2.1 Study design

We implemented a QUAL→qual mixed-methods design [19], consisting of a qualitative cross-sectional survey [20] followed by open-ended semi-structured interviews with a subsample of surveyed PTs. According to Morse and Niehaus, “QUAL” indicates a qualitatively driven study with a qualitative core component; “qual” indicates a qualitative supplemental component, and → suggests that the supplemental component was conducted sequentially after the core component.

Our study involved a two-phase approach: a survey to gather initial data and qualitative interviews with a selected group of participants who had consented to further involvement. The survey collected PTs’ experiences through questions informed by the Critical Incident Technique (CIT) [21,22], a research method used to systematically collect and analyze significant events, or “critical incidents,” profoundly impacting an individual’s experience or behavior in specific situations. Developed by John Flanagan in 1954, CIT involves gathering detailed descriptions of particularly important or challenging events. These incidents are then analyzed to identify patterns, key themes, and insights into how people respond to specific circumstances. CIs in this study refer to situations perceived as significant by PTs caring for cancer patients during the pandemic. In the study’s first phase, some PTs agreed to be contacted for further research (by leaving their contact information). In the second phase, these PTs were invited to participate in qualitative interviews. The purpose of these interviews was to explore more deeply the contents of CIs they had reported during the survey and to gain deeper insights into their experiences as PTs during the initial wave of the COVID-19 pandemic in Italy. Findings from both phases were combined through a process known as triangulation. We integrated data from the survey and qualitative interviews to provide a more comprehensive and multi-dimensional understanding of PTs’ experiences during the first wave of the COVID-19 pandemic by combining insights from the survey (CIs) and the in-depth qualitative interviews (that explored these incidents further), triangulation allowed for cross-validation of findings (Carter et al., 2014), thus enhancing the credibility and depth of the study by ensuring that the results are not based on a single data source but are corroborated through different perspectives, leading to a richer and more nuanced representation of the PTs’ experiences. In Fig 1, we provide a representation of this process.

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Fig 1. Mixed-methods design process.

https://doi.org/10.1371/journal.pone.0318241.g001

2.1.3 Semi-structured interview development and administration.

We formulated the semi-structured interview guide using the survey questions (Table 1). It encompassed specific prompts designed to explore the CIs reported in the survey by PTs, explore the perceived effects of the current situation on their clinical practice and personal life, and identify the specific concerns, objectives, or tasks that PTs considered necessary while caring for cancer patients.

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Table 1. Interview guide.

https://doi.org/10.1371/journal.pone.0318241.t001

Three team researchers (LDP, MEDC, and AMR) conducted all the interviews by telephone or remotely from August to September 2020. We audio-recorded and verbatim transcribed the interviews.

2.2 Data analysis

Two researchers (AMR and SDL) analyzed socio-demographic and professional information using descriptive statistics. Responses regarding CIs were analyzed using the framework method [23,24]. The framework method systematically analyzes qualitative data, involving several steps: familiarization with the data, developing a coding framework, indexing (or applying the framework), charting, and interpretation. The method is flexible and allows for inductive (emerging from the data) and deductive (based on predefined concepts) analysis. Data are organized into a matrix that enables researchers to visualize patterns and relationships between themes, making it easier to compare responses across participants. The framework method is beneficial for team-based research, as it promotes transparency and reproducibility by structuring how data is analyzed and interpreted. In our study, we used this method to systematically explore the understanding of how the pandemic impacted PTs‘ experiences and practices through the PTs’ accounts and perspectives.

Initially, three researchers (MEDC, MP, FDV) independently analyzed approximately 30% of the PTs’ responses to the open-ended survey questions [20], developing an initial coding framework inductively. During this phase, the researchers discussed discrepancies in labeling or identifying recurring concepts in regular meetings. When differences in interpretation arose, the team revisited the original data and deliberated until a consensus was reached. Once the initial framework was established, two additional researchers (LG and SDL) reviewed and refined it, ensuring that the identified themes accurately reflected the data. This step involved further discussions within the team to address any remaining disagreements. This iterative process resolved discrepancies collaboratively, ensuring the final framework was comprehensive and consistent with the data.

After these revisions, three researchers (LG, SDL, and LDP) thoroughly checked the second version of the framework before applying it to the entire dataset. During the subsequent analysis of the remaining survey responses, two researchers (MEDC and FDV) used the framework to calculate the frequency and intensity of themes.

For the interview analysis, we used the same framework deductively. Four researchers (MP, ER, MEDC, and FDV) analyzed the responses, again working collaboratively to resolve any discrepancies. This ensured that the framework remained consistent while allowing for in-depth exploration of new insights that emerged during the interviews. All disagreements were resolved through group discussion, carefully ensuring that all voices were heard and that the final coding accurately represented the data.

