what has public perception got to do with the feasibility of a project?
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The value of existent-globe testing: a qualitative feasibility study to explore staff and organisational barriers and strategies to support implementation of a clinical pathway for the direction of anxiety and depression in adult cancer patients
Pilot and Feasibility Studies volume 6, Article number:109 (2020) Cite this article
Abstract
Background
Effective translation of evidence-based inquiry into clinical practice requires assessment of the many factors that can touch implementation success. Inquiry methods that draw on recognised implementation frameworks, such equally the Promoting Activity Research in Health Services (PARiHS) framework, and that test feasibility to gain information prior to total-calibration roll-out, can back up a more structured arroyo to implementation.
Objective
This paper presents qualitative findings from a feasibility report in ane cancer service of an online portal to operationalise a clinical pathway for the screening, assessment and management of feet and depression in developed cancer patients. The aim of this study was to explore staff perspectives on the feasibility and credence of a range of strategies to support implementation in gild to inform the full-scale roll-out.
Methods
Semi-structured interviews were conducted with fifteen hospital staff property a range of clinical, authoritative and managerial roles, and with differing levels of exposure to the pathway. Qualitative data were analysed thematically, and themes were after organised within the constructs of the PARiHS framework.
Results
Barriers and facilitators that affected the feasibility of the online portal and implementation strategies were organised across 8 key themes: staff perceptions, culture, external influences, attitudes to psychosocial care, intervention fit, familiarity, brunt and appointment. These themes mapped to the PARiHS framework's three domains of prove, context and facilitation.
Conclusions
Implementation success may be threatened past a range of factors related to the real-world context, perceptions of the intervention (prove) and the process past which it is introduced (facilitation). Feasibility testing of implementation strategies can provide unique insights into bug likely to influence full-calibration implementation, allowing for early tailoring and more than effective facilitation which may save time, money and endeavor in the long-term. Use of a determinant implementation framework can assist researchers to synthesise and finer answer to barriers as they arise. While the current feasibility written report related to a specific implementation, strategies such as regular appointment with local stakeholders, and word of barriers arising in real-time during early testing is likely to be of benefit to all researchers and clinicians seeking to maximise the likelihood of long-term implementation success.
Peer Review reports
Background
Evidence-based interventions are associated with improved patient outcomes and greater price-effectiveness of care [1], but despite careful planning, are not always successfully implemented in the real world [2]. The discipline of Implementation Scientific discipline seeks to identify key factors that facilitate uptake of show-based interventions into clinical exercise [3]. A range of implementation frameworks at present exist to guide researchers [4], from determinant frameworks that focus on factors influencing implementation outcomes, such as the Promoting Action Research in Health Services framework (PARiHS) [5], to implementation theories, such as the Normalisation Procedure Theory [half dozen], to those that focus on evaluating the implementation process, such equally the RE-AIM framework [7]. A carefully selected framework can provide a stiff theoretical footing from which to approach assessment of implementation, from the early stages of pilot and feasibility testing, to long-term sustainability.
To better the likelihood of successful implementation, recent guidance from the U.k. Medical Enquiry Council recommends early assessment of the feasibility of key components underlying the implementation procedure prior to a full evaluation [8]. This small scale existent-world testing allows researchers to discover the process of translating enquiry into practice, identify barriers that may not have been evident during the development phase, and develop strategies for facilitating smoother implementation in the long-term [9]. Inside implementation science, such feasibility studies seek to assess aspects of the implementation process rather than the intervention. Whilst many studies study lessons learned by researchers during pilot and feasibility phases, the systematic review indicates that fewer have collected formal information on the views of staff experiencing the implementation, particularly in relation to clinical pathways [10]. Frontline staff are intimately involved with the implementation of whatsoever new intervention, and can therefore contribute vital information well-nigh the feasibility of key components.
