All six implementation strategies were delivered to the twelve services. However, the extent to which services received the relevant strategies as planned differed within core and enhanced services. Adaptations to strategies were made to facilitate delivery of implementation strategies. Two hundred and fifty-three interviews were conducted with 122 different staff members over three timepoints at T0 (n=88), T1, (n= 89) and T2 (n=76). See Table 2 for interview participant characteristics. There were 167 staff interviews analysed in the enhanced arm and 86 staff interviews in the core arm. The acceptance and attrition rates for staff who participated in interviews have been described elsewhere [25]. In brief, the response rates across all three time points were 64% (70% at T0, 66% at T1, and 57% at T2). There were 87 staff (71%) who participated in multiple interviews. Staff perceptions of the strategies generally remained stable over time and between randomisation arm, however, any changes or differences were noted. Quotes are identified by study arm: enhanced (E) versus core (C); profession, oncology service (S1-12), personal ID and time of assessment (T0-2). Additional quotes are provided in Additional file 2.

Table 2 Staff interview participants: demographic and professional characteristicsaFidelity and adaptations to awareness campaignsRoadshows

At least one in-person Roadshow was delivered to each service to inform staff about the ADAPT CP (Mean=3 per service, range 1-5) to raise awareness and increase engagement with the ADAPT CRCT. Adaptations to the number, duration and timing of Roadshows were made based on availability of staff and space within cancer services. Roadshows were held later than the intended eight weeks prior to implementation, due to: non-availability of forums/meetings till later (n=2), intended meeting falling on a holiday (n=1); or compressing the whole engagement process to enable Go-Live before year-end (n=1). In total, 271 staff across the 12 services attended a Roadshow (Mean=23 per service) (Table 3).

Table 3 Roadshow delivery and attendance

For many participants, the Roadshow was their first exposure to the ADAPT CP; those who attended had positive perceptions of this strategy, feeling it gave staff a “better understanding of what [the ADAPT CP]’s actually all about” (E_NURS_S12P02T0).

Some participants suggested holding the Roadshow or a refresher session closer to Go-Live, or holding more Roadshows to maximise staff attendance and ensure information was retained.

Reminder strategies:Posters

All services received two sets of posters, the first (ADAPT Is Coming) displayed prior to go-live, the second (ADAPT Support information) displayed at Go-live (on the first day of implementation). Enhanced strategy arm services received an additional ADAPT is LIVE poster at Go-live for one month, and two refresh/replacement of the ADAPT Support poster at 4 and 8 months into implementation. Of the 48 posters displayed across all services, the majority (n=34) were displayed as planned; some were displayed earlier or delayed. Reasons for delay included governance or staff approval, requests for additional information on the poster, the Champion forgetting, and a decision to delay display until the ADAPT Team site visit.

Further adaptations to the poster strategy were noted in some services. Six services from the enhanced study arm requested additional patient-facing posters, or changes to the posters to fit local context (i.e., e-posters for display on electronic poster boards). Two services requested further communication emails to staff or patients to increase awareness.

Newsletters

Five e-newsletters, tailored to each of the eight enhanced strategy arm services, were sent to service staff across the implementation period, containing information on service progress, and reminders about the ADAPT CP and Portal. Most newsletters (n=37/40) were emailed to service staff within one week of their intended delivery date. Service staff (typically the Champion) were asked to review and approve newsletters prior to dissemination; delays or failure to respond meant some newsletters were delayed.

Across the 1036 newsletters sent, only 239 (24%) of newsletters received were opened. Across all services, 48% of staff opened at least one newsletter. In addition to written content, newsletters contained on average one link (range 0-2) to additional information, including online health professional training. However, clicks on newsletter links were very low: 7 clicks across all newsletters received (0.6% of maximum possible clicks). Services were encouraged to tailor newsletter content to their service; there was generally low engagement with this tailoring. See Fig. 1.

