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Abstract

Introduction:

Considering the global increase in cancer, integrative medicine combines conventional and complementary methods, offering a holistic approach to treating cancer patients. To optimize care and support care continuity for oncological patients, the integrative healthcare structure CCC-Integrativ provided evidence-based, interprofessional counseling in four oncology centers in Southern Germany. A process evaluation explored the program’s perceived effects and factors relevant to the implementation process to identify opportunities and challenges for a sustainable implementation of the program.

Methods:

In a qualitative study, semi-structured guide-based interviews with medical and nursing staff directly and indirectly involved in the program were conducted to explore their perspectives. The generated data were analyzed in a content analysis. Participant perceptions regarding potential program effects and factors influencing its’ implementation were first identified through open inductive coding. The Consolidated Framework for Implementation Research (CFIR) was then used as a categorizing analytical framework to guide further coding and facilitate a deeper understanding of the implementation process.

Results:

N = 21 interviews were analyzed (n = 12 directly involved in counseling; n = 9 indirectly involved through leadership position). Participants perceived an added value of the integrative care approach and expressed a positive attitude towards a continuation of the program. Patient interest in complementary medicine and care, their positive response to the program, and a perceived supportive effect of the interprofessional collaboration were reported as promoting factors. Still, insufficient evidence and a perceived low acceptance of some complementary medicine methods by hospital staff, skepticism, lack of space, and recruitment problems, were identified as key challenges for successful long-term implementation.

Conclusions:

A variety of factors need to be addressed for sustained implementation. Promoting acceptance of supportive complementary methods is essential for evidence-based, patient-centered cancer care. Consideration of interprofessional care could be a key factor for the long-term implementation of consultations on complementary and integrative healthcare.

Keywords

integrative medicine integrative oncology complementary methods complementary and integrative healthcare patient-centered care evidence-based practice interprofessional counseling implementation research process evaluation CFIR framework qualitative research

Introduction

The global rise in cancer cases continues to attract significant attention, as cancer remains a leading cause of morbidity and mortality despite medical advancements.¹ The World Health Organization (WHO) projects up to 70% increase in cancer cases by 2050. This is attributed to various influencing factors such as changing environmental conditions, risk factors (smoking, alcohol consumption, obesity), and advancements in early cancer detection and cancer treatment.^2,3 Particularly the demographic shift towards an aging population presents healthcare systems with new and unprecedented challenges in disease management and requires innovative approaches, as well as a broad range of medical, therapeutic, and nursing interventions that go beyond conventional medical therapy.^4,5

Integrative medicine offers a promising, holistic concept characterized by a patient-centered and interprofessional approach. It combines conventional medical procedures with complementary methods, considering the person as a whole, including biopsychosocial and spiritual dimensions, and is seen as a contemporary approach for providing medical care in the 21st century.^6,7 The integration of knowledge from various medical disciplines is also seen as a crucial factor in current healthcare.⁸ In addition to conventional therapies such as chemotherapy, radiation, immunotherapies, and surgical interventions, the integrative approach is gaining increasing importance in oncology.^9,10 This approach offers the potential to improve the quality of life for cancer patients and alleviate symptoms often associated with cancer and its treatment.^11
-14 Various complementary-integrative treatment methods, also known as complementary and integrative healthcare (CIH), have shown positive effects on cancer patients in randomized controlled trials and meta-analyses.^15
-18 For example, meditation, and mindfulness-based stress reduction can help to manage mood disorders and depression. Similarly, yoga and tai chi have positive effects on quality of life and can reduce fatigue.^12,14 According to the updated German S3 guideline “Complementary Medicine in the Treatment of Oncological Patients,” acupuncture can reduce cancer-related fatigue, and help with pain relief and control. Moreover, exercise interventions such as cycling or walking as an alternative to intensive exercise therapy can prevent specific fatigue symptoms.^11,19,20 These CIH approaches highlight the increasing relevance and their potential benefits in overall oncological care.¹⁶

It has already been established that medical personnel have knowledge gaps regarding CIH treatment methods and rarely inquire whether patients utilize them in addition to chemotherapy.²¹ This is partly due to existing care structures in hospitals, as well as a lack of time, resources, and the fact that many healthcare professionals do not feel adequately prepared to support patients using CIH approaches.^17,22
-25 The lack of knowledge regarding CIH treatment methods has been identified as a significant barrier to discussing such approaches with oncology patients and highlights the importance of patient-physician discussions about CIH, as well as the necessity for practitioners to be aware of their patients’ use of CIH.²⁶

CCC-Integrativ Study

The CCC-Integrativ study was initiated to promote knowledge of CIH among medical and nursing staff and to strengthen interprofessional collaboration (IC) and knowledge transfer between various professions in healthcare. One goal of the intervention is patient activation, meaning active participation in one’s own treatment, and to strengthen confidence in one’s own disease management and self-management with CIH.^21,27 Defined as an individual’s knowledge, skill and confidence for managing their health and healthcare, patient activation is a behavioral concept that covers core involvement components which are important for active engagement and participation.²⁸ Patient activation levels can be assessed using the validated Patient Activation Measure (PAM) which indicates lower (PAM Levels 1 and 2) or higher patient activation (PAM Levels 3 and 4).²⁹