3.1 Survey sample characteristics

The software used for the survey returned a total of 141 PTs. We cleaned the dataset from duplicate and invalid responses. PTs who were not treating cancer patients during the first wave of the lockdown were excluded as they were not eligible. The final dataset included 102 valid questionnaires (S1 dataset). Survey sample characteristics are summarized in Table 2. Most PTs were female (88.2%) and mainly aged between 41 and 60 (60.8%). Half of the PTs worked in the so-called “red zones” of northern Italy, where the virus spread peaked in March 2020. Nineteen (6%) PTs were subjected to compulsory quarantine during the weeks before the survey (March-May 2020). Cognitive and psychodynamic approaches were the most represented psychotherapeutic approaches used by PTs. Most (74.5%) had worked in psycho-oncology for at least six years, mainly treating adult cancer patients. Over half (57.8%) were employed in a hospital or a cancer research institute.

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Table 2. Sociodemographic and professional characteristics of participants (survey respondents and interviewees).

https://doi.org/10.1371/journal.pone.0318241.t002

3.2 Interviewee sample characteristics

Thirty-nine PTs out of 102 consented to be interviewed by providing their contact details; 17 PTs chose not to participate in the study, citing reasons of being occupied with other commitments (n=11) or because researchers could not establish contact (n=6). One male and 21 females participated in the interview-based study. Most of them were 41–50 years old and worked in the northern regions of Italy. Almost all the interviewed PTs (n=18) were quarantined in March-May 2020. Half have been employed in the psycho-oncology field for at least 11 years. All were caring for adult cancer patients

3.3 Qualitative findings

Four themes were identified by analyzing the CIs and the semi-structured interviews: patient relationships, clinical practice management, emotional aspects, and organizational recognition. Several subthemes were also identified. The following sections describe emerging themes, subthemes, and illustrative quotations. Table 3 lists the themes and subthemes, with frequency across the PTs’ CIs reported and intensity of labels. Figure 2 provides a thematic map to visualize the relationships between the different themes and subthemes.

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Table 3. Themes and sub-themes from qualitative analysis of CIs and semi-structured interviews, frequency of themes across CI’s participants, and intensity of labels within themes.

https://doi.org/10.1371/journal.pone.0318241.t003

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Fig 2. Thematic map.

https://doi.org/10.1371/journal.pone.0318241.g002

4.1 Summary of findings

To the best of our knowledge, this study, which was performed on a large sample of PTs from several Italian regions, is the first to focus on the practice of psychotherapy addressed to cancer patients during the first phase of the pandemic. We employed a qualitative method to gather information from the PTs’ “real world” and through their voices. As reported elsewhere [26–28], this allowed the researchers to obtain data concerning the PTs’ direct experiences rather than theoretical reflections or opinions.

Qualitative analysis performed on both the CIs and the semi-structured interviews led us to group the PTs’ experiences and practices into four theme-based categories, each including specific subthemes: patient relationships (the impact of restrictions on family ties, the impact of restrictions within the healthcare environment), clinical practice management (new problems and tools for psychological interventions, timing and continuity of care, changes in the number of requests for psychological interventions), emotional aspects (emotions captured in patients, emotions captured in other professionals, the emotional landscape of psychotherapists during the pandemic), and organizational elements (investments in psychological support and service coordination, issues related to employment status). Specific themes and subthemes from our qualitative analysis are reminiscent of those identified in previous research on psycho-oncology professionals during the pandemic, even though these prior studies employed diverse methodological approaches. In the study performed in the UK by Archer and colleagues [14], participants reported concerns about the disruption of psychological care delivered to patients, a reduction in patients referred to psycho-oncology services, and worries about the ability to provide the same standard of care through remote methods. Nevertheless, the drive to implement improvements in working practice also emerged through reducing process barriers and fostering inter-professional collaboration. Costantini and colleagues [5], in their study aimed at assessing Italian psycho-oncologists’ well-being, found that moderate and severe peritraumatic distress levels were associated with living alone and the perception of being avoided by family or friends because of work. The subject of challenges linked to the use of remote consultations was the focus of three studies. In the phenomenological research conducted by Morgan and their team in the UK [13], participants detailed how the practice of remote consultations evolved, transitioning from an initial crisis state to a new normal. In a Dutch study led by van der Lee and collaborators [2], video consultations emerged as a viable alternative when in-person meetings became overly burdensome for patients and as a promising tool with potential utility beyond the pandemic, particularly for patients who are too frail to travel or require motivation for therapeutic exercises in some psychotherapies. Similar findings were documented in a study conducted in the UK by Millar and their colleagues [12], where participants also highlighted the high rate of patients receiving psychological interventions via remote consultations and the relief expressed by patients who felt validated in avoiding healthcare settings associated with the trauma of illness.

