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Education Competencies for Integrative Oncology—Results of a Systematic Review and an International and Interprofessional Consensus Procedure

Education Competencies for Integrative Oncology—Results of a Systematic Review and an... Integrative oncology is a burgeoning field and typically provided by a multiprofessional team. To ensure cancer patients receive effective, appropriate, and safe care, health professionals providing integrative cancer care should have a certain set of compe- tencies. The aim of this project was to define core competencies for different health professions involved in integrative oncology. The project consisted of two phases. A systematic literature review on published competencies was performed, and the results informed an international and interprofessional consensus procedure. The second phase consisted of three rounds of consensus procedure and included 28 experts representing 7 different professions (medical doctors, psychologists, nurses, naturopathic doctors, traditional Chinese medicine practitioners, yoga practitioners, patient navigators) as well as patient advocates, public health experts, and members of the Society for Integrative Oncology. A total of 40 integrative medicine competencies were identified in the literature review. These were further complemented by 18 core oncology competencies. The final round of the consensus procedure yielded 37 core competencies in the following categories: knowledge (n =11), skills (n = 17), and abilities (n = 9). There was an agreement that these competencies are relevant for all participating professions. The integrative oncology core competencies combine both fundamental oncology knowledge and integrative medicine competencies that are necessary to provide effective and safe integrative oncology care for cancer patients. They can be used as a starting point for developing profession-specific learning objectives and to establish integrative oncology education and training programs to meet the needs of cancer patients and health professionals. . . . . Keywords Cancer Core competencies Integrative oncology Interprofessional collaboration Consensus procedure * Claudia M. Witt American College of Traditional Chinese Medicine at California claudia.witt@uzh.ch Institute of Integral Studies, San Francisco, CA, USA Memorial Sloan Kettering Cancer Center, New York, NY, USA Institute for Complementary and Integrative Medicine, University Oakland University, School of Nursing, Rochester, MI, USA Hospital Zurich and University of Zurich, Sonneggstrasse 6, Department of Epidemiology, School of Public Health and Rutgers, 8091 Zurich, Switzerland Cancer Institute of New Jersey, New Brunswick, New Jersey, USA Institute for Social Medicine, Epidemiology, and Health Economics, Memorial Health Care System, FL, Hollywood, USA Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin NorCal CarciNET Community, Oakland, CA, USA Institute of Health, 13353 Berlin, Germany Smith Center for Healing and the Arts, Institute for Integrative College of Nursing, Rady Faculty of Health Sciences, University of Oncology Navigation, Washington, DC, USA Manitoba, Winnipeg, Canada Smith Center for Healing and the Arts, Washington, DC, USA Department of Oncology, Cumming School of Medicine, University Department of Family Medicine and Nutritional Sciences Schools of of Calgary, Calgary, Canada Medicine and Public Health, University of Michigan, Ann Chicken Soup Chinese Medicine, San Francisco, CA, USA Arbor, Michigan, USA 500 J Canc Educ (2022) 37:499–507 Introduction been used by the Institute for Health Care Improvement in the USA called the “Collaborative Model for Achieving The use of complementary and integrative medicine (CIM) by Breakthrough Improvement” has been adapted to the needs cancer patients [1] and cancer survivors [2] is widespread with of the project [10]. After the topic of the core competencies meta-analytic evidence showing that more than 40% of cancer was identified, the SIO Board members representing different patients use CIM [3]. The term “integrative oncology” has professions were recruited for the project. The project been defined [4] using a consensus process, by the Society consisted of two phases, and the teams for the phases were for Integrative Oncology (SIO [5]), as “a patient-centered, selected based on their expertise. Phase I included a system- evidence-informed field of cancer care that utilizes mind and atic review of the literature, the identification of relevant com- body practices, natural products, and/or lifestyle modifications petencies, as well as categorizing them. In Phase II, building from different traditions alongside conventional cancer treat- on the results of the systematic review, an international and ments. Integrative oncology aims to optimize health, quality interprofessional consensus procedure was conducted to de- of life, and clinical outcomes across the cancer care continuum velop a set of core competencies for healthcare professions and to empower people to prevent cancer and become active who deliver integrative oncology care. participants before, during, and beyond cancer treatment” [6]. Founded in 2003, SIO is an interprofessional non-profit Systematic Literature Review organization whose mission is to advanced evidence- based, comprehensive integrative healthcare to improve Literature Inclusion and Exclusion Criteria the lives of people affected by cancer. Through education, research, and knowledge transfer initiatives, such as an Publications focused on education integrative oncology com- annual international conference and the development of petencies for physicians, nurses, integrative oncology practi- clinical practice guidelines, SIO’svision istohavere- tioners, and other healthcare professionals that were published search inform the integration of complementary modalities in scientific journals or as reports, consensus papers, and into oncology care so that evidence-based integrative on- working papers or theses were included. Publications were cology care is accessible and standard for all patients excluded if the education competencies or activities did not across the cancer continuum. SIO provides much needed, include CIM in the context of cancer, if the reporting of the evidence-informed leadership and collaborative opportuni- education activity did not include competencies or details ties to the interdisciplinary integrative oncology research about the curricula, or if the publication was not available in and clinical practice communities around the world. English or German. As integrative oncology involves various healthcare pro- fessionals [7], its implementation into clinical practice re- Search Strategy quires a divergent set of competencies [8]. Although integra- tive oncology content exists in courses, curricula, syllabi, and Scientific literature about integrative oncology education and trainings, information about the required core competencies is information about education activities, such as curricula, syl- incomplete and not yet standardized [8, 9]. To date, no core set labi, and course objectives, were searched and analyzed to get of education competencies for integrative oncology that re- an overview about required core competencies. The search flects different professions and countries has been developed. strategy was conducted using an explicit and reproducible This may be due to heterogeneous education systems and methodology in the following electronic databases from in- activities across countries as well as different legal, ethical, ception until February 6, 2017: Ovid MEDLINE, CENTRAL, regulatory, and political influences on the practice of integra- CINAHL, EMBASE, PsychINFO, PsychARTICLES, and tive oncology. As such, the primary aim of this project was to Web of Science. The search included all types of papers pub- systematically develop a set of core education competencies lished related to competencies in integrative oncology by for integrative oncology that would be applicable to a wide using the following keywords or free text words