The results of this study regarding Canadian and Norwegian RTs’ perceptions related to PSSC align with previously published work. For example, Larsen et al. [10] previously noted that Canadian RTs identified PSSC as an integral aspect of providing quality care. Larsen et al. [10] further reported that engaging in PSSC enables RTs to gain greater personal fulfillment and satisfaction from their work. The level of fulfillment and satisfaction RTs derive from delivering PSSC may be shaped by their personal convictions and motivations, as some RTs with life experience or tragedy related to cancer were more motivated to provide such care [10]. Despite potential differences in personal convictions and motivations, many Canadian RTs in this study shared that providing PSSC allows them to fulfill their full scope of practice. Norwegian RTs identified PSSC as a key part of their responsibilities but were undecided about whether providing such care allowed them to work to their full scope of practice. These differences suggest that perceptions of PSSC are not only influenced by the personal convictions and motivations of RTs but may also be shaped by systemic factors or cultural conceptions of care within radiation therapy settings across both countries.

Despite similar confidence levels in addressing PSSC needs, Canadian RTs expressed a greater interest in expanding their knowledge and capacity to engage in PSSC compared to Norwegian RTs. Larsen et al. [10] previously revealed that Canadian RTs were interested in expanding their scope of practice to engage in PSSC by specializing in advanced practice radiation therapy or pursuing research in PSSC within their professional practice. Although Canadian RTs shared a greater desire to engage in PSSC, they reported feeling less equipped and prepared than Norwegian RTs to address the PSSC needs of their patients. This is an interesting finding given that expanding upon RTs’ current capacity to engage in PSSC requires sufficient time, resources, and support, which are currently limited in Canadian radiation therapy departments [22, 23]. Canadian RTs’ desire to expand their scope of practice within a healthcare system that is experiencing resource constraints, as well as workload and staffing pressures [22, 23], may reflect underlying cultural values about providing more holistic patient-centered care rather than simply addressing the physical aspects of disease. There is a growing focus on holistic patient-centered care in radiation therapy settings across Canada [10, 24], urging clinicians to consider the circle-of-care. This is reflected in the CAMRT Code of Ethics and Standards of Practice [25], as well as the clinical practice guidelines [11], which both stress the importance of RTs to focus on addressing the needs of both patients and their family members or caregivers in all aspects of their healthcare interactions.

Additionally, there may be important differences in professional practice, organizational structures, and institutional support around PSSC between the two countries. In Canada, the national clinical practice guidelines [11], as well as provincial resources for PSSC [26,27,28], may increase recognition of the importance of PSSC and contribute to the desire for an expanded scope of practice among Canadian RTs as seen in our study. Some Norwegian RTs indicated that their main focus was on the technical aspects of care and that delivering PSSC was the responsibility of other healthcare providers. There are no clinical practice guidelines for PSSC available in Norway that encourage RTs to integrate PSSC into their daily treatment, which may account for the differences noted between Canadian and Norwegian RTs with respect to their perceptions about which tasks fall within their scope of practice.

Canadian RTs in this study additionally reported a lack of clarity around their role in providing PSSC. Many Canadian RTs expressed a need for more PSSC resources and training, which is an interesting finding given that clinical practice guidelines for PSSC already exist as a resource in Canada [11]. This suggests that there may be a need for greater knowledge translation of these guidelines into clinical practice. Canadian RTs may also benefit from increased promotion of other complementary resources, such as provincial guidelines and resources [26,27,28], that will clarify and support their role in delivering PSSC. Norwegian RTs reported greater training and clarity regarding their role in addressing the PSSC needs of their patients, but were less interested than Canadian RTs in expanding their scope of practice. This is perhaps due to time constraints, as Norwegian RTs already spend significantly more time than Canadian RTs on PSSC delivery and may not be able to expand their current capacity. Moreover, Canadian RTs may be more interested in broadening their scope of practice, as some perceived a recent reduction in their time dedicated to providing PSSC and wish to return to delivering such care at their previous capacity. Even though perceptions related to PSSC differed between both countries, Canadian and Norwegian RTs agreed that addressing the PSSC needs of their patients is an important aspect of providing quality care.

In this study, Norwegian RTs estimated spending more time engaging in PSSC activities than Canadian RTs. Larsen et al. [10] previously reported that Canadian RTs spent 6.2 h per week on PSSC, which may indicate a reduction in providing such care over time. The time RTs dedicated to providing PSSC in the Larsen et al. [10] study was based on data collected from a single institution, whereas the present study encompassed RTs practicing across Canada. Despite these contextual differences, Canadian RTs in this study also shared that their time dedicated to providing PSSC has decreased over the last decade in response to an increasing demand for prioritizing the technical aspects of care. Canadian RTs have shifted focus to integrating PSSC into routine tasks and relying on screening tools due to time constraints [10, 17]. As there is no prior data from Norway, the results of this study suggest that Norwegian RTs dedicate more time on average to PSSC delivery. This may be a function of differences in organizational structures, as there are generally higher staffing levels in Norwegian radiation therapy departments compared to other countries [29], which may reduce individual workloads and allow RTs to dedicate more time to addressing the needs of patients.

This study further revealed differences in the types of PSSC practices utilized by RTs in Canada and Norway, which may reflect distinct healthcare approaches and systemic factors. Norwegian RTs emphasized the importance of personalized interactions with patients, which aligns with Newton et al. [30] who indicated that patients value direct personal support, and may account for the extended amount of time Norwegian RTs reported spending on PSSC activities. In contrast, Canadian RTs demonstrated a more structured approach to PSSC delivery, often involving family members or friends in PSSC and using screening tools to identify unmet PSSC needs. However, other studies reported limited effectiveness and support for the use of such tools to address patient needs [10, 17].