From our findings, three main issues characterizing the delivery of psychological interventions to Italian cancer patients during the COVID-19 emergency can be outlined, which we will discuss in the following sections.

4.2 The challenge of delivering psychotherapy through information and communication technologies

The first issue concerns the role of information and communication technologies (ICTs) in the organizational changes made within the health system during the pandemic. These changes, which also concerned oncology and palliative care settings, raised significant questions about the continuity of psychological care for cancer patients. On the one hand, the suspension of in-person psychological interventions challenged PTs’ ability to be a source of professional support for their patients [13,27]. On the other hand, such service restrictions changed how patients experienced and accessed psychological services. As reported elsewhere, the surveyed PTs initially felt displeased about suspending their clinical activity [12]. Nonetheless, a new way to approach patients and maintain therapeutic relationships became possible thanks to the prompt use of ICTs, a measure strongly suggested in Italy soon after the lockdown and implemented in many other countries [27].

Although online ICT was considered an opportunity [12,29] and a means to reconnect with patients [2], the shift from face-to-face to online meetings caught many PTs off guard. As highlighted elsewhere, they sometimes felt they needed to be more skilled and comfortable using digital devices [14,27]. They questioned their ability to deliver the same standard of care effectively to their patients. Recent studies on cancer patients and healthcare professionals have widely discussed this topic, emphasizing the strengths and limitations of ICT employment in clinical consultations during the COVID-19 pandemic [26,30–32]. According to Clerici and colleagues, ICT can be helpful within an established doctor‐patient relationship but is very difficult for new patients [26]. Millar and colleagues outlined that patients and therapists adapted well to these changes [12].

Since the first wave of the pandemic, the increasing employment of ICTs represented (and still means) an innovative way of delivering psychotherapy within both institutional and private contexts [10]. Promptly, PTs gleaned from the pandemic that fostering a sense of “closeness” and “presence” was achievable even through a screen or a phone. Nevertheless, it is essential to acknowledge that these tools are not neutral. During communicative exchanges, they significantly restrict the perception of time and space, physical postures, and interpersonal distances. Additionally, they limit body language and eye contact while omitting other non-verbal socio-emotional cues like scents, physical contact, and sensory input from the environment. Individuals may compensate for these limitations by filling the information gap with their imagination, which is inherently tied to their past experiences and expectations. However, all the factors mentioned above inevitably impact the efforts of PTs in establishing and maintaining authentic relationships based on empathy and compassion that form the cornerstone of every psychological intervention.

As highlighted elsewhere [33], some measures can be implemented to mitigate the inherent constraints of video consultations. For example, selecting a noise-free environment with a stable internet connection and positioning the webcam at an appropriate distance from the patient‘s image on the screen to enhance eye contact and ensure proper framing of one‘s face. During these communicative interactions, it is essential to be attentive to fluctuations in one‘s vocal tone and the patient‘s, facilitating the establishment and maintenance of emotional connection and resonance.

Thus, future research on this topic should address the following issues, i.e., how remote consultations could impact therapeutic goals, how the quality of the therapeutic alliance can be effectively ensured, and the extent to which strategies and tools from different psychotherapeutic approaches may continue to be used or need to be adjusted to maintain their efficacy in the context of a digital environment [2,33]. In addition, the acceptability and feasibility of online psychological interventions for cancer patients is still a matter for further investigation despite evidence suggesting the positive effects of such an approach on these patients’ perceived support, knowledge, and information competence [34]. Another point concerns the need for specific training on the potential advantages of ICTs and how to conduct online consultations, which are starting to be implemented in webinars.

4.3 The “bridging” role of psychotherapists between different users and healthcare settings

A second issue that emerged from our findings is what can be defined as the “bridging” role of PTs. Our PTs described themselves as collectors of multiple support requests. The needs of cancer patients related to the pandemic increased their pre-existing psychological burden, thereby complexifying PTs’ work for an indefinite period, as has already been suggested [2,8,10,33]. In some cases, hospital-based PTs were the only people with whom patients could relate when Italian oncological departments were reorganizing their service provision. Many were involved in national helpline activities to support bereaved relatives or were asked to help other healthcare professionals with their experiences related to work overload and emotional burdens. In this way, by detecting and responding to both users’ and providers’ emotional issues and psychological needs and sustaining the interpersonal relationships limited by lockdown restrictions, the PTs acted as a bridge between all the actors involved in the care process and within different healthcare settings. Other studies also highlight this role in describing how COVID-19 impacted psycho-oncology service provision [2,14,26]. In the picture of PTs’ emotional condition and inner resources during the pandemic provided within the cross-sectional web-based study performed in Italy in 2020, the surveyed PTs showed greater resilience and ability to maintain a positive vision of the future than other healthcare professionals. Indeed, PTs are trained to help others, deal with cancer-related limitations, and review their values considering stressful changes. The authors propose that psycho-oncology associations should play a role in implementing policies designed to foster a sense of social connectedness. This can be achieved by offering interactive guidance and a scientific engagement system [5].