in combina- range of healthcare providers from different educational back- tion with subject headings, where available: disciplines possi- grounds and countries. bly related to integrative oncology (integrative oncology OR complementary medicine OR alternative medicine OR inte- grative care OR integrative nursing OR integrative medicine) Methods AND educational element (course OR curriculum OR educa- tion or program* OR session or teaching OR training OR The absence of clearly defined core competencies for integra- workshop OR competencies OR value OR knowledge OR tive oncology was seen by the SIO Board at its retreat in 2016 attitude OR skill* OR mission* OR vision* OR syllab*) as a quality-related problem in integrative healthcare. To close AND type of publication (evaluation OR investigation OR study or trial OR proposal OR examination OR research OR the gap between what is and what is desired, a model that has J Canc Educ (2022) 37:499–507 501 survey). MeSH terms were used to restrict the results to liter- (Asia/Australia, Europe, North America). The extended ex- ature specific to oncology, depending on the respective data- pert group helped broaden the expertise represented in the base. In addition, the SIO members were asked to provide consensus procedure and allowed perspectives from different gray and/or unpublished literature on education competencies. international regions to be included. The consensus process involved three online surveys and an onsite survey at an in- Selection of Studies ternational integrative oncology conference (SIO conference in 2017) as well as direct feedback from the task force mem- All items identified by the literature search were entered into a bers. Each survey was followed by a task force conference call bibliographic database. One reviewer thoroughly checked all and emails to revise the competencies. searched items by assessing titles and abstracts, excluding In the first online survey, the importance of each compe- clearly ineligible articles based on the search criteria and aim tency found in the literature was rated by the task force and of the project. Full text copies were obtained of all remaining extended experts on a scale from 0 (not important) to 10 (very articles and assessed by two reviewers independently for eli- important). In addition, the task force indicated their agree- gibility. Publications were excluded only with the agreement ment with the placement of the competencies in one of the of both reviewers. Reasons for exclusion were documented KSA categories, and new core competencies that were not and any disagreements resolved by discussion. If several pub- listed could be suggested. lications for a single study were published, all publications The second online survey was again forwarded to the task were reviewed if they met the eligibility criteria. force and extended experts for review. The revised list of competencies was then prioritized based on how important Data Extraction each competency was for a given healthcare profession (low, moderate, high priority, or not applicable for my profession). Two reviewers extracted data from selected publications using The final set of competencies was included in a survey that a standardized form. The results of the data extraction were was sent to all SIO members using a link in a newsletter and collated into the categories, “knowledge,”“skills,” and “abil- was also provided as a hardcopy version at the annual SIO ities” (KSA), to structure the results and to summarize find- conference in November 2017. Respondents were asked to ings. The KSA classification was drawn from the basic core prioritize and comment on the competencies with respect to competency model used by the Association of American the importance for their respective profession. During each Medical Colleges for Entering Medical Students [11]. In this conference call, the task force consented agreed upon a thresh- classification, knowledge was defined as a body of informa- old that needed to be met to keep a competency on the list. tion applied directly to the performance of a function; skills as Competencies reaching the threshold were only discussed if at least one task force member wanted to discuss optional chang- observable competence to perform a learned psychomotor act; and ability as a competence to perform an observable behavior es. All competencies not reaching the threshold were or a behavior that results in an observable product. Any un- discussed in detail. All decisions during the conference calls certainties regarding data extraction and classification for spe- were based on full consensus among the group. cific publications were discussed by the reviewers, with dis- agreements resolved by consensus and the final decisions re- solved by a third reviewer. Results Consensus Procedure Systematic Literature Review In Phase II, a consensus procedure was performed involving a task force, an extended expert group, and knowledgeable SIO The literature review yielded 21 eligible studies (see Fig. 1). members. The initial set of competencies developed from the The vast majority were from North America (n =10 from the literature review and additional core oncology competencies USA, n = 2 from Canada) and Europe (n = 7). Most publica- was further refined through a multistep process that was guid- tions (n = 18) mentioned competencies that could be classified ed by the task force. The task force consisted of 12 experts into the three KSA categories. Nearly all publications (n =19) representing seven different professions (medical doctors reported competencies for the broader field of integrative (MDs), psychologists, nurses, naturopathic doctors (NDs), tra- medicine, but 2 publications [12, 13] defined competencies ditional Chinese medicine (TCM) practitioners, yoga practi- that were of special interest for health professionals working tioners, patient navigators) and additional relevant perspec- in the field of breast cancer oncology. Most publications ad- tives (public health and patient advocates). Each task force dressed several professions; 5 publications focused on nurses member identified further experts from a similar professional only [13–17], 3 publications on physicians [18–20], and 1 on background representing three different regional areas medical students [21]. 502 J Canc Educ (2022) 37:499–507 Fig. 1 Flowchart for literature Records idenfied through search and study selection database search (n = 6,176) Duplicates excluded (n = 1,630) Records eligible for screening Records excluded by tle (n = 4,546) screening (n = 4,466) Competencies not menoned (n = 2,011) Not about cancer (n = 256) No integrave strategy (n = 1,430) Inappropriate design/wrien in language other than English or German (n = 68) Records eligible for Unrelated to overall topic (n = 693) abstract analysis Provided informaon not sufficient (n = 8) (n = 80) Records excluded by abstract analysis (n = 60) Full-text arcles assessed for eligibility (n = 20) Records arcles excluded by full-text assessment (n = 6) Literature search records included in qualitave synthesis (n = 14) Records idenfied by experts (n = 18) Records excluded by full- text assessment (n = 11) Experts records included in qualitave synthesis (n = 7) Records included in qualitave synthesis (n = 21) A total of 28 competencies were identified from the Consensus Procedure literature review, summarized and classified into the KSA categories (see Table 1). Some of these 28 com- A total of 25 experts from 7 different healthcare professions petencies had elaborate descriptions that had to be sum- and 3 international regions completed the initial web-based marized, and several of the competencies needed to be survey (24% from Asia/Australia, 20% from Europe, 56% broken up into single competencies. Following this pro- from North America). cess, a total of 40 single competencies were developed. The majority (n = 20, 80%) of the participants agreed with In addition, 18 other competencies that are known to be the suggested KSA competency categories. The task force core competencies for medical oncology were added by