Fig. 1

Percentage of newsletters opened over time across all enhanced strategy arm services

Go-live email correspondence (See Table 1, 1.3)

The ADAPT team sent a planned email, the “Go-Live Email Correspondence” which contained essential information about the ADAPT CP and Portal, the date of CRCT implementation and what staff needed to do in preparation for this, for site Champions to disseminate to staff, as planned in the eight core services.

Some participants reported having seen ADAPT posters and email correspondence, whilst others had not. Whilst some commented that these strategies acted as “a constant reminder that… the program is there” (NURS_S03P03T0) and helped to increase awareness particularly amongst non-lead team staff, others felt these were easily overlooked and thus not effective.

Participants commented that briefly mentioning ADAPT during existing meetings may be more effective to raise awareness amongst wider service staff. Overall, participants commented that the combined awareness strategies (Roadshows, posters, emails, newsletters) helped to increase wider service staff awareness prior to Go-Live.

“with the posters and the emails, and the face-to-face sessions, it was really… capturing everybody’s attention… so when it went live… everybody was on board with it… we…registered lots of patients in the first few weeks which was really good.” (E_AH_S06P03T2)

Fidelity to champion correspondence

Champions at each service were sent six Portal “Tips and Tricks” emails, each containing a “Portal Tip” to be circulated by Champions to registered ADAPT Portal Users at 4, 8, 12, 16, 28 and 40 weeks into implementation. Most were disseminated as planned (62/72), the remaining were sent earlier (3/72) or later (7/72). We were unable to capture how many Portal Users received the “Portal Tip” email.

Most participants were aware who was nominated as the ADAPT champion at their service, believing that Champions played a critical role in driving service change, and in relation to ADAPT. More generally, these champions increased awareness and engagement of service staff including senior management and ensured responsibility for implementation was not diffused.

“having key players… who check in and… rally a team… can be dependent if any issues come up… and just having someone who has relationships with the key players who can move things forward, I think that’s probably pretty critical.” (E_PSYCH_S09P03T0)

Participants saw the ADAPT champion as a ‘go-to’ person who could train and upskill staff, communicate necessary information about the ADAPT CP and Portal, answer questions and troubleshoot issues as they arose. This eased the perceived burden of implementation, as one participant said:

“I think yeah, the champions were key in that finding solutions to the implementation and being committed to doing it. And making sure everybody else who needed to do something, did their thing.” (C_MED_S01P09T2)

Attributes of a successful champion

Participants commented that the champion’s role, authority and workload capacity could impact the success of this strategy.

Role

Clinical staff with regular patient contact were seen as well-placed to champion, tailor and enact the CP. They had well-established collegial relationships with staff implementing the CP, making them approachable if staff required assistance.

“[champion]’s got a lot of clinical experience and especially in psycho-oncology…she’s very good at seeing how systems work and what the patients need clinically and trying to modify or trying to make ADAPT fit with the care, with the needs of the service so… I think she’d be good.” (C_NURS_S11P04T0)

Having a champion who held a clinical role also meant this role could continue beyond the 12-month implementation period. Where the champion role was taken on by, for example, a clinical trials staff member there were concerns this role would not continue beyond the implementation period.

Authority

Participants commented on the importance of service change being championed or supported by senior management staff. At one service participants commented that champions “lacked the power” to secure staff engagement, which made this strategy less effective.

Workload Capacity

Participants acknowledged that championing ADAPT would require additional time and energy on top of the Champion’s existing clinical load. Hence the success of this strategy depended upon the champion’s ability to dedicate time to this role. For example, where funding was secured for a dedicated part-time role, the ADAPT CP implementation could be successfully prioritised.

“I think that was the key because I think having someone dedicated to that role, means actually having it done. Whereas I think… if they get that added to their role as part of their current role… it can be quite difficult to add that to their workload.” (C_NURS_S12P01T2)

On the flip-side, however, staff in the same service commented that having a designated champion limited wider service staff engagement.