This report aimed to accost this gap by eliciting staff perspectives on individual and organisational barriers to the implementation of an online portal to operationalise a clinical pathway for the direction of anxiety and depression in adult cancer patients (the ADAPT CP [eleven]). Specifically, our objectives were to identify staff perceptions of the strategies underlying the implementation of the Arrange CP including the online portal, the preparation and the implementation support, to assess their feasibility within the planned cluster randomised trial and identify factors that would facilitate successful uptake of the CP in routine care. Planning and analysis were guided by the PARiHS framework, a determinant framework that was chosen due to its grounding in health services research, its generation from the clinical evidence base and its careful attention to existent-world elements of context and facilitation, which may be critical to understanding the issues that ascend in airplane pilot stages [five]. The PARiHS posits that successful implementation is probable to occur when the evidence is robust, the context is supportive, and the intervention is appropriately facilitated [12].
The study context
The Adjust CP was developed in response to the recognised high rates of anxiety and low in people with cancer and the lack of standardised screening, cess and management processes [11, 13]. It incorporates iterative screening, triaging to five levels of anxiety/depression with specific recommendations regarding the content, process and intensity of care, and the ability to be tailored to individual centres' available resources, referral networks and preferred models of intendance. Development was guided by evidence review, wide stakeholder consultation, and a Delphi consensus process involving > eighty experienced multi-disciplinary clinicians [13]. Guided by a bulwark and enabler analysis [fourteen], resource and strategies were incorporated into the Adapt CP and its planned implementation. The barrier and enabler analysis was carried out with 12 multi-disciplinary health professionals from 8 medical and allied disciplines, who reviewed and provided feedback on potential barriers and enablers to implementation of the new clinical pathway; their responses informed evolution of resources and strategies for the full trial and the strategies tested within this feasibility written report [xiv].
A core resource is the online portal (the Arrange Portal), which systematically operationalises the ADAPT CP and carries out a range of automated processes for screening, alerts and referrals. Alongside the Portal, the Accommodate implementation strategies include awareness campaigns, academic detailing, reporting and technical back up [15]. This single-site report was designed to assess the feasibility and acceptability of the ADAPT CP implementation strategies in routine clinical practice, including the ADAPT Portal, in order to refine these strategies for use during a large implementation-focused cluster randomised trial to implement the Suit CP in 12 cancer services across New South Wales, Australia [xv].
Methods
Pattern
This feasibility study used a non-randomised, cross-sectional blueprint, collecting qualitative information at a single site. Contempo research has highlighted the important office of qualitative research in providing greater depth of information regarding cardinal feasibility challenges, which may then exist used to further refine the implementation strategies prior to a full trial [xvi]. We therefore selected this approach to meet the aims of the electric current study and used the consolidated criteria for reporting qualitative research (COREQ), a 32-item checklist for interviews and focus groups (see Additional file 1), to guide structure and reporting [17]. This feasibility study was designed to inform the multi-site cluster randomised trial, in which sites will be randomised to different levels of implementation back up—full details of the main trial are available in the published protocol [15].
Setting and procedure
Cancer service staff at a large, 3rd, public hospital participated in this feasibility study. This procedure included atomic number 82 team engagement meetings to analyze roles and processes, followed by training and employ of the Accommodate Portal and resources for v months, with arrangement support. Afterwards, fifteen staff took part in semi-structured interviews either confront-to-face at the service in a private room, or via phone at a time convenient for participants. Interviews were audio-recorded and transcribed verbatim.
Participants
Staff were eligible to participate if they had been involved in any fashion with the ADAPT Portal and implementation strategies. Staff were purposively sampled across clinical and not-clinical roles and invited to participate via electronic mail. All agreed to participate. The report was approved by the Homo Inquiry Ethics Commission of the participating healthcare institution.
Methodological orientation and interview guide
The interviews comprised questions designed to appraise all elements of the implementation strategies and overall staff experience of the implementation procedure, informed by the PARiHS framework and our recent systematic review of hospital-based implementation barriers and facilitators [10]. The interview guide was pilot tested by two authors (LG and PB). Sample interview questions are shown in Additional file 2. Participants were informed that the interviewer (LG) was a clinical psychologist familiar with the Adjust CP and Portal, but not involved in the study process at the wellness service, and that their data would be kept confidential and reported only in summary format.