decided that all competencies with a level of importance rating one task force member (GD) to the list [22]. This re- specified by median and/or mean of least 9 on the 0–10 (10 sulted in a total of 58 competencies as a starting point being a very important competency) scale would remain on for the consensus procedure. the list. All other competencies were discussed in detail and J Canc Educ (2022) 37:499–507 503 Table 1 Overview of competency categories identified in the systematic literature review Knowledge Skill Ability General knowledge about evidence-based Provide evidence-based, balanced, resource-oriented, Respect individual differences in the medicine [7, 17, 20, 21, 24–26] up-to-date complementary and integrative medi- understanding and implementation cine (CIM) information that assists patients to of integrative oncology make a decision [7, 9, 15, 16, 18–20, 27–31] [17, 19–21, 24, 26] Knowledge on how to access and appraise scientific Identify, understand, and contextualize relevant Respect cultural and ethnic differences in literature on integrative oncology [19, 20, 31] information on CIM [7, 12, 15–19, 21] the understanding and implementation of integrative oncology [7, 21, 29] Knowledge about cancer [18, 26, 28] Understand patients, the problems patients face, and Appreciate a whole person and their needs [14, 19, 29, 31, 32] patient-centered approach [16, 25] Knowledge about common complementary medicine Engage with patients (and caregivers) Be empathic [12, 19, 29] (CM) therapies, including their history, theory, to build resilience and resources proposed mechanisms, safety/efficacy profile, to best empower patients during cancer contraindications, prevalence, and patterns of use treatments [12, 18, 19, 21, 26, 28–30] [7, 12–15, 17–20, 26, 27, 29, 31–33] Knowledge about services/providers’ quality Master the principles and practices of communication Respect of patient’s beliefs [7, 12, 17–20] assurance and reimbursement [19, 21] [12, 18, 19, 21, 26, 28–30] Knowledge about the principles of a healing Inquire about patients’ use of CIM Be open-minded [7, 12, 18–20, 28, 29] environment [14, 17, 21] and their motives [7, 12, 14, 15, 17, 19, 20, 29] Knowledge about communication Work in an interprofessional team Be attentive [19] theories and strategies [9, 28] [14–16, 19, 21, 24, 28] Knowledge about conventional medical Have an adequate training in one or more CIM Be self-aware [15, 19, 20, 24, 29, 31] language [15, 24, 30] modalities and be able to apply it to cancer patients [14, 17, 19, 26, 28, 30, 34] Identify suitable CIM providers for a Be able to accept that CIM use is often respective patient [15, 16, 19, 20, 25, 29] based on no/unclear evidence [29] Adequate documentation of interventions and patients’ response to them [14, 15, 21, 24, 29] Use adequate medical terminology [15, 29] either rephrased, merged, or deleted. This process led to a total nurse practitioners) and 36 others (i.e., researcher, students, of 38 competencies: 10 knowledge, 15 skill, and 7 ability administrator, yoga practitioners, patient navigators)) and competencies and an additional 2 knowledge, 2 skill, and 2 overall agreed about the relevance of the core competency ability competencies that were newly developed or extensive- set as shown in their ratings. The findings of the second survey ly modified by the task force. (task force and extended expert group) and third survey (SIO In the second online survey, 28 experts from 7 different members) are summarized in Table 2. healthcare professions (14% from Asia/Australia, 18% from Europe, 68% from North America) prioritized the competencies according to the importance for their profes- Discussion sion and gave feedback on the new or modified competen- cies. As all competencies met the overall threshold of im- This study is among the first to identify core competencies portance (rated at least moderate or high priority, using the for integrative oncology healthcare providers. Based on an categories low/moderate/high), the task force decided to iterative process including a comprehensive literature re- examine the feedback from the different professions and view by an expert task force and multi-disciplinary oncol- to retain all competencies that were of high priority for at ogy providers and by a survey of members of SIO, a final least 80% of the participants of each profession. All other set of 37 core competencies for integrative oncology was competencies were again discussed by the task force group identified. These 37 competencies were further categorized and either rephrased (n = 1)oromitted (n =1). The final list into knowledge, skills, and abilities and agreed on by rep- with 37 competencies included 11 knowledge, 17 skill, and resentatives from seven different professions from Asia, 9 ability competencies. Europe, and North America. There was a full agreement among task force members that Searching the literature on integrative oncology competencies all 37 competencies were relevant for all participating and complementing it with current fundamental knowledge in healthcare professions. oncology will ensure that future healthcare providers who devel- A total of 57 SIO members answered the online or the hard op these competencies are competent and able to take a safe and copy survey ((40% MD, 14% TCM specialist, 9% nurses/ knowledgeable approach to integrative oncology care. The 504 J Canc Educ (2022) 37:499–507 Table 2 Results of the extended expert group and SIO member surveys Knowledge competencies Rated as priority (%) Skill competencies Rated as priority (%) Ability competencies Rated as priority (%) Health professionals working in Experts SIO members Health professionals working Experts SIO members Health professionals working in Experts SIO members integrative oncology should in integrative oncology should integrative oncology should Have general knowledge about 96.4 100 Provide evidence-based and bal- 96.7 100 Respect individual, cultural, and ethnic 96.4 100 evidence-based medicine anced CM information differences in the understanding and implementation of integrative oncology Know how to access and appraise 100 96.5 Stay up-to-date with CM informa- 100 98.2 Appreciate a patient-centered, whole 100 100 the scientific literature on tion person approach complementary medicine (CM) Demonstrate the understanding of 96.4 93.0 Provide reputable websites and other 100 100 Be empathic, non-judgmental, open 100 100 the basics of history, theory, and information or resources on CM minded attentive, and self-aware and mechanisms of common CM respect patients’ beliefs therapies demonstrate the understanding of 100 98.2 Assist patients to make a decision 92.9 93 Establish rapport and form a therapeutic 100 100 safety/effectiveness, interaction partnership with patient profiles, and contraindications of common CM therapies Understand the major cancer 100 91.2 Identify, understand, and 96.4 98.2 Identify one’s own knowledge 100 98.2 treatment modalities (surgery, contextualize relevant deficiency and know where to find chemotherapy, radiotherapy, informationonCM help endocrine, and biological therapy) List common symptoms associated 100 94.7 Master the principles and practices 100 96.5 Pursue lifelong learning and continuous 100 96.5 with cancer of communication, which means self-improvement an empathic, open, trustful communication that follows common recommendations of communication with cancer patients List common side effects 100 94.7 Engage with patients (and 100 96.5 Respect the strengths and limitations of 100 100 of cancer treatment caregivers) to build resilience and applying evidence-based medicine resources to best empower principles to the circumstances of an patients during cancer treatment individual patient Describe the cancer 100 94.7 Inquire about patients’ use of CM 100 93.0 Be able to obtain key information 92.9 92.9 care continuum and their motives regarding the patient’s cancer history: type of cancer, types of previous treatments (surgery, chemotherapy, radiation, endocrine, targeted therapy), current disease stage, and current treatment Discuss the psycho-social-cultural 