This article, titled “The utility of the implementation science framework “Integrated Promoting Action on Research Implementation in Health Services” (i‑PARIHS) and the facilitator role for introducing patient‑reported outcome measures (PROMs) in a medical oncology outpatient department”, published in Quality of Life Research in 2021, explores the effectiveness of an implementation science framework in integrating patient-reported outcome measures into routine clinical care.
Key aspects of the article include:
- Purpose of the Study: The study aimed to evaluate the utility of the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework for introducing Patient-Reported Outcome Measures (PROMs) into a medical oncology outpatient department. It also sought to understand the conditions critical for integrating PROMs, describe the Facilitator’s role in overcoming barriers, and determine changes in clinician and staff perceptions of PROMs.
- What are PROMs? PROMs are tools that improve communication between patients and clinicians, which can lead to benefits in quality of life and survival in clinical trials. In this study, the PRO-CTCAE (Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events) was used, measuring cancer-specific symptoms like constipation, nausea, fatigue, and pain. The immediate availability of standardized symptom reports from PROMs has been shown to improve symptom detection, management, quality of life, and mortality in randomized controlled trials.
- The i-PARIHS Framework: This framework is designed for implementing complex interventions in healthcare. It identifies four core constructs for implementation: Facilitation, Innovation, Context, and Recipients.
- Facilitation is central to i-PARIHS, activating implementation by assessing and responding to characteristics of the Innovation and the Recipients within their Contextual setting. It plays a particularly important role in overcoming barriers.
- The Innovation refers to “what” is implemented, in this case, the PRO-CTCAE.
- The Recipients are “who” receives the intervention, focusing on clinical staff (nurses, doctors, allied health professionals) in this study.
- The Context is “where” the implementation takes place, encompassing the characteristics of the setting, including inner and outer context factors like leadership support, culture, and existing systems.
- Intervention and Setting: The PROMs intervention involved patients completing the PRO-CTCAE on a touchscreen in the waiting room of two oncology clinics in Queensland, Australia, with reports then being printed for the care team and imported into the electronic medical record.
- Key Findings on Barriers and Enablers: The i-PARIHS framework was useful in identifying various factors impacting implementation.
- Identified Barriers included time constraints, previous negative experiences with technology, concerns about disproportionate burden on staff if colleagues did not engage, professional silos, limited inter-discipline communication. Workflow compatibility was also an initial barrier, as PROM completion and filing did not initially fit easily into existing workflows. Concerns about the health service’s resources to respond to additional patient needs identified by PROMs were also noted.
- Identified Enablers included good leadership support, a culture of learning, strong professional values of person-centred care, the emergence of peer champions, and project support from the Medical Director. The clarity of the PRO-CTCAE, its trialability (starting small scale), and its perceived relative advantage (supported by credible research) were also enablers.
- Role of the Facilitator: A novice Facilitator (an oncology nurse) supported by an expert Facilitator and a multidisciplinary peer group, used various strategies to address identified barriers. These strategies included:
- Educational strategies such as training sessions for clinicians and staff on PROMs and interpretation.
- Hands-on technical support and contingent problem-solving to help the innovation integrate into workflows.
- Open dialogue to alleviate staff concerns about colleagues’ engagement and potential burdens.
- Maintaining momentum through consistent PROMs reporting at the clinic level and ensuring transfer into the EMR.
- Audit and feedback processes were also used to inform and engage care teams.
- Changes in Staff Perceptions: Post-implementation surveys showed an improvement in staff’s perceived usefulness, perceived understanding, and interpretation skills for PROMs. While staff acceptability of PROMs increased, the lack of time to use PROMs during patient visits remained a major perceived barrier, particularly for nursing and medical staff.
- Conclusion: The study concluded that the i-PARIHS framework was useful for guiding the implementation of PROMs in routine oncology care. All four core i-PARIHS constructs needed to be addressed for successful implementation, with Facilitation playing a particularly important role in moderating the other domains. The article highlights that while the PROMs intervention was acceptable to many staff, complex barriers suggest that sustainability may not be achieved if the facilitation role is withdrawn, underscoring the need for further research into efficient implementation and sustainability of PROMs.
Reference: Roberts, N. A., Janda, M., Stover, A. M., Alexander, K. E., Wyld, D., Mudge, A., & ISOQOL PROMs/PREMs in Clinical Practice Implementation Science Work Group. (2021). The utility of the implementation science framework “Integrated Promoting Action on Research Implementation in Health Services”(i-PARIHS) and the facilitator role for introducing patient-reported outcome measures (PROMs) in a medical oncology outpatient department. Quality of Life Research, 30, 3063-3071.
