Table 10 Actionable barriers and challenges in ARCADE implementation.

3

To share the strategy and the vision

The Research & EBP Unit and the health professions of the oncological department discussed these priority work areas described in Table X with the administrative director of the hospital facility and the health professions director of the integrated clinical care network. They also met with the nurse tattooists and the plastic surgery service director for further feedback on recent activities and plans. The vision was developed from a shared perspective of feasibility, sustainability, and training and focused on the significance and necessity of its inclusion in a precise care pathway. The added value that the public service can provide is its highly specialized and evidence-based care in an comprehensive cancer care framework.

Oct – Nov 2024

2, 3

To guarantee safety, quality and continuity

The team refined the procedure, consent, and organizational documents necessary for the service formalization. The service is considered a nurse-led clinic within the hospital’s plastic surgery unit.

Dec 2024 – May 2025

5, 6, 7

To define training, competence levels and indicators

The team established an annual training plan for nursing competence in NAC tattooing of cancer patients. It aims to:

• provide and consolidate theoretical and technical knowledge on NAC medical tattooing;

• develop competence in taking charge of the person candidate for NAC tattooing;

• Promote professionals’ autonomy in performing the NAC tattooing procedure.

Blended modality training, incorporating both theoretical and practical frameworks, is conducted within an extendible 30-hour plan. Initially, practice will be conducted on available clinic days with minimal impact on activities.

Jan – May 2025

1, 7

Better staff management to provide continuity and sustainability

Personnel stabilization at the clinic encountered several barriers due to their transfer from other working settings, even within the territory. In the first months, services coordinators of the nurse tattooists were contacted to ensure their collaboration in facilitating shifts and transfers between hospitals. An agreement has been reached, dedicating the more expert nurse to the clinic three working days a month.

Jan – May 2025

2, 3, 4

To guarantee safety, quality and continuity

To provide materials supply, a 2-year contract for needles and pigments has been set up with the provider.

The patient pathway begins with the medical indication for tattooing. Medical staff will also evaluate and order consultations with specialists, such as dermatologists or allergists. Then, a computerized request is forwarded by the surgeon through the internal hospital system, allowing the patient to schedule the first appointment. That medical request has a coded referral for NAC tattooing care (86.02.3), which is reimbursed by the National Healthcare System and included in the essential levels of care in Italy. The agenda at this point is editable by the breast unit case manager with appointments and notes.

Feb – May 2025

2

To systematically collect complete clinical information.

The team collaborated with the informatics department of the healthcare facility to develop an electronic chart integrated with the hospital’s Electronic Health Record System. It tracks patients’ anamnesis, medical indications, NAC projects, operational data for each session, and follow-ups. Photographic devices are connected to the system for a secure and systematic collection of photos before and after the sessions.

Feb – May 2025

3, 7

To renew the dialogue and engagement with patients, associations, caregivers, and the community.

As in the development phase, the breast cancer patients’ association was crucial in sustaining the project: two training demographers and synthetic skin for tattoo practice were donated. The team actively participated in community-open events, where the involved associations were invited to provide feedback on the project’s evolution. Moreover, brochures of ARCADE were updated and refined to provide clearer information.

Feb – May 2025