Contributions to the literature
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This implementation study was conducted in parallel with an RCT which demonstrates an ability to conduct an implementation study in an isolated practice setting while testing the feasibility of the tool itself
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The CRISP tool which was being implemented was improved and designed with the feedback from practice nurses
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Implementation strategies were identified through trial and error in real time
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We have developed an evidence-based implementation strategy that can be used to prospectively implement tools into general practice
Background
The problem: the right screening for bowel cancer based on an individual’s risk
Development and clinical testing of CRISP
The CRISP tool
What is known and the research gap
Methods
Research aims
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To develop an evidence-based implementation intervention capable of supporting the adoption of CRISP in general practice, in a sustainable way,
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To determine methods for scaling-up the implementation of CRISP into general practices in Australia, and
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To develop an approach to implement risk assessment tools for other cancers into general practice.
Theoretical approach
Characteristics of intervention | Inner setting | Outer setting | Individuals involved | Implementation process |
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- Intervention source - Evidence strength and quality - Relative advantage - Adaptability - Trialability - Complexity - Design quality - Cost | - Structural characteristics - Networks and communications - Culture - Implementation climate | - Patient needs and resources -Cosmopolitanism - Peer pressure - External policies and incentives | - Knowledge and beliefs about the intervention - Self-efficacy - Individual stage of change - Individual identification with organisation - Other personal attributes | - Planning - Engaging - Executing - Reflecting and evaluating |
Recruitment and consent
Participant tasks
Planning and engaging
Executing
Reflecting and evaluating
Analysis
Participant incentives
Results
Sample
Implementation strategies
The implementation strategies that were co-designed with practice nurses and other practice staff included: • nurse training that encompassed how to use the CRISP tool, how to explain the risk output, and how to inform the doctors of the result; • educational material designed for nurses, helping them explain CRISP results to the patients; • provision of a sample National Bowel Cancer Screening FIT kit for the nurses to demonstrate how to do a test with patients; • improved and more accurate instructions for patients on how to do a FIT test; • a fidelity checklist for research staff to verify that CRISP was being used correctly, and to help the nurses self-audit (Fig. 1); • training sessions for the doctors to ensure they understood the clinical implications of the CRISP output for their patients; • the incorporation of CRISP into preventive health consultations including chronic disease management plan consultations; • alerts in the patient management system, prompting the nurses to perform a CRISP assessment for eligible patients; • engagement with local pathology providers to explore barriers to FOBT kit availability outside the NBCSP; • engagement with local colonoscopic services to determine the availability of their services; and • identifying a ‘champion’ in the practice to drive the implementation. |
Evaluation
Characteristics of intervention | Inner setting | Outer setting | Individuals involved | Implementation process |
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-CRISP was a valuable intervention and prompted them to discuss bowel cancer screening -As CRISP is a website, the nurses had trouble using the desktop shortcuts after the tool was updated -It was suggested that CRISP should be embedded within the electronic medical records - CRISP took time to complete and auto-populating fields from the electronic medical records would save time | - The general practice where CRISP was implemented changed a lot over the duration of the study - During flu season it was hard for practice nurses to find time to use CRISP -Nurses identified opportunities to use CRISP i.e. during cervical screening appointments -The clinic’s billing system changed, and some patients had to pay out of pocket | - CRISP encouraged participation in the National Bowel Cancer Screening Program - As there are long waiting times for colonoscopic screening in the public system, CRISP decreased the need for unnecessary ones - CRISP increased risk appropriate screening, so more the right people used the right screening methods | - The nurses were unaware of the risk factors for colorectal cancer that were presented in CRISP, so ongoing training was essential for its appropriate use - GPs were pressed for time and felt overwhelmed by having to discuss the CRISP recommendations with their patients who often presented with multiple health concerns | - The clinic is a teaching clinic and they were incredibly flexible and open to change which may not be the same for other clinics - The nurses were comfortable using the Fidelity Checklist, presented in Table 2, with their patients during consultations - CRISP was well received by the practice and patients during consultations |
Characteristics of the intervention (CRISP)
1a “I think the tool itself is really good because it also helps us to focus on their diet and lifestyle, and it’s making people think more about proactive help.” (Practice nurse 1)
