Table 1 Summary of findings according to the Consolidated Framework for Implementation Research constructs and representative quotes from dietitian focus groups
CFIR domain and construct themes | Summary of findings | Additional representative quotes from study dietitians (n = 4–8) who participated in the focus groups |
|---|---|---|
1. Intervention Characteristics: features or characteristics of intervention. | ||
1.1 Adaptability | Dietitians needed to adapt the pathway due to individual patient variability (particularly at diagnosis). | “One of the challenging aspects is the screening part of it, and to really pin down the story behind it.” [December 2018] “As we have experienced, it can be really quite fluid and the plans at the beginning can sort of take a little bit of time to really solidify. So, keeping track of all of that, particularly when it’s going over multiple weeks.” [August 2019] |
1.2 Complexity | Complex clinical situations were reflected by complexity within the NCP, which is directly linked to ongoing clinical care. | “It’s quite a complex, you know, following the pathway with multiple different time points…” [November 2018] “I think you just really learn a lot in terms on how complex the decision making is around these people.” [August 2019] |
1.3 Relative advantage | Co-location of the dietitian in clinic was more advantageous to patient outcomes and MDT relationships. | “I think it’s been a great way to better communicate with the surgeons and touch base with patients more easily now.” [December 2018] “If you were sitting in hospital before your surgery, you were inpatient, you didn’t get seen by a dietitian beforehand. …now if you’re an outpatient, you will get much more proactive care.” [August 2019] |
2. Outer Setting: features or characteristics of the external context or environment. | ||
2.1 Patient needs and resources | The outpatient model of care met patient needs by providing timely dietetic care, while balancing their emotional needs was difficult. Adaptations to the NCP increased care coordination time. | “It’s exhausting by the end of it because you have to wait for them to see the doctors and for us it’s surgeon and oncologist at the same time. It gets quite overwhelming.” [November 2018] “I was able to spread the assessment and then recruitment over 2 weeks in effect.” [November 2018] “He couldn’t come in on a weekly basis just to see me, so we’ve been doing some phone reviews.” [December 2018] “I know the patient… is really engaged…[and she’s] really taking on the advice that I’ve given her.” [December 2018] “We consider a weekly phone call. We’ve offered that and none of the patients are interested in that. They just want to see us when they come to their chemo and they’re sitting in the chair and doing it face to face.” [February 2019] “And there’s literally no way of knowing if the patient even knows about the diagnosis yet, so it makes it quite difficult for then that dietitian to get onto them early.” [February 2019] “They need to process the information about the diagnosis first, and then engaging with them on the nutrition level is better to come a little bit later down the track once they’ve had a little bit of time to process it all.” [August 2019] “I think in a way you become one of the patient’s main contact points for like a gateway to the team … they really valued being able to get in contact whenever they felt they needed to.” [August 2019] |
3. Inner Setting: features or characteristics of the implementing organization. | ||
3.1 Networks and communication | Communications regarding medical treatment plans and appointments remained a consistent barrier to effective NCP implementation. Communication with the surgical oncology team around nutrition was perceived to significantly improve throughout implementation. | “Like whereabouts are they in the treatment pathway and making sure that nobody slips through the cracks. That, I have found, takes a bit of time as your numbers are bigger.” [November 2018] “And you think, okay, they are coming Thursday, I’m going to see them, but they’ve already come on the Monday.” [January 2019] “Patient discussed [in the MDM], nothing on the system and can’t figure out where he is up to…. things aren’t documented. There are lots of offline discussions that are not documented.” [January 2019] “So a lot of checking and checking and checking and checking to make sure that we actually catch them.” [January 2019] “Because she [the nurse coordinator] was able to just tell us…they come in next week and I’ll make sure that they see you and things like that.” [November 2018] “I think it’s been a great way to better communication with the surgeons and touch base with patients more easily now…it’s great.” [December 2018] “Surgeons are now coming and knocking on the door more than they ever have before.” [December 2018] |
