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Background: Optimal strategies to facilitate implementation of evidence-based clinical pathways are unclear. We evaluated two implementation strategies (core versus enhanced) to facilitate implementation of a clinical pathway for the management of anxiety and depression in cancer patients (the ADAPT CP). Methods: Twelve cancer services in NSW Australia were cluster randomised, stratified by service size, to the core versus enhanced implementation strategy for the ADAPT CP over 12 months. The core strategy included a lead team with champions, staff training and awareness campaigns prior to implementation, plus access to feedback reports and telephone or online support during implementation. The enhanced strategy included all core supports plus monthly lead team meetings, and proactive, ongoing advice on managing barriers, staff training and awareness campaigns throughout implementation. All patients at participating sites were offered the ADAPT CP as part of routine care, and if agreeable, completed screening measures. They were allocated a severity step for anxiety/depression from one (minimal) to five (severe) and recommended management appropriate to their severity step. Multi-level mixed-effect regression analyses examined the impact of core versus enhanced implementation strategy on adherence to the ADAPT CP (binary primary outcome: adherent=³70% of key ADAPT CP components achieved versus non-adherent=Results: Of 1,280 registered patients, 696 (54%) completed at least one screening. As patients were encouraged to re-screen, there were in total 1,323 screening events (883 in core and 440 in enhanced services). The main effect of implementation strategy on adherence was non-significant in both binary and continuous analyses. Anxiety/depression step was significant, with adherence being higher for step 2 than for other steps (p=0.001). The interaction between study arm and anxiety/depression step was significant (p=0.02) in the continuous adherence analysis only: adherence was significantly higher (by 7.5% points) for step 3 in the enhanced arm (p=.02) and trending to significance for step 4. Discussion: These results support ongoing implementation effort for the first year of implementation to ensure successful uptake of new clinical pathways in over-burdened clinical services. Trial registration: ANZCTR Registration: ACTRN12617000411347 (Trial registered 22/03/2017; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372486&isReview=true)

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. 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 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 these important conversations. 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 organisational support and incentivisation for frontline staff to undertake training is critical for wider engagement. A multimodal approach to delivery of training to cater for staff preferences for face to face and/or online staff may maximise training uptake and increase effectiveness of training interventionsTrial Registration: Pilot study ACTRN12616001490460 (27/10/2016). ADAPT RCT ACTRN12617000411347(22/03/2017)

Background 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. Methods 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. Results 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. Conclusions 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. Trial registration The study was registered prospectively with the ANZCTR on 22/3/2017. Trial ID ACTRN12617000411347.

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). 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. 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. 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.

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 ACTRN12617000411347

Purpose: Substantial health disparities exist between Māori—the indigenous people of Aotearoa New Zealand—and non-Māori New Zealanders. This article explores the experience and impact of racism on Māori registered nurses within the New Zealand health system. Method: The narratives of 15 Māori registered nurses were analyzed to identify the effects of racism. This Māori nursing cohort and the data on racism form a secondary analysis drawn from a larger research project investigating the experiences of indigenous health workers in New Zealand and Canada. Jones’s levels of racism were utilized as a coding frame for the structural analysis of the transcribed Māori registered nurse interviews. Results: Participants experienced racism on institutional, interpersonal, and internalized levels, leading to marginalization and being overworked yet undervalued. Discussion and Conclusions: Māori registered nurses identified a lack of acknowledgement of dual nursing competencies: while their clinical skills were validated, their cultural skills—their skills in Hauora Māori—were often not. Experiences of racism were a commonality. Racism—at every level—can be seen as highly influential in the recruitment, training, retention, and practice of Māori registered nurses. Implications for Practice: The nursing profession in New Zealand and other countries of indigenous peoples needs to acknowledge the presence of racism within training and clinical environments as well as supporting indigenous registered nurses to develop and implement indigenous dual cultural-clinical competencies.

To explore Maori health worker perspectives on colorectal screening and identify factors that may influence Maori participation in a colorectal screening programme.Thirty Maori health workers were interviewed to explore their experience with screening programmes, knowledge of colorectal cancer and their perspective on a potential colorectal screening programme. Health workers shared their perspective informed by both their own whanau and whanau they encountered professionally through their health work.Participants were largely positive about potential colorectal screening; however, various access barriers were identified. These included patient-clinician engagement and communication, lack of provision for patient's privacy during screening and patients feeling discouraged to take part in screening. Factors enabling screening included having an established relationship with their General Practitioner, screening clinicians taking time to build rapport, answer questions and share information, screening practices that were inclusive of Maori cultural norms and possessing high health literacy.Evidence points to growing disparity between the colorectal cancer incidence rates of Maori and non-Maori; disparities in colorectal cancer survival rates are already marked. Participants in the current pilot could provide valuable information to help ensure that the health education, promotion, and clinical practice surrounding a national colorectal screening programme are effective for Maori in reducing disparity and improving health outcomes.