The CCC-Integrativ intervention featured a blended learning approach that combined digital and face-to-face training formats for interprofessional teams. Physicians and nurses were jointly prepared through a structured program encompassing both theoretical knowledge and practical communication skills tailored to CIH counseling in oncology.²¹ The training content was organized into six thematic modules, including an introduction to the project’s goals, principles of collaboration between professions, fundamentals of evidence-informed healthcare, effective patient communication and motivational strategies, key oncology-related counseling issues, and the integration of CIH approaches into supportive cancer care.²¹ Online learning included self-paced materials such as recorded lectures, slides with commentary, thematic fact sheets, and access to an evidence-based CIH database. These were supplemented by synchronous elements like live webinars, case discussions, and practical exercises using simulated counseling scenarios.²¹

The training covered a broad range of CIH topics relevant to cancer care such as dietary counseling, physical activity, herbal medicine, stress management techniques, aromatherapy, acupressure, and strategies for managing symptoms like fatigue, nausea, and sleep disorders. A central aim of the program was to enable healthcare professionals to adapt CIH advice to individual patient needs and support informed self-care within a structured and empathetic counseling process.³⁰ A special feature of this approach was its’ exclusive focus on counseling, taking into account the guideline recommendations^11,20 and experience from other studies that positively evaluated both counseling and application by medical and nursing staff.^31,32 This means that within the newly implemented counseling service, interested patients could be recommended to qualified CIH providers (eg, for rowing, yoga, qi gong) or patients received instructions for self-application at home (eg, for compresses, aromatherapy, acupressure).

The implementation of the intervention was accompanied by a three-part process evaluation (PE) to explore the program’s perceived effects and factors relevant to the implementation process. As part of sub-study 2 in the PE, this present qualitative study explored acceptance and influencing factors for the implementation of interprofessional consultations from the perspective of directly and indirectly involved healthcare providers with the aim to contribute to tailoring the intervention.

Methods

Study Design

PEs complement outcome evaluations by examining the implementation of an intervention to understand how and why specific outcomes were achieved. Furthermore, a PE can help to identify opportunities and challenges related to the uptake and sustainment of a new care program from the perspective of the involved medical and nursing staff.^33,34 Overall, the PE in CCC-Integrativ used a mixed-methods design (qualitative/quantitative) and three sub-studies to (1) evaluate intervention fidelity; (2) explore healthcare provider perspectives; and (3) patient experiences regarding the interprofessional counseling. All data sources and applied quantitative data collection tools are defined by and listed in the published study protocol.³³ (Ethical approval by the Medical Faculty Heidelberg on 24 November 2020, S-307/2020.²¹)

As part of sub-study 2, this cross-sectional qualitative study exclusively focused on the perspectives of directly and indirectly involved healthcare providers regarding acceptance of and influencing factors for the implementation of interprofessional consultations. The Consolidated Criteria for Reporting Qualitative Research (COREQ)³⁵ was used as a reporting guideline in the preparation of this work.

Recruitment and Data Collection

As per study protocol, recruitment efforts for this qualitative study were to include equal numbers of healthcare providers directly and indirectly involved in the intervention from each Comprehensive Cancer Center (CCC). No sample size calculation was performed.³³ A purposive sampling aimed to facilitate focus on the areas of interest and gather in-depth data. Potential participants had to be CCC staff members directly (interprofessional counseling teams) or indirectly (managerial medical staff) involved in the intervention. No further inclusion criteria were defined. The research team provided verbal and written information regarding study aim and the option to participate in an interview to all staff involved in the intervention. Participants were not selected, but could express interest voluntarily. Recruitment aimed to include 2 to 3 physicians and nurses working in the interprofessional consultation teams in each CCC as directly involved healthcare providers, and 2 to 3 physicians and nurses in medical and nursing management positions who were not involved in the interprofessional counseling sessions as indirectly involved healthcare providers. No strategy to influence the spread in the sample was applied. The targeted participant number was based on the expectation to reach thematic saturation with this number of interviews as suggested in the literature.³⁶ If individuals were interested, an informed consent form was completed. Staff members without connection to the intervention were excluded from participation.

The interview guide for directly involved individuals covered five thematic blocks: (1) interprofessional tandem; (2) implementation of the counseling concept; (3) patient/seeker of advice; (4) materials to support counseling; and (5) training sessions. The guide for interviews with indirectly involved persons focused on site-specific aspects and cross-sector collaboration with other healthcare providers. The interview guides (Supplemental Appendices 1 and 2) were designed by the research team and based on the Consolidated Framework for Implementation Research (CFIR).³⁷

Two female research team members (background in psychology and health services research, and in nursing and health services research) conducted all interviews, both experienced in conducting interviews with patients and providers. All data were collected and audio-recorded during face-to-face meetings, or via videoconference or telephone between March 2021 and June 2022. All participants provided written consent prior to data collection. There was no prior relationship between participants and interviewers. No further individuals were present during the interviews.

