1. Introduction

Health care professionals (HCPs) in the field of oncology are encouraged to identify and address supportive care needs by employing tailored and evidence-based interventions, including meditation, music, art therapy or relaxation [1]. Nonpharmacological interventions such as evidence-based forms of stress reduction are recommended to facilitate the self-management of psychosocial cancer-related symptoms [2]. Among other integrative approaches, meditation has been strongly recommended (grade A) as a way of reducing anxiety and stress as well as improving the moods and quality of life of patients with breast cancer [2].

Mindfulness meditation involves training in self-regulation exercises aimed at increasing the individual’s deliberate control of attention with regard to a specific or unspecific target [3]. The main objective of such meditation is to foster self-reliant behavior aimed at improving one’s well-being and health in general [4]. The mindfulness-based stress reduction (MBSR) program consists of 8 weekly in-group classes provided by a certified teacher. Several mindfulness-based interventions (MBIs) have been adapted to meet the needs of specific populations. The mindfulness-based cancer recovery (MBCR) program was adapted in 1996 for patients affected by cancer with the goal of supporting their self-care [5], and its effectiveness has been investigated by several clinical trials [6–9]. The MBCR involves sitting meditation, body scan meditation, gentle yoga, loving-kindness and mountain meditation, mini-breathing exercises, psychoeducation, and exercises focused on stress reactivity and sleep. Home practice of 45 min per day between classes is recommended [10].

Studies addressing questions relevant to the implementation and dissemination of MBIs as a primary goal from the HCP perspective are still rare [11]. Eyles et al. [12] reported that nurses and oncologists believed that an 8-week MBSR program was acceptable for patients with metastatic breast cancer and exhibited positive attitudes toward its implementation in the National Health Service. However, they highlighted some challenges, such as the time commitment, distance, and costs, associated with this approach. A qualitative study explored the experiences of 15 MBI teachers and 2 managers regarding the implementation of MBIs in Sweden’s health care system [13]. Three themes were highlighted as important determinants of MBI implementation: (1) the training of MBI teachers and the importance of support for the implementation from local champions (persons who are particularly engaged in the implementation of an intervention), (2) patient referrals (including increased collaboration with coworkers and awareness of the benefits of MBIs), and (3) managers’ and HCPs’ knowledge and acceptance of MBIs as well as financial factors.

HCPs have been shown to be ideally suited to the task of introducing mindfulness meditation to patients with cancer since they have access to all relevant information, thus enabling them to identify patients who might benefit from self-care interventions [14]. However, HCPs may not feel prepared to discuss, guide, or monitor patients regarding their use of complementary medicine [15]. Access to HCPs who are trained in mindfulness meditation is one of the challenges associated with attempts to integrate MBIs into routine care [2]. In Europe, only approximately 20% of oncology departments offered complementary approaches in 2014 [16]. Although the availability of such resources might have increased in some countries, such as Switzerland, during the last decade, patients still exhibit many unmet needs in terms of integrative cancer care and self-management support in Switzerland [17].

The implementation of an MBI in routine care should be explored in diverse cultural and economic contexts [18, 19]. The contexts of implementation should be carefully understood, and strategies should be adapted to local conditions to foster acceptance or minimize implementation costs [18]. To our knowledge, studies of in-group MBIs in oncology in Switzerland [20] as well as a systematic evaluation of the factors that may influence the implementation of MBIs in cancer care remain lacking. As part of a larger bicentric prerandomized controlled trial [21] investigating patients’ and instructors’ perspectives as well, the present study describes HCPs’ perceptions of the determinants influencing the implementation of an online mindfulness-based cancer recovery (eMBCR) program in the hospital oncology setting.

2. Materials and Methods

3. Results

In total, five focus groups were conducted, each of which lasted between 53 min and 1.5 h. A total of 51 HCPs were invited, and 19 people ultimately participated in the focus groups. Due to last-minute absences, the number of participants per group ranged between 3 and 6. Three focus groups were conducted online, and two were conducted in a face-to-face format.

4. Discussion

This study identified some facilitators and barriers that must be accounted for in attempts to increase the readiness of HCPs and organizations to successfully implement mindfulness meditation programs such as the eMBCR and even, more broadly, validated complementary approaches in the context of cancer care in Switzerland.

Despite the available evidence and current clinical guidelines encouraging the use of mindfulness meditation in oncology, this study highlighted the contrasting views of HCPs regarding its integration into a hospital oncology setting. The negative attitudes of some HCPs are a concern, as many patients will use this type of approaches during their cancer journey, and seek to engage in dialog with HCPs [15]. Indeed, patients affected by cancer from Australia, Canada, New Zealand, the United States, and Europe have increasingly (40%) been using complementary and alternative medicines (CAMs) in the last 20 years [28]. A European study highlighted the fact that patients with breast cancer in Switzerland exhibited one of the highest rates (52.6%) of CAM use in 2004 [29]. In French-speaking areas of Switzerland, some patients affected by cancer have reported using alternative medicines to deal with some side effects of treatment due to a lack of support from medical staff [30]. Other reported motivations are to address unmet needs, to reduce cancer symptoms, and to improve their quality of life [2]. Therefore, it appears reasonable for the hospital to be, at a minimum, a place where patients can engage in open discussions with their HCPs regarding these complementary approaches. Furthermore, although the literature reported mixed results regarding HCPs’ perceived usefulness of practicing integrative medicine [15], the hospital should probably also be a place where a certain number of validated interventions are offered, so that they can be carried out in a safe context and by trained HCPs.