Data analysis
NVivo10 qualitative data analysis software was used for data direction and analysis. Thematic analysis was used to identify key themes regarding barriers and facilitators to implementation. A subset (twenty%) of transcripts were coded separately by four authors (LG, Pb, NR and HS) to identify preliminary concepts, with iterative give-and-take to refine codes and sub-codes. Post-obit this, LG coded the remaining transcripts. Similar concepts were grouped into themes; patterns between themes and subthemes were mapped into a thematic schema, with illustrative quotes. In line with qualitative enquiry standards [18], reflection and reflexivity were used to mitigate whatever biases. Summaries of the findings were sent to a subset of participants for review; all affirmed the findings were accurate. Themes were so grouped in relation to the PARiHS framework.
Results
Participant sample details
15 multidisciplinary staff, including psychologists, social workers, doctors, nurses, administrators, and managers participated. The sample comprised both full-time and part-time staff, who had been in their electric current role an average of iii years (range v months to 7 years). Interviews ranged in length from 16-l min (average 25 min).
Qualitative analysis
We identified 8 fundamental themes that impacted the implementation process and feasibility of the implementation strategies during the report: staff perceptions of the intervention, culture, external influences, attitudes to psychosocial care, intervention fit, familiarity/exposure, appointment and burden (come across Tabular array ane). Themes were mapped to the PARiHS domains of evidence context and facilitation, allowing u.s.a. to situate findings within an established implementation science framework, while at the same fourth dimension illustrating the aspects that held most relevance to this context. Themes are presented under each PARiHS domain.
Evidence
Staff perceptions of the evidence underlying ADAPT CP, equally presented during preparation and awareness campaigns, elicited both facilitators and barriers to implementation. In general, the bear witness-base backside the ADAPT CP was well-recognised and accepted by staff, acting equally a motivator and facilitator for implementation. However, staff acceptance of the evidence of need for the ADAPT CP in their service was lower, which at times acted as a disincentive for implementation.
Staff perceptions of the intervention
Awareness that the Suit CP was being implemented every bit office of an testify-based research program, and comprised reputable and recognised resources acted as a key facilitator to implementation:
I like the fact that it's linked up with the CRUFAD [Clinical Enquiry Unit of measurement for Anxiety and Depression] cancer program [an online cognitive behavioural program]. (Participant 7)
The fact that this is being done in the protective beat of a research program is very helpful …. many may exist sceptical virtually the benefits of some of these programs for their patients, and if it's couched in a study way, they're much more likely to accept that it needs to be looked at. (Participant 14)
Staff generally perceived the ADAPT CP would improve the mental health outcomes of their patients, particularly noting the benefits of more formal processes for care, ensuring that screening occurred consistently and patients were matched with specialist staff with the advisable skills and abilities:
"From the people I've spoken to, everyone said, oh, it's a really good idea, … nosotros don't desire to miss those patients who might not necessarily obviously need back up." (Participant 3)
"So, it's nice to become a referral that'south related to their psychological wellbeing …considering, we are trained in that. And then that'southward been good. Refreshing." (Participant 3)
Notwithstanding, staff responses to the Arrange CP and Portal were also shaped past local knowledge of their existing system, which they perceived to be highly effective, thus making the Accommodate CP somewhat redundant in their setting:
I tin can come across how it would exist helpful for maybe smaller hospitals or hospitals that don't accept good triaging in place, but here, it already feels like the needs are beingness met. (Participant vii)
Staff suggested that low perceived evidence of demand could exist addressed by providing more information about the evidence-base and rationale for screening and care, and highlighting the positives of the Suit CP through early on sharing of information as an boosted strategy:
The rationale can often brand information technology easier for staff… it would be, this is why we're doing it… Instead of, we've got to do it. (Participant 9)
If they can see that their action using the Portal has resulted in a benefit for at to the lowest degree some of the patients … I think that they will be very neat to continue it. (Participant 14)
Context
Service culture, external influences and attitudes to psychosocial intendance all had an bear upon on how the Adjust Portal and CP strategies were received during the implementation process.