“having the champion also, to have it as her focus role is a positive thing, because I guess in that regard a number of us have stepped back thinking, well, that’s her role now.” (C_AH_S12P06T0)

Fidelity and changes to educationClinical Pathway Overview Training

All services received CP Overview Training. Ideally, cancer service staff co-led this training with the ADAPT Program manager to increase ownership and staff engagement. Psychosocial staff co-led training at 9 services (Table 4). Delivery of training was delayed at some services. Changes to planned delivery of training was due to: service awaiting governance approval, delayed nursing staff approval of screening and scheduling issues.

Table 4 Attendance and duration of the clinical pathway, portal overview, portal user and super user training1Portal overview training

Twenty Portal Overview Training sessions of on average 24 minutes (range 5-135 minutes) were held. Adaptations to this strategy included, providing abbreviated 5-minute, 2-3 slide Portal Overview presentation during their CP Overview Training upon site request instead of the training session (n=6 services) (Table 4). Reasons for this were due to difficulty finding sufficient time for staff to attend.

Portal user training

A total of 79 Portal User training sessions (average 43 minutes) were held (average 7 trainings per service, range 0-14 trainings). Most (n=59) were one-on-one, the rest (n=20) were in small groups (average group-size, n=3, range 2-9). A total of 121 Portal User Training attendances were recorded (Mean=10 attendances per service). All portal site administrators (n=12) at participating cancer services received the super user training as planned.

Training sessions participants reported these as useful, succinct, and professionally delivered. Participants particularly appreciated the one-on-one nature of the Portal User Training, which was interactive (a “learn by doing” approach; E_PSYCH_S08P04T1), tailored to their role and allowed them to ask questions.

Fidelity in delivery of education relies on capacity of services to facilitate staff attendance, which is dependent on the needs of the clinical area on a given day and time. Flexibility and adaptability in meeting needs of part-time and shift-based workforce, and staff turnover is also required. Participants commented that education needed to accommodate this to optimise effectiveness. Advance scheduling, flexible and adaptable delivery and keeping sessions short helped to maximise attendance as it enabled staff to fit this in alongside their clinical loads.

“we’ve got a very small permanent staff base at the moment so [training] will need to be rolled out again as we recruit… repeating them keeping in mind that the, kind of, issues associated with a rotating roster and actually capturing people.” (E_NURS_S09P02T0).

At T1 and T2, some participants commented that they received additional training from the ADAPT Team during the implementation period (e.g., staff new to the service, returned from secondment/ leave, or missed initial training), which was viewed positively.

“nothing was too much trouble. Every person was trained…any new staff that we had new training needs… they did that, and were really very flexible, very accommodating… I guess without that…everyone would have gone, no, this is too hard.” (E_NURS_S02P08T2)

Impact of education on preparedness

Most staff felt they had been provided with adequate information about the CP and Portal to start implementing the ADAPT CP at their service.

At T0, participants felt they needed to use the ADAPT CP and Portal ‘in practice’ to solidify the knowledge and skills learnt during training. Whilst they thought implementation would initially be challenging, they expressed faith that it would get easier over time and with practice, and that problems which arose would be overcome.

“there’s probably going to be things that we need to iron out and problem solve as they crop up… we haven’t got it perfect… but I think we’re prepared enough to start actioning it.” (E_PSYCH_S07P02T0)

“once I start playing around with the portal…registering patients… really getting stuck into it, it’s going to be a lot easier” (C_ADMIN_S01P05T0)

Training was perceived to be most effective when delivered close to staff enactment of the CP and Portal. Time-lags between training and first use, or intermittent use of the CP and Portal, were barriers to preparedness as it meant information was less likely to be retained and staff had to “re-learn things again” (C_NURS_S01P01T2). Refresher training just prior to Go-Live, or throughout the 12-month implementation period when staff were enacting the CP, were suggested.

Using the ADAPT CP and Portal ‘in practice’, contacting the ADAPT Support Service, and referring to the User Guides and Quick Guides helped to overcome issues and increased preparedness.

