2.1.1 Source and method of recruitment.

After meeting with the Administrative Director of nurses and caregivers at the different facilities, the former provided a list of names of all the nurses’ managers to contact in each care unit (oncology and hematology). Each healthcare manager presented the study to his/her entire team, supported by the study information leaflet at their disposal, which had been validated by the Ethics Committee. Depending on the dates of meetings that we had arranged beforehand, the study was proposed to all the professionals who were scheduled to work in the units on these specific days. Concerning the treatment teams, caregivers were contacted either directly by the representatives, who personally arranged the appointments, or through an e-mail sent by the representative, with a copy of the e-mail to our team, requesting they make an appointment with the interviewers.

2.1.2 Inclusion and exclusion criteria.

The inclusion criterion consisted of an agreement by the nurses to participate in collecting data. Consent was given by e-mail or verbally during the appointment arrangement process. The exclusion criterion was a refusal to take part in the study. All those designated agreed to participate and were subsequently interviewed.

2.2.1 Using the Theoretical Domains Framework (TDF).

The TDF was developed by Michie et al. to understand health professionals’ practices and identify elements of these practices to target for the implementation of new recommendations and evidence-based practice [13, 14]. According to Lou Atkins et al., this framework was primarily used in healthcare settings to explore factors influencing clinical behaviors in order to design implementation interventions; to identify barriers and facilitators to change [15–17]. Alan Glasper and Colin Rees explained that each domain of the TDF represented a behavioral determinant, mediators of behavioral change. [18] The TDF was composed of 12 original theoretical domains: (1) knowledge, (2) skills, (3) social/ professional role and identity, (4) beliefs about capabilities, (5) beliefs about consequences, (6) motivation and goals, (7) memory, attention and decision processes, (8) environmental context and resources, (9) social influences, (10) emotion regulation, (11) behavioral regulation, and (12) nature of the behavior. [14] Employing this tool helped identify elements that either hindered or facilitated the implementation of new modes of care in everyday practice. Michie et al. suggested a prompt containing the wording of a series of follow-up questions related to each theoretical area [14]. We performed a double translation of the prompt. We then conducted a testing phase with five persons of differing profiles to ensure adequate understanding in French and subsequently presented it to four health professionals to confirm its relevance to the target audience.

2.2.2 The interview guide.

The form and substance of the interview schedule were approved by a medical anthropologist with a PhD, specialized in the field of cancer research. To begin with, the guide consisted of the following open prompt: “Please tell me about the management of addictions in cancer patient care.” The interview was organized to assess how health professionals defined MI and motivational positioning, addictions and their management in the cancer care pathway. Each interview was conducted in a single session, individually, in a quiet office, with the schedule organized to ensure the professional’s full attention.

2.5.1 Ethics approval.

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or the national research committee (Ethics Committee of the Saint Etienne University Hospital, France. NCT03706937) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

2.5.2 Consent to participate.

Informed consent was obtained from all individual participants included in the study.

2.5.3 Consent for publication.

Informed consent was obtained from all individual participants included in the study.

3.1.1 More complex patients.

For the majority of nurses, patients with alcohol addiction were described as "somewhat uncommon patients,” “Always more complicated than other patients!" or "those kinds of patients.” They were perceived as apart. Most nurses believed these patients required more time and that an effort had to be made to avoid confrontation, language hostilities or upsetting the patient.

"For us, it is complicated to treat patients who have an ear, nose or throat cancer and who still have addiction issues; it is difficult for the treatment I give them (…) they are somewhat uncommon… they are non-communicative, they do not talk to us or they are verbally a bit aggressive (…) It is not always easy to give care; they refuse treatment." (Nurse)

For the onco-psychologist, anchored in a psychoanalytical approach like his or her colleagues, patients with an unresolved addictive disorder were viewed as more vulnerable than patients already weakened by cancer. They described complex care management without behavioral changes in the patients in question.

"Addiction, which is added on top of cancer (…) (is an) exacerbating factor or a vulnerability." "They represent two major entities: addiction and cancer. Together, they make for a particularly complex situation.” (Onco-Psychologist)

3.1.2 Cancer seen as a burden.

Cancer remained central to concerns. The patient was seen as stupefied by the announcement of a cancer diagnosis. Caregivers perceived it as a unique disease compared to other care pathways.