100 96.5 Work in an interprofessional team 100 96.5 Help patient understand the risks and 96.4 98.2 context of cancer care benefits of evidence-based CM ap- proaches so that they may choose care that aligns with their values and goals J Canc Educ (2022) 37:499–507 505 Table 2 (continued) Knowledge competencies Rated as priority (%) Skill competencies Rated as priority (%) Ability competencies Rated as priority (%) Health professionals working in Experts SIO members Health professionals working Experts SIO members Health professionals working in Experts SIO members integrative oncology should in integrative oncology should integrative oncology should Discuss the distinction between the 96.4 96.5 Understand patients, the problems 100 98.2 terms “healing” and “curing” patients face, and their needs Have knowledge and or ability to 100 91.2 Identify CM providers for a patient 89.3 94.7 obtain information about services/providers’ quality assurance, licensing government regulation, and reimbursement of CM adequately document interventions 100 94.7 and patients’ response to them Use appropriate medical 96.4 94.7 terminology Assess patients’ 100 95.7 psycho-social-cultural environ- ment and identify barriers to proper care Implement a personal self-care strat- 100 96.5 egy (may include nutrition awareness, self-regulatory techniques, exercise, journaling, creative arts, spirituality, mind body skills, etc.) Discuss CIM in the context of 92.8 93.0 different types of cancer Be able to obtain information about 92.8 93.0 cancer pathogenesis, the general course of the disease, and treatment outcomes of common cancers Percentage of respondents that rated competencies as moderate or high priority for their profession 506 J Canc Educ (2022) 37:499–507 consensus procedure incorporated practical experiences and per- of integrative oncology therapies. For those professions who are spectives from different professions and international regions to part of the cancer care team and are engaged in the integrative be embedded in the competencies. In addition, we partially uti- oncology care, the core competencies will play a more substan- lized a model that has been used by the Institute for Health Care tive role. Nevertheless, each profession will have to determine Improvement for breakthrough advancement in health care [10]. which of the defined integrative oncology competencies are al- However, we adapted this model to our needs. The so-called ready part of their undergraduate curricula (e.g., MD or nursing action periods that typically take place between the “learning degrees) and which will need to be embedded in graduate and sessions” (exchange between experts) were used for discussions continuing education courses and programs. Furthermore, within each profession because implementing the changes profession-specific and perhaps even country-specific competen- (competencies) and measuring the outcomes as typically done cies may require development and detailed learning objectives, within this model would have taken too long for the scope of this and didactical approaches would have to be defined. project. An alternative result of the project would have been Competencies are of high relevance because the evidence for developing different core competencies for each healthcare pro- selected CIM interventions is growing. If patients decide, based fession, which would have been supported by the general ap- on the advice of their oncology healthcare provider, to pursue a proach called for in the Collaborative Model for Achieving CIM treatment, it would be of limited help if the provider does Breakthrough Improvement. Interestingly, there was full consen- not have relevant core competencies for integrative cancer care sus on having the same competencies for all professions, which [23]. This core set of integrative oncology competencies will help will make it much easier to inform about the results and measure to have more competent providers in the future, who provide the impact in the future. evidence-based care for symptom reduction and quality of life Validationbyan evenbroader international group was also improvement of cancer patients and are able to avoid negative possible by giving SIO members the opportunity to provide aspects of those interventions such as time herb-drug interactions. feedback on the competency list. However, the study also had Acknowledgments Open access funding provided by University of limitations. We only included papers in English and German in Zurich. This work was partially funded by the National Cancer Institute the systematic review. In addition, surveys typically do not (NCI grant R25CA203651 to Suzie Zick) and the German Cancer Aid reach all stakeholders, and only those SIO members who have (Deutsche Krebshilfe grant 70112369 to Claudia Witt). We like to thank a strong educational interest might have completed the member the SIO membership and further international experts that provided feed- back during the development of the core competencies. survey. In addition, SIO members might reflect a unique group of healthcare providers in integrative oncology, resulting in a Data Availability The raw data supporting the conclusion of this manu- response bias. They might be more drawn to a scientific, evi- script will be made available by the corresponding author on reasonable dence-based, and interprofessional approach and see funda- request. mental oncology knowledge as a basis for integrative oncology. Nevertheless, a strong advantage of SIO is that it is an interpro- Compliance with Ethical Standards fessional organization with integrative oncology experts from Conflict of Interest The authors declare that the research was conducted world-leading cancers centers. As such, integrative oncology as in the absence of any commercial or financial relationships that could be represented by this set of core competencies would reflect an construed as a potential conflict of interest. approach that can be integrated in cancer centers globally and aims for best outcomes and to provide best care. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adap- The development of a core set of competencies for integra- tation, distribution and reproduction in any medium or format, as long as tive oncology that encompasses seven professions highlights you give appropriate credit to the original author(s) and the source, pro- the interprofessional nature of the field and the potential for vide a link to the Creative Commons licence, and indicate if changes were future development of interprofessional trainings to benefit made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a cancer patients and improve outcomes. credit line to the material. If material is not included in the article's The 37 core competencies defined in this study are an impor- Creative Commons licence and your intended use is not permitted by tant starting point and inform future integrative oncology educa- statutory regulation or exceeds the permitted use, you will need to obtain tion and training programs for different healthcare professions. permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. It is important to distinguish between the different sectors of health care when applying education competencies for integra- tive oncology. In acute care situations, such as brief hospital stays (e.g., fever during chemotherapy) or emergency room visits, an References integrative oncology approach will play a less important role. In contrast, in outpatient care situations (e.g., ambulatory chemo- 1. 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Reed FC, Pettigrew AC, King MO (2000) Alternative and comple- 20(4):207–212 mentary therapies in nursing curricula. J Nurs Educ 39(3):133–139 18. Hubner J, Muenstedt K, Muecke R, Micke O, Stoll C, Kleeberg UR, Buentzel J, Dennert G, Prott FJ (2013) Counseling cancer Publisher’sNote Springer Nature remains neutral with regard to jurisdic- patients on complementary and alternative medicine: background, tional claims in published maps and institutional affiliations. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Cancer Education Springer Journals