Data Analysis

With the consent of the interviewees, the conversations were digitally recorded for analysis, subsequently pseudonymized, and transcribed by Transkripto (Rotterdam, NL) according to Dresing and Pehl.³⁸ Transcripts were not returned to participants. After transferring the transcripts to MAXQDA 2022 (Version 22.7.0 Verbi Software, Berlin, Germany), participant perceptions regarding potential effects of the program and factors that potentially could influence the implementation of the intervention were identified through an initial open inductive coding as part of the qualitative content analysis.^39,40 The initial coding was first conducted by one researcher and then discussed with and validated by senior researchers with expertise in qualitative data analysis.

For an in-depth understanding of the implementation process, the CFIR was used as an analytical framework.³⁷ This framework allows for the identification and categorization of aspects that influence implementation. The CFIR is divided into five key domains and a total of 39 constructs: (1) innovation; (2) outer setting; (3) inner setting; (4) characteristics of individuals; and (5) implementation process. The five domains of the CFIR were chosen as main categories in a deductive step and supplemented with subcategories, both deductively from the constructs of the framework and inductively de novo from the data material when not reflected by CFIR. The coding tree was developed iteratively in MAXQDA and refined through repeated engagement with the data. Additionally, the coding structure was repeatedly discussed in the research team to ensure conceptual clarity and alignment with the research question. During the final phase of analysis, anchor examples were retrieved, and coding of the entire data was finalized. Case-based thematic summaries were created for the coded text passages. Text passages were included in the analysis only if they were relevant to the research questions guiding Study 2, specifically with regard to factors influencing the implementation and perceived effects of the CCC-Integrativ approach. Relevance was determined based on a thematic connection to the implementation context and the intervention. Content not directly related to the research question—such as personal digressions or discussions of unrelated organizational processes—was excluded in order to maintain a focused analysis.

Results

Sample Description

A total of n = 21 interviews were conducted with all interested CCC medical and nursing staff involved in the intervention. Of these, n = 12 were directly involved in the counseling sessions (n = 6 physicians and n = 6 nurses), n = 9 were not directly involved but held important leadership positions within their respective CCCs (medical directors, personnel management staff, and executive management). The interviews with directly involved individuals had an average duration of 48 minutes (min/max: 34-59 minutes), while the conversations with indirectly involved staff had an average duration of 29 minutes (min/max: 10-42 minutes). One interview with an indirectly involved person could not be fully included in the analysis due to a technical issue, as it was recorded only up to minute 21. No interview had to be repeated. Participant feedback on findings was not obtained.

Findings of this study are reported based on the primary categories defined in the analysis according to the CFIR’s original domains. The constructs of the respective domains describe influencing factors from the perspective of nursing and medical staff. Inserted quotations from the data are labeled with the interview number (I1-I21) and position in the transcript. The abbreviations d and i indicate whether the statement is from a directly (d) or indirectly (i) interviewed person (eg, I8_d, Pos. 62). To ensure data protection and ethical standards, gender, location, and profession of the interviewed individuals are deliberately omitted. While the directly involved individuals played a significant role in the implementation and execution of the counseling sessions, the indirectly involved individuals were not immediately engaged in the consultations and reported, among other things, on the process before the introduction. Figure 1 identifies domains and constructs that were recognized as influencing factors for the successful implementation of the CCC-Integrativ approach across both groups and structures the presentation of results.

Figure 1.

Identified domains and constructs of the CFIR.

Innovation Domain

Innovation Evidence-Base

Regarding effectiveness and evidence of complementary medicine and nursing applications, the participants expressed heterogeneous views. Some directly involved individuals pointed out that, due to the diversity and individuality of these applications, it would be challenging to maintain an overview of their evidence base. Concerning the guideline, it was emphasized that there was still insufficient evidence for specific areas of application. One participant described that some colleagues perceived the evidence for CIH approaches as less robust compared to extensive chemotherapy studies. One directly involved participant expressed a desire for further scientific investigations on these topics.

And of course, the evidence for topical applications is also somewhat more challenging. It’s not yet well-established. It would be great if more work could be done in this area. But where will it come from? We would need to conduct several studies and investigations first. (I10_d, Pos. 73)

Innovation Adaptability

Regarding innovation adaptability, there were predominantly positive responses. Participants reported that the transition of training modalities for staff from in-person events to online or hybrid formats due to the COVID-19 pandemic had worked well. Although purely online events were considered impractical, many directly involved participants expressed a positive attitude toward a hybrid format.

Yes, I found it excellent. It was an extremely good concept. I think they really made the best of what could be done during this challenging COVID period. The online format was simply ideal. (I06_d, Pos. 94)

Innovation Cost

Regarding intervention costs, only one indirectly involved person commented that financing potentially could be a significant challenge for the program’s implementation. This person considered the intervention to be highly resource-intensive and difficult to integrate into standard care.