1b “Well it’s sort of like quit smoking, if we ask the question, we’re not necessarily asking them to quit smoking, but it’s raising awareness to their health issues. It’s the same with Pap smears and testicular screening. It’s just raising awareness. I think more and more people are becoming more educated about their health.” (Practice nurse 1)
1c “The tool crashed on the GP as he had an older version [of the shortcut] on his desktop.” (Practice nurse 4)
1d “Just wondered if there’s some way of putting it into the EMR software so you could actually remember it like the geriatric depression thing…and things that you can just take down” (Practice nurse 3)
1e “So, we were talking about how having the tool autofill some things. I know it’s been possible with us in the other program we were using so maybe we can try that? It would save a few minutes.” (Practice nurse 4)
Inner setting
2a “...not gone off our radar at all or enthusiasm, it’s simply not been able to fit this in.” (Practice nurse 3)
2b “There could have been people we missed out on, if I was travelling well for time then I could use the CRISP tool with the patients but no I didn’t catch everyone, sometimes it is impossible to fit something extra into a consultation.” (Practice nurse 2)
2c “Cervical screening because my nurse team usually have 30 minutes for cervical screening, usually. That’s probably been an opportunity where we really have been able to do it at the CRISP tool.” (Practice nurse 2)
2d “The care plans [chronic disease management plans], you know 30 minutes is very tight if you know the client well and the paperwork is fairly well organised, you could possibly fit it in there.” (Practice nurse 4)
2e “[We have a] new billing system - some patients will be charged an out-of-pocket fee of $20” (Practice nurse 1)
2f “Patients who aren’t on a care plan must pay out of pocket for their visit to [the practice] now, they may be hard to recruit” (Practice nurse 1)
2g “All four [of the nurses] have been championing this... They’ve been absolutely on board with it” (Practice nurse 2)
Outer setting
3a “I find it helpful in terms of trying to dial people away from colonoscopies because we have a lot who are captured by specialists who… they’ve had a colonoscopy and are immediately booked in for another one.” (Practice nurse 3)
3b “They want to know are they iron deficient, are they anaemic, and that’s how they are prioritising so the referral’s going to enter the public system and face a lengthy wait and if you’re raising with the patient, “based on your history we think colonoscopy is the way to go but you may have to wait 9 months to a year for an interval colonoscopy” (Practice nurse 3)
3c “… people throw the NBCSP kit in the bin, so I do think this will be useful once we start approaching more people and people get used to being asked questions about it…” (Practice nurse 1)
3d “If I actually have a demonstration kit to show the patients how to use it I probably will but if I need to leave the consultation room to try and find one I might not use it or show them how to do it…this could be another barrier to implementation” (Practice nurse 2)
Characteristics of individuals
4a “Why is calcium a problem? I take calcium for my osteoporosis… I thought I better stop taking my calcium tablets if it will increase my risk.” (Practice nurse 2)
4b “So HRT increases your risk of breast cancer if you take it for a certain period of time and calcium has some risks as well. So that’s one thing that we clarified with you and also the more information when it comes to the analgesic stuff as well.” (Practice nurse 1)
4c “When you say NSAIDs, is Panadol an NSAID?” (Practice nurse 3)
4d “… if someone has had significant bowel disease, like ulcerative colitis and diverticulitis the tool shouldn’t be used for them, right? (Practice nurse) [Researcher response: “That’s actually a very good question. If someone has diverticulitis they can be included if it is not significant as it is very common].” (Practice nurse 3)
4e “I think we have to give them a bit of time to get their heads around this. One of the GPs who was overwhelmed coped two patients who had a history of polyps from me.” (Practice nurse 2)
4f “Because the GPs must dig in the patient’s records, they don’t feel they can manage this. Patients are booked for one item per consult, the GPs have said that they want the patients to come back.” (Practice nurse 2)
4g “…the GPs felt overwhelmed talking to the patients about the tool as they have very limited time to do so” (Practice nurse 2)
Process
5a “If you look at a lot of things that happen in our clinics, I think we’re probably fairly motivated here. Not that other nurses aren’t but it depends on what they’re doing with the… the quicker and the … simpler you make it, the easier it will be to continue to apply in the longer-term basis.” (Practice nurse 2)
5b “But you’re quite right, because we flag things on our care plan, particularly the breast screening, cervical screening, FIT, that is the time to flag and I thought to myself, I rebook for this, I give you the phone number for that, I’ve got time I’ll even do it on the phone in my room immediately.” (Practice nurse 4)
5c “We usually go through a bit of a fidelity checklist which I know we’ve done that with you before and it seems like that was all… everything was being used in the right way.” (Practice nurse 1)
5d “Mine have been fairly straight forward if I’m lucky.” (Practice nurse 4)
5e “I found that the patients I asked were very keen and liked going through the tool, it’s great at bringing awareness tool and gets people talking about their risk” (Practice nurse 3)