Most RTs in Canada and Norway reported experiencing barriers to effective PSSC delivery. Canadian RTs face ongoing systemic and organizational constraints, such as staffing shortages and inadequate funding, which may hinder their ability to provide comprehensive PSSC [17, 22, 23]. Hulley et al. [17] and Jones et al. [18] found that RTs are often constrained by high workloads and limited time, further restricting their capacity to effectively deliver PSSC. This aligns with barriers identified in our study, as RTs cited high workloads and time constraints as challenges that may contribute to the reduction in time spent on PSSC activities in Canada. These systemic pressures intensify staffing shortages and the fast-paced healthcare environments in which RTs work, which Sarra and Feuz [31] identified as contributors to burnout among RTs and reduced capacity for patient support.

Although Norwegian RTs benefit from greater institutional support, including higher staffing levels [29], they continue to face practical challenges in delivering PSSC, such as a lack of private spaces for patient interactions and time constraints. Merchant et al. [32] noted that radiation therapy environments that are not conducive to privacy can act as a barrier to communication between patients and RTs. Moreover, patients often pick up on time and efficiency pressures in radiation therapy departments, which can induce stress and anxiety during their appointments [32]. Effective communication and sufficient resources (i.e., time and space) are integral to reducing patient anxiety during treatment [33], which highlights a need for continued support and training that will enable RTs to deliver quality care. Elsner et al. [7] also noted that ongoing support and mentorship ensure the effective implementation of training into clinical practice. This underscores the need for enhanced training, resources, and institutional support in both countries to improve PSSC delivery and patient outcomes.

The results of this study have several implications for clinical practice. Given the importance of PSSC for delivering quality care and maximizing patient outcomes, the role of advanced practice radiation therapists (APRTs) within the care team should be considered. APRTs can perform delegated tasks and effectively support patients in cancer management, as they possess additional knowledge and advanced clinical skills in a particular area of radiation therapy [34]. A feasibility study by Harnett et al. [34] revealed that APRTs already provide patient education, streamline referral processes, and ensure timely access to services in some radiation therapy settings in Canada. APRTs can choose to specialize in palliative radiation therapy and supportive care among other areas [34], although there is currently no option for specialization in PSSC. To this end, expanding professional practice for an APRT role specializing in PSSC would have the potential to mitigate time constraints and other institutional pressures.

As many RTs in our study were interested in expanding their scope of practice to engage in PSSC but may not have the capacity to become an APRT, it is important to leverage existing resources and tools that can improve the capabilities of all RTs with respect to delivering PSSC. For example, greater knowledge dissemination of the clinical practice guidelines in Canada [11] would ensure that RTs throughout the country are supported in delivering PSSC and more aware of how certain PSSC tasks may fall within their scope of practice. As there are no clinical practice guidelines for PSSC in Norway, it is recommended that such guidelines be created and disseminated to Norwegian RTs to encourage more widespread PSSC delivery and to hold RTs accountable to a national standard of care.

Both Canadian and Norwegian RTs reported time constraints as barriers to PSSC delivery, which could be addressed by integrating screening tools, such as the Edmonton Symptom Assessment Scale, more widely into practice or adopting new and efficient screening tools that have been implemented in comparable settings to identify patient needs. For example, the Patient-Reported Outcome Measures for Personalized Treatment and Care (PROMPT-Care) tool was recently introduced in Australia to improve screening efficiency for PSSC needs [16]. Although greater uptake among RTs is needed, with the appropriate education and training, this may prove to be a valuable tool that can help with referral processes, educating patients on radiation therapy, and identifying signs of anxiety, depression, and distress [16]. A similar tool could benefit RTs practicing in Canada and Norway if integrated into workflow, as it could help streamline processes for identifying patient needs and making referrals to other support services. Other strategies could include the investment in continuing professional development and additional training and education in advanced communication skills, which could support RTs in enhancing their ability to provide PSSC and feel more obliged to provide it [18].

This study addressed an important gap in the literature on PSSC, as it allowed for an international comparison of clinical practices between Canada and Norway, for which no prior comparison existed. An evidence-informed survey incorporating prior research on the topic was used to gain insight into the scope of PSSC delivery and opportunities for improvement. The survey was piloted with RTs practicing in Canada and Norway prior to the study start to ensure face validity. Moreover, participants were recruited from various Canadian provinces and Norwegian counties, which enhanced the external validity of the study findings within each country. However, this study also had some limitations. The low response rate from Canadian participants may have limited the generalizability of the study findings nationally. Additionally, recruitment in Canada was limited to RTs who received communication emails from CAMRT, and not every practicing RT is signed up for their listserv. This study also explored comparable populations of RTs, as both Canada and Norway are high-income countries with universal access to healthcare. However, this limits the external validity of the study findings, as results may not be generalizable to RTs working in low- or middle-income countries without universal access to healthcare. Future research should seek to explore if our results would be consistent in other such contexts. As there was no incentive provided to complete the study, participants may have primarily consisted of RTs who were most interested or experienced in delivering PSSC. The translation of survey questions from English to Norwegian may have additionally led to differences in interpretations of questions between participants in both countries. However, members of the Canadian and Norwegian study team collaborated on the survey development to ensure a contextually accurate translation and to mitigate this potential bias.