Advanced Practice Nurses and Their Roles in Swiss Cancer Care: A Cross-Sectional Study.

OBJECTIVES: To examine the advanced practice nurse workforce in Swiss cancer care and how their roles are being implemented (eg, role structures, processes) to achieve optimal outcomes for patients and their families, care organizations, and the broader health care system. METHODS: A cross-sectional study was conducted. The sample included master-prepared advanced practice nurses in cancer care, who completed an online questionnaire from December 2021 to January 2022. Thirty-nine items assessed structures (eg, role characteristics, utilization), processes (eg, role activities, interventions), and perceived outcomes (eg, for patients, the health care system) of advanced practice nurses in Swiss cancer care. Data from closed questions were analyzed using descriptive statistics. Data from open-ended questions were organized and summarized into categories related to domains of advanced practice nursing and its reported frequency by the advanced practice nurses. RESULTS: The participating advanced practice nurses (n = 53), worked in half of the 26 Swiss cantons. Interventions were identified within nine categories, of which most were targeted to patients and their families (n = 7), followed by health care professionals (n = 2). Perceived positive outcomes were patient symptom management, length of hospital stay, and health care costs. Participants felt less confident in cancer care (eg, autonomous practice) and reported 15 professional development needs (eg, medical interventions, teaching). CONCLUSIONS: This study provides a comprehensive examination of 53 advanced practice nurses, detailing the characteristics of their roles and utilization across various jurisdictions and health care settings. The results highlight the diverse dimensions of advanced practice nursing and its potential to enhance cancer services and outcomes in Switzerland. Opportunities for role development support and expansion are identified. IMPLICATIONS FOR NURSING PRACTICE: More systematic health human resource planning is needed to expand the deployment of advanced practice nurses across jurisdictions, practice settings, and more diverse patient populations. Role development needs show the desire for specialized educational preparation in cancer care.

The Nurse Practitioner Role in Complex Malignant Hematology: A Qualitative Descriptive Study.

OBJECTIVES: Internationally, there is limited evidence about the role and impact of nurse practitioners (NPs) in complex malignant hematology (CMH). In one Canadian CMH program, NPs have existed for 20 years but not been evaluated. This study aimed to understand stakeholder perceptions of CMH NP role structures, processes, and outcomes and the extent to which the role meets patient and health service needs. METHODS: A qualitative descriptive study was conducted, guided by the PEPPA-Plus framework. Purposive sampling was used to recruit stakeholders who participated in focus groups and interviews. Content analysis was used to analyze the data. RESULTS: Participants included patients (n = 8) and healthcare professionals (n = 27). Themes about structures related to evolution of the CMH Program, model of care, and need for strategic vision. Process themes related to provision of accessible, comprehensive, and holistic care and NP workload. Positive and negative outcomes and lack of outcome measurement were identified. CONCLUSION: Structures related to patient and NP characteristics, organizational change, staffing, and how NP work is organized impacts on NP role implementation and outcomes. Organizational structures can be strengthened to improve the model of care and NP role implementation and workload. Value-added NP contributions related to providing comprehensive care with attention to safety and social determinants of health. Research is needed to evaluate NP role outcomes in CMH. IMPLICATIONS FOR NURSING PRACTICE: The results can inform role design and organization policies and strategies to promote the recruitment, retention, and optimization of NP roles in CMH settings. Priorities for future research are also identified.

Advanced Practice Nursing Titles and Roles in Cancer Care: A Scoping Review.

OBJECTIVES: Advanced practice nursing roles in cancer care are diverse and exist across the cancer care continuum. However, the titles used and the scope of practice differ across countries. This diversity is likely to be misleading to patients and influence nurses' contribution to health care. An understanding of the current state of advanced practice nursing roles in cancer care internationally is needed to inform opportunities for future role development and enhance cancer nursing career pathways. METHODS: This scoping review included a systematic search of four databases: MEDLINE, CINAHL, PsycINFO, and Academic Search Complete. Independent screening for papers meeting the review's inclusion criteria was undertaken using online screening software. Data extraction, coding, and mapping were undertaken in NVivo 12. RESULTS: Of the 13,409 records identified, 108 met the review's inclusion criteria. A variety of roles in cancer care settings were described. The United States and the United Kingdom had the most titles for advanced practice nursing roles. Tumor-specific roles were described and integrated into different phases of the cancer care continuum. Trends in continuing professional development for advanced practice nurses in cancer care included the rise in Fellowship programs in the United States and practice-based education in the United Kingdom. CONCLUSIONS: The differences in advanced practice nursing roles in cancer care allow regional and institutional variation to meet the needs of patient populations and health care system demands. However, a lack of clarity surrounding titles and roles results in confusion and underutilization of these nurses' highly specialized skill sets. IMPLICATIONS FOR NURSING PRACTICE: Incongruence in titles and scope of practice internationally will ultimately result in a merging of roles. There is a need for international agreement on education requirements for advanced practice nursing roles to promote career pathways.