"Cancer is a very heavy disease.” “Patients suffering from cancer are in a state of stupefaction (…) they have just been told that they have cancer, which defines the specificity of care." (Nurse)

Nurses described the diagnosis of cancer as representing a drastic change in the patient's life. They explained that as soon as the disease was announced, patients became psychologically affected, due to the intensity of emotions and upheaval it caused. They also mentioned that the entire daily life of the patient required a reorganization; that these sudden changes were transformations for the body, but also for the mind of the patient.

"So, in fact, the specificity is that you have to give them time too! They have so much information, that their brain cannot do everything at the same time! This is the difference, this stupefaction!" (Nurse)

Patients are often seen as very tired, psychologically and physically.

"There are also patients who are not doing well, they have cardiac issues, so this must be mentioned too! There are patients with advanced, already metastatic diseases, with a full range of symptoms.” (Nurse)

For patients with an advanced stage of the disease, the concept of project and future projection was modified. Nurses struggled to cope with unsolved addictive disorders associated with cancer, since the cancer was an advanced state and the patient’s life span uncertain. Nurses felt the patient was accumulating burdens.

"I think it's the cancer, on top of the addiction, that makes the problem harder, it adds an additional burden, anyway! And afterwards, the prognosis is often short-term, often… for conditions that are a bit particular, anyway!" (Nurse)

Managing a cancer patient’s addiction presented a challenge for nurses, who felt like they were overloading the patient already dealing with cancer.

“We are going to ask people to make an extra effort, when they are already facing cancer. So, it’s true that it can actually be complicated. (…) Cancer is a whirlwind that turns everything upside down, and yet we are asking that of them too! It’s the part about adding something more again!” (Nurse)

3.1.3 Lack of awareness of smoking cessation.

The tobacco specialist nurse emphasized the overused image that nurses and doctors had of their role in the care. Caregivers appeared to pose a major obstacle to specific support for patients with unresolved addictive disorders.

“We have several barriers to seeing all the patients; the barrier of the caregivers, in any case!” (Tobacco specialist nurse)

For many nurses, managing tobacco addiction was tantamount to total abstinence, which explained why they found it hard to understand the modalities of management based on a reduction in consumption associated with a prescription for nicotine replacement (in this case, patches).

“It won't change anything if they stop (…) Once they have met the tobacco specialist nurse, there is not always a change in the patient—some of them will still go outside and smoke their cigarette, like they did before meeting her. They tell us that they have an agreement with the tobacco specialist nurse and that they can smoke, even with the patches, despite things like that, yes!” (Nurse)

For the other staff members, the opposite was true. They held the conviction that the total abstinence approach of the tobacco specialist nurse caused conflict and hurt the patient, forcing him/her to stop smoking when cancer had just been diagnosed. The tobacco specialist nurse insisted that it was vital to treating physical dependence in the cancer care pathway.

“Addiction is not only about wearing the patch (…) Sometimes, we can be sure of temporary abstinence; a patient who has cancer and who is confined to his/her bed—it is not normal that the person suffer from abstinence.” (Tobacco specialist nurse)

The care management strategies of this specialist opposed the representations of his peers, not trained in the specific management of addictions.

"We have the specificity regarding the staff, where we have quite a few obstacles to overcome, in any case. Some experience our intervention as something ‘violent’ regarding the patient who has just been diagnosed with cancer. For some, it’s not obvious." (Tobacco specialist nurse)

3.2.1 A taboo on alcohol and drug addiction.

For the majority of the sample participants, tobacco was the addiction addressed the most often. Alcohol came in second place but was seldom discussed in a meaningful way. Drug addiction was only very briefly brought up by the three professionals (n = 3: 1 psychologist and 2 caregivers).

"There are drugs. People who take drugs (…) I don’t know if it’s not too taboo because we don’t talk about it much.” “It can apply to alcohol as well and opiates can be even more taboo; we don’t even talk about it. Ultra-taboo." (Onco-psychologist)

For sterile containment units, addictions seemed inexistant, with the exception of tobacco, which remained questionable for nurses, who lacked a rational explanation.