The problem is that I consider it extremely time-consuming. This means it is very difficult to manage. Additionally, it will eventually become unaffordable. Therefore, one would need to find a solution that A) identifies those who could benefit more and B) possibly streamlines the process to make it feasible on a more manageable basis. (I20_i, Pos. 103)

Outer Setting Domain

Critical Incidents

The COVID-19 pandemic was partly described as a challenge for the implementation and execution of the intervention since recruiting patients for consultations was perceived as extremely difficult due to the pandemic. Some reported that, due to COVID-19 restrictions, family members were not allowed to accompany patients. This was considered unfortunate by some participants, as they generally valued the presence of family members and saw it as supportive for the interdisciplinary counseling sessions.

Due to COVID-19, exactly. I think it’s important to say clearly that the study has, in my opinion, suffered significantly due to the pandemic conditions. (I09_i, Pos. 97)

Inner Setting Domain

Work Infrastructure

Regarding the interprofessional collaboration within the CCC-Integrativ intervention, all directly and indirectly involved participants expressed positive feedback, finding it enriching and helpful. Learning aspects were discussed, such as creating a multifaceted learning environment through intensive exchange of profession-specific knowledge between different disciplines and the coverage of a broader range of expertise. It was particularly emphasized that the various professions could complement and support each other in their interprofessional collaboration.

As a physician, specifically an obstetrician, I find the interprofessional approach very enriching. I think it’s extremely helpful that we complement each other so well; when someone is unsure, the other person can step in. It’s truly wonderful and a great opportunity to work together, having ample time and continuously supporting each other. (I01_d, Pos. 11)

Communication (Perspectives of Directly Involved Participants)

Participants described that communication and dissemination of the program were carried out through differentiated information and communication strategies, which included both medical briefings and general hospital conferences. It was detailed that the program was specifically introduced in specialized professional circles, and that inpatient information sessions were conducted in various areas, including rehabilitation, and outpatient clinics. One directly involved participant described that sometimes ideas were exchanged after such presentations. Participants perceived that presentations to general practitioners were only occasionally performed, and flyers were sent out infrequently.

Communication regarding the program was considered particularly important by most, as a lack of or insufficient information dissemination was perceived to potentially lead to misunderstandings.

Regarding the counseling specifically, what is often misunderstood is that we are not just providing advice, but that it is a scientific program where patients need to be informed and complete a questionnaire. We frequently encounter this issue, and we must ensure that it is clearly understood. (I06_d, Pos. 44)

Some directly involved individuals expressed concerns about communication barriers with the medical staff in the context of the program. It was noted that the hospital staff often was not adequately informed about the objectives and content of the initiative. Additionally, some indicated that their medical colleagues were not well-informed or adequately briefed about the program.

One must distinguish between nursing and non-nursing staff. I would argue that the topic has always been present in nursing. However, it is quite different with physicians, based on my observations. (I09_i, Pos. 17)

Available Resources

The provision of physical spaces for the implementation and execution of the intervention was reported as challenging by most participants. The statements frequently highlighted the difficulties in finding suitable spaces for counseling purposes and emphasized that the lack of available physical resources constituted an obstacle to the project’s organizational structure.

Organizationally, the issue of space is certainly still unresolved. This is quite discouraging and inappropriate. (I09_i, Pos. 23)

Active use of materials and tools provided for the consultations was described, with informative leaflets being particularly well-received. Regular use of the knowledge database for research and information gathering on specific topics was reported. Generally, the materials were considered helpful for preparing and conducting consultations and were perceived as a positive contribution to work practice, enhancing their effectiveness and improving information dissemination to patients. Some participants perceived that dynamically updating the online knowledge database and topic guidelines could serve to enhance the clarity of the content presentation. A timely provision of concise information on relevant recent research findings was also suggested.

Access to Knowledge and Information

Predominantly positive evaluations were expressed regarding the blended learning program. Participants perceived the effectiveness of the training program, particularly regarding the comprehensive preparation for counseling contexts and the associated increase in professional competence. The interactive exchanges during the practical afternoons, which were part of the program, were highlighted as an essential component of the learning process. A desire to expand the training content to include additional topics was expressed.

Individuals’ Domain

Other Implementation Support (Perspectives of Indirectly Involved Participants)

Internal collaboration with the interprofessional teams was generally assessed positively. An indirectly involved participant mentioned that internal contact within the CCC was particularly good due to the tumor conferences and that the co-providers (oncology, psychology, etc.) were in close communication.

Potential for improvement was seen regarding external collaboration with outpatient care services, which was perceived as inadequate. The interaction with general practitioners was described by most participants as limited, with feedback being largely absent and communication via occasional exchange of letters given to patients after consultations. It was emphasized that there was potential for enhancing external communication.