Civilisation
Strong values around quality patient intendance led staff to appoint proactively with the ADAPT Portal despite barriers:
"People are always wanting to provide the best that we tin can for the patients." (Participant 1)
Staff as well reported a culture of supporting and drawing on each other to accost any implementation barriers:
If I got a referral at present I'd just speak to the team or the ones who take used it [Suit Portal] … I'd go to them first. (Participant four)
A cardinal civilization-based barrier related to communication about service goals for the implementation, and a perceived lack of shared controlling inside the service. Some clinical staff felt the implications of implementation for their workload had not been adequately considered, and noted that greater date by managerial and leadership staff with their views, needs and resources could have overcome these bug:
I recollect probably rather than agreeing to it straight abroad, it should have involved more of the team arroyo… I don't recollect information technology really took into account the implications that it would take on staffing and the increase in time. (Participant 7)
Managerial staff reported the reason for participating in the ADAPT feasibility study was to improve communication and consensus across different roles and teams, to overcome a siloed model of intendance and foster greater multidisciplinary action and clearer referral pathways:
The projection came at a very good time, because we'd been trying to implement ...a more integrated approach … our psychosocial care staff were ...very segmentalised, with a bit of a disconnect between the 3 roles of nursing, social work, and clinical psychology, ... and we found that referrals to any of those three categories of psychosocial support from medical staff were inconsistent from the point of view of reason for referrals or normal sort of pathways. (Participant 13)
These motivations for taking on the study were not always communicated across the service, leading to defoliation well-nigh the true purpose of service interest, impacting user acceptance of the process and creating barriers to successful implementation.
External influences
The broader external context in which the service existed besides had bearing on how staff responded to the implementation strategies and processes. Some staff believed that their service had participated in the report to influence public perception by appearing more than inquiry intensive, which reduced motivation to engage:
I'm sure there's something where [the service] want to expect like they're involved in this cut-border research or, you know, rather than is at that place actually a need for it here. (Participant seven)
Another external bulwark was the perception that intervention sustainability later enquiry is completed is dependent on external funding sources, fostering a belief that interventions such as Suit CP were oftentimes short-term, rather than leading to sustained and adequately resourced clinical alter:
If the programme shows that this is very useful and that people should have this, …, well where is it going to come up from? Sure, studies like this enable united states of america to anteroom government for more than funding … just information technology's very difficult in practice to get that kind of funding. (Participant fourteen)
Attitudes to psychosocial care
Where staff felt that managing anxiety and depression fitted with their existing role, integration of the Adapt Portal and ADAPT CP was easier:
From mean solar day one I've ever been enlightened that at that place are needs around these patients' anxiety, depression, and I've seen information technology, so for me personally it hasn't been really difficult. (Participant two)
The response to the implementation process was besides stronger when staff believed the Suit Program could increment staff skills and confidence to accost mental health issues:
One of the key benefits that I see from a projection like this, is empowerment of the nursing and allied health staff; that it's okay yes, in fact, more than than okay, it's your job to refer someone... And so that's …an effect that I think is supported by this institution …to brand sure that everybody feels empowered to say something if they're concerned nearly a patient under their care. (Participant 14)
Facilitation
Themes related to facilitation suggested a demand for further tailoring of Adjust implementation strategies to accost issues of intervention fit, familiarity with the pathway, sense of burden and engagement.
Intervention fit
A fundamental implementation strategy designed to support the ADAPT CP was the Arrange Portal, and analysis revealed several feasibility issues related to lack of fit and duplication with existing systems and procedures in terms of IT, advice and work patterns:
[It] kind of double dips considering we have all electronic medical records, that nosotros make our referrals through and and so obviously have the ADAPT Portal which we were taking the referral through…so it was 2 separate systems. (Participant 10)
Duplication was quickly resolved past discussion with the inquiry team and amendment of the ADAPT Portal to integrate into existing care workflows and electronic medical records, resolving this consequence for participants:
On MOSAIQ® they would say…already linked in with psych. So the nurses would know not to re-screen. (Participant vii)
Intervention fit to patient abilities also concerned some staff, who were aware that some of their patients lacked the skill to utilise or access technology. Notwithstanding, staff noted that when carried out in clinic, the procedure had been relatively smooth, indicating that the onsite Portal utilise was viable:
Some patients would probably not have that engineering science to exercise it at home and [with] the assistance of the nurses are able to navigate the Portal a scrap better. (Participant two)
Familiarity/exposure
For some staff, lack of exposure to the Adjust Portal created challenges to implementation, with staff noting a fourth dimension lag betwixt preparation and their first existent use of the Portal. This was partially related to constructive existing referral networks making identification of such patients via the ADAPT Portal exceptional:
By the time nosotros got a referral we thought, oh how do we do this? How do we log in? What do we do? (Participant 3)
Staff, especially those not involved in the implementation lead team, were not e'er clear about their roles, indicating that information had not e'er trickled down fairly. These staff had often had less intensive training, which compounded their sense of uncertainty.