A qualitative study on healthcare professional and patient perspectives on nurse-led virtual prostate cancer survivorship care.

BACKGROUND: Virtual nurse-led care models designed with health care professionals (HCPs) and patients may support addressing unmet prostate cancer (PCa) survivor needs. Within this context, we aimed to better understand the optimal design of a service model for a proposed nurse-led PCa follow-up care platform (Ned Nurse). METHODS: A qualitative descriptive study exploring follow-up and virtual care experiences to inform a nurse-led virtual clinic (Ned Nurse) with an a priori convenience sample of 10 HCPs and 10 patients. We provide a health ecosystem readiness checklist mapping facilitators onto CFIR and Proctor's implementation outcomes. RESULTS: We show that barriers within the current standard of care include: fragmented follow-up, patient uncertainty, and long, persisting wait times despite telemedicine modalities. Participants indicate that a nurse-led clinic should be scoped to coordinate care and support patient self-management, with digital literacy considerations. CONCLUSION: A nurse-led follow-up care model for PCa is seen by HCPs as acceptable, feasible, and appropriate for care delivery. Patients value its potential to provide role clarity, reinforce continuity of care, enhance mental health support, and increase access to timely and targeted care. These findings inform design, development, and implementation strategies for digital health interventions within complex settings, revealing opportunities to optimally situate these interventions to improve care.

Prostate cancer (PCa) survivors in Canada receive follow-up care after treatment through a specialist-led model, which is currently straining to meet patient needs. We interviewed healthcare providers (HCPs) and patients to investigate the design and development of a healthcare service that uses technology, also known as virtual care, to provide nurse-led follow-up care. Mixed experiences with virtual care informed participant feedback and concerns, including impacts of the pandemic and digital literacy considerations. We show that HCPs and patients see potential benefit in virtual nurse-led follow-up care if it can increase access to resources, clarify patient and provider care roles, and improve access and continuity of care. This type of approach to follow-up care may help to improve survivor quality of life and PCa follow-up care while extending the reach of healthcare systems with limited resources.

An Actionable Expert-System Algorithm to Support Nurse-Led Cancer Survivorship Care: Algorithm Development Study.

BACKGROUND: Comprehensive models of survivorship care are necessary to improve access to and coordination of care. New models of care provide the opportunity to address the complexity of physical and psychosocial problems and long-term health needs experienced by patients following cancer treatment. OBJECTIVE: This paper presents our expert-informed, rules-based survivorship algorithm to build a nurse-led model of survivorship care to support men living with prostate cancer (PCa). The algorithm is called No Evidence of Disease (Ned) and supports timelier decision-making, enhanced safety, and continuity of care. METHODS: An initial rule set was developed and refined through working groups with clinical experts across Canada (eg, nurse experts, physician experts, and scientists; n=20), and patient partners (n=3). Algorithm priorities were defined through a multidisciplinary consensus meeting with clinical nurse specialists, nurse scientists, nurse practitioners, urologic oncologists, urologists, and radiation oncologists (n=17). The system was refined and validated using the nominal group technique. RESULTS: Four levels of alert classification were established, initiated by responses on the Expanded Prostate Cancer Index Composite for Clinical Practice survey, and mediated by changes in minimal clinically important different alert thresholds, alert history, and clinical urgency with patient autonomy influencing clinical acuity. Patient autonomy was supported through tailored education as a first line of response, and alert escalation depending on a patient-initiated request for a nurse consultation. CONCLUSIONS: The Ned algorithm is positioned to facilitate PCa nurse-led care models with a high nurse-to-patient ratio. This novel expert-informed PCa survivorship care algorithm contains a defined escalation pathway for clinically urgent symptoms while honoring patient preference. Though further validation is required through a pragmatic trial, we anticipate the Ned algorithm will support timelier decision-making and enhance continuity of care through the automation of more frequent automated checkpoints, while empowering patients to self-manage their symptoms more effectively than standard care. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1136/bmjopen-2020-045806.

A Web-Based Cancer Self-Management Program (I-Can Manage) Targeting Treatment Toxicities and Health Behaviors: Human-Centered Co-design Approach and Cognitive Think-Aloud Usability Testing.