With primary care physicians, I believe there is often room for improvement. They are certainly informed in writing about findings and further therapies. However, personal conversations rarely take place, except in cases of problems. It would definitely be beneficial for everyone if time could be allocated for such interactions. There is certainly potential for improvement in this area. (I04_i, Pos. 37)

Acceptance

It was indicated that reactions to the newly implemented healthcare structure CCC-Integrativ ranged from skepticism and rejection to positive interest. Some of the directly and indirectly involved nursing staff described initial skepticism and rejection, particularly among medical staff, who were generally critical or dismissive of naturopathic approaches, attributing this to preconceptions about alternative medicine. A detailed explanation of the approach was perceived as necessary to overcome these reservations as often a positive surprise and increased openness toward the approach was noted once sufficient information was provided. One directly involved person stated that acceptance was high once colleagues were adequately informed. Also, it was assumed that physicians might oppose the introduction of interdisciplinary counseling sessions.

Many doctors are not very receptive to this. They might not recommend it further, as they fear it could lead to patients using more herbal supplements or adopting ideas that do not align well with tumor therapy. (I01_d, Pos. 62)

Innovation Deliverers—Perception of Effectiveness

Many participants reported a positive perception regarding the conducted consultations, highlighting the benefit to the patients as a central factor. They emphasized that the interdisciplinary counseling sessions significantly contributed to encouraging open communication about patient concerns. The promotion of patient self-activation, a key feature of the approach, was seen as a crucial advantage, as it was perceived to allow patients not only to actively participate in the counseling process but also to develop increased personal responsibility for their health. This was particularly valued because participants felt it enabled patients to act not just as passive recipients of information, but as active participants in improving their health situation.

The participants described patients generally reacted positively to the CCC-Integrativ counseling and particularly appreciated the interdisciplinary sessions in a tandem format. Both, directly and indirectly involved participants often perceived patients as pleased and grateful for the service, feeling valued, and highly satisfied with the effectiveness of the consultations.

Innovation Recipients

Participants described that from their point of view, passive patients were those with a somewhat limited understanding of their illness, who did not adhere to recommended measures and were still in the phase of processing their disease. Additionally, they perceived that passive patients exhibited low willingness to change, little interest in their health, and continued to maintain potentially harmful lifestyles. Some differentiated between patients based on high and low levels of activation. It was described that most patients who found their way to the consultations already were activated. One participant felt this was problematic since passive patients with a low activation level would not be reached.

I observe that many patients with a high PAM (Patient Activation Measure) level come to us, and we actually aim to reach people with a low PAM level and help them achieve a higher PAM level. The question I am facing is how can we reach those individuals, because I feel like they are not reaching us at all. (I12_d, Pos. 63)

Implementation Process Domain

Assessing Context

Some participants perceived it was generally difficult for patients to reach a person responsible for the program and access to the service needed to be lower threshold since it was too cumbersome currently. In addition, program implementation was seen as an organizational challenge due to a lack of staff and time.

It’s not easily integrable into practice or care because it’s too time-consuming and not feasible with the current staffing. Even if we were to address these issues and had eighty percent of patients participate, it would be impossible to manage in terms of personnel. This needs to be clearly stated. (I20_i, Pos. 103)

Described challenges also included a lack of acceptance among colleagues, insufficient communication and collaboration with co-providers, particularly general practitioners, and a lack of public and media interest. Some participants also mentioned factors potentially supportive to implementing the program and suggested that it could be advantageous if patients brought family members to the interdisciplinary counseling sessions.

Yes, I am always glad when family members are present. As mentioned, this way, four ears hear what would otherwise be heard by just two. I very much appreciate having the family members involved. (I05_i, Pos. 101)

A facilitating factor mentioned was to make the counseling easily accessible to the patients and ideally located centrally within the hospital. It was also considered helpful to continuously improve communication and awareness of the program through regular updates and stronger involvement of colleagues who were less receptive to the CIH topic. The importance of educational work was emphasized as essential for familiarizing these individuals with the principles of CIH.

Many people are still unaware of this. I think it’s important to keep raising awareness and regularly present current information to ensure it remains in focus. (I05_i, Pos. 111)

Engaging

Patient recruitment was seen as a significant challenge for a successful implementation of the interprofessional counseling sessions, and stronger support and program promotion were deemed necessary. Most participants described patient recruitment as problematic since the amount of provided information was perceived to lead to feelings of being overwhelmed and a lowered willingness to participate. Additionally, the specificity of the inclusion criteria was mentioned as a barrier. One directly involved participant noted that medical staff often did not support recruitment due to a lack of openness toward CIH. Another participant emphasized that recommendations from hospital staff were more crucial than using flyers or posters in raising awareness among patients about the offer.

What we are still struggling with, and I believe everyone is, are the recruitment issues. We need to think much more about advertising and how to get patients to reach out to us. (I01_d, Pos. 60)

Reflecting and Evaluating

Many participants expressed positive views regarding the start of the implementation process. The months leading up to the consultations were described as eventful and exciting, given the extensive preparation required. It was noted that this effort did not pose a significant obstacle. After overcoming these initial organizational challenges, the consultations proceeded smoothly from the outset, with no difficulties reported in their execution.