Education Competencies for Integrative Oncology—Results of a Systematic Review and an International and Interprofessional Consensus Procedure

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Springer Journals
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Copyright © The Author(s) 2020
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0885-8195
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10.1007/s13187-020-01829-8
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Abstract

Integrative oncology is a burgeoning field and typically provided by a multiprofessional team. To ensure cancer patients receive effective, appropriate, and safe care, health professionals providing integrative cancer care should have a certain set of compe- tencies. The aim of this project was to define core competencies for different health professions involved in integrative oncology. The project consisted of two phases. A systematic literature review on published competencies was performed, and the results informed an international and interprofessional consensus procedure. The second phase consisted of three rounds of consensus procedure and included 28 experts representing 7 different professions (medical doctors, psychologists, nurses, naturopathic doctors, traditional Chinese medicine practitioners, yoga practitioners, patient navigators) as well as patient advocates, public health experts, and members of the Society for Integrative Oncology. A total of 40 integrative medicine competencies were identified in the literature review. These were further complemented by 18 core oncology competencies. The final round of the consensus procedure yielded 37 core competencies in the following categories: knowledge (n =11), skills (n = 17), and abilities (n = 9). There was an agreement that these competencies are relevant for all participating professions. The integrative oncology core competencies combine both fundamental oncology knowledge and integrative medicine competencies that are necessary to provide effective and safe integrative oncology care for cancer patients. They can be used as a starting point for developing profession-specific learning objectives and to establish integrative oncology education and training programs to meet the needs of cancer patients and health professionals. . . . . Keywords Cancer Core competencies Integrative oncology Interprofessional collaboration Consensus procedure * Claudia M. Witt American College of Traditional Chinese Medicine at California claudia.witt@uzh.ch Institute of Integral Studies, San Francisco, CA, USA Memorial Sloan Kettering Cancer Center, New York, NY, USA Institute for Complementary and Integrative Medicine, University Oakland University, School of Nursing, Rochester, MI, USA Hospital Zurich and University of Zurich, Sonneggstrasse 6, Department of Epidemiology, School of Public Health and Rutgers, 8091 Zurich, Switzerland Cancer Institute of New Jersey, New Brunswick, New Jersey, USA Institute for Social Medicine, Epidemiology, and Health Economics, Memorial Health Care System, FL, Hollywood, USA Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin NorCal CarciNET Community, Oakland, CA, USA Institute of Health, 13353 Berlin, Germany Smith Center for Healing and the Arts, Institute for Integrative College of Nursing, Rady Faculty of Health Sciences, University of Oncology Navigation, Washington, DC, USA Manitoba, Winnipeg, Canada Smith Center for Healing and the Arts, Washington, DC, USA Department of Oncology, Cumming School of Medicine, University Department of Family Medicine and Nutritional Sciences Schools of of Calgary, Calgary, Canada Medicine and Public Health, University of Michigan, Ann Chicken Soup Chinese Medicine, San Francisco, CA, USA Arbor, Michigan, USA 500 J Canc Educ (2022) 37:499–507 Introduction been used by the Institute for Health Care Improvement in the USA called the “Collaborative Model for Achieving The use of complementary and integrative medicine (CIM) by Breakthrough Improvement” has been adapted to the needs cancer patients [1] and cancer survivors [2] is widespread with of the project [10]. After the topic of the core competencies meta-analytic evidence showing that more than 40% of cancer was identified, the SIO Board members representing different patients use CIM [3]. The term “integrative oncology” has professions were recruited for the project. The project been defined [4] using a consensus process, by the Society consisted of two phases, and the teams for the phases were for Integrative Oncology (SIO [5]), as “a patient-centered, selected based on their expertise. Phase I included a system- evidence-informed field of cancer care that utilizes mind and atic review of the literature, the identification of relevant com- body practices, natural products, and/or lifestyle modifications petencies, as well as categorizing them. In Phase II, building from different traditions alongside conventional cancer treat- on the results of the systematic review, an international and ments. Integrative oncology aims to optimize health, quality interprofessional consensus procedure was conducted to de- of life, and clinical outcomes across the cancer care continuum velop a set of core competencies for healthcare professions and to empower people to prevent cancer and become active who deliver integrative oncology care. participants before, during, and beyond cancer treatment” [6]. Founded in 2003, SIO is an interprofessional non-profit Systematic Literature Review organization whose mission is to advanced evidence- based, comprehensive integrative healthcare to improve Literature Inclusion and Exclusion Criteria the lives of people affected by cancer. Through education, research, and knowledge transfer initiatives, such as an Publications focused on education integrative oncology com- annual international conference and the development of petencies for physicians, nurses, integrative oncology practi- clinical practice guidelines, SIO’svision istohavere- tioners, and other healthcare professionals that were published search inform the integration of complementary modalities in scientific journals or as reports, consensus papers, and into oncology care so that evidence-based integrative on- working papers or theses were included. Publications were cology care is accessible and standard for all patients excluded if the education competencies or activities did not across the cancer continuum. SIO provides much needed, include CIM in the context of cancer, if the reporting of the evidence-informed leadership and collaborative opportuni- education activity did not include competencies or details ties to the interdisciplinary integrative oncology research about the curricula, or if the publication was not available in and clinical practice communities around the world. English or German. As integrative oncology involves various healthcare pro- fessionals [7], its implementation into clinical practice re- Search Strategy quires a divergent set of competencies [8]. Although integra- tive oncology content exists in courses, curricula, syllabi, and Scientific literature about integrative oncology education and trainings, information about the required core competencies is information about education activities, such as curricula, syl- incomplete and not yet standardized [8, 9]. To date, no core set labi, and course objectives, were searched and analyzed to get of education competencies for integrative oncology that re- an overview about required core competencies. The search flects different professions and countries has been developed. strategy was conducted using an explicit and reproducible This may be due to heterogeneous education systems and methodology in the following electronic databases from in- activities across countries as well as different legal, ethical, ception until February 6, 2017: Ovid MEDLINE, CENTRAL, regulatory, and political influences on the practice of integra- CINAHL, EMBASE, PsychINFO, PsychARTICLES, and tive oncology. As such, the primary aim of this project was to Web of Science. The