I don't feel actually confident about it at present… I wasn't certain what else my responsibility was. (Participant 1)
However, staff believed that they would become more comfortable with Adjust Portal processes over time:
It's just general awareness, just a matter of like, really getting in the addiction of doing it. (Participant ii)
To address these concerns, echo training and on-the-spot training were recommended in add-on to local prompts, summary sheets and uncomplicated reminders with step-past-step processes as helpful tools to ameliorate exposure and confidence in their roles. To assist with familiarity and exposure, staff also proposed that more than one trainer and champion could be nowadays at the services in the early on stages to reinforce the rationale and procedure of the ADAPT CP and Portal:
I think it would be nice for people to come up back and check periodically to see … what's going on, you lot know? Is there annihilation we demand to practise… and but explain to usa why patients are doing this. (Participant 9)
Brunt
Facilitation was also impacted by a sense that implementation of Conform would issue in an increased workload for staff, with staff shortages and heavy existing workloads contributing to a sense of burden. Restricted time had menstruum-on furnishings, impacting staff power to attend preparation to follow proposed processes:
Information technology's non that it takes that long, but ...information technology'southward like obviously an extra thing that you're being asked to do. (Participant ane)
Staff time was probably the biggest [barrier]… finding time, for the training of everyone. (Participant half dozen)
These issues were resolved during facilitation meetings between the research team and staff, in which the pathway was tailored and modified to improve fit with the flow of the service:
So that did take a footling flake of pushback for them…simply ultimately, … we got there in the end. (Participant eleven)
This sense of additional brunt was as well related to an overload of new data, both in relation to Suit and other ongoing initiatives. However, this was mostly perceived every bit a usual and expected office of change-management:
I think there was underlying sense of …oh god, you lot know, in that location's another system nosotros've got to use. (Participant 13)
So I did find a footling scrap of tension only, I think, that'southward natural whenever you're introducing something new. (Participant 6)
Finally, information technology was noted that despite this apprehension, initial concerns about increased workload were non realised in one case the study commenced:
When information technology, rolled out, nosotros were all panicking and we thought…how are we going to take on all these new patients? Nosotros were really surprised that we only got a couple. (Participant three)
Engagement
As noted in the "Culture" section, staff felt they had been inadequately engaged in the early stages, and as such lacked a sense of ownership or connexion to the process, despite the Adapt implementation strategies designed to target these issues. To address this, staff highlighted the demand to arroyo all stakeholders early to seek feedback, and to secure buy-in from key service members, such as doctors:
Ideally it would be meeting with the researchers and hearing about the project, being told that information technology is a pick … being told why [the service] want to do information technology, … assuasive clinicians to experience as though they played a function in the decision. (Participant 7)
I think information technology needs to be presented to the Department Heads…needs to get purchase in from the clinicians, the doctors. (Participant 10)
Boosted back up every bit an implementation strategy from both the external facilitators and internal team members were too proposed:
At that place should be someone from the group who wanted to outset this program to continue to be the other presence, and perhaps only to mayhap get a session from the educator, just to remind anybody why we're doing this. (Participant 2)
However, others had mixed attitudes toward the office of researchers as facilitators. While all staff reported liking and respecting the researchers, some noted a lack of shared terminology, and poor perceived researcher agreement of the reality and priorities of clinical care:
Yeah, information technology took a little while to get to that point, because the research squad… their expectations of what we were capable of doing and what we should exist doing was a piffling fleck unrealistic. (Participant 11)
Finally, staff indicated that to support appointment at the service level, dissemination of information and training needed to be better tailored to meet the needs of role-fourth dimension and shift-workers. Timetabling and scheduling of educational activity to fit staff shifts were proposed every bit an implementation strategy to accost this problem:
It happens all the time and nosotros need to get them remember that we're part-time and sometimes you don't know that the new way of doing something, until you are getting pulled up for not doing information technology. (Participant one)
Give-and-take