Discussion

Based on CFIR domains, challenges and facilitating factors for the implementation of the CCC-Integrativ approach were identified after the program was implemented. Emphasized challenges included a still limited effectiveness and evidence of CIH practices, and their acceptance among hospital staff. In addition, skepticism and a dismissive attitude of medical colleagues, lack of physical resources, and difficulties in recruiting patients were cited as relevant challenges.

In contrast, there was positive feedback regarding the program itself, as well as a demonstrated need and strong interest from patients in CIH. Furthermore, the enriching interprofessional collaboration and the supporting materials were highlighted as key factors that facilitated the implementation of the integrative care approach. The endorsement of a continuation of the program underscores the perceived relevance and significant value of this approach for oncology patients. However, while the program was highly valued by the participants, its sustainability might depend on overcoming the critical barriers of recruitment and outreach to a broader patient population since identified challenges could hinder the long-term implementation of the program. In Germany, several independent integrative medicine wards and affiliated outpatient clinics with different areas of focus have been established in recent years. They offer primarily consultation or more extensive therapy options in addition to the entire diagnostic and therapeutic spectrum of a hospital, mainly with focus on internal medicine, gynecological oncology, gastroenterology, cardiology, pediatrics and integrative oncology.⁴¹ Thus, learning from their experiences as well as further investigation of factors such as funding, training, collaboration, and availability of specialized staff, and infrastructural requirements should be considered with regards to a long-term implementation.

Within the domain of Innovation, the construct Innovation Evidence-Base was particularly highlighted as a challenge for a successful implementation of the CCC Integrative approach. Notably, the S3 guideline on “Complementary Medicine in the Treatment of Oncology Patients” established in 2021, provides a comprehensive and detailed review of complementary medicine. As an evidence- and consensus-based guideline of the highest methodological standard, it combines systematic literature reviews with expert consensus to ensure robust and practice-relevant recommendations. While the guideline emphasizes the challenges inherent in evaluating the effectiveness of many complementary therapies within oncology, it does support certain interventions. For example, physical activity and exercise to alleviate fatigue received the highest level of endorsement (Grade A). Additionally, five other complementary therapies received a “should” recommendation (Grade B), reflecting moderate evidence and expert agreement. However, the majority of the 129 reviewed treatment methods were assigned recommendations ranging from “may be considered” to “should not be used,” indicating variable levels of supporting evidence and underscoring the need for cautious, evidence-based implementation and further research in this area.¹¹

Skepticism and rejection of CIH methods among medical staff were identified as a challenging dynamic, which is also addressed in the literature. This skepticism is considered to often stem from a perceived lack of evidence and leads to physicians either not discussing complementary treatment options or questioning their benefits.⁴² Such a dismissive attitude might disrupt communication between medical personnel and patients, ultimately resulting in suboptimal care for the patients.^42
-45 Conversely, patients still seek information about CIH despite the limited evidence of its effectiveness.⁴³ For example, a cross-sectional study among patients with breast cancer in Germany found that out of 710 patients approximately 90% were interested in integrating at least one form of CIH into their cancer treatment.^44,46

An integrative care model that considers both individual patient goals and wishes, as well as modern advancements in specialized oncology, facilitates improved care and highlights the importance of training medical staff in CIH. While most dietary supplements in CIH are considered safe and effective for healthy individuals, their use during chemotherapy is controversial due to potential interactions with conventional medications.^{26,35,45,47
-49} This underscores the significance of communication between patients and their treating healthcare team regarding the use of CIH. Participants in this study indicated that open communication and sharing research findings could help alleviate skepticism, especially among medical staff. This can promote and optimize the integration of effective CIH approaches into holistic patient care.^13,24 However, the noted lack of strong evidence requires careful consideration and continued research efforts.

Within the Inner Setting domain, the constructs of Communications and Available Resources were primarily identified as challenges. Despite comprehensive approaches for both internal and external information exchange, communication barriers, particularly with medical staff, were described by some participants as a significant issue. It was noted that clinic staff, particularly physicians, were often insufficiently informed about the program’s objectives and content. These communication barriers can undermine program effectiveness and hinder its implementation which highlights the need for continuous adjustment and evaluation of communication strategies to ensure successful integration into existing clinical structures.

A central organizational challenge and a significant barrier to implementing the interprofessional consultations were identified at the infrastructural level, specifically in providing adequate spaces for the execution and delivery of the intervention—an issue already highlighted in the literature.⁵⁰ Damschroder et al³⁷ emphasize in the CFIR the importance of the physical environment as a factor influencing the introduction and sustainable implementation of innovations in the healthcare sector. Therefore, future efforts should also focus on developing solutions to address spatial issues to facilitate successful program implementation in the CCCs.