BACKGROUND: Patients with cancer require adequate preparation in self-management of treatment toxicities to reduce morbidity that can be achieved through well-designed digital technologies that are developed in co-design with patients and end users. OBJECTIVE: We undertook a user-centered co-design process in partnership with patients and other knowledge end users to develop and iteratively test an evidence-based and theoretically informed web-based cancer self-management program (I-Can Manage). The specific study aims addressed in 2 phases were to (1) identify from the perspective of patients with cancer and clinicians the desired content, features, and functionalities for an online self-management education and support (SMES) program to enable patient self-management of treatment toxicities (phase 1); (2) develop the SMES prototype based on human-centered, health literate design principles and co-design processes; and (3) evaluate usability of the I-Can Manage prototype through user-centered testing (phase 2). METHODS: We developed the I-Can Manage program using multiperspective data sources and based on humanistic and co-design principles with end users engaged through 5 phases of development. We recruited adult patients with lung, colorectal, and lymphoma cancer receiving systemic treatments from ambulatory clinics in 2 regional cancer programs for the qualitative inquiry phase. The design of the program was informed by data from qualitative interviews and focus groups, persona and journey mapping, theoretical underpinnings of social cognitive learning theory, and formalized usability testing using a cognitive think-aloud process and user satisfaction survey. A co-design team comprising key stakeholders (human design experts, patients/caregiver, clinicians, knowledge end users, and e-learning and digital design experts) was involved in the developmental process. We used a cognitive think-aloud process to test usability and participants completed the Post-Study System Usability Questionnaire (PSSUQ). RESULTS: In the initial qualitative inquiry phase, 16 patients participated in interviews and 19 clinicians participated in interviews or focus groups and 12 key stakeholders participated in a persona journey mapping workshop to inform development of the program prototype. The I-Can Manage program integrates evidence-based information and strategies for the self-management of treatment toxicities and health-promoting behaviors in 6 e-learning modules (lay termed "chapters"), starting with an orientation to self-management. Behavioral exercises, patient written and video stories, downloadable learning resources, and online completion of goals and action plans were integrated across chapters. Patient participants (n=5) with different cancers, gender, and age worked through the program in the human factors laboratory using a cognitive think-aloud process and all key stakeholders reviewed each chapter of the program and approved revisions. Results of the PSSUQ (mean total score: 3.75) completed following the cognitive think-aloud process (n=5) suggest patient satisfaction with the usability of I-Can Manage. CONCLUSIONS: The I-Can Manage program has the potential for activating patients in self-management of cancer and treatment toxicities but requires testing in a larger randomized controlled trial.

Impact of a Training Program on Oncology Nurses' Confidence in the Provision of Self-Management Support and 5As Behavioral Counseling Skills.

BACKGROUND: Cancer patients and their families play a central role in the self-management of the medical, emotional, and lifestyle consequences of cancer. Nurses with training in self-management support can enable cancer patients to better manage the effects of cancer and treatment. METHODS: As part of a randomized controlled trial, we developed a training program to build nurses' confidence in the provision of self-management support (SMS). The SMS skills taught were adapted from the Stanford Peer Support training programs and embedded within the 5As (Assess, Advise, Agree, Assist, and Arrange) behavioral counseling process. We evaluated the impact of the training program on oncology nurses' and coaches' confidence using a Student's t-test for paired samples in a nonrandomized, one-group pre/postsurvey. RESULTS: Participants were experienced oncology nurses from three participating cancer centers. A two-tailed Student's t-test for paired samples showed a significant improvement in nurses' confidence for the 15 SMS microskills targeted in the training between the pretest and post-test as follows: for Center 1, a mean difference of 0.79 (t = 7.18, p ≤ 0.00001); for Center 2, a mean difference of 0.73 (t = 8.4, p ≤ 0.00001); for Center 3, a mean difference of 1.57 (t = 11.45, p ≤ 0.00001); and for coaches, a mean difference of 0.52 (t = 7.6, p ≤ 0.00001). CONCLUSIONS: Our training program improved oncology staff nurses' and cancer coaches' confidence in 15 SMS microskills and has potential for SMS training of nurses in routine care.

Feasibility and Effectiveness of Self-Management Education and Coaching on Patient Activation for Managing Cancer Treatment Toxicities.

