Introduction
The legislator has initiated legislative work on an act, which aims to regulate the conditions and principles of medical practice in professions that have not been covered by statutory regulations so far. The legislative initiative includes issues related to professional development and professional liability of medical professionals [1]. The indicated draft includes professions such as, among others, the orthoptist, podiatrist, preventive medicine specialist, or medical sterilization technician, but not psycho-oncologist. Recognizing the need to raise the profile of other allied medical professions, it was decided to regulate, in the form of the specializationin the fields applicable in healthcare, the profession of addiction psychotherapy specialist [2], and in relation to the profession of a psychotherapist, work in this field is in progress [3]. The profession of psycho-oncologist has not been included in any of the above legislative projects while its current legal regulation is inconsistent, as indicated in the doctrine [4]. The survey research, which is the subject of this article, aimed at analyzing whether the de lege lata state allows psycho-oncologists to provide highly desirable services in the system of guaranteed services in an uninhibited manner, with appropriate guarantees regarding the legal framework of professional activity or whether the availability of health services of this kind is affected.
Currently, according to the Regulation of the Minister of Health on guaranteed benefits in-hospital treatment, a psycho-oncologist is a person with higher psychological or medical education, who has completed higher education and obtained a master’s degree or an equivalent degree and who has completed post-graduate studies in psycho-oncology [5]. A psycho-oncologist participates in the process of providing healthcare services in the general health insurance system and outside it. As part of the guaranteed services, the payer requires the medical institution to have in their personnel a psycho-oncologist in selected types of facilities, including palliative and hospice care (Regulation of the Minister of Health of October 29, 2013, i.e. Journal of Laws of 2022, item 262), outpatient specialist care (Regu- lation of the Minister of Health of November 6, 2013, i.e. Journal of Laws of 2016, item 357, as amended), or medical rehabilitation (Regulation of the Minister of Health of November 6, 2013, i.e. Journal of Laws of 2021, item 265). The Minister of Health indicated that the presence of a psycho-oncologist is required during the pro- vision of such services as comprehensive oncological care, e.g. for a patient with breast cancer (KON- -PIERS) and a patient with colorectal cancer (KON-JG; Regulation of the Minister of Health of 22 November 2013 on guaranteed benefits in the field of hospital treatment, i.e. Journal of Laws of 2021, item 290, as amended). In addition, psycho-oncologists support people with cancer and their families, in particular, in stationary and home hospices, which are run by private entities, and finan- ced outside the guaranteed benefits system.
The legal definition of the profession of psycho- -oncologist, which remains in force, is inconsistent with the regulation of this profession, which has been in force since 2018, and results from the announcement of the Minister of Health on the Polish Qualifications Framework (PQF) system [6]. This is because the PQF restricts the group of people who can obtain a qualification in psycho-oncological diagnosis and care to psychologists and psychiatrists only, thus limiting the number of people who are qualified to practice as psycho- -oncologists. A third path to acquiring professional qualifications of a psycho-oncologist is through certification in the process of the Polish Psycho-Oncology Society (PPOS). Under this procedure, in addition to psychologists and doctors, representatives of other professions, such as nurses or clergy employed in hospices, would also become certified. In light of the regulations mentioned above, people certified in this way will mostly be unable to formally practice the profession, as the regulations do not allow for the recognition of certificates awarded by PPOS as equivalent to psycho-oncology qualification under PQF. The term ‘psycho-oncologist’, therefore, currently denotes PPOS-certified psycho-oncologists, not included by the legislator in any of the regulations, psycho-oncologists with postgraduate studies in psycho-oncology as well as psycho-oncologists who will become qualified under the currently implemented market qualification: “Diagnosis and psycho-oncological support for oncological patients, post-cancer patients, and their families and environment”.