"Frankly no, it's very strange (…) no, curiously, we don't have people, I mean, I have come across very few in our department. Whereas, when you go to other departments, you will find some! But not in our department!" (Nurse)

Nurses pointed out that the consideration of dependence was directly related to the spontaneous reporting of the patient. For example, in the case of a young opioid-dependent patient (as stated in the medical record), nothing had been implemented, since she had not declared or requested anything.

“There was nothing specific about opiates. There weren't any things implemented at that time. She wasn't describing a dependence, but there too, they have to be able to say they're dependent! (Nurse)

However, the nurse was obliged to collect information from the patient to fill out the medical file. The majority of nurses were uncomfortable with how they approached the addiction subject with the patient. When the nurse broached the topic, it was in a mode that emphasized thoroughness. Otherwise, as seen above, the nurse waited for the patient to declare unresolved issues of addiction on his/her own.

“Because, it’s always taken badly when I ask this question, because it means I put the word ‘addiction’ on it (…) It has a pejorative side, I find (…) I don’t know how to ask the question in another way.” (Nurse)

The interview was described as containing leading questions, essentially akin to an interrogation, with the computer as an intermediary, employing closed questions that required binary answers of yes or no. The patient therefore answered these questions of the nurse, without the possibility of speaking about other areas, problems or individual priorities.

“To know the patient’s priorities, I will ask them the question. But it remains a pointed question; it is an interrogation.” (Nurse)

Thus, the directive nursing interview, employing closed questions, like an inventory checklist, seemed to protect the nurse from having to raise questions on sensitive subjects such as the consumption of or addiction to alcohol or other illicit substances.

"For me, it's easier to ask (…) like a quote-unquote ‘inventory checklist,’ because falling into judging (them) I find difficult (…) To avoid being judgmental.” (Nurse)

3.2.2 The curative approach: Cancer-centered.

For nurses, the fact that the patient continued to consume tobacco while managing cancer did not change the standards of care. The caregiver did not invest heavily in addiction.

"Afterwards, I'm not going to make any specific adjustment in treatment, because there is no real point (…) I realize that we haven’t done anything concrete about it." (Nurse)

However, an exception could be made for the sterile hematology sector. Indeed, nurses explained that these patients in sterile isolation rooms had no choice but to avoid the tobacco or other drugs. Abstinence appeared to be an easy “action,” since the patient could not take any other action, given the hospitalization conditions: complete hospitalization over several weeks without the possibility of leaving the sterile room.

“Afterwards, I’d say that sterile hospitalization is easy, because, all of a sudden, they don’t have a choice!” (Nurse)

According to the nurses, the medical oncologists seemed to focus only on the treatment aspect of cancer. Other ailments, such as pain or fatigue, did not appear to have a place in starting care. It was therefore not uncommon for the patient, experiencing a certain level of pain, not to go to his or her treatment appointment. The medical approach remained pathological-centered and left no room for a holistic approach of the person.

“For example, the doctor, what is incredible is that he will only be interested in chemo! We have the impression that chemo interests him more than the patient! And it’s a bit complicated! (…) Later on, we sometimes realize there is a problem with pain, and that’s why the patient didn’t come; but the problem wasn’t handled on the first day because it wasn’t the question of the day! For the doctor, the question of the day was to know whether the patient had chemo or not!” (Nurse)

Addictions were added as an additional burden (although they often existed prior to the cancer), with the cancer remaining the central concern, directing management toward a disease-centered approach rather than a patient-centered approach. In most cases, nurses were helpless in the face of cancer-treated patients with unresolved issues of addiction. Cancer care was the priority of the institution and the healthcare teams working there. Therefore, unresolved issues of addiction were not high on the nurses’ list of responsibilities, even if it was sometimes one of the patient's priorities.

"We are treating a cancerous disease; we do not treat addiction. Addiction is not the priority; I’d say that, even for me, it is not my priority, whereas sometimes it is the priority for the patient!” (Nurse)

This is probably the reason why nurses pointed out the absence of smoking prevention in the hospital.