search included all types of papers pub- systematically develop a set of core education competencies lished related to competencies in integrative oncology by for integrative oncology that would be applicable to a wide using the following keywords or free text words in combina- range of healthcare providers from different educational back- tion with subject headings, where available: disciplines possi- grounds and countries. bly related to integrative oncology (integrative oncology OR complementary medicine OR alternative medicine OR inte- grative care OR integrative nursing OR integrative medicine) Methods AND educational element (course OR curriculum OR educa- tion or program* OR session or teaching OR training OR The absence of clearly defined core competencies for integra- workshop OR competencies OR value OR knowledge OR tive oncology was seen by the SIO Board at its retreat in 2016 attitude OR skill* OR mission* OR vision* OR syllab*) as a quality-related problem in integrative healthcare. To close AND type of publication (evaluation OR investigation OR study or trial OR proposal OR examination OR research OR the gap between what is and what is desired, a model that has J Canc Educ (2022) 37:499–507 501 survey). MeSH terms were used to restrict the results to liter- (Asia/Australia, Europe, North America). The extended ex- ature specific to oncology, depending on the respective data- pert group helped broaden the expertise represented in the base. In addition, the SIO members were asked to provide consensus procedure and allowed perspectives from different gray and/or unpublished literature on education competencies. international regions to be included. The consensus process involved three online surveys and an onsite survey at an in- Selection of Studies ternational integrative oncology conference (SIO conference in 2017) as well as direct feedback from the task force mem- All items identified by the literature search were entered into a bers. Each survey was followed by a task force conference call bibliographic database. One reviewer thoroughly checked all and emails to revise the competencies. searched items by assessing titles and abstracts, excluding In the first online survey, the importance of each compe- clearly ineligible articles based on the search criteria and aim tency found in the literature was rated by the task force and of the project. Full text copies were obtained of all remaining extended experts on a scale from 0 (not important) to 10 (very articles and assessed by two reviewers independently for eli- important). In addition, the task force indicated their agree- gibility. Publications were excluded only with the agreement ment with the placement of the competencies in one of the of both reviewers. Reasons for exclusion were documented KSA categories, and new core competencies that were not and any disagreements resolved by discussion. If several pub- listed could be suggested. lications for a single study were published, all publications The second online survey was again forwarded to the task were reviewed if they met the eligibility criteria. force and extended experts for review. The revised list of competencies was then prioritized based on how important Data Extraction each competency was for a given healthcare profession (low, moderate, high priority, or not applicable for my profession). Two reviewers extracted data from selected publications using The final set of competencies was included in a survey that a standardized form. The results of the data extraction were was sent to all SIO members using a link in a newsletter and collated into the categories, “knowledge,”“skills,” and “abil- was also provided as a hardcopy version at the annual SIO ities” (KSA), to structure the results and to summarize find- conference in November 2017. Respondents were asked to ings. The KSA classification was drawn from the basic core prioritize and comment on the competencies with respect to competency model used by the Association of American the importance for their respective profession. During each Medical Colleges for Entering Medical Students [11]. In this conference call, the task force consented agreed upon a thresh- classification, knowledge was defined as a body of informa- old that needed to be met to keep a competency on the list. tion applied directly to the performance of a function; skills as Competencies reaching the threshold were only discussed if at least one task force member wanted to discuss optional chang- observable competence to perform a learned psychomotor act; and ability as a competence to perform an observable behavior es. All competencies not reaching the threshold were or a behavior that results in an observable product. Any un- discussed in detail. All decisions during the conference calls certainties regarding data extraction and classification for spe- were based on full consensus among the group. cific publications were discussed by the reviewers, with dis- agreements resolved by consensus and the final decisions re- solved by a third reviewer. Results Consensus Procedure Systematic Literature Review In Phase II, a consensus procedure was performed involving a task force, an extended expert group, and knowledgeable SIO The literature review yielded 21 eligible studies (see Fig. 1). members. The initial set of competencies developed from the The vast majority were from North America (n =10 from the literature review and additional core oncology competencies USA, n = 2 from Canada) and Europe (n = 7). Most publica- was further refined through a multistep process that was guid- tions (n = 18) mentioned competencies that could be classified ed by the task force. The task force consisted of 12 experts into the three KSA categories. Nearly all publications (n =19) representing seven different professions (medical doctors reported competencies for the broader field of integrative (MDs), psychologists, nurses, naturopathic doctors (NDs), tra- medicine, but 2 publications [12, 13] defined competencies ditional Chinese medicine (TCM) practitioners, yoga practi- that were of special interest for health professionals working tioners, patient navigators) and additional relevant perspec- in the field of breast cancer oncology. Most publications ad- tives (public health and patient advocates). Each task force dressed several professions; 5 publications focused on nurses member identified further experts from a similar professional only [13–17], 3 publications on physicians [18–20], and 1 on background representing three different regional areas medical students [21]. 502 J Canc Educ (2022) 37:499–507 Fig. 1 Flowchart for literature Records idenfied through search and study selection database search (n = 6,176) Duplicates excluded (n = 1,630) Records eligible for screening Records excluded by tle (n = 4,546) screening (n = 4,466) Competencies not menoned (n = 2,011) Not about cancer (n = 256) No integrave strategy (n = 1,430) Inappropriate design/wrien in language other than English or German (n = 68) Records eligible for Unrelated to overall topic (n = 693) abstract analysis Provided informaon not sufficient (n = 8) (n = 80) Records excluded by abstract analysis (n = 60) Full-text arcles assessed for eligibility (n = 20) Records arcles excluded by full-text assessment (n = 6) Literature search records included in qualitave synthesis (n = 14) Records idenfied by experts (n = 18) Records excluded by full- text assessment (n = 11) Experts records included in qualitave synthesis (n = 7) Records included in qualitave synthesis (n = 21) A total of 28 competencies were identified from the Consensus Procedure literature review, summarized and classified into the KSA categories (see Table 1). Some of these 28 com- A total of 25 experts from 7 different healthcare professions petencies had elaborate descriptions that had to be sum- and 3 international regions completed the initial web-based marized, and several of the competencies needed to be survey (24% from Asia/Australia, 20% from Europe, 56% broken up into single competencies. Following this pro- from North America). cess, a total of 40 