Table 1 Summary of Included Articles

EPOC Implementation Strategies

System/health professional level

Reminders: update practice reminders provided by project leader to regularly reinforce the program.

Local Opinion leaders: DNP student, clinical nurse specialist, nurse practitioners informed content and development.

Continuous Quality Improvement: Senior leaders, existing and new team members were regularly updated on intervention progress. ● Dedicated quality improvement program. ● Protocol revisions based on feedback from clinicians, patients, or family.

Managerial supervision & Monitoring Performance: Regular reports to senior leaders.

Interprofessional Education & Educational meetings: Presentations on evidence on CRF, physical activity and the Energy Through Motion program at staff meetings, unit in-services, Educational materials: pocket guides provided for clinicians

Outcomes

Effectiveness

• Results

° Fatigue: Decreased by an average of 2 points compared to an increase of 0.69 in usual care arm (p = 0.0006)

° Activity Levels: Increased activity levels by a mean of 2.59 points (p = 0.0016) compared to usual care (decreased levels by a mean of 1.07)

° QOL: Improved in all measured areas from 1.24–2.41 points (0–10 scale) compared to decrease (0.69–1.14 points) in usual care.

° Program evaluation: Participants reported that the program was helpful and beneficial. Connecting activity trackers to the computer and follow-along activity videos considered least helpful (Information videos also reported as not used regularly).

• Percent attrition: 10%

Implementation

• Completion rate: 90%

Maintenance (Setting Level)

Program still maintained at the University of Iowa Holden Comprehensive Cancer Centre

EPOC Implementation Strategies:

System/ Health Professional Level

Local Consensus Processes & Clinical Guidelines: Intervention informed by the National Comprehensive Cancer Network (NCCN). A ‘Patient Pain Knowledge Tool’ was created based on NCCN pain guidelines.

Educational Meetings & Material: Regular meetings with nurses. ● Pain and fatigue presentations by national experts to oncologists and nurse practitioners. ● Monthly newsletter to practitioners for ongoing education and communication. ● Internal Advisory Board met quarterly to gain clinician input from researchers involved in the intervention.

Organisational Culture (Phase 3): Pain and fatigue education provided to all clinicians at a total of 38 in-services. ● Pain and fatigue information provided at key meetings. ● Routine fatigue assessment added to outpatient clinic vital sign flow sheet. ● Increased referrals to supportive care departments for pain and fatigue. ● Patient education materials were translated into Spanish. ● Patient education materials made available on employee Intranet. ● Advocacy posters placed around clinic to remind staff and patients to discuss fatigue. ●

Audit and feedback: Clinical feedback reports completed for patients and provided to MDs and NPs based on chart audits with specific feedback for pain and fatigue management.

Tailored interventions: Strategies created to address identified patient, professional and system barriers.

Outcomes

Reach

• Participation rate (Phase 3): 93%

Effectiveness

• Phase 1 & 2: Fatigue - fatigue management barriers were significantly higher in the usual care group than in the intervention group. The usual care group had significantly more fatigue (beta = −0.155).

• Phase 3: Fatigue - Significant immediate and sustained effects were shown on the Fatigue Barriers Scale (FBS) for the intervention group. The intervention group demonstrated a significant delayed effect in Physical QOL – maintained baseline levels of QOL throughout the study when we would normally expect a decrease in QOL. Statistically significant differences between QOL measures were small.

Maintenance (Individual)

• (2-month follow-up) Attrition rate: 32.5%

EPOC Implementation Strategies

Clinical Guidelines: Canadian Association of Psychosocial Oncology (CAPO) guidelines for CRF used to inform education sessions.

Local Consensus Processes: Clinical guidelines adapted to the Ottawa context after consensus amongst stakeholders.

Local opinion leaders & Tailored Intervention: Focus interviews and program development with stakeholder groups (patients, health care professionals and community support professionals, pedagogy expert) to identify barriers to change; subsequent strategies then created.

Educational materials: All participants provided with a flipchart that contains information on assessing and managing fatigue.

Outcomes

Reach

Participation Rate: 90%

Implementation Impact

• Program was effective in increasing knowledge, self-efficacy and intent to apply guidelines.

• CRF Knowledge: −3.959(14), p = 0.001) with a large effect size (d = 0.98).

• Self-Efficacy in CRF Assessment (t = 2.621(13), p = 0.021) with a large effect size (d = 0.88).

• Self-efficacy to intervene for CRF (t = 2.924(13), p = 0.012) with a large effect size (d = 1.13).

• Intent to apply Clinical Guidelines in Practice: t = 4.786(13), p = 0.000) with a large effect size (d = 1.35).

• Feasibility: mean satisfaction score (52.27 ± 6.97 out of 60 points maximum).