The unknown effects of some complementary approaches [2] and the risk of patients’ misuse further highlight the need to provide better information to patients [31]. Integrating efficient approaches alongside conventional care may increase patients’ participation and improve their quality of life [32]. The choice of interventions should be based on patients’ distress and needs as well as on existing evidence and available resources, starting with the most natural, effective, and least invasive interventions [33]. Attention should be paid to determinants influencing patients’ participation and adherence to MBIs. Barriers to adherence to MBIs can be categorized into four domains: (1) practical barriers; (2) person-related barriers, (3) health-related barriers, and (4) meditation-specific barriers [34, 35]. HCPs identified several strategies to enhance accessibility and adherence, including flexible delivery formats (e.g. online MBIs) and adjustments in session frequency and duration.

This study highlighted the need for training on ways of guiding patients through the safe use of CAM. Currently, a lack of knowledge among HCPs remains a barrier to the future implementation of MBIs in cancer care [15, 36, 37]. Many HCPs at hospitals do not feel prepared to discuss integrative medicine or to guide or monitor patients in this context [15]. The inability to provide recommendations and guidance or a tendency to avoid the topic may lead to negative impacts on the patient–provider relationship and patients’ outcomes [38]. Poor patient–provider relationships can increase rates of nonadherence to cancer treatments, which may in turn increase the risk of disease progression or even mortality [39]. Thus, training HCPs is essential to meet patients’ needs more effectively [40], and such training may improve CAM referral as well as dialog between professionals and patients [41]. In this sense, the KOKON-KTO framework encompassing a 20-min consultation to inform patients about complementary and integrative medicine in a structured way during routine consultations has been shown to be feasible among oncology physicians in a German-speaking context [42]. The physicians were trained through a hybrid learning method based on e-learning and a 2-day onsite workshop [40]. However, the acceptability and feasibility of such a consultation in the oncological departments of academic hospitals in French-speaking areas of Switzerland remain unclear. The KOKON-KTO framework [42] could be tested among oncology physicians in these contexts and if feasible, this framework would allow the systematic guidance of patients with cancer on complementary and integrative medicine [43]. Such a framework could be extended to nurses as well [42]. It could be adapted and integrated into their teaching plan, as well as being part of a continuing education program for nurse managers and advanced practice nurses. Registered nurses and advanced practice nurses are in a key position to refer patients to MBIs or to train themselves to deliver MBIs [14]. Translation of the learning and manual in French would be a first step if considering testing and adapting this method to local contexts. Training could be made dynamic, and delivery methods varied to cater to different learning styles [44].

The study, supported by the literature, suggests national implementation strategies that may be tested for effectiveness in a future trial (Algorithm 2). The referral of patients to MBIs and integrative medicine in general may depend on the personal interest and understanding of the relevant HCPs [13]. In a worst-case scenario, these factors may have consequences for patient safety if HCPs are not able to guide patients regarding the safe use of complementary medicine [15]. The establishment of collaborations and relationships among colleagues with the goal of increasing their awareness of MBIs may be a way to overcome this barrier [13]. Positive experiences expressed by the patients themselves may, for example, increase their awareness [13]. Future implementation strategies may focus on HCP attitudes toward mindfulness meditation [45]. The theory of planned behavior, for example, posits that both motivation (intention) and ability (opportunities and resources, e.g., time, skills, and money) are necessary to trigger a behavior [46]. The determinants of intentions and attitudes toward the behavior (a favorable or unfavorable evaluation of the intervention: beliefs), the subjective norm (the perceived pressure to engage in the behavior), and the perceived behavior control (facilitators of or barriers to the behavior) could be explored [46]. Teaching integrative medicine may lead to increased referrals, improved patient–health care provider communication, and enhanced positive attitudes regarding complementary approaches on the part of HCPs [15]. Educating service managers is also important for increasing effective referrals [47]. Finally, most HCPs acknowledged the need for and value of the presence of a center for integrative medicine within the hospital, including HCPs with specific knowledge and dedicated time for integrative consultations. However, the evidence shows that even when a meditation and yoga center is located within a hospital, HCPs are not necessarily aware of this fact [48]. Therefore, actively informing HCPs and patients regarding existing resources via a website, for example, may increase the visibility of such resources [49].

Implementation strategies may be tested for effectiveness in a future trial. Indeed, knowing that mindfulness meditation research has been mainly focused on early-stage designs (e.g. adapting and testing MBIs), implementation and dissemination studies should be further developed [11]. More pragmatic trials and hybrid designs are needed to understand the effectiveness of implementation strategies [50]. This would help in the development of a national implementation toolkit for MBCR, as it was done in the United Kingdom for the implementation of MBCT [51]. National specific guidelines for MBIs (e.g. national training requirements) may ensure patient safety and outcomes by avoiding inconsistencies in the delivery of such programs.

5. Conclusion

This qualitative study improved our understanding of the multilevel components that may positively or negatively affect the implementation of a complex intervention such as an MBI in the context of cancer care. The results from the focus groups conducted with HCPs suggest some specific barriers, e.g., the lack of reimbursement, the need for education regarding mindfulness meditation and CAM in general, the lack of time dedicated to CAM during patients’ consultations and care activities, and negative attitudes toward mindfulness meditation and its integration within hospitals. Strategies for increasing access to MBIs within hospitals, among other evidence-based approaches, could be adjusted to accommodate those barriers. The establishment of a multidisciplinary implementation group, including leaders, that can target professionals’ attitudes and skills and overcome some barriers in terms of resources could be a first step toward addressing the contextual needs thus identified.

Conflicts of Interest

The authors declare no conflicts of interest.

Funding

This study was supported by the Leenaards Foundation, the Swiss Cancer Research Foundation, and the Universities of Geneva and Lausanne.

Supporting Information

Interview guide for the focus groups, based on relevant CFIR domains.