BACKGROUND: Poorly managed cancer treatment toxicities negatively impact quality of life, but little research has examined patient activation in self-management (SM) early in cancer treatment. METHODS: We undertook a pilot randomized trial to evaluate the feasibility, acceptability, and preliminary effectiveness of the SMARTCare (Self-Management and Activation to Reduce Treatment Toxicities) intervention. This intervention included an online SM education program (I-Can Manage) plus 5 sessions of telephone cancer coaching in patients initiating systemic therapy for lymphoma or colorectal or lung cancer at 3 centers in Ontario, Canada, relative to a usual care control group. Patient-reported outcomes included patient activation (Patient Activation Measure [PAM]), symptom or emotional distress, self-efficacy, and quality of life. Descriptive statistics and Wilcoxon rank-sum tests were used to examine changes over time (baseline and at 2, 4, and 6 months) within and between groups. We used general estimating equations to compare outcomes between groups over time. The intervention group completed an acceptability survey and qualitative interviews. RESULTS: Of 90 patients approached, 62 (68.9%) were enrolled. Mean age of the sample was 60.5 years. Most patients were married (77.1%), were university educated (71%), had colorectal cancer (41.9%) or lymphoma (42.0%), and had stage III or IV disease (75.8%). Attrition was higher in the intervention group than among control subjects (36.7% vs 25%, respectively). Adherence to I-Can Manage was low; 30% of intervention patients completed all 5 coaching calls, but 87% completed ≥1. Both the continuous PAM total score (P<.001) and categorical PAM levels (3/4 vs 1/2) (P=.002) were significantly improved in the intervention group. CONCLUSIONS: SM education and coaching early during cancer treatment may improve patient activation, but a larger trial is needed. CLINICALTRIALS: gov Identifier: NCT03849950.

Information Provision, Decision Self-efficacy, and Decisional Conflict in Adopting Health Behaviors Among Patients Treated for Colorectal Cancer: A Cross-sectional Study.

BACKGROUND: Health promotion is necessary to mitigate the negative consequences of colorectal cancer and its treatment. Rates of behavior modification are low in populations of cancer patients. Studies are needed to determine the factors, such as decisional conflict, which influence adoption of healthy behaviors following a cancer diagnosis. OBJECTIVE: To examine the effects of information provision, decision self-efficacy, and decisional conflict on the adoption of healthy behaviors among patients with colorectal cancer. METHODS: This cross-sectional study focused on 251 patients with colorectal cancer in South Korea. Information provision, decision self-efficacy, and decisional conflict were measured using validated instruments. Patients rated their decisional conflict related to the adoption of behaviors that include regular exercise and a balanced diet. RESULTS: Most participants (73%) reported low satisfaction with the amount of information received. Of the participants, 64% had low decision self-efficacy, and 80% experienced decisional conflict. The perception of a higher level of information provision was associated with greater decision self-efficacy (odds ratio, 4.63; 95% confidence interval, 1.61-13.35). Higher decision self-efficacy was associated with lower decisional conflict (odds ratio, 5.19; 95% confidence interval, 2.33-11.59). CONCLUSION: Receiving adequate information is important for promoting patients' confidence in making decisions about their health and reducing decisional conflict in the adoption of healthy lifestyle changes following a cancer diagnosis. IMPLICATION FOR PRACTICE: Oncology nurses should assess patient information needs and promote decision self-efficacy, thus empowering patients diagnosed with colorectal cancer to make lifestyle decisions that improve their health and quality of life.

Effectiveness of registered nurses on patient outcomes in primary care: a systematic review.

BACKGROUND: Globally, registered nurses (RNs) are increasingly working in primary care interdisciplinary teams. Although existing literature provides some information about the contributions of RNs towards outcomes of care, further evidence on RN workforce contributions, specifically towards patient-level outcomes, is needed. This study synthesized evidence regarding the effectiveness of RNs on patient outcomes in primary care. METHODS: A systematic review was conducted in accordance with Joanna Briggs Institute methodology. A comprehensive search of databases (CINAHL, MEDLINE Complete, PsycINFO, Embase) was performed using applicable subject headings and keywords. Additional literature was identified through grey literature searches (ProQuest Dissertations and Theses, MedNar, Google Scholar, websites, reference lists of included articles). Quantitative studies measuring the effectiveness of a RN-led intervention (i.e., any care/activity performed by a primary care RN) that reported related outcomes were included. Articles were screened independently by two researchers and assessed for bias using the Integrated Quality Criteria for Review of Multiple Study Designs tool. A narrative synthesis was undertaken due to the heterogeneity in study designs, RN-led interventions, and outcome measures across included studies. RESULTS: Forty-six patient outcomes were identified across 23 studies. Outcomes were categorized in accordance with the PaRIS Conceptual Framework (patient-reported experience measures, patient-reported outcome measures, health behaviours) and an additional category added by the research team (biomarkers). Primary care RN-led interventions resulted in improvements within each outcome category, specifically with respect to weight loss, pelvic floor muscle strength and endurance, blood pressure and glycemic control, exercise self-efficacy, social activity, improved diet and physical activity levels, and reduced tobacco use. Patients reported high levels of satisfaction with RN-led care. CONCLUSIONS: This review provides evidence regarding the effectiveness of RNs on patient outcomes in primary care, specifically with respect to satisfaction, enablement, quality of life, self-efficacy, and improvements in health behaviours. Ongoing evaluation that accounts for primary care RNs' unique scope of practice and emphasizes the patient experience is necessary to optimize the delivery of patient-centered primary care. PROTOCOL REGISTRATION ID: PROSPERO: International Prospective Register of Systematic Reviews. 2018. ID=CRD42 018090767 .