Implementation

Completion Rate: 88.9%

EPOC Implementation Strategies:

System/health professional level

Continuous Quality Improvement & Audit and Feedback: Feedback and suggestions periodically collected to determine whether further specific training or modification (to nursing procedure) was required.

Educational materials: CRF Education booklet and other training print materials given to nursing staff.

Educational meetings: Training courses on CRF nursing care were established, including elementary training on evidence-based nursing practice and specific training on CRF nursing care. Seminars on evidence-based practice concerning CRF management.

Clinical Practice Guidelines/ Local Consensus Processes: The “Clinical Practice Guideline: Nursing Care of Cancer-Related Fatigue in Adults with Cancer was developed by interventionists.

Local opinion leaders: Creation of a steering group (six directors from nursing, medical oncology, radiotherapy, Traditional Chinese Medicine, Psychiatry departments. ● Opinion leader identified to change nurse negative opinion of the project, train other nurses and act as a role model for fellow clinicians. ● Integration of existing staff into facilitation team.

Tailored Intervention: Initial focus groups and discussions conducted to identify barriers to change. Subsequent strategies then created.

Outcomes

Implementation Impact

• Nurse Outcomes: After implementation of the project, knowledge, attitudes, and behaviour scores were all higher than at baseline.

• Patient Outcomes:

° No differences were detected between the baseline and final scores of the “self-efficacy questionnaire for CRF management” (SQFM) scale.

° Patients adopted more effective CRF management strategies (previously just rested to alleviate fatigue)

° CRF scores lower after intervention than prior to intervention [5.59(2.09) vs. 6.50 (1.90); t = 2.22, p = 0.04].

EPOC Implementation Strategies:

System/Health Professional Level

Local Opinion leaders: Program development by physical therapist, medical and radiation oncologists, general surgeons, nurses, cancer survivors. ● Phone interviews with intervention leaders from other programs to provide additional insight on recruitment, retention, program design education session topics, screening tools, etc.

Continuous Quality Improvement: Program was modified to include all cancer types (originally only breast cancer survivors) after results from initial program evaluation. Sessions were limited to 12 participants after previous larger class sizes caused challenges in providing individualised support.

Outcomes

Effectiveness/ Efficacy

Participants reported improvements in their fatigue, pain, sleep disturbances, depression, and quality of life, (demonstrated from their pre-, mid-, and post program scores).

• • Fatigue: [5.58 (2.11) vs. 3.55 (1.86); p < 0.0001]

• Sleep [4.77 (2.5) vs. 3.26 (2.27); p < 0.0001],

• Quality of life [3.63 (2.27) vs. 2.08 (1.86); p < 0.0001],

• Pain [2.52 (2.31) vs. 1.85 (1.85); p < 0.001],

• Depression [2.72 (2.21) vs. 1.65 (1.49); p < 0.0001].

Implementation

Participation/Attendance Rates: 80%. From 2007 to approx. 2013: 182 participated in program and 152 completed the program

Maintenance (Setting Level)

Program still maintained at the Bryan Health Medical Centre

EPOC Implementation Strategies

Local Opinion Leaders: Routine communication with stakeholders to inform strategy development and promote good clinical practice.

Clinical Guidelines: Content of all educational materials derived from the NCCN CRF guidelines.

Organisational Culture & Educational materials: Information brochures and posters about CRF management strategies developed for patients and staff. ● Flow chart detailing CRF assessment steps created and displayed in nursing unit. ● Paper-based CRF assessment tools (including BFI) created and distributed for use.

Educational meetings: Formal 2-h education sessions on CRF background, management and assessment delivered to all nurses. ● ‘Practice fatigue assessments’ and patient education sessions completed by nurses (under supervision).

Monitoring Performance & Managerial Supervision: Ongoing discussions, communication, and monitoring of nurses to ensure compliance.

Tailored interventions: Clinical audit conducted to address barriers to change. ● Procedures adjusted to account for changes in environment, workload and time restrictions (i.e., reallocation of work tasks, management support, time management via prioritisation of work tasks, balancing resources).

Outcomes

Implementation Impact

Compliance with best practice audit criteria (compliance rates) -

• Health professional received education and training: Baseline audit – 0% Follow up audit - 97%

• CRF assessment upon admission and at regular intervals throughout care: Baseline audit – 0% Follow up audit - 86%

• Focused assessment of fatigue undertaken in patients who screen positively: Baseline audit – 0% Follow up audit - 64%

• Patient education about physical activities: Baseline audit – 3%, Follow up audit - 78%

• Patient informed about the strategies to manage cancer related fatigue: Baseline audit – 0% Follow up audit - 83%