The electric current written report sought to explore the feasibility and user acceptance of a range of implementation strategies to support the Suit CP, including the Arrange Portal. While the benefits of evidence-based clinical pathways for patients are well-recognised, our real-world feasibility testing of the ADAPT Portal and Arrange CP implementation strategies demonstrates the importance of evidence, contextual, and facilitation factors when implementing a stepped-care intervention in a clinical service. Early identification and assessment of barriers in these areas provide vital information, allowing researchers to tailor strategies in order to resolve real-globe challenges prior to full-calibration rollout. Our qualitative analysis identified eight singled-out themes where barriers arose in relation to the Portal and implementation process. Mapping these themes to the iii domains of the PARiHS framework allowed us to situate them within a recognised implementation scientific discipline framework and farther synthesise this data for applied use.
The offset expanse that impacted user feel of the implementation process was evidence. The PARiHS framework posits that implementation is most likely to be successful when show for the intervention is robust: not merely traditional notions of prove arising from randomised controlled trials (codified evidence), but also other types of bear witness that inform clinical exercise, including practitioner expertise, patient experiences, and local information (non-codified prove) [19]. In the current study, both codification and non-codified evidence strongly influenced the style staff perceived implementation of the ADAPT Portal and CP. Staff were motivated past known codification evidence supporting the efficacy of screening and management of anxiety and low. Nevertheless, local perceived evidence regarding the efficiency of electric current processes for managing anxiety and depression led them to view the Conform Portal and CP equally redundant. These findings highlight the need for implementation scientists to explore local forms of evidence and how these may shape perceptions and create avoidable barriers to implementation. Information technology is possible that locally collected pre-implementation data (such every bit inspect and review) on the success of current service approaches prior to the introduction of the Adjust CP could have been useful in shifting views. Indeed, studies of clinical pathways in other areas propose that provision of quantifiable outcomes in pre-implementation tin can be a fundamental strategy to generating effective dialogue with clinical staff [20]. Inspect and feedback information from the ADAPT Portal could likewise help to provide an boosted source of real-fourth dimension, concrete prove of changes resulting from the implementation over fourth dimension. The main cluster randomised trial of ADAPT will integrate audit and feedback as a strategy to support continual awareness of the impact of the implementation.
Contextual factors of service culture, external influences and attitudes to psychosocial care also influenced acceptance of the implementation process and strategies. Staff acknowledged diversity in the goals of dissimilar teams within their service, at times creating dissonance and barriers to implementation. This is consistent with the PARiHS framework view of health-intendance services every bit multiple interconnected systems, whose interactions tin can create friction and complexity [21]. To overcome these barriers, staff suggested that management and enquiry staff exist more transparent virtually implementation goals and intended outcomes. While the PARiHS framework highlights the office of leadership in driving change [21], researchers may need to engage non only with leaders, simply staff at all levels, particularly those implementing strategies on the ground. This would ensure that various perspectives are heard and reflected in intervention design and option of implementation strategies. Researchers may in plough exist able to back up leaders and champions to create a unified approach and commitment to implementation, maybe even creating cultural change across the intervention itself. The cluster randomised trial will prefer a more extended appointment process, allowing researchers to empathise the unique dynamics of each service and connect with staff in all roles. Staff besides perceived that their service was impacted by a range of external influences, such as public perceptions and funding requirements, which they felt could impact on sustainability of the implementation. This is consistent with findings showing that external demands that create a sense of threat or uncertainty have a significant affect on innovation implementation in teams, reducing openness to modify [22]. Given the positive culture reported around patient care, explaining more clearly how the clinical pathway tied into this value could have improved motivation and acceptance. Additionally, staff who felt that involvement with the Suit CP could provide an opportunity for strengthening their skills and documented feel in psychosocial care were more receptive to the implementation process. Emphasising these potential unexpected staff-related benefits of an intervention could be part of an implementation strategy where the civilization is expected to benefit from this.