Effectiveness of registered nurses on system outcomes in primary care: a systematic review.

BACKGROUND: Internationally, policy-makers and health administrators are seeking evidence to inform further integration and optimal utilization of registered nurses (RNs) within primary care teams. Although existing literature provides some information regarding RN contributions, further evidence on the impact of RNs towards quality and cost of care is necessary to demonstrate the contribution of this role on health system outcomes. In this study we synthesize international evidence on the effectiveness of RNs on care delivery and system-level outcomes in primary care. METHODS: A systematic review was conducted in accordance with Joanna Briggs Institute methodology. Searches were conducted in CINAHL, MEDLINE Complete, PsycINFO, and Embase for published literature and ProQuest Dissertations and Theses and MedNar for unpublished literature between 2019 and 2022 using relevant subject headings and keywords. Additional literature was identified through Google Scholar, websites, and reference lists of included articles. Studies were included if they measured effectiveness of a RN-led intervention (i.e., any care/activity performed by a primary care RN within the context of an independent or interdependent role) and reported outcomes of these interventions. Included studies were published in English; no date or location restrictions were applied. Risk of bias was assessed using the Integrated Quality Criteria for Review of Multiple Study Designs tool. Due to the heterogeneity of included studies, a narrative synthesis was undertaken. RESULTS: Seventeen articles were eligible for inclusion, with 11 examining system outcomes (e.g., cost, workload) and 15 reporting on outcomes related to care delivery (e.g., illness management, quality of smoking cessation support). The studies suggest that RN-led care may have an impact on outcomes, specifically in relation to the provision of medication management, patient triage, chronic disease management, sexual health, routine preventative care, health promotion/education, and self-management interventions (e.g. smoking cessation support). CONCLUSIONS: The findings suggest that primary care RNs impact the delivery of quality primary care, and that RN-led care may complement and potentially enhance primary care delivered by other primary care providers. Ongoing evaluation in this area is important to further refine nursing scope of practice policy, determine the impact of RN-led care on outcomes, and inform improvements to primary care infrastructure and systems management to meet care needs. PROTOCOL REGISTRATION ID: PROSPERO: International prospective register of systematic reviews. 2018. ID= CRD42018090767 .

Implementation strategies to address barriers to evidence-informed symptom management among outpatient oncology nurses: a scoping review protocol.

INTRODUCTION: Despite the availability of clinical practice guidelines for cancer symptom management, cancer care providers do not consistently use them in practice. Oncology nurses in outpatient settings are well positioned to use established guidelines to inform symptom assessment and management; however, issues concerning inconsistent implementation persist. This scoping review aims to (1) identify reported barriers and facilitators influencing symptom management guideline adoption, implementation and sustainability among specialised and advanced oncology nurses in cancer-specific outpatient settings and (2) identify and describe the components of strategies that have been used to enhance the implementation of symptom management guidelines. METHODS AND ANALYSIS: This scoping review will follow Joanna Briggs Institute methodology. Electronic databases CINAHL, Embase, Emcare and MEDLINE(R) and grey literature sources will be searched for studies published in English from January 2000 to March 2022. Primary studies and grey literature reports of any design that include specialised or advanced oncology nurses practicing in cancer-specific outpatient settings will be eligible. Sources describing factors influencing the adoption, implementation and sustainability of cancer symptom management guidelines and/or strategies to enhance guideline implementation will be included. Two reviewers will independently screen for eligibility and extract data. Data extraction of factors influencing implementation will be guided by the Consolidated Framework for Implementation Research (CFIR), and the seven dimensions of implementation strategies (ie, actors, actions, targets, temporality, dose, justifications and outcomes) will be used to extract implementation strategy components. Factors influencing implementation will be analysed descriptively, synthesised according to CFIR constructs and linked to the Expert Recommendations for Implementating Change strategies. Results will be presented through tabular/diagrammatic formats and narrative summary. ETHICS AND DISSEMINATION: Ethics approval is not required for this scoping review. Planned knowledge translation activities include a national conference presentation, peer-reviewed publication, academic social media channels and dissemination within local oncology nursing and patient networks.