Within the Individuals Domain, the construct of Innovation Recipients was identified as a challenge. Prior research already emphasized the importance of targeted communication and tailored interventions to broaden the spectrum of patient activation thus highlighting the necessity of adapting interventions to specific needs and individual baseline conditions.⁵¹ Therefore, it is essential to critically evaluate existing patient outreach approaches and, if necessary, adjust. Participants perceived passive patients as those with a somewhat limited understanding of the illness, lower adherence to recommended measures, and little willingness to change potentially harmful lifestyles. That said, such views may be provider-centric and shaped by implicit biases or limited interaction with patients who face systemic barriers. However, one of the key aims in the CCC Integrative program is to activate patients.⁵² Statements from several participants suggest that predominantly already activated patients were reached, while passive patients less frequently engaged in the program and the counseling sessions. This observation raises questions regarding effectiveness and target audience reach. The difficulty in reaching passive patients points to the need to reconsider and adapt chosen approaches to patient outreach, such as the distribution and display of flyers and posters.

In the Implementation Process Domain, the construct of Engaging was identified as a challenging influencing factor that made it particularly difficult to recruit patients for the counseling sessions, partly due to concerns from medical professionals about potential impacts on the quality and effectiveness of the primary treatment. Challenges in recruiting study participants, such as healthcare providers’ concerns that participation might lead to differing treatment conditions, have been previously investigated.⁵³ These reservations can be addressed through transparent communication and involving medical staff in the study design process to address their concerns and feedback.^53,54

Patient activation through the interprofessional counseling sessions was perceived very positively, and most participants felt that the consultations not only encouraged the use of CIH methods but also motivated patients to take a more proactive role in managing their illness. This is particularly significant, as increased patient activation (measured by PAM) correlates with several positive health outcomes. These include improved healthcare results, higher adherence to recommended treatment plans, and potential reductions in healthcare costs. Findings in this study highlight the importance of counseling sessions as a tool for enhancing patient activation and suggest that the integrative use of CIH, coupled with targeted counseling, can positively influence the health behavior and management of patients.⁵⁴ Whether patients in this program continued managing their illness proactively should be explored in a follow-up study.

Under the construct of Work Infrastructure, passages related to interprofessional collaboration were coded in this study. The analysis revealed that the interprofessional counseling sessions themselves were a facilitating factor for implementation. This finding is supported by statements highlighting the value of a multidisciplinary approach for holistic patient care. According to these statements, the combined expertise of two professions allows for a broad range of information and recommendations to be provided. Ultimately, this leads to deeper and more effective patient counseling, as corroborated by both the participants and current literature.⁵⁵

Additionally, the materials and resources provided proved to be highly beneficial, contributing to the enhancement of program quality according to the participants. They are perceived as a facilitating factor for implementation, as they enable targeted and effective design of counseling sessions and prepare staff well for the individual needs of patients. Moreover, these resources facilitate the communication of complex information by making communication clearer and more understandable for patients. The training sessions and practical afternoons for staff were also particularly appreciated and identified as a supportive factor.

The integrative approach is in line with current trends in modern medicine, where evidence-based practice is increasingly incorporating lifestyle-related interventions such as exercise, nutrition and mental health. Although such interventions are considered part of CIH, they are also recognized in modern medical strategies. One example is exercise therapy, which is already applied in conventional medicine as an effective treatment for chronic diseases such as diabetes, cardiovascular problems, pain and mental disorders.^56,57 However, those are often offered only in specialized cancer clinics that provide counseling services for integrative oncology, indicating that the distinction between conventional and CIH medicine remains in some clinics. It can therefore be argued that modern medicine is increasingly moving towards integrating these holistic approaches trying to close the gap between conventional and CIH care. This development is supported by a growing evidence base demonstrating the benefits of lifestyle-based interventions—a component of the CIH approach.^58,59

The CFIR framework³⁷ allows identification and categorization of aspects that might influence an implementation. The five key domains used as analytical approach in this study provide 39 constructs relating to potential implementation challenges. Not all of these constructs were applicable in this study and its setting in an integrative care structure for oncological patients and associated care providers since they did not emerge as themes from the data. Nevertheless, considering constructs which address potential barriers regarding Financing, Policies and Laws (Outer Setting domain) or High-level Leaders and Implementation Facilitators (Individuals domain) appears to be recommendable when pursuing a sustainable implementation of the evaluated care approach.

This present work underlines the relevance of an integrative care structure such as the CCC-Integrativ approach. It also emphasizes the need for knowledge dissemination regarding evidence-based treatment options, and transparent, and interprofessional communication in healthcare to continuously improve the quality of patient care and to adapt to ever-evolving demands in oncological care.