Finally, the importance of facilitation was evident within the themes of intervention fit, familiarity, burden and engagement. In the current study, tailoring the implementation strategies and systems supporting the Conform Portal, so that information technology complemented rather than replaced existing processes, were key to addressing issues. Adjustments to the strategies of preparation and education, such as repeat sessions to see the needs of office-time workers and provision of in-person service support, were besides integrated for the cluster randomised trial. The PARiHS framework highlights the importance of engaging stop users as role of the facilitation process. While engagement prior to implementation is often discussed in the public wellness implementation literature [23, 24], it has but recently begun to be explored in relation to hospital service implementation [25]. Early connection with service staff has a powerful role in establishing relationships, providing insight into context, and highlighting the key facilitation needs of the service. Our findings reinforce the importance of a well-considered engagement strategy to ensure a strong sense of staff ownership of the intervention and the implementation process. To assist this process during the cluster randomised trial, an extended engagement process has been adopted, assuasive the research squad more fourth dimension to understand the service context and support the service champions to implement the ADAPT CP.
This real-globe feasibility study was helpful in fine tuning the ADAPT Portal and implementation strategies for the subsequent cluster randomised trial, which commenced in 2017, with final information collection envisaged for 2020 [15]. Conversations about terminology, hospital processes and flow of systems immune the facilitators and staff to develop a shared language and pre-empted some barriers during the written report. The established relationship also allowed for open up communication betwixt staff and the research team during implementation, meaning information about challenges was quickly relayed, and could often exist collaboratively resolved. Finally, the office of the research team as an external facilitator is garnering increasing attention in implementation science [26]. Qualitative research has long acknowledged the role of reflexivity [eighteen] and information technology is highly relevant in implementation enquiry, where researchers frequently spend extended amounts of time in the setting, supporting implementation processes and responding to barriers. They may be a crucial component in the change process [26]. Researchers' awareness of how they may influence implementation outcomes and their affect on sustainability is an area ripe for further investigation.
Strengths and limitations
The strengths of the study include the collection of formal qualitative information from service staff, which provided depth of information about the implementation experience, the high level of methodological rigour applied to information collection, synthesis and analysis and the utilize of a widely used implementation framework specifically adult for health services. A number of study limitations must besides be considered. The modest sample of participants meant that only 1-2 participants from each role type were interviewed. The generalisability of our findings is impacted by the specialist setting of oncology. Notwithstanding, many of the bug raised were non express to oncology just to clinical pathway implementation in general, suggesting our findings may accept relevance to other clinical services. This feasibility study was conducted in an urban service, potentially impacting generalisability to regional or rural settings.
Time to come directions and clinical implications
Our findings highlight the need for early engagement with stakeholders, and the use of co-designed implementation strategies to effectively transfer evidence-based approaches into existent-world settings. Feasibility testing of resource, programs and strategies provides early on insight into changes that may lead to greater implementation success long-term [27]. To fully understand and effectively assess context and evidence, time to come implementation studies should comprise use of quantitative data, to let triangulation with qualitative results, adding rigour and breadth to early stage findings. Recent piece of work with the PARiHS framework poses a ii-part process, in which context and bear witness are assessed first, and and so tailored facilitation follows [28]. This approach is likely to garner the virtually benefits from the framework, and the planned Suit cluster randomised trial will follow this approach.
Conclusion
This study demonstrates the importance of identifying and addressing practical barriers that may emerge but during existent-earth testing, underscoring the importance of the pocket-sized-scale testing to assess feasibility and credence of implementation strategies and processes. In line with the PARiHS framework, issues emerged in the current feasibility report across the iii domains of testify, context and facilitation. Our results show that clinical service staff are securely connected to testify shaped non only by bookish research, but also past years of local, co-created cognition of their own practice and the needs of their patients [29]. Engaging with this local noesis, and respectfully taking time to empathize the dominant cultural narratives of the service are essential to creating an implementation procedure that can integrate with existing practices, respond to potential barriers or insufficient resource, and connect to the values and needs of staff who will carry out fundamental roles. Finally, the power of the implementation squad to provide a smooth process of facilitation, that addresses these issues as openly every bit possible, cannot be underestimated. Taking time to create a collaborative relationship between implementation researchers and clinical staff provides a firm base of operations from which to approach the challenges of real-world implementation, in a way that increases the likelihood of longer-term success.