Improving the quality of self-management support in ambulatory cancer care: a mixed-method study of organisational and clinician readiness, barriers and enablers for tailoring of implementation strategies to multisites.

INTRODUCTION: Improving the quality of self-management support (SMS) for treatment-related toxicities is a priority in cancer care. Successful implementation of SMS programmes depends on tailoring implementation strategies to organisational readiness factors and barriers/enablers, however, a systematic process for this is lacking. In this formative phase of our implementation-effectiveness trial, Self-Management and Activation to Reduce Treatment-Related Toxicities, we evaluated readiness based on constructs in the Consolidated Framework for Implementation Research (CFIR) and Normalisation Process Theory (NPT) and developed a process for mapping implementation strategies to local contexts. METHODS: In this convergent mixed-method study, surveys and interviews were used to assess readiness and barriers/enablers for SMS among stakeholders in 3 disease site groups at 3 regional cancer centres (RCCs) in Ontario, Canada. Median survey responses were classified as a barrier, enabler or neutral based on a priori cut-off values. Barriers/enablers at each centre were mapped to CFIR and then inputted into the CFIR-Expert Recommendations for Implementing Change Strategy Matching Tool V.1.0 (CFIR-ERIC) to identify centre-specific implementation strategies. Qualitative data were separately analysed and themes mapped to CFIR constructs to provide a deeper understanding of barriers/enablers. RESULTS: SMS in most of the RCCs was not systematically delivered, yet most stakeholders (n=78; respondent rate=50%) valued SMS. For centre 1, 7 barriers/12 enablers were identified, 14 barriers/9 enablers for centre 2 and 11 barriers/5 enablers for centre 3. Of the total 46 strategies identified, 30 (65%) were common across centres as core implementation strategies and 5 tailored implementation recommendations were identified for centres 1 and 3, and 4 for centre 2. CONCLUSIONS: The CFIR and CFIR-ERIC were valuable tools for tailoring SMS implementation to readiness and barriers/enablers, whereas NPT helped to clarify the clinical work of implementation. Our approach to tailoring of implementation strategies may have relevance for other studies.

Virtual care for prostate cancer survivorship: protocol for an evaluation of a nurse-led algorithm-enhanced virtual clinic implemented at five cancer centres across Canada.

INTRODUCTION: Prostate cancer (PCa) is the most common cancer in Canadian men. Current models of survivorship care are no longer adequate to address the chronic and complex survivorship needs of patients today. Virtual care models for cancer survivorship have recently been associated with comparable clinical outcomes and lower costs to traditional follow-up care, with patients favouring off-site and on-demand visits. Building on their viability, our research group conceived the Ned Clinic-a virtual PCa survivorship model that provides patients with access to lab results, collects patient-reported outcomes, alerts clinicians to emerging issues, and promotes patient self-care. Despite the promise of the Ned Clinic, the model remains limited by its dependence on oncology specialists, lack of an autonomous triage algorithm, and has only been implemented among PCa survivors living in Ontario. METHODS AND ANALYSIS: Our programme of research comprises two main research objectives: (1) to evaluate the process and cost of implementing and sustaining five nurse-led virtual PCa survivorship clinics in three provinces across Canada and identify barriers and facilitators to implementation success and (2) to assess the impact of these virtual clinics on implementation and effectiveness outcomes of enrolled PCa survivors. The design phase will involve developing an autonomous triage algorithm and redesigning the Ned Clinic towards a nurse-led service model. Site-specific implementation plans will be developed to deploy a localised nurse-led virtual clinic at each centre. Effectiveness will be evaluated using a historical control study comparing the survivorship outcomes of 300 PCa survivors enrolled in the Ned Clinic with 300 PCa survivors receiving traditional follow-up care. ETHICS AND DISSEMINATION: Appropriate site-specific ethics approval will be secured prior to each research phase. Knowledge translation efforts will include diffusion, dissemination, and application approaches to ensure that knowledge is translated to both academic and lay audiences.

Patient and clinician perspectives of desired features for a web-based self-management program (icanmanage.ca): exposing patients "hard work" of managing acute cancer.