single competencies were developed. The majority (n = 20, 80%) of the participants agreed with In addition, 18 other competencies that are known to be the suggested KSA competency categories. The task force core competencies for medical oncology were added by decided that all competencies with a level of importance rating one task force member (GD) to the list [22]. This re- specified by median and/or mean of least 9 on the 0–10 (10 sulted in a total of 58 competencies as a starting point being a very important competency) scale would remain on for the consensus procedure. the list. All other competencies were discussed in detail and J Canc Educ (2022) 37:499–507 503 Table 1 Overview of competency categories identified in the systematic literature review Knowledge Skill Ability General knowledge about evidence-based Provide evidence-based, balanced, resource-oriented, Respect individual differences in the medicine [7, 17, 20, 21, 24–26] up-to-date complementary and integrative medi- understanding and implementation cine (CIM) information that assists patients to of integrative oncology make a decision [7, 9, 15, 16, 18–20, 27–31] [17, 19–21, 24, 26] Knowledge on how to access and appraise scientific Identify, understand, and contextualize relevant Respect cultural and ethnic differences in literature on integrative oncology [19, 20, 31] information on CIM [7, 12, 15–19, 21] the understanding and implementation of integrative oncology [7, 21, 29] Knowledge about cancer [18, 26, 28] Understand patients, the problems patients face, and Appreciate a whole person and their needs [14, 19, 29, 31, 32] patient-centered approach [16, 25] Knowledge about common complementary medicine Engage with patients (and caregivers) Be empathic [12, 19, 29] (CM) therapies, including their history, theory, to build resilience and resources proposed mechanisms, safety/efficacy profile, to best empower patients during cancer contraindications, prevalence, and patterns of use treatments [12, 18, 19, 21, 26, 28–30] [7, 12–15, 17–20, 26, 27, 29, 31–33] Knowledge about services/providers’ quality Master the principles and practices of communication Respect of patient’s beliefs [7, 12, 17–20] assurance and reimbursement [19, 21] [12, 18, 19, 21, 26, 28–30] Knowledge about the principles of a healing Inquire about patients’ use of CIM Be open-minded [7, 12, 18–20, 28, 29] environment [14, 17, 21] and their motives [7, 12, 14, 15, 17, 19, 20, 29] Knowledge about communication Work in an interprofessional team Be attentive [19] theories and strategies [9, 28] [14–16, 19, 21, 24, 28] Knowledge about conventional medical Have an adequate training in one or more CIM Be self-aware [15, 19, 20, 24, 29, 31] language [15, 24, 30] modalities and be able to apply it to cancer patients [14, 17, 19, 26, 28, 30, 34] Identify suitable CIM providers for a Be able to accept that CIM use is often respective patient [15, 16, 19, 20, 25, 29] based on no/unclear evidence [29] Adequate documentation of interventions and patients’ response to them [14, 15, 21, 24, 29] Use adequate medical terminology [15, 29] either rephrased, merged, or deleted. This process led to a total nurse practitioners) and 36 others (i.e., researcher, students, of 38 competencies: 10 knowledge, 15 skill, and 7 ability administrator, yoga practitioners, patient navigators)) and competencies and an additional 2 knowledge, 2 skill, and 2 overall agreed about the relevance of the core competency ability competencies that were newly developed or extensive- set as shown in their ratings. The findings of the second survey ly modified by the task force. (task force and extended expert group) and third survey (SIO In the second online survey, 28 experts from 7 different members) are summarized in Table 2. healthcare professions (14% from Asia/Australia, 18% from Europe, 68% from North America) prioritized the competencies according to the importance for their profes- Discussion sion and gave feedback on the new or modified competen- cies. As all competencies met the overall threshold of im- This study is among the first to identify core competencies portance (rated at least moderate or high priority, using the for integrative oncology healthcare providers. Based on an categories low/moderate/high), the task force decided to iterative process including a comprehensive literature re- examine the feedback from the different professions and view by an expert task force and multi-disciplinary oncol- to retain all competencies that were of high priority for at ogy providers and by a survey of members of SIO, a final least 80% of the participants of each profession. All other set of 37 core competencies for integrative oncology was competencies were again discussed by the task force group identified. These 37 competencies were further categorized and either rephrased (n = 1)oromitted (n =1). The final list into knowledge, skills, and abilities and agreed on by rep- with 37 competencies included 11 knowledge, 17 skill, and resentatives from seven different professions from Asia, 9 ability competencies. Europe, and North America. There was a full agreement among task force members that Searching the literature on integrative oncology competencies all 37 competencies were relevant for all participating and complementing it with current fundamental knowledge in healthcare professions. oncology will ensure that future healthcare providers who devel- A total of 57 SIO members answered the online or the hard op these competencies are competent and able to take a safe and copy survey ((40% MD, 14% TCM specialist, 9% nurses/ knowledgeable approach to integrative oncology care. The 504 J Canc Educ (2022) 37:499–507 Table 2 Results of the extended expert group and SIO member surveys Knowledge competencies Rated as priority (%) Skill competencies Rated as priority (%) Ability competencies Rated as priority (%) Health professionals working in Experts SIO members Health professionals working Experts SIO members Health professionals working in Experts SIO members integrative oncology should in integrative oncology should integrative oncology should Have general knowledge about 96.4 100 Provide evidence-based and bal- 96.7 100 Respect individual, cultural, and ethnic 96.4 100 evidence-based medicine anced CM information differences in the understanding and implementation of integrative oncology Know how to access and appraise 100 96.5 Stay up-to-date with CM informa- 100 98.2 Appreciate a patient-centered, whole 100 100 the scientific literature on tion person approach complementary medicine (CM) Demonstrate the understanding of 96.4 93.0 Provide reputable websites and other 100 100 Be empathic, non-judgmental, open 100 100 the basics of history, theory, and information or resources on CM minded attentive, and self-aware and mechanisms of common CM respect patients’ beliefs therapies demonstrate the understanding of 100 98.2 Assist patients to make a decision 92.9 93 Establish rapport and form a therapeutic 100 100 safety/effectiveness, interaction partnership with patient profiles, and contraindications of common CM therapies Understand the major cancer 100 91.2 Identify, understand, and 96.4 98.2 Identify one’s own knowledge 100 98.2 treatment modalities (surgery, contextualize relevant deficiency and know where to find chemotherapy, radiotherapy, informationonCM help endocrine, and biological therapy) List common symptoms associated 100 94.7 Master the principles and practices 100 96.5 Pursue lifelong learning and continuous 100 96.5 with cancer of communication, which means self-improvement an empathic, open, trustful communication that follows common recommendations of communication with cancer patients List common side effects 100 94.7 Engage with patients (and 100 96.5 Respect the strengths and limitations of 100 100 of cancer treatment caregivers) to build resilience and applying evidence-based medicine resources to best empower principles to the circumstances of an patients during cancer treatment individual patient Describe the cancer 100 94.7 Inquire about patients’ use of CM 100 93.0 Be able to obtain key information 