Material and methods
The study used an original anonymous questionnaire entitled Survey on selected aspects of the psycho-oncology profession in the context of its scope and method of legal regulation (hereinafter: POA) and, with the author’s consent, the Job Satisfaction Scale questionnaire (hereinafter: SSP) [7]. The POA questionnaire contained 12 open-ended and closed-ended questions in which the researchers asked respondents about their educational background, qualifications under which they practice as psycho-oncologists, their intention, if any, to enter the validation and certification process under the Integrated Qualification System (IQS), their perceptions about the nature of the psycho-oncology profession, their preferences regarding access to this profession for different categories of underlying professions, as well as their assessment of the legal status of this profession as per current legislation. In the open-ended questions, the respondents could give free answers to questions about the possible intention to obtain a psycho-oncologist certificate under the Integrated Qualifications System and the reasons why they made this decision or abandoned such an intention, whether they see the profession of psycho-oncologist as strictly medical or in other categories, and whether the current state of legal regulation of this profession in Poland negatively affects the fulfillment of duties of psycho-oncologists or raises concerns about the future of their performance. The respondents were also asked to indicate the three most important, in their opinion, differences in the psycho-oncological practice by representatives of various professions (doctors, psychologists, and psychiatrists) and to specify what their expectations are regarding the legal regulation of the profession in Poland. The SSP questionnaire consisted of 5 questions on job conditions and job satisfaction, rated by the respondents on a scale from 1 to 7, where 1 meant ‘strongly disagree’ and 7 — ‘strongly agree’. Both questionnaires were available through a free Google tool, and all respondents provided their consent to participate in the study, which was a prerequisite for being able to complete the survey. The tool was made available on various platforms and disseminated to specialized cancer care clinics and other centers providing psycho-oncological care. However, because the professional community is not large, comprising about 1 000 people across the country: 95 people with the Psycho-oncologist Certificate in the Polish Psycho-oncology Association (extraordinary procedure) and about 900 graduates of postgraduate studies in the field of psycho-oncology [8], the survey, conducted in the second half of 2022, was completed by 41 respondents. The data analysis was qualitative.
Results
Of those taking part in the survey, 79.5% declared that they had a degree in psychology, just under 13% had a degree in medicine, and 7.7% were graduates in sociology, nursing, education and counseling, and public health. Most respondents (64.9%) stated that they practice as psycho-oncologists after completing postgraduate studies in psycho-oncology, while 35.1% were certified as psycho-oncologist by PPOS. At this point, it should be emphasized that none of the respondents held the market qualification (Diagnosis and psycho-oncological support for oncological patients, post-cancer patients, and their families and environment) provided under the Integrated Qualifications System in the PQF validation and certification process, which was introduced in December 2018.
Not all respondents declared whether they intended to join the certification process to obtain qualifications under the Integrated Qualifications System. Fewer than 30% declared that they did not intend to due to a lack of financial resources to cover the costs involved; because the certificate would only confirm the status quo (skills); because having postgraduate studies is enough to practice the profession in the light of the Regulation of the Minister of Health on guaranteed inpatient care; because they already held PPOS certification; due to lack of knowledge on how to initiate the procedure; because the course and procedure are below the respondent’s qualifications; and also because it is not required by the public payer. The same percentage of respondents who declared their intention to follow this training pathway justified their decision by claiming that a qualification of this kind would confirm their skills in the EU, that it would be part of extrinsic motivation for continuous development or a confirmation of their qualification level, and that by doing so they would improve their knowledge in the field.
While answering open questions, when asked about the nature of their profession as a psycho-oncologist, 47.4% of the respondents said that they saw it as a specialization in psychology, while 42.1% described it as a difficult interdisciplinary field of study, requiring specific know-how and expertise. Only a small proportion of the respondents defined their profession as a typical medical profession (5.3%). The question of whether the current legal status of the psycho-oncology profession in Poland raises anxiety about its prospects within the system of guaranteed healthcare benefits was answered by slightly more than 50% of people, while about 20% indicated that the current legal status has a negative impact on both the way the profession is practiced and their performance.