Fidelity to academic detailing and support

Champions were provided with a written (de-identified) report summarising amongst other issues that were explored during the staff interviews, staff acceptability of the ADAPT CP implementation (T0, T1, T2). Reports were sent to the ADAPT Champion at all services, as planned, after completion of staff interviews at each timepoint.

Engagement meetings

All services participated in Engagement Meetings to prepare for the implementation of the ADAPT CP, and challenges and benefits of convening a local Lead team regularly with the ADAPT team were evident. Across the results, we noted a lack of consistency in using the Engagement Meetings strategy (6-8 planned meetings spaced about 2 weeks apart). Reasons for this included non-availability of Lead Team staff, and service desire to move efficiently through decision-making. For example, at one service, delays in forming a Lead Team and securing multidisciplinary attendance stalled decision-making and led to a protracted Engagement Phase (n=12 meetings across 41 weeks) (Table 5). Meetings were in-person (n=55, 69%) or via teleconference (n=25, 31%) and involved 402 attendees (Mean=34 per service), the majority (n=370, 92%) lead team members. The time from first Engagement Meeting to CRCT implementation/Go-Live was, on average, 25 weeks (range 10-41 weeks).

Table 5 Number, duration and attendances to the engagement meetings

On a more positive note, those who attended appreciated their structured nature of having clear agenda facilitated focused decision-making, were succinct, and had a clear purpose.

“they were really quick and they ran on-time… straight to the point… there was a purpose behind them and they answered the questions, and yeah, the agenda was set up really well.” (C_PSYCH_S03P03T0)

Having time between meetings enabled tailoring decisions made during meetings to be discussed outside meetings and later finalised or revised. However, some participants noted too many meetings, or too much time spent during meetings revising tailoring decisions made previously, which ensured preparedness but was perceived as “overkill”. These participants suggested that meetings be condensed, for example by minimising the time spent reviewing tailoring decisions or having fewer meetings that lasted longer.

At one service, adaptations to meeting mode (i.e., held via email) at the service’s request, which reduced burden and enabled them to fit within staff workload/flow.

“[ADAPT Program Manager] tailored it to suit us a little better by disbanding the actual telehealth meetings and actually doing a lot of it via email, which was really good… [engagement meetings] were only an hour but that was a big, big drain on trying to do your work and getting the meeting and dedicating that time. A lot of information very quickly, but at least it was backed up with emails and sort of discussion that way.” (E_NURS_S02P05T0)

Impact of engagement meetings on preparedness and ownership

Having a series of meetings prior to Go-live increased staff awareness of ADAPT and ensured staff from different disciplines were “on the same page” (E_PSYCH_S07P02T0) about how the CP would be enacted at their service and what was required of them.

“we just managed to build that momentum through those meetings so that the key people, the psychologists, the clinical trial staff, senior nursing staff in the clinic and doctors all had enough awareness, that meant when it went live, it was fresh, and they were really able to capture people.” (E_MED_S06P02T0)

However, one participant commented that staff roles/responsibilities needed to be more clearly specified from the earliest engagement meetings to maximise engagement.

“if you were slightly ignorant of what’s going on and not quite clear about what you are being asked to do, there’s sort of a sense of look, I’m pretty busy anyway, and if this means extra work for me, and, you know, my team, well, then maybe I won’t do it.” (E_MED_S06P02T0)

Participants described working collaboratively with the ADAPT team during the engagement meetings to tailor the CP to their site. The ability for staff to have input into their ADAPT roles also promoted a sense of ownership and ensured roles fit their skills, experience and capacity.

In contrast, nursing staff at one site felt they had limited input during the meetings and were concerned that their ADAPT roles had the potential to exceed their scope of clinical practice in delivering psychosocial care.