PURPOSE: People with cancer benefit from self-management support, but report limitations in the type/amount of support they receive from healthcare professionals during cancer treatment. To intervene in this critical period, our team is developing a web-based self-management system, called I Can Manage Cancer (ICMC). The purpose of this paper is to report patient and clinician perspectives on the preferred features and functions in a self-management system that informed the development of the ICMC program. METHODS: We used descriptive qualitative methods, conducting interviews with people diagnosed with cancer (n = 16) and focus groups with cancer clinicians (n = 19). Data were thematically analyzed using the NVivo qualitative software. FINDINGS: People with cancer describe engaging in hard work when employing cancer self-management. Our findings lend insight into features and functions they deem vital in a self-management system to support this work. Based on patient and clinician accounts, we developed three themes describing specific content and design features for the ICMC program to support self-management needs of people with cancer during the acute phase of treatment: (1) being able to connect, observe, and learn from others; (2) the ability to tailor and customize information; and (3) the capacity to track symptoms over time. Clinicians and patients emphasized the need to optimize all available resources to support people with cancer as they engage in the work to manage their diagnosis. CONCLUSIONS: Our findings describe the how peoples' cancer experiences and the gaps in self-management care can be enhanced by specific features and functions within the ICMC.

Selecting, implementing and evaluating patient-reported outcome measures for routine clinical use in cancer: the Cancer Care Ontario approach.

BACKGROUND: The use of Patient-Reported Outcome Measures (PROMs) in routine clinical care can help ensure symptoms are identified, acknowledged and addressed. In 2007, the provincial cancer agency, Cancer Care Ontario, began to implement routine symptom screening with the Edmonton Symptom Assessment System (ESAS) for ambulatory cancer patients. Having had a decade of experience with ESAS, the program developed a strategic interest in implementing new and/or additional measures. This article describes the development of a streamlined PROM selection and implementation evaluation process with core considerations. METHODS: Development of the PROM selection and implementation evaluation process involved analysis of quantitative and qualitative data as well as consensus building through a multi-stakeholder workshop. Core PROM selection considerations were developed through a literature scan, review and refinement by a panel of methodological experts and patient advisors, and testing via a test case. Core PROM implementation evaluation considerations were developed through analysis of PROM evaluation frameworks, and review and refinement by a committee of provincial implementation leads. RESULTS: Core PROM selection considerations were identified under three overarching themes: symptom coverage, usability and psychometric properties. The symptom coverage category assesses each PROM to determine how well the PROM items address the most prevalent and burdensome symptoms in the target patient population. The usability category aims to assess each measure on characteristics key to successful implementation in the clinical setting. The psychometric properties category assesses each PROM to ensure the data collected is credible, meaningful and interpretable. A scoring system was developed to rate PROM performance by assigning a grade of "weak", "average" or "good" for each category. The process results in a summary matrix which illustrates the overall assessment of each PROM. Implementation evaluation considerations were identified under three overarching concepts: acceptability, outcomes, and sustainability. A consensus building exercise resulted in the further identification of patient, provider, and clinic specific indicators for each consideration. CONCLUSION: To address the need for a systematic, evidence-based approach to selection, implementation and evaluation of PROMs in the clinical setting, Cancer Care Ontario defined a process with embedded core considerations to facilitate decision-making and encourage standardization.

Patient-reported outcome instruments used in immune-checkpoint inhibitor clinical trials in oncology: a systematic review.

CONTEXT: Immune-checkpoint inhibitors (ICI) have shown significant benefits for overall survival across various cancer types. Patient-reported outcomes (PROs) are assessed in clinical trials as a measure of efficacy. However, it remains unclear to what extent current PRO instruments capture symptoms specific to ICI toxicities. We conducted a systematic review to identify the use and content validity of PRO instruments in ICI clinical trials in oncology. METHODS: Literature was retrieved from PubMed, Embase, PsycINFO, Medline and CINAHL databases. Articles presenting ICI clinical trials' PRO results, clinical trial study protocols, and conference abstracts stating the use of PRO measures were assessed. We evaluated the validity of identified instruments by comparing their symptom-related content with the adverse events reported in each ICI clinical trial. RESULTS: From database inception until January 2020, we identified 191 ICI clinical trials stating the use of PRO measures of which 26 published PRO results. The cancer-specific EORTC QLQ-C30 and the generic EQ-5D questionnaires were the most widely used instruments, often in combination with disease-specific PROs. Instruments used to report PRO symptom-related toxicities covered 45% of the most frequently reported AEs, whereas 23% of AEs were partially covered and 29% were not covered at all. Of non-covered AEs, 59% referred to the dermatologic system. Partially covered AEs related to endocrine and specific types of pain. CONCLUSION: Despite the high frequency of symptom-related toxicities related to ICI, these events are only partially covered (or not addressed) by current PRO instruments, even when combined. Further research is needed to develop new strategies to tailor PRO instruments to specific ICI toxicities.