“It is true that the team doesn’t do prevention (…) in terms of the establishment… there is not a whole lot of prevention, not in the hallways either.” (Nurse)

3.2.3 Motivational positioning at the margin of current practices.

We noted one exception: a nurse with experience in treating alcohol and tobacco dependence stood out from his/her peers. This nurse suffered from the lack of consideration and specific management of addictions by his/her colleagues. This nurse managed to identify and create a rapport with the patient to encourage the latter to talk and built trust with patients during their cancer care. This nurse supported patients in their daily lives, while trying to inspire them to change their behavior. This nurse practiced motivational positioning, but the action remained strictly isolated, with no connection or possibility of sharing with other colleagues.

For the tobacco specialist nurse, who was affiliated with another institution, his/her intervention seemed to fall entirely outside the care pathway, again, focused 100% on cancer. This specialist nurse explained that there was no link to overall care, which, in his/her view, influenced the effectiveness of care.

“The problem of addictology in the cancer treatment facility—I have the impression that we are a pawn among the rest of it (…) Our care is very, very, very ‘psy’ (psychological). And the info that we do not have here, it’s kind of a pity!” (Tobacco specialist nurse)

The tobacco specialist nurse practiced MI on a daily basis in care. This specialist nurse, trained in this process, saw the benefits of care in terms of results with the patient. The current nursing practice was based on all the fundamentals of MI, utilized to care for patients undergoing cancer treatment and suffering from unresolved issues of addiction.

This specialist nurse explained that alcohol was often addressed by the tobacco person, because patients suffering from alcohol addiction found it difficult to admit. In this case, the nurse adopted motivational positioning with regard to alcohol and subsequently directed the patient to the addiction specialist team, who intended to follow up.

"People have a little trouble confessing their alcohol consumption, so through tobacco, we're going to bring up the other products that exist." (Tobacco specialist nurse)

The Social worker informed us of training received in conducting social interviews in the course of his/her studies. Mastering the social interview technique was a requisite for obtaining the degree. The foundations of MI provided the framework that guided the social interview: an interview for and with the patient, to bring out the patient’s motivations for change. The Social worker stressed the need to adopt an empathetic posture, rely on reflective listening and use reformulation and enhancement. Respect for the patient’s rhythm was central to the professional’s approach, not acting in the patient’s place. The formulation of hypotheses and the use of the decision-making balance were an integral part of the practice.

“It is this relational technique that we are asked to use, which combines empathy, a patient-centered approach, valorization, reformulation, active listening.” (Social worker)

The Social worker related how, when there was a medical injunction to arrange directive home care, against the will of the patient, it ended in failure, with the patient doing an about-face upon returning home.

“The person tells me, ‘No! I don’t want it!’ But I still arrange everything urgently, because the patient will return home, which comes with a medical protocol, an obligation, and we are responsible for their discharge (…) The home aides called and said that he didn’t want it, you know? (…) When we don’t follow the timing of the patient, it does (results in) this!” (Social worker)

The Social worker highlighted the difference that this directive stance created with the patient, compared to patient-centered care, where the patient felt considered.

“The patient feels much more considered in terms of his care, that’s it, he feels he is receiving care! It makes a difference! I see this difference.” (Social worker)

Almost a majority of nurses had never heard of MI. A third of the participants of the sample attempted to explain representations of MI but did not corroborate its definition and modalities. They always positioned themselves first, with their filters and their care and management priorities, which was in contrast to the posture taken in motivational positioning. Some claimed it was due to their training and educational experience. They mentioned not knowing how to work differently: the nurse is in a perpetual state of motion with the patient; the nurse must always provide a solution or meet a measurable objective nearly instantaneously.

“People who listen fully- that is not an objective for me! I'm not going to play the pop psychologist!” (Nurse)

The tobacco specialist nurse tried to show other nurses that listening to the patient is the key to managing unresolved issues of addiction. In motivational positioning, listening is a treatment, it is considered care.

"But it does not prevent us from fighting against this; talking is a treatment, but it's not the same as administering an injection. There are degrees of ‘nobility.’” (Tobacco specialist nurse)

At times when the nurse wanted to help the patient move towards weaning, the nurse quickly found himself/herself in an impasse. Clearly, the posture adopted by the nurse, combined with the way of connecting with the patient and any addictive problems, was met with a resistance to change in the patient. Furthermore, the discourse increased this resistance to modify his or her habits.