4.4 The poor recognition of psycho-oncology

The third issue concerned the lack of professional recognition of PTs’ role in their increased workload during the pandemic and the need to ensure psychological interventions are integrated with other healthcare services and coordinated at a national level. In our study, many PTs complained about a lack of recognition of the value of their work, despite the perceived increase in their clinical activities with cancer patients, their relatives, and healthcare staff, and the positive feedback from users concerning the benefits of the psychological interventions they were provided with during this time. Given the fundamental role of cancer-related psychological support not only during but also beyond health emergencies and outbreaks [7,8,28,35,36], this pandemic may represent an impetus for the effective integration of psycho-oncology into organizations, as widely recommended by international and national guidelines (please see www.siponazionale.it) [16,36,37]. The results of a survey recently performed by SIPO highlight how psycho-oncology services are not uniformly distributed across Italy; furthermore, these services are heterogeneous both in terms of the activities performed and the number of PTs involved (please see www.siponazionale.it). As in many other countries worldwide, even in Italy, the core curriculum of the psycho-oncologist has not yet been clearly defined, nor is the training path needed for the certification of the psycho-oncologist profession [38].

Nonetheless, in the last two years, some necessary actions have been taken to promote and enhance psycho-oncology in our country. In July 2022, the Regional Council of Lazio approved the first regional law on psycho-oncology, which establishes the criteria to promote psycho-oncological care services within the regional cancer network [39]; presently, the process for the proposal or approval of a law on psycho-oncology has been started or is underway in other four Italian regions. In October 2022, a national bill for establishing and strengthening psycho-oncology services was presented and is currently being examined by the Chamber of Deputies Health Commission [40]. The bill represents a significant turning point for the development of psycho-oncology in our country. It recognizes the importance of psychological intervention for cancer patients, their families, and health professionals and systematizes such intervention as an integral part of the care pathway. According to the bill, the psycho-oncologist must be included within all hospital oncology and once-hematology units, participate in the multidisciplinary healthcare teams, and be involved in the Diagnostic and Therapeutic Care Pathways. Besides, the training required to carry out the psycho-oncologist profession is initially defined as the first step for developing a core curriculum and establishing a specific health profile for the Ministry of Health. We believe that the approval and implementation of this bill, as the result of a long process toward raising awareness of the role of psycho-oncology in the bio-psycho-social approach to cancer care, could give an essential boost to the development of this discipline and provide an appropriate response to the unmet psychological support needs of many cancer patients and their families.

4.5. Strengths and limitations

Findings from this study should be interpreted considering its strengths and limitations. In this mixed-methods research, we employed a convenience sampling approach, which introduces selection bias due to participation’s voluntary and self-selected nature [41]. PTs who responded to the survey and interviews did so voluntarily, meaning our sample may not fully represent all PTs working with cancer patients in Italy. Consequently, our findings reflect the experiences of those who chose to participate, potentially omitting perspectives from those less inclined to engage in research, particularly those underrepresented in some regions of psycho-oncology.

Most of the participating PTs worked with adult cancer patients, limiting the generalizability of the findings to those working with pediatric oncology populations. This lack of representation from psychotherapists specializing in pediatric patients is a significant limitation, as pediatric oncology’s challenges and therapeutic approaches may differ considerably from those in adult settings. Furthermore, the regional concentration of PTs, particularly those from the “red zones” heavily impacted by the initial wave of the pandemic, may have skewed the data toward experiences in regions the most affected by COVID-19. This regional bias limits the ability to generalize findings to PTs in areas with differing levels of pandemic impact.

Despite these limitations, our study gathered valuable insights from a nationwide pool of PTs representing diverse psychotherapy approaches and substantial experience in psycho-oncology. The data collected through the survey were further enriched by qualitative individual interviews, providing a comprehensive understanding of PTs’ experiences and practices during the pandemic. Although the sample may not fully represent all PTs involved in the survey, the findings offer important lessons and reflections on the challenges faced and strategies employed by PTs during public health crises. These insights can contribute to better preparedness and support for PTs in future emergencies.