Estratégia de implementação para a prática avançada de enfermagem na Atenção Primária à Saúde no Chile / Estrategia de implementación para la práctica avanzada de enfermería en la Atención Primaria de Salud en Chile / Implementation strategy for advanced practice nursing in primary health care in Chile

Resumo Objetivos: (i) Delinear os passos e progressos realizados pelo Chile para implementar a prática avançada do papel da enfermagem usando o Enfoque PEPPA (Participatory Evidence-based Patient-focused Process) como guia, (ii) demonstrar a eficácia da estrutura do PEPPA para a identificação de barreiras e guiar o processo de implementação, e (iii) discutir os próximos passos para a implementação do papel da enfermagem. Métodos: O enfoque inclui nove etapas em um processo flexível e iterativo. Resultados: O presente estudo fornece uma análise aprofundada das atividades empregadas para cada etapa do Enfoque PEPPA e sua contribuição para o desenvolvimento do papel da enfermagem na prática avançada no Chile. Em particular, as atividades de participação das partes interessadas foram essenciais para informar os principais decisores e formuladores de políticas de saúde sobre o papel das práticas avançadas de enfermagem, obtendo sua adesão e apoio ao papel da enfermagem e estabelecendo um consenso sobre suas prioridades. As estratégias usadas para superar alguns desafios na implementação das etapas do PEPPA também são discutidas, juntamente com os próximos passos para avaliar e monitorar a implementação e o estabelecimento do papel da enfermagem na prática avançada a longo prazo. Conclusão: O Enfoque PEPPA fornece diretrizes importantes para os países em que a prática avançada do papel da enfermagem está recém sendo introduzida, por meio da identificação e análise de barreiras para o delineamento eficaz do papel e sua implementação exitosa.

Resumen Objetivos: (i) Delinear los pasos y avances logrados por Chile para implementar el rol de la práctica avanzada de enfermería utilizando el enfoque PEPPA (Participatory Evidence-based Patient-focused Process) como guía, (ii) demostrar la eficacia de la estructura del PEPPA para identificar barreras y guiar el proceso de implementación, y (iii) debatir los próximos pasos para la implementación de roles. Métodos: El enfoque incluye nueve etapas dentro de un proceso flexible e interactivo. Resultados: El presente estudio ofrece un análisis profundo de las actividades empleadas en cada etapa del enfoque PEPPA y su contribución al desarrollo del rol de la práctica avanzada de enfermería en Chile. En particular, las actividades de participación de las partes interesadas fueron esenciales para informar a los principales tomadores de decisiones y formuladores de políticas de salud sobre el rol de las prácticas avanzadas de enfermería, con lo que se obtuvo su adhesión y apoyo al rol de la enfermería y se estableció un consenso sobre las prioridades. También se discuten las estrategias usadas para superar algunos problemas de la implementación de las etapas del PEPPA, junto con los próximos pasos para evaluar y monitorear la implementación y el establecimiento del rol de la práctica avanzada de enfermería a largo plazo. Conclusión: El enfoque PEPPA ofrece importantes directrices para los países en que el rol de la práctica avanzada de enfermería está recién siendo introducido, por medio de la identificación y análisis de barreras para el diseño eficaz de roles y su correcta implementación.

Abstract Objectives: (i) Outline the steps and progress made by Chile to implement the advanced practice nursing role using the PEPPA framework as a guide, (ii) demonstrate the effectiveness of the PEPPA framework to identify barriers and guide the implementation process, and (iii) discuss the next steps for role implementation. Methods: The framework includes nine steps in a flexible and iterative process. Results: This paper provides an in-depth analysis of activities employed for each step of the PEPPA Framework and their contribution to advanced practice nursing role development in Chile. In particular, stakeholder engagement activities were essential for informing key health care decision and policy-makers about the advanced practice nursing role, obtaining their buy-in and support for the role, and establishing consensus on role priorities. Strategies used to overcome some challenges in implementing framework steps are also discussed along with next steps to evaluate and monitor the implementation and establishment of the advanced practice nursing role in the long term. Conclusion: The PEPPA Framework provides important guidance for countries where advanced practice nursing roles are just being introduced by identifying and addressing barriers to the effective role design and successful implementation.