92.9 92.9 care continuum and their motives regarding the patient’s cancer history: type of cancer, types of previous treatments (surgery, chemotherapy, radiation, endocrine, targeted therapy), current disease stage, and current treatment Discuss the psycho-social-cultural 100 96.5 Work in an interprofessional team 100 96.5 Help patient understand the risks and 96.4 98.2 context of cancer care benefits of evidence-based CM ap- proaches so that they may choose care that aligns with their values and goals J Canc Educ (2022) 37:499–507 505 Table 2 (continued) Knowledge competencies Rated as priority (%) Skill competencies Rated as priority (%) Ability competencies Rated as priority (%) Health professionals working in Experts SIO members Health professionals working Experts SIO members Health professionals working in Experts SIO members integrative oncology should in integrative oncology should integrative oncology should Discuss the distinction between the 96.4 96.5 Understand patients, the problems 100 98.2 terms “healing” and “curing” patients face, and their needs Have knowledge and or ability to 100 91.2 Identify CM providers for a patient 89.3 94.7 obtain information about services/providers’ quality assurance, licensing government regulation, and reimbursement of CM adequately document interventions 100 94.7 and patients’ response to them Use appropriate medical 96.4 94.7 terminology Assess patients’ 100 95.7 psycho-social-cultural environ- ment and identify barriers to proper care Implement a personal self-care strat- 100 96.5 egy (may include nutrition awareness, self-regulatory techniques, exercise, journaling, creative arts, spirituality, mind body skills, etc.) Discuss CIM in the context of 92.8 93.0 different types of cancer Be able to obtain information about 92.8 93.0 cancer pathogenesis, the general course of the disease, and treatment outcomes of common cancers Percentage of respondents that rated competencies as moderate or high priority for their profession 506 J Canc Educ (2022) 37:499–507 consensus procedure incorporated practical experiences and per- of integrative oncology therapies. For those professions who are spectives from different professions and international regions to part of the cancer care team and are engaged in the integrative be embedded in the competencies. In addition, we partially uti- oncology care, the core competencies will play a more substan- lized a model that has been used by the Institute for Health Care tive role. Nevertheless, each profession will have to determine Improvement for breakthrough advancement in health care [10]. which of the defined integrative oncology competencies are al- However, we adapted this model to our needs. The so-called ready part of their undergraduate curricula (e.g., MD or nursing action periods that typically take place between the “learning degrees) and which will need to be embedded in graduate and sessions” (exchange between experts) were used for discussions continuing education courses and programs. Furthermore, within each profession because implementing the changes profession-specific and perhaps even country-specific competen- (competencies) and measuring the outcomes as typically done cies may require development and detailed learning objectives, within this model would have taken too long for the scope of this and didactical approaches would have to be defined. project. An alternative result of the project would have been Competencies are of high relevance because the evidence for developing different core competencies for each healthcare pro- selected CIM interventions is growing. If patients decide, based fession, which would have been supported by the general ap- on the advice of their oncology healthcare provider, to pursue a proach called for in the Collaborative Model for Achieving CIM treatment, it would be of limited help if the provider does Breakthrough Improvement. Interestingly, there was full consen- not have relevant core competencies for integrative cancer care sus on having the same competencies for all professions, which [23]. This core set of integrative oncology competencies will help will make it much easier to inform about the results and measure to have more competent providers in the future, who provide the impact in the future. evidence-based care for symptom reduction and quality of life Validationbyan evenbroader international group was also improvement of cancer patients and are able to avoid negative possible by giving SIO members the opportunity to provide aspects of those interventions such as time herb-drug interactions. feedback on the competency list. However, the study also had Acknowledgments Open access funding provided by University of limitations. We only included papers in English and German in Zurich. This work was partially funded by the National Cancer Institute the systematic review. In addition, surveys typically do not (NCI grant R25CA203651 to Suzie Zick) and the German Cancer Aid reach all stakeholders, and only those SIO members who have (Deutsche Krebshilfe grant 70112369 to Claudia Witt). We like to thank a strong educational interest might have completed the member the SIO membership and further international experts that provided feed- back during the development of the core competencies. survey. In addition, SIO members might reflect a unique group of healthcare providers in integrative oncology, resulting in a Data Availability The raw data supporting the conclusion of this manu- response bias. They might be more drawn to a scientific, evi- script will be made available by the corresponding author on reasonable dence-based, and interprofessional approach and see funda- request. mental oncology knowledge as a basis for integrative oncology. Nevertheless, a strong advantage of SIO is that it is an interpro- Compliance with Ethical Standards fessional organization with integrative oncology experts from Conflict of Interest The authors declare that the research was conducted world-leading cancers centers. As such, integrative oncology as in the absence of any commercial or financial relationships that could be represented by this set of core competencies would reflect an construed as a potential conflict of interest. approach that can be integrated in cancer centers globally and aims for best outcomes and to provide best care. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adap- The development of a core set of competencies for integra- tation, distribution and reproduction in any medium or format, as long as tive oncology that encompasses seven professions highlights you give appropriate credit to the original author(s) and the source, pro- the interprofessional nature of the field and the potential for vide a link to the Creative Commons licence, and indicate if changes were future development of interprofessional trainings to benefit made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a cancer patients and improve outcomes. credit line to the material. If material is not included in the article's The 37 core competencies defined in this study are an impor- Creative Commons licence and your intended use is not permitted by tant starting point and inform future integrative oncology educa- statutory regulation or exceeds the permitted use, you will need to obtain tion and training programs for different healthcare professions. permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. It is important to distinguish between the different sectors of health care when applying education competencies for integra- tive oncology. In acute care situations, such as brief hospital stays (e.g., fever during chemotherapy) or emergency room visits, an References integrative oncology approach will play a less important role. In contrast, in outpatient care situations (e.g., ambulatory chemo- 1. 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Journal

Journal of Cancer Education – Springer Journals

Published: Jun 1, 2022

Keywords: Cancer; Core competencies; Integrative oncology; Interprofessional collaboration; Consensus procedure

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