The purpose of this study was to identify barriers related to HCPs and HCS in the implementation of quality and timely IV CT. In the present study, participants noted miscommunication between HCPs and patients, especially during patient education, and subsequently patients’ distrust as barriers to the implementation of quality IV CT. Other studies confirm that one of the most important factors in the healthcare system that affects adherence is the relationship that care providers establish with patients (26). Findings from a study by Wu et al. showed that some patients reported that incidents of non-adherence occur due to inadequate training or unavailability of immediate medical guidance. One of the reasons for non-adherence includes physician-patient communication issues (27). According to Ghoshal et al., newly diagnosed cancer patients report more distressing symptoms, however, oncologists do not pay enough attention to them (28). Poor communication, lack of trust, and patient dissatisfaction and distrust in caregivers are also involved in poor adherence (21).
The purpose of education and proper communication with the patient is to empower patients in self-care and management of CT complications, which increases the patient's adaptation, tolerance, and adherence to CT and results in more successful treatment. Therefore, if the education of and communication with the cancer patient are not carried out well, this can be a barrier to implementing quality and timely CT.
In the present study, non-native HCPs and the resulting communication problems and poor attention to communication and patient education and providing inaccurate and wrong information to patients and family caregivers caused a sense of distrust in the HCS and HCPs and prevented patient referral. Therefore, it may be a barrier to timely visits and quality of CT or the continuation of the CT process. Dean’s study showed distrust in HCS is negatively related to treatment adherence, defined as the failure to initiate or complete physician-recommended adjuvant treatment after breast cancer (29). The barriers to adherence include physicians’ failure to accurately explain the benefits and side effects of CT, lack of attention to costs, and poor communication regarding treatment (30).
Participants noted HCPs’ lack of practical knowledge and skills and lack of communication skills and training as barriers to effective chemotherapy. Evidence suggests that health professionals have poor skills in accurately identifying non-adherent patients (31, 32). Sharour also showed that nurses' knowledge about chemotherapy management was insufficient, affecting the quality of care for patients with drug extravasation (33). A study by Salarvand et al. showed that nurses working in chemotherapy departments did not have sufficient skills in IV line insertion and control of drug extravasation. The same study showed that oncologists’ skills in establishing communication and giving bad news to patients are essential when providing care to such patients (34). These mentioned cases can lead to a decline in the quality of care and lack of quality IV CT.
Some participants mentioned a lack of clean and calming care environments. In a study by Summerhayes, nurses and pharmacists expressed the need for sanitary rooms and space (35). A study by Salarvand et al. showed that the development and improvement of care and physical environment to provide services, the need to maintain personal and environmental hygiene during the course of chemotherapy by patients and their families, emphasis on a calming chemotherapy environment in terms of structure, personnel, and facilities, and the need to maintain the privacy and respect of the patients undergoing chemotherapy were among the care needs pointed out by oncologists that were lacking (34).
Participants in the present study cited drug shortages as a barrier to timely and successful CT. Studies have shown that drug shortages are common in the United States and have increased significantly over the past decade (36). Delays in treatment, disruption of treatment, lack of treatment options for certain cases, and replacement of drugs in less effective and harmful regimens can adversely affect the prognosis and outcomes (37). The shortage of injectable chemotherapy drugs puts the successful treatment of cancer patients at risk (38).
Participants cited insufficient numbers of nurses and chemotherapy HCPs in the care system as a barrier to quality CT. Wise has reported that the shortage of specialist oncological nurses in the chemotherapy department caused this ward to be closed down at a hospital (39). The shortage of HCPs leads to increased workload and pressure on other staff, which will hinder the quality of care during IV CT.
Participants stated a lack of follow-up and patient support from the time of diagnosis to rehabilitation as a barrier to quality CT. Other studies confirm that a lack of patient support in various aspects can lead to failure to show up for follow-up and treatment failure (40). In a study by Salarvand et al., oncologists mentioned that one of the priorities in caring for patients undergoing CT is the existence of comprehensive support for various aspects of the cancer disease trajectory from diagnosis to rehabilitation (34). This may be due to HCPs’ unawareness of the needed support or lack of infrastructure to provide the support.
The present study demonstrated that one of the barriers to patients’ adherence to IV chemotherapy was a lack of cooperation among HCPs and multidisciplinary teams. Carroll's study also showed that a lack of coordination among individuals involved in cancer care can be a cause of non-compliance and treatment failure (40). If there is no multidisciplinary treatment team in the care structure, this may be a barrier to quality care during CT.
Participants mentioned poor management, including failure to employ expert healthcare professionals, compulsory employment of some nurses in chemotherapy wards and its consequences, inadequate nursing staff and lack of suitable support for nurses working in CT wards by authorities and failure to provide training to healthcare professionals and its consequences as barriers to the quality and successful implementation of IV CT. In the study by Summerhayes, nurses and pharmacists working in oncology wards pointed to HCP shortages, increased workload and stress, increased waiting times, and a significant imbalance between CT workloads and HCPs capacity to initiate IV CT (35).
Participants pointed to the forced employment of some nurses in chemotherapy wards and inadequate support for nurses working in these wards by authorities. No study was found on the compulsory employment of nurses in oncology and CT wards and the support and respect they received. Toh found that nurses, who worked in sub-standard work units, often expressed dissatisfaction, stress, and burnout, which encouraged them to seek a new job out of oncology (41).
Participants reported a lack of training for HCPs and, consequently, inadequate knowledge and skills of HCPs regarding the management of IV CT. No completely relevant study was found on this topic. Findings from other studies confirm this. Two studies showed that the number of nurses who were trained in the safe administration of chemotherapy before starting work is small, most nurses receiving this training while working in a CT center. For this reason, nurses experience anxiety, irritability, and fear while performing chemotherapy due to a lack of prior training on the subject (42). Many nursing programs do not teach difficult communication skills such as giving bad news or answering difficult questions (Such as "Am I dying?”) .(43) In a study by Salarvand et al., oncologists stated that they had not been trained in the skills of communication with and in giving bad news (36). The fact is that many practical and theoretical skills, such as breaking bad news, the attention to patient assessment and its condition, are not taught adequately in educational curricula and retraining programs. This reduces the quality of CT care.