More than half of the respondents indicated that, in their opinion, only psychologists should have access to the profession, 20% believed that this profession should be open to all medical professions, and the same proportion said that it should also be open to members of professions such as philosophers, theologians, sociologists, occupational therapists, and social workers. The smallest number of respondents considered the profession to be specifically reserved for psychiatrists, i.e. one of the two categories of professions currently eligible for PQF certification. Of all participants, 65.8% provided their psycho-oncologist services based on the requirements of the National Health Fund (NFZ), as part of their contracts for publicly funded healthcare. When asked about job satisfaction level, the majority of the respondents (66%) agreed with the statement that their job was close to ideal, and almost the same number said that their job conditions were excellent (63%). As many as 80% of respondents stated that they were satisfied with their job, and the same number that they so far managed to achieve their goals at work. If the respondents had to choose their job again, as many as 82% would choose the same job.
In their responses to open-ended questions, survey participants emphasized that the lack of legal regulation of the profession of psycho-oncologist is a source of frustration for them and makes them anxious about practicing the profession in an environment where the same services are also provided by insufficiently qualified people. The respondents pointed out that the inconsistency in legal regulations and the long learning path may result in restricted access to the profession, with a consequent reduction in the number of practitioners and thus patients’ access to their services. The respondents emphasized their doubts about the legal credentials required to use the professional title of psycho-oncologist and the passive approach of state legislators when it comes to sorting out the existing legal ramifications, as well as the organizational confusion resulting from different educational pathways.
Survey participants pointed out the lack of symmetry in individual competencies of practitioners with different underlying professions: in the case of doctors, highlighting their lack of psychological training, and in the case of psychologists, the need to acquire knowledge of the diagnosis and treatment of the oncology patient and incorporate it into therapy. Another related problem noted by the respondents is that psychologists are not authorized to prescribe pharmacotherapy and, on the other hand, those psycho-oncologists who are not psychologists do not have the necessary training to provide counseling and are unfamiliar with specific counseling techniques, the use of psychological tools, and lack a certain range of soft skills. As indicated by the respondents, the positioning of psycho-oncologists in the system of guaranteed services may translate into how psycho-oncological help is provided and the time devoted to the recipient of such services, i.e. the frequency and duration of meetings.
The respondents highlighted differences in the approach to the patient: therapeutic (in the case of practitioners with a background in psychology) and medical (in the case of those with a background in psychiatry). The answers provided indicated the important role of knowledge of patients’ psychological functioning, understanding the background of different reactions to the illness, and the ability to communicate with the patient and their relatives, as well as different methods of counseling. As a result, a psychologist who uses a subjective and individualized approach, as well as communication skills, conducts their interaction with the client/patient in a different way than a doctor.
When identifying expectations regarding the regulation of the psycho-oncology profession in Poland, the respondents emphasized the need to clarify the current legal situation in the profession, clearly define the scope of responsibilities of practitioners, and the mechanism of building professional and interpersonal qualifications. It was proposed that a specialization in psycho-oncology is created, similar to the specialization in clinical psychology, or that access to the profession be restricted to psychologists only, or that a single, coherent system of awarding qualifications in this area be created. It was noted that it would be desirable to standardize and facilitate access to this profession and legally determine the categories of practitioners who could use this professional title, pointing out the lack of legal transparency in the psycho-oncology profession. Finally, it was advocated that psycho-oncologist should be explicitly included in the category of medical professions and their status upgraded to a specialization in the healthcare system, to provide guarantees for better funding in the system.
