Comparison of implementation strategies to influence adherence to the clinical pathway for screening, assessment and management of anxiety and depression in adult cancer patients (ADAPT CP): Study protocol of a cluster randomised controlled trial

© 2018 The Author(s). Background: Health service change is difficult to achieve. One strategy to facilitate such change is the clinical pathway, a guide for clinicians containing a defined set of evidence-based interventions for a specific condition. However, optimal strategies for implementing clinical pathways are not well understood. Building on a strong evidence-base, the Psycho-Oncology Co-operative Research Group (PoCoG) in Australia developed an evidence and consensus-based clinical pathway for screening, assessing and managing cancer-related anxiety and depression (ADAPT CP) and web-based resources to support it - staff training, patient education, cognitive-behavioural therapy and a management system (ADAPT Portal). The ADAPT Portal manages patient screening and prompts staff to follow the recommendations of the ADAPT CP. This study compares the clinical and cost effectiveness of two implementation strategies (varying in resource intensiveness), designed to encourage adherence to the ADAPT CP over a 12-month period. Methods: This cluster randomised controlled trial will recruit 12 cancer service sites, stratified by size (large versus small), and randomised at site level to a standard (Core) versus supported (Enhanced) implementation strategy. After a 3-month period of site engagement, staff training and site tailoring of the ADAPT CP and Portal, each site will "Go-live", implementing the ADAPT CP for 12 months. During the implementation phase, all eligible patients will be introduced to the ADAPT CP as routine care. Patient participants will be registered on the ADAPT Portal to complete screening for anxiety and depression. Staff will be responsible for responding to prompts to follow the ADAPT CP. The primary outcome will be adherence to the ADAPT CP. Secondary outcomes include staff attitudes to and experiences of following the ADAPT CP, using the ADAPT Portal and being exposed to ADAPT implementation strategies, collected using quantitative and qualitative methods. Data will be collected at T0 (baseline, after site engagement), T1 (6 months post Go-live) and T2 (12 months post Go-live). Discussion: This will be the first cluster randomised trial to establish optimal levels of implementation effort and associated costs to achieve successful uptake of a clinical pathway within cancer care. Trial registration: The study was registered prospectively with the ANZCTR on 22/3/2017. Trial ID ACTRN1261700041134

Development, acceptability and uptake of an on-line communication skills education program targeting challenging conversations for oncology health professionals related to identifying and responding to anxiety and depression.

BACKGROUND: Anxiety and depression screening and management in cancer settings occurs inconsistently in Australia. We developed a clinical pathway (ADAPT CP) to promote standardized assessment and response to affected patients and enhance uptake of psychosocial interventions. Health professional education is a common strategy utilised to support implementation of practice change interventions. We developed an interactive on-line education program to support staff communication and confidence with anxiety/depression screening and referral prior to the ADAPT CP being implemented in 12 oncology services participating in the ADAPT CP cluster randomised controlled trial (CRCT). The aim of this research was to assess acceptability and uptake of the education program. Patient Involvement: Although the wider ADAPT Program included patient consumers on the Steering Committee, in the context of this research consumer engagement included health professionals working in oncology. These consumers contributed to resource development. METHODS: Development was informed by oncology and communication literature. The five online modules were pilot tested with 12 oncology nurses who participated in standardised medical simulations. Acceptability and uptake were assessed across the 12 Oncology services participating in the ADAPT CRCT. RESULTS: During pilot testing the online training was reported to be acceptable and overall communication and confidence improved for all participants post training. However, during the ADAPT CRCT uptake was low (7%; n = 20). Although those who accessed the training reported it to be valuable, competing demands and the online format reportedly limited HPs' capacity and willingness to undertake training. CONCLUSIONS: This interactive on-line training provides strategies and communication skills for front-line staff to guide important conversations about psychosocial screening and referral. Building workforce skills, knowledge and confidence is crucial for the successful implementation of practice change interventions. However, despite being acceptable during pilot testing, low uptake in real world settings highlights that organisational support and incentivisation for frontline staff to undertake training are critical for wider engagement. A multimodal approach to delivery of training to cater for staff preferences for face to face and/or online training may maximise uptake and increase effectiveness of training interventions. TRIAL REGISTRATION: Pilot study ACTRN12616001490460 (27/10/2016). ADAPT RCT ACTRN12617000411347(22/03/2017)

What factors influence organisational readiness for change? Implementation of the Australian clinical pathway for the screening, assessment and management of anxiety and depression in adult cancer patients (ADAPT CP)

Aims: Translation of evidence-based psycho-oncology interventions into routine care can significantly improve patient outcomes, yet effective implementation remains challenging due to numerous real-world barriers. A key factor that may influence implementation is organisational readiness for change. This mixed method study sought to identify factors associated with organisational readiness for implementing the Australian clinical pathway for the screening, assessment and management of anxiety and depression in adult cancer patients (ADAPT CP). Methods: We collected data from multidisciplinary staff across six Australian cancer services who were preparing to implement the ADAPT CP. Services were categorised as having ‘high’ versus ‘mid-range’ organisational readiness based on a median split on the Organizational Readiness for Implementing Change (ORIC) questionnaire (score range = 12–60). Qualitative data from the semi-structured interviews based on the Promoting Action Research in Health Services (PARiHS) framework were analysed thematically and compared for services with high- versus mid-range organisational readiness. Results: Three services with high- (mean ORIC range, 52.25–56.88), and three with mid-range (range, 38.75–46.39) organisational readiness scores were identified. Staff at services reporting higher readiness described a more collaborative and proactive service culture, strong communication processes and greater role flexibility. They also reported greater confidence in overcoming anticipated barriers and clearer strategies for addressing issues. Conclusions: Levels of organisational readiness were related to distinct qualitative themes. Targeting these issues in services where readiness is mid-range or low prior to full-scale roll-out may improve staff levels of confidence and efficacy in implementing psycho-oncology-focused interventions

The value of real-world testing: A qualitative feasibility study to explore staff and organisational barriers and strategies to support implementation of a clinical pathway for the management of anxiety and depression in adult cancer patients

Background: Effective translation of evidence-based research into clinical practice requires assessment of the many factors that can impact implementation success. Research methods that draw on recognised implementation frameworks, such as the Promoting Action Research in Health Services (PARiHS) framework, and that test feasibility to gain information prior to full-scale roll-out, can support a more structured approach to implementation. Objective: This paper presents qualitative findings from a feasibility study in one cancer service of an online portal to operationalise a clinical pathway for the screening, assessment and management of anxiety and depression in adult cancer patients. The aim of this study was to explore staff perspectives on the feasibility and acceptance of a range of strategies to support implementation in order to inform the full-scale roll-out. Methods: Semi-structured interviews were conducted with fifteen hospital staff holding a range of clinical, administrative and managerial roles, and with differing levels of exposure to the pathway. Qualitative data were analysed thematically, and themes were subsequently 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 eight key themes: staff perceptions, culture, external influences, attitudes to psychosocial care, intervention fit, familiarity, burden and engagement. These themes mapped to the PARiHS framework's three domains of evidence, context and facilitation. Conclusions: Implementation success may be threatened by a range of factors related to the real-world context, perceptions of the intervention (evidence) and the process by which it is introduced (facilitation). Feasibility testing of implementation strategies can provide unique insights into issues likely to influence full-scale implementation, allowing for early tailoring and more effective facilitation which may save time, money and effort in the long-term. Use of a determinant implementation framework can assist researchers to synthesise and effectively respond to barriers as they arise. While the current feasibility study related to a specific implementation, strategies such as regular engagement with local stakeholders, and discussion 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