with certain medications” (Pharmacist 2). One physician identified that the use of pharmacists in multidisciplinary clinics could also delegate some of the education done in the consenting process. Each HCP was identified as having a different focus and emphasizing different teaching components which was felt to be beneficial for patients in understanding information. This also highlighted the importance of each HCP in the delivery of oncology medication education.

Communication among healthcare professionals.

Participants identified a lack of knowledge about what information had previously been provided to the patient by other HCPs. Participants felt this communication gap could be improved with documentation. Written information about adverse effects and drug reactions that patients experienced was felt to be valuable to have documented in the patient file. Participants also identified that documenting education that was provided to patients about their chemotherapy was important. Nurse 2 acknowledged concern about fertility discussions with young patients and chemotherapy: “there’s no way we’re going to start opening up the can of worms of fertility issues the day they are starting treatment”. In addition, sharing educational resources with community HCPs was identified as important: “family doctors should know about this [chemotherapy adverse effect information] because they’re often the first people to hear about toxicities” (Physician 3). Participants also thought community HCPs could reinforce supportive medication teaching; however, it was identified that they may not have the same knowledge or comfort.

Differences in healthcare professional roles.

Healthcare professionals identified different roles in the delivery of oncology medication education. All participants identified that nurses provide the bulk of chemotherapy education. This education focused on “side effect management” and “cytotoxic precautions” related to chemotherapy. Nurses and pharmacists associated planning, such as scheduling and arranging community supports as part of the nurse’s role. Nurses were also identified to play a significant role “supporting” and “encouraging” patients emotionally as they go through treatment.

Pharmacists were felt to provide “focused” education to patients about their chemotherapy medication in addition to other therapies for chronic diseases. This involved identifying drug interactions or other drug related problems a patient may have while on treatment (e.g., patients at risk of hyperglycemia while on steroids). “They are great any time you have questions about the [chemotherapies] themselves—how the drugs could potentially interact, and they have been great sitting down with patients and going through their medications and making sure there are no [drug] interactions and making specific [recommendations] about the drugs themselves” (Physician 5). They were also identified as having a role in adjusting home medications and suggesting alternatives to therapy with patient drug allergies or intolerances. Pharmacists were acknowledged as being the main educators for patients taking complimentary/natural health products.

Education that physicians provided to patients about their chemotherapy medications included introducing the treatment options, identifying treatment goals and informing patients about the risks. Much of the physician’s time was felt to be spent providing information to the patient on their cancer diagnosis and outcomes.

Lack of knowledge of other healthcare professionals.

“So yeah I haven’t thought too much in depth who does education because I know what I want to do as long as someone is doing the other things” (Physician 3). Words like “I assume” were used as HCPs described what information was being provided by others. Some participants were not sure how other team members could be integrated into the delivery of oncology medication education. Physician 4 acknowledged uncertainty in how pharmacists could help optimize oncology medication education based on their current interaction, “I don’t know how the pharmacist would intervene [because] I’ve never worked with one in a long time”.

Current resources.

A lack of staffing resources was identified as a barrier to providing patient-centred education. Pharmacists were noted to spend the majority of their time verifying chemotherapy orders resulting in limited time for patient education in the outpatient setting. “Do [pharmacists] have time to come out of the pharmacy room—the pharmacy office and ask [patients] personally?—No, because if they do that then the other patients are going to be delayed” (Nurse 1). The treatment area where education was often delivered by pharmacists and nurses was described as hectic and lacking privacy which was not ideal for teaching. These HCPs thought this environment would be difficult for patients to discuss private and personal health concerns. Nurse 4 stated, “I mean in an ideal world, if we’re not busy and myself, as the nurse, has time to sit and go over everything and I have [the patient’s] undivided attention—things aren’t beeping off and I am not getting up and going and doing things and coming back to start over or pick up where I left off”. This setting for education delivery was felt to be distracting and not conducive for learning.

Understanding healthcare professional needs.

In response to quickly evolving chemotherapy treatment regimens, HCPs identified a desire to stay up to date with in-services or “education refreshers” to improve patient care. “What used to be the ‘gold standard’ for treating certain diseases has evolved over the years and now treatment can consist of second line therapy or things you have never heard of” (Nurse 3). Participants also identified a desire to work to their full scope of practice with the introduction of specialized practitioners in the clinic to provide education and perform assessments.

Avoiding misleading information.

Healthcare professionals identified a number of ways patients can be provided with misleading information during chemotherapy education. Group teaching sessions could potentially create confusion as patients with different diagnoses and treatments are grouped together. “I do think they need to have differences between intravenous [chemotherapy] and the immunotherapies because if you don’t have that divide they’re not the same” (Physician 5). A lack of educational resources available for patients receiving immunotherapy or oral chemotherapy was also identified. To improve this gap in care, HCPs thought efforts should be in place to better support these patients. Available educational resources were also identified to be a potential source of confusion if not reviewed first. As Pharmacist 4 explained, “Sometimes our protocols don’t match well with the educational resources we have available to us through the [British Columbia] Cancer Agency, so if that’s the case I don’t give it to the patients because I feel that’s just confusing them more”.

Strengths and limitations.

Strengths of this research include the incorporation of multidisciplinary perspectives using a qualitative design to obtain rich research data which would not have been possible using quantitative methods. Steps were taken to ensure participant confidentiality and promote an open discussion during the interviews (See Rigour and Trustworthiness). Although we believe that theoretical data saturation was achieved with 15 participant interviews, it is unknown whether more codes would have emerged with more interviews [31,41]. Another limitation is that the themes identified in this research relate to the opinions of HCPs working in oncology at NSHA and may not be transferable to other institutions.

Implications of findings and recommendations.

This research describes the HCP perspective of optimal oncology medication education at NSHA and follows up on previous studies that have examined the patient perspective. Facilitators to education delivery such as verbal communication and written material have previously been supported by patients receiving oncology medication education and this formatting should be maintained in future medication education models [3,5,33]. Additionally, patients being treated at NSHA have expressed a desire to have reliable internet resources available to them [3,5]. Standardization of written information and recommended online resources could help to avoid the distribution of misleading information. As outlined by HCPs, the use of new technology such as applications or web-based resources could also be explored.

Healthcare professionals identified that patients with similar cancers could be grouped together in education sessions. Patients have also identified that access to patient support groups should be a component of education as hearing others’ experiences can help lessen anxiety and confusion [5]. Therefore, future changes in oncology education sessions should focus on trying to group patients with similar diseases and treatments together.

Since the educational needs of patients change over time, and both HCPs and patients have identified the need for continuous education, it may be beneficial to allow patients the opportunity to schedule additional education sessions, such as follow-up phone calls or appointments with pharmacists [3,5]. Offering follow-up phone calls gives patients an opportunity to absorb and formulate questions, provides the patient with privacy for questions that may not feel comfortable asking in a treatment area and also tailors the discussion to the patient. These were all described as barriers to education delivery in the current model [3,5]. Telephone follow-ups could be piloted in any future education models that are developed. Knowledge gained from this research will be translated within our facility and a multidisciplinary approach in the provision of oncology medication education is recommended in which there is an expanded clinical role of the pharmacist.

The results of this research will be used to improve medication education delivery to oncology patients by HCPs at NSHA, and to help guide any new educational resources that are developed to improve patient-centred care and the quality of oncology education provided to patients. This research may also promote multidisciplinary teams providing oncology medication education to patients, and further promote pharmacist clinical services in oncology at NSHA and at other institutions. More research is needed to determine whether these results apply to the broader oncology HCP population.