Discussion
The literature emphasizes the role of psycho-oncology as a multidisciplinary field on the borderline between medicine and social sciences [9]. The conducted research has shown, however, that the variety of basic professions entitled to practice as psycho-oncologists causes significant differences in professional performance, which means that the standard of practice is not uniform. A psycho- -oncologist who is a psychiatrist by education has medical knowledge, while a psycho-oncologist psychologist is competent to provide psychological assistance. In the case of psycho-oncologists with education other than the indicated professions, their qualifications are closely related to the competencies obtained in formal education, i.e. higher psychological or medical studies, defined by the legislator in a very general way, provided that they complete postgraduate studies in psycho-oncology what results in differences in the qualifications held. On the other hand, after obtaining formal qualifications to provide psycho-oncology services, there are no legal instruments to monitor the standard of their performance because the certificate awarded under the IQS is valid indefinitely, and after completing postgraduate studies in psycho- -oncology, the practice is unlimited timewise. Meanwhile, the literature indicates the need for developing a useful model of supervision in psycho-oncology [10, 11], as the profession of a psycho-oncologist includes providing therapy for people affected by cancer and their families.
The lack of uniform regulation of the profession results in the impossibility of qualifying it as a medical profession with consequences regarding liability for damage caused in the course of its practice. The lack of professional self-government means that there is nobody that would guard a specific standard of psycho-oncological services within the system of guaranteed benefits and outside it. No entity in the system would be competent to deprive a psycho-oncologist of his/her ‘license’ in the event of improper performance of services, and there is no procedure applicable in such a situation. Although new challenges for this interdisciplinary activity relate, in particular, to the support of patients and their families in the face of new methods of cancer treatment [12], there is no specific model of continuing education in this field.
Problems related to psycho-oncological care in different countries are closely related to the organization of the healthcare system [13]. In major oncology centers in the world, the inclusion of psychological help in the scope of services is a standard, which results in an improvement in the quality of treatment of patients and an increase in the quality of their lives and dying [14]. As a result of the conducted research, it has been revealed that inconsistent system solutions negatively affect decisions to choose this profession, which in turn may result in a low number of people competent to perform it and thus limit access to these services. A decade ago it was already indicated that not all pediatric onco-hematology centers provide the same satisfactory level of psychosocial care [15].
Conclusions
Taking into account the sample size, the conducted research does not allow for conclusions generalizable to the entire professional environment of psycho-oncologists, however, it seems legitimate to confirm certain assumptions from the data obtained. The way in which the profession of psycho-oncologist is currently regulated in Poland seems insufficient. As this study shows, under the current legislation, there is organizational chaos which negatively affects not only how psycho-oncologists practice their profession but also the accessibility of the services they provide. Legal steps are needed to unify the current system of training which is now split into three non-equivalent paths, as has already been pointed out in the literature [4]. The opinions of our respondents correspond fully with the initiative of the Polish Psycho-Oncology Society, which since 2012 has been requesting that the profession of psycho-oncologist be formally recognized [16]. It seems reasonable for the legislator to intervene to modify the legal regulation of the profession, in particular by unifying the method of obtaining professional qualifications and providing access to the profession. In this regard, it seems desirable to choose one of the modes of access to the profession both by defining the catalog of entry-level professions, which will entitle one to obtain the license to practice as a psycho- -oncologist, as well as to define the path of education considering the differences resulting from entry qualifications. Depending on whether a psycho-oncologist will be a doctor, or psychologist, or will represent another profession, the education process should take into account the differences resulting from their education and related system regulations. The legislator should determine the nature of the psycho-oncologist profession as a medical profession, creating legal guarantees of a specific standard of its performance, and consider the postulates of that part of the psycho-oncology community which expresses concerns about the current state of legal regulation of the profession.
Article Information and Declarations
Data availability statement
The data was collected on the basis of voluntary, anonymous surveys.
Ethics statement
Not applicable.
Author contributions
K.K.: conception, design, execution and interpretation of the data.
M.Ch.: execution and interpretation of the data.
M.S.: execution and interpretation of the data.
M.J.J.: conception, design, execution of the data.
Funding
None to declared.
Acknowledgments
The authors would like to thank prof. Anna Maria Zalewska for providing of the analytic tool — SSP questionnaire.
Conflict of interest
The authors declare no conflict of interest.
Supplementary material
None.