Table 2.
Descriptive example of consistent determinants identified across sites using the Consolidated Framework for Implementation Research
| Domain | Construct | Description of determinant | Example |
|---|---|---|---|
| Intervention | Evidence strength and quality (E) | Research is used to build buy-in and support for exercise EBIs. |
At (case site name) exercise is an adjunct therapy embedded in standard cancer care. We follow the COSA position statement that recommends patients with a history of cancer should avoid inactivity and: Engage in at least 150 min of moderate intensity or 75 min of vigorous intensity aerobic exercise per week (jogging cycling swimming) engage in 2–3 resistance exercise sessions per week, targeting major muscle groups (i.e. lifting weights) — (DR-33) |
| Relative advantage (E) | Over time the perceived benefits of exercise have grown and it is seen as the most effective treatment for many side effects of cancer treatment. | “It’s a bit of a panacea to everything” (Int-4) | |
| Adaptability (E) |
The workforce adapts: - The exercise EBI to suit patient preferences; and - The referral process to suit referral sources needs |
“it (exercise) is just an evolving thing. We work with the clinicians and how they like to work and I think that is how we (are) successful….” (Int-1) “originally, we didn’t run group programs, we used to run individual sessions…one of the biggest changes was with the duration of the intervention…” (Int-2) |
|
| Trialability (E) | The exercise EBI commenced through a research trial. | “It is slightly different now because originally it was a research trial.” (Int-6) | |
| Outer setting | Patient need and resourcing (E) | The mechanisms exist to embed the patient voice within EBI design and delivery (i.e., through advisory groups and satisfaction surveys). This includes being responsive to patient direction and making adaptions to the EBI (see adaptability). | “we established a youth advisory board…who come together to advise us on all issues to do with… cancer, not just for us as a service, but they also report up through to State government. So they're actually advising and guiding on policy as well.” (Int-14) |
| Cosmopolitan (E) | The organisation develops relationships with other organisations to build capacity of the exercise EBI (i.e., on referral of patients when the service reaches capacity). | “So, we do have a longstanding relationship with a certain institution…they had a common interest in cancer and then from there, they had the capacity to take more referrals over.” (Int-2) | |
| External policy and incentives (E) | The COSA position statement on cancer and exercise helped validate the role of exercise in standard cancer care. State government policies reference exercise, which provides strategic policy alignment. | “The reason that we could establish it was because of the policy of the (State government name) cancer policy to support survivorship. I would say that certainly helped us (and) the COSA position statement and the advocacy and awareness that have come around that.” (Int-9) | |
| Inner setting | Networks and communications (E) | Strong connections existed between individual staff and within teams that facilitated efficiencies in working relationships and implementation (i.e., corridor conversations, call/email (in place of following formalised procedures)). | “The other thing is having a personal relationship is actually good. Yeah, we work as a team. I think we know each other pretty well.” (Int-5) |
| Implementation climate (E) | Organisations expect innovation and to be a leader in cancer, which allowed the exercise EBI to grow and transform, despite difficult conditions. | “I think it can be challenging implementing innovative programs in a time of austerity. With that said I think there is a lot of passion and commitment.” (Int-1) | |
| Compatibility (E) | Systems are implemented (i.e., opt-out referral, IT system coordination and EMR) to ensure exercise EBIs fit and are aligned with existing workflows. | “We have an opt-out model of care…. so everyone that gets referred into the service will be offered exercise physiology throughout the course of their treatment.” (Int-11) | |
| Learning climate (E) | Healthcare staff feels supported to seek out new and better ways to integrate evidence/learning in routine practice. | “There is no expectation that you know, everything. You know, we want to be learning and growing together as a team to make sure that we can deliver the best quality service.” (Int-9) | |
| Available resources (B) | Healthcare providers lack of time, which is a byproduct of lack of funding, is a barrier to growing/optimising the exercise EBI. | “We need more, we need more space, we need more (AEPs), we need more time, we don’t think enough of that…. we could do with more admin support to help with programs that we are all running.” (Int-4) | |
| Access to knowledge and information (E) | Healthcare providers aim to create a one-stop shop for exercise and cancer. This means referral sources have easy access to the information they need. | “I guess I found it difficult to know who to refer to….and to try and find people to refer to is actually quite hard. And so I'd refer people to (organisation name)…. its got a website... and then it's done, it's very quick. I don't have to send an e-mail or anything like that, it's done then and there.” (Int-10) | |
| Individual | Self-efficacy (E) | Healthcare providers are confident to raise and discuss exercise with patients, akin to how they talk about other treatments. Albeit there are laggards who don’t see it as their role. | “So, a lot of the patients… they are very surprised to hear me talking about exercise when they have just been diagnosed with say breast cancer…. And I am sort of saying well actually there is all this evidence and I have seen patients (with) … very similar cancer and treatments that you’re having and I am going to start prescribing exercise with chemotherapy.” (Int-4) |
| Individual stage of change (B) | Providers are aware of the value of exercise, but they do not routinely act to discuss/refer for exercise. They make decisions about timing and what are the highest priorities for discussion at that stage of treatment. This is negated with opt-out systems. | “When you meet new people, they've usually got a hell of a lot going on. And is that the right time to talk about exercise?” (Int-17) | |
| Other personal attributes (E) | Healthcare providers are committed, passionate and do more than is typically expected of their role (particularly evident of exercise delivery staff). | “Everyone’s got the same passion for what we’re doing and that goes along way.” (Int-7) | |
| Process | Champion (E) | A champion exists who is influential with executives, peers and their direct reports. They use this influence to advocate for increased resources and funding. Champions also build other advocates (i.e., patients and peers) so there is a sense of unity in messaging around exercise EBIs and cancer. | “My line manager is the best support champion of this program and has been the driver for this expanding over the years.” (Int-2) |
| Reflecting and evaluating (E) | Procedures are established to monitor and evaluate the implementation process, albeit this is not conducted in a systematic way. Sites use the information as needed to create the story they need to tell at that time. | “So, when you start to see those patterns where either your activities are going up, wait lists are blowing out, a certain type of service is required because it's getting requested, etc. That's generally the driver behind pulling that data and doing a business case.” (Int-16) |
B Barrier, COSA Clinical Oncology Society Australia, DR document review, EBI evidence-based intervention, EMR electronic medical record, E enabler, NA not applicable