"After a quarter of an hour, quickly, we were stuck! I thought something was missing and I couldn’t see how to get out of this situation! I didn't find an opening or anything, I didn’t know what to do! (…) It was so painstaking for fifteen minutes! There was an opening that told me that he was worried about it, but I felt blocked and I didn’t see how! Then he asked me if I had a lighter! I told him no, there’s a limit to everything! It was too much for me!” (Nurse)

Clinical care remained under the influence of the nurses’ corrective reflex, referring to the tendency to advise patients about the “right” path to follow for good health. Thus, the nurse advised and warned the patient about the dangers of addiction. The nurse only intended to convince the patient that his/her health would improve, and treatments would prove more efficient after the changes, to provide support. Every fact and gesture of the patient was known to each member of the care team. Caregiver treatment was directive or even injunctive.

“This is what we are trying to do, but it just doesn’t work.” (Make the patient’s own motivation emerge and depart from the common discourse). “I think we are not very good at highlighting the positive, we know how to criticize. We have a hard time moving forward at the patient's pace as a caregiver.” (Nurse)

For hospitalized patients, nurses claimed they insisted on education. They reiterated that they were obliged to follow up on what the oncologist did because the latter “made a big deal out of it.” The nurses explained to the patient that smoking increased risks that affected the curability of the cancer. They concluded with the patient, “If there are other addictive elements that come into play, we will not be able to cure them!”

Many nurses disclosed that they used the technique of fear to stimulate the weaning process necessary for the hospital environment (complete hospitalization, sterile post-transplant area).

"My technique is fear (…) It is my way of being in contact with this specific domain." (Nurse)

3.3.1 The contributions of motivational positioning to cancer care.

Those who practice MI and motivational positioning explained that it was the best way to encourage the patient to change. The decision-making scale involved a technique widely used to enable patients to integrate the notion of management of current addictions while undergoing cancer treatment.

“We are not necessarily going to talk about completely quitting tobacco because often, people are scared, thinking we are going to forbid them to smoke (…) So we’re going to cite all the pros of quitting smoking and all the cons of cigarettes (…) Then we are going to show them a rather empathetic attitude, we are not going to impose things on them, we are going to gently help them come around to quitting, which is different (…) We evoke the efforts they have made, highlight what they have already achieved, and in no case are we going to make them feel guilty." (Tobacco specialist nurse)

Thanks to this motivational support technique, patients were often satisfied and comforted. Non-directive care, with full listening, without guilt or judgement, reassured patients. They could thus move forward at their own pace and take an active part in changing their behavior and habits, if they so desired. The healthcare professional trained in this approach was there to respect their timing and support them in this process.

“Actively listening to the patient, (being) empathetic (…) many people have an idea of the care regarding tobacco that is completely different; often people do not want to see us (….) (but) at the end of the appointment, they are happy because, and this is the point, they did not expect our particular approach.” (Tobacco specialist nurse)

3.3.2 A need for training for a patient-centered approach emerging among nurses.

For nurses, a need for training was raised—training that would enable them to relate in a relevant and effective manner to patients undergoing cancer treatment and suffering from an unresolved addictive disorder.

“For starters, I don’t have the skills because I have no specific training.” “In my opinion, we have to come to a realization (…) (that) I don’t have the skills; I don’t have the training.” (Nurse)

Nurses justifiably questioned the mirror game between themselves and the patients. The former seemed to be regularly challenged when facing these patients, amassing counter-attitudes or results against productivity, even though they had fervently invested in care.

“I think if we had training to approach this type of patient, it wouldn’t be so bad! (…) I wonder if we are showing them the appropriate attitude.” (Nurse)

As the nurses had previously mentioned, they were the product of a training system with a medico-centered approach. It was the nursing posture anchored in the paternalistic and prescriptive attitude, tinged with the corrective reflex described here.

“I tell myself that there might be a way to approach it in a different manner.” (Nurse)

4.3.1 Limitations of the study.

The results of our research should be compared with similar studies at other cancer treatment facilities. The sample did not include ‘advanced practice nurses’ because, as a new profession, French establishments generally do not employ them. We suggest that research should be pursued on a wider scale, in several comprehensive cancer centers, when ‘advanced practice nursing’ becomes more prevalent in cancer treatment facilities to collect information for further findings.

The small size of the sample cannot be used to extract representative quantitative statistical data due to lack of power. However, the sample size is compatible with reliable qualitative analysis [31].