Availability of information and materials
The datasets generated and analysed during the current study are non publicly available, as this was a qualitative report with specific goals and questions. The data have been fully analysed for this manuscript and therefore will not be bachelor to other researchers, although the researchers are happy to consider reasonable requests via the corresponding author.
Abbreviations
- Conform CP:
-
Anxiety and Depression Clinical Pathway
- PARiHS Framework:
-
Promoting Action Research in Health Services Framework
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Acknowledgements
The authors admit and give thanks the cancer service, the staff and the patients for their participation in the feasibility study.
Funding
The ADAPT Program is funded by a Translational Plan Grant from the Cancer Institute NSW. Liesbeth Geerligs is funded by a scholarship from the Australian Post-Graduate Awards Scheme (Australian Regime), and additional top-up funding from Sydney Catalyst and the Conform Program. The funding bodies had no part in study pattern, data collection, assay or writing of the manuscript.
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Contributions
All authors were involved in conceptualising the manuscript. Members of the Adjust Portal Working Group, Hour, JS, LM and HD provided clinical and academic expertise throughout the evolution and feasibility testing of the Accommodate Portal. LM provided Portal grooming to all service staff. LG carried out the qualitative interviews. LG, HS, NR and PB contributed to the development of the thematic framework. LG wrote the starting time draught of the manuscript. NR, HS and PB made significant contributions to preliminary drafts. All authors contributed to making revisions of the later drafts, and all authors read and approved the final manuscript. The ADAPT Portal and Accommodate CP were developed as part of the Feet and Depression Pathway (ADAPT) Program, led past the Psycho-oncology Cooperative Research Grouping (PoCoG). Members of the ADAPT Program Group accept contributed to ADAPT activities and resource. The authors admit the ADAPT Plan group members for their contribution to the blueprint and delivery of the ADAPT Program. Accommodate Plan grouping members: Prof Gavin Andrews, Kate Baychek, A/Prof Philip Beale, Karen Allison, A/Prof Josephine Clayton, Dr Joseph Coll, Jessica Cuddy, Prof Afaf Girgis, Dr Peter Grimison, Prof Tom Hack, Prof Brian Kelly, Dr Laura Kirsten, Dr Toni Lindsay, A/Prof Melanie Lovell, Dr Tim Luckett, Dr Michael Murphy, Dr Jill Newby, Dr Frances Orr, Dr Alison Pearce, Don Piro, Prof Tim Shaw, John Stubbs Prof Rosalie Viney, Fiona White, Jackie Yim.
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Nosotros confirm that we accept included a argument of ethics approval in the submitted manuscript. The name of the Human Research Ethics Committee is suppressed in the manuscript to protect the confidentiality of the participating service and participants (we are happy to provide these details to Editors and Reviewers and discuss how all-time to address this).
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The authors declare that they take no competing interests.
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Supplementary information
Additional file 1.
COREQ Checklist. Consolidated criteria for reporting qualitative checklist (text data in table grade).
Additional file ii.
Sample interview questions from moderator guide. Text information extract from interview guide (tabular array form).
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Geerligs, L., Shepherd, H.L., Rankin, N.M. et al. The value of real-earth testing: a qualitative feasibility study to explore staff and organisational barriers and strategies to support implementation of a clinical pathway for the direction of anxiety and depression in adult cancer patients. Airplane pilot Feasibility Stud vi, 109 (2020). https://doi.org/x.1186/s40814-020-00648-4
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DOI : https://doi.org/10.1186/s40814-020-00648-4
Keywords
- Implementation science
- Health services research
- Clinical pathway
- Feasibility written report
- Psycho-oncology
- Barrier analysis
- Qualitative analysis
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