The University of Sydney, School of Psychology, Psycho-Oncology Co-operative Research Group (PoCoG), Sydney, NSW, 2006, Australia.
The University of Sydney, Faculty of Medicine and Health, Sydney, NSW, Australia.
BMC Health Serv Res. 2022 Feb 14;22(1):192. doi: 10.1186/s12913-022-07532-2.
Clinical pathways (CPs) are intended to standardise and improve care but do not always produce positive outcomes, possibly because they were not adapted to suit the specific context in which they were enacted. This qualitative study aimed to explore staff perspectives of implementation of a CP for routine screening, assessment, referral and management of anxiety and depression (the ADAPT CP) for patients with cancer, focussing on perceived feasibility of the CP and negotiated adaptations made during the implementation phase.
The ADAPT CP was implemented in 12 urban and regional oncology services in Australia. Services were randomised to receive core versus enhanced implementation strategies. Core sites received support until implementation commencement and could access progress reports. Enhanced sites received proactive, ongoing support during the 12-month implementation. Purposively selected staff were interviewed prior to implementation (n = 88) and 6 months later, half-way through the implementation period (n = 89). Monthly meetings with lead multi-disciplinary teams at the eight enhanced sites were recorded. Data were thematically analysed.
Six overarching themes were identified: ADAPT is of high value; timing for introducing the CP and screening is difficult; online screening is challenging; a burden too much; no-one to refer patients to; and micro-logistics are key. While early screening was deemed desirable, diverse barriers meant this was complex, with adaptations made to time and screening location. Online screening prompted by email, seen as time-saving and efficient, also proved unsuccessful in some services, with adaptations made to in-clinic or phone screening, or repeated email reminders. Staff negative attitudes to ADAPT, time constraints, and perceived poor fit of ADAPT to work roles and flows, all impacted implementation, with key tasks often devolving to a few key individuals. Nevertheless, services remained committed to the ADAPT CP, and worked hard to create, review and adapt strategies to address challenges to optimise success.
This study demonstrates the interactive nature of health service change, with staff actively engaging with, forming views on, and problem-solving adaptations of the ADAPT CP to overcome barriers. Obtaining staff feedback is critical to ensure health service change is sustainable, meaningful and achieves its promise of improving patient outcomes.
The study was registered prospectively with the ANZCTR on 22/3/2017. Trial ID ACTRN12617000411347.
临床路径（CPs）旨在标准化和改善护理，但并不总能产生积极的结果，可能是因为它们没有适应实施的具体环境。本定性研究旨在探讨工作人员对实施用于常规筛查、评估、转介和管理癌症患者焦虑和抑郁（ADAPT CP）的看法，重点关注 CP 的可行性和在实施阶段进行的协商调整。
ADAPT CP 在澳大利亚的 12 个城市和地区肿瘤服务机构实施。服务机构被随机分配接受核心或增强实施策略。核心站点在实施开始前获得支持，并可以访问进度报告。增强站点在 12 个月的实施期间接受主动、持续的支持。在实施前（n=88）和实施 6 个月后（n=89），即实施中期，对有针对性选择的工作人员进行了访谈。每月与 8 个增强站点的多学科领导团队举行会议并记录。数据进行了主题分析。
确定了六个总体主题：ADAPT 非常有价值；引入 CP 和筛查的时间很困难；在线筛查具有挑战性；负担过重；无人转介患者；微物流是关键。虽然早期筛查被认为是理想的，但多样化的障碍使得这变得复杂，因此对时间和筛查地点进行了调整。通过电子邮件提示的在线筛查，被认为节省时间和高效，但在某些服务中也不成功，因此调整为门诊或电话筛查，或重复电子邮件提醒。工作人员对 ADAPT 的负面态度、时间限制以及认为 ADAPT 与工作角色和流程不匹配，都对实施产生了影响，关键任务往往由少数关键人员承担。然而，服务机构仍然致力于 ADAPT CP，并努力制定、审查和调整策略，以解决挑战，优化成功。
本研究表明了卫生服务变革的互动性质，工作人员积极参与、形成意见并解决 ADAPT CP 的调整以克服障碍。获取工作人员的反馈对于确保卫生服务变革的可持续性、意义和实现改善患者结果的承诺至关重要。
该研究于 2017 年 3 月 22 日在澳大利亚临床试验注册中心进行了前瞻性注册。试验注册号：ACTRN12617000411347。