3.2 Structural characteristics | Structural characteristics of health services (e.g. shared care, rural and regional patients) created significant implementation barriers. Sites in a single campus or location reported less structural barriers. | “The handing them back and forth between oncology and then back to us and then, you know, have they been booked into clinic yet? Have they been discussed the MDM yet?” [November 2018]“I want to see them if they’ve got surgery in 2 weeks. So they definitely want them to come in if they are within the vicinity. I guess with rural patients, it’s been trying to call them and leave a message.” [December 2018] “It hasn’t been straight forward… the dietitian has had to chase them if they haven’t been booked back into clinic. So, staying on top of where they are at is a bit tricky…almost have to take on the role of coordinator.” [January 2019] |
3.3 Compatibility | A weekly clinic model was most compatible with NCP; however workflows could not always align with the NCP. | “Say if they’re coming in ad hoc, if their preadmission clinic appointment was a different day; that’s the first time I’m actually seeing them face to face.” [November 2018] “He was coming for clinic that day, and he was right there. It was a really good time to have a chat with him. He sounded like he really needed some dietetic intervention.” [December 2018] “I’ve spent maybe two and a half hours screening the patient to figure out, then calling [the medical team] and asking, then calling [the nurse], and trying to really map out what’s been happening to the patient.” [December 2018] “It’s just sort of balancing sometimes the operations, you’ve got students, or you’re covering.” [August 2019] |
3.4 Available resources | Insufficient resources allocated because time required to coordinate care was underestimated. The weekly clinic quickly began to exceed capacity. | “I find that if I had one person [like a coordinator] to go to that could tell me the answers, that would save me from emailing (NAME).” [December 2018] “A lot of patients are being seen late in the clinic. I am struggling to catch them before they go.” [January 2019] “Given the scope of how serious some of these cancers are and the timeframes from time of diagnosis to surgery, I feel as though I need an assistant to help me with some of [the coordination].” [February 2019] “In that clinic, the dietitian will be trying to see all of the preop patients, and the newly diagnosed patients as well as all about postop follow-up patients within the same clinic. And it can really get quite busy.” [August 2019] |
4. Individual characteristics: characteristics of individuals involved in implementation. | ||
4.1, 4.2 Knowledge and beliefs around the intervention, and Self-Efficacy | Evidence limitations were well recognised and understood by dietitians. They used clinical reasoning to adapt the pathway and meet any challenges. Despite the gaps in the evidence, the NCP was also perceived as supportive of the significant role dietitians can play preoperatively and consolidate understanding of the patient treatment journey. | “But unfortunately, there’s just not enough evidence to say that everyone should get [a feeding tube].” [November 2018] “It solidifies my understanding of the whole pre surgical treatment, how that all works in the hospital. That has been a massive positive.” [January 2019] “So it does come down to clinical judgement and discussions with the team about things like feeding tube insertions…But I think it can be quite overwhelming to want to follow it specifically.” [August 2019] “But what we noticed was situations when we were actually using clinical judgment… making that decision was actually okay.” [August 2019] |
5. Process: implementation strategies or tactics. | ||
5.1 Engagement | Engagement between dietitians and other members of the MDT was observed to improve throughout the study. | “The [clinic nurses] are more open to helping us to identify patients, they have a better understanding of how the patients will get through their treatment, what to expect...and the patients appreciate the support so much.” [August 2019] |
5.2 Execution | NCP perceived to be moderately acceptable, feasible and implementable. | “I have found that it can be a bit of a challenge staying on top of things, as your numbers grow and grow [to keep track of] where patients are at in their treatment pathway.” [November 2018] “I was finding sometimes that the clinic would blow out a little bit and the patients themselves might start to get a little bit restless and probably just completely overloaded with information.” [August 2019] |
5.3 Reflection | Dietitians highlighted the positive aspects of implementation (i.e. providing more proactive care, improved MDT relationships, greater understanding of the patient journey). The main implementation barrier was the complexity and variation in patient care. | “I think I didn’t anticipate as much coordinating of those sorts of things, I thought it’d be a bit more streamlined, but I guess, I got a really good realistic perspective of it.” [February 2019] “Knowing each patient’s journey is so different – a very heterogenous group even within the same tumour stream.” [January 2019] “That’s really, really encouraging to say that all the hard work resulted in some improved care, more proactive care and changes being seen.” [August 2019] |