Strengths and Limitations

Several limitations of this study must be reported that could constrain the interpretation of its results. Sample size or power calculation were not performed for the overall process evaluation and this qualitative study. The analysis was limited to semi-structured, guided individual interviews with CCC staff members, which may have excluded other relevant perspectives and led to a one-sided representation of the implementation of the counseling concept. Potential prior experiences with CIH approaches were not explored in this study. Due to a technical issue, one interview with an indirectly involved person could not be fully included in the analysis. However, as only a few last minutes were not recorded, post-scriptum notes were taken after the interview to mitigate data loss. Data collection ended 3 months before the intervention period ended. It is possible that some perceptions and experiences changed during this period and potentially significant insights were not captured or were overlooked. Another limitation arises from potential selection bias due to the purposive sampling and voluntary participation of the interviewees. Individuals with specific characteristics or opinions may be overrepresented. The personal connection of the interviewers to the program could have introduced biases. Although the interview guides were based on the CFIR framework, there is a possibility that important aspects of the implementation process were overlooked, leading to an incomplete analysis. Furthermore, data collection through self-reports from interview participants carries the risk of biases from social desirability or inaccurate memories.

The study exhibits several strengths. The use of qualitative methodology, particularly semi-structured interviews, provides in-depth insights into the challenges and opportunities associated with the implementation of the program, as perceived by both directly and indirectly involved individuals. Furthermore, the study advocates for the integration of CIH methods into clinical oncology care, thereby promoting a more holistic and patient-centered approach to treatment. In addition, the transferability of the findings to other clinical or institutional contexts may be limited due to the specific characteristics of the study setting.

The application of the CFIR offered a systematic and evidence-based structure for analyzing implementation factors, enabling a comprehensive understanding of the barriers and facilitators influencing the program’s success. Though it may be argued that the inductive domain Acceptance could also be classified under the concept “individual motivation,” integrating inductive data analysis alongside CFIR-supported identification of context-specific factors that were not fully encompassed by the framework, thus contributing a nuanced and flexible perspective on implementation challenges.

Conclusion

There is an urgent need for research on the effectiveness of various integrative treatment approaches, as well as the identification of barriers to access and the development of strategies to increase acceptance among medical personnel. Further studies should explore how professional roles, organizational culture, and patient experiences influence the adoption and long-term sustainability of integrative oncology healthcare approaches. Investigating these aspects can help formulate well-founded recommendations for implementing integrative approaches and thereby ensure a long-term, evidence-based, and patient-centered integrative care model for oncology patients.

Supplemental Material

sj-docx-1-his-10.1177_11786329251392422 – Supplemental material for Opportunities and Challenges of an Integrative Care Structure for Oncological Patients: A Qualitative Analysis of Provider Perspectives

Supplemental material, sj-docx-1-his-10.1177_11786329251392422 for Opportunities and Challenges of an Integrative Care Structure for Oncological Patients: A Qualitative Analysis of Provider Perspectives by Luis Scheck, Jasmin Bossert, Michel Wensing, Nadja Klafke and Regina Poß-Doering in Health Services Insights

Supplemental Material

sj-docx-2-his-10.1177_11786329251392422 – Supplemental material for Opportunities and Challenges of an Integrative Care Structure for Oncological Patients: A Qualitative Analysis of Provider Perspectives

Supplemental material, sj-docx-2-his-10.1177_11786329251392422 for Opportunities and Challenges of an Integrative Care Structure for Oncological Patients: A Qualitative Analysis of Provider Perspectives by Luis Scheck, Jasmin Bossert, Michel Wensing, Nadja Klafke and Regina Poß-Doering in Health Services Insights

Supplemental Material

sj-docx-3-his-10.1177_11786329251392422 – Supplemental material for Opportunities and Challenges of an Integrative Care Structure for Oncological Patients: A Qualitative Analysis of Provider Perspectives

Supplemental material, sj-docx-3-his-10.1177_11786329251392422 for Opportunities and Challenges of an Integrative Care Structure for Oncological Patients: A Qualitative Analysis of Provider Perspectives by Luis Scheck, Jasmin Bossert, Michel Wensing, Nadja Klafke and Regina Poß-Doering in Health Services Insights

Footnotes

Acknowledgements

The authors would like to thank all participants of this study for their valuable contributions. Many thanks also go to all CCC-Integrativ employees and managers for their collaboration, and all patients who were interested in evaluating this interprofessional counseling structure.

ORCID iDs

Michel Wensing

Regina Poß-Doering

Ethical Considerations

This study was conducted in accordance with the Declaration of Helsinki and received approval from the ethics commission of the Medical Faculty, University Heidelberg, Germany (reference (S-307/2020; November 24, 2020).

Author Contributions

Luis Scheck: Conceptualization, methodology, data analysis, writing. Regina Poß-Doering: Conceptualization, methodology, data analysis, writing, supervision. Michel Wensing: Review. Nadja Klafke: Study conception and design, methodology, material preparation, data collection, review, supervision. Jasmin Bossert: Data collection, review.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The CCC-Integrativ study is funded by the Innovation Committee at the Federal Joint Committee (G-BA), Berlin (01NVF18004). The funder had no role in the design of this study, data collection, data analysis, interpretation, or writing of the paper.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

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