“I know in nursing we do deal with… mental health and that, but…in terms of triaging it feels like it is, you know, we’re not trained psychologists and even though a patient may be at a level two in their survey it feels like it could lead to a lot more.” (E_NURS_S04P03T0)

Monthly meetings (enhanced strategy arm services)

Monthly meetings with the eight enhanced strategy arm services were scheduled in advance (n=96); timing and mode of meetings was adapted to maximise lead team attendance. Eighty-four monthly meetings of on average 34 minutes, were held (on average 10 meetings per service) (Table 6). Meetings were held in-person (n=41, 49%), online (n=35, 42%) or via teleconference (n=8, 10%). Reasons for discrepancies in the number of meetings delivered (n=84 compared to 96 planned) included cancellation upon service request and lead team unavailability (e.g., leave, holiday period).

Table 6 Number, duration and attendances to the monthly meetings

Participants from Enhanced services found the monthly meetings valuable; they gave staff a chance to review ADAPT progress at their site, identify emergent implementation barriers and brainstorm possible solutions. Discussing site progress throughout the implementation period also helped to maintain staff engagement and facilitated team cohesion.

“keeping people updated it creates a bit of buy in as well so people remain interested in, enthusiastic and involved” (E_AH_S06P03T2)

“we always use that meeting as a forum for bring up problems and getting solutions of those problems” (E_NURS_S02P08T1)

Staff were positive about the ADAPT Team facilitators, who drew on previous implementation experience to help services come up with solutions to identified barriers.

“[the ADAPT Team] tried to really brainstorm, specifically what was going on at our local site. They didn’t pass judgement. They weren’t saying you’ve got to do better or anything like that… trying to facilitate us coming up with the answers which I thought was excellent.” (E_AH_S10P07T2)

However, some staff commented that meetings were difficult to attend for example due to competing clinical demands, shift work, or that there was inadequate representation (particularly of senior management staff) to optimise effectiveness.

“it’s all very well that we’d come up with any ideas of what can happen, what could happen… but unless there’s higher management there to action it … it makes it really difficult” (E_AH_S06P03T2)

Participants from Core services reported having informal conversations about ADAPT with other staff, adding short discussions about ADAPT to existing meetings (e.g. team or steering committee meetings) or trouble-shooting issues individually as they arose.

A few Core participants commented that regular meetings throughout implementation would have helped to identify and address emergent implementation barriers and maintain staff engagement – which were otherwise difficult to raise.

“[meetings would] open up a dialogue about what’s working, what’s not working, what we can do differently, what we can do better” (C_PSYCH_S11P01T1)

Fidelity to reports

Twenty-two staff across all services generated at least one report in the ADAPT Portal (Mean=2 staff per service, range = 0-6 staff); most were local Champions or Portal Site Administrators (n=13, 59%). Across all services 525 reports were generated, most frequently the Screening Report (n=190, 37%), which provided a summary of patient screening events in the reporting period and the Planned Notifications report (n=108, 21%), which showed upcoming notifications to be sent to cancer service staff.

Content of monthly reports were adapted upon service requests. Few (n=3) enhanced strategy arm sites requested additional information for inclusion in these reports, to enable them to focus on specific data of interest, such as patient registrations by tumour streams or clinical departments. The monthly reports enabled staff to reflect on their service’s progress and identify and resolve emergent issues. They also helped to maintain staff engagement by “keeping the program on people’s radar” (C_MED_S11P05T1). At one site, reports showed that no referrals to psychosocial support had been made despite a number of patients screening high prompting staff about the lack of psychosocial supports available, and subsequently new referral pathways were identified. Several staff commented that the Portal-generated patient reports helped them to identify and understand patients’ issues, which facilitated triage conversations and treatment.

“because some of the people that were screening, I was already seeing or…were getting referrals for from other sources. So, the information on their screening…was useful for me when I was seeing them.” (E_PSYCH_S02P01T1)

Fidelity of technical support

There were approximately 485 contacts between service staff, patients and the ADAPT Team during the engagement and implementation periods. Approximately 37% of contacts (~ 179 contacts) related to registering patient or staff on the ADAPT Portal and log-in issues followed by technical issues related to online screening (approximately 99 contacts).

Most participants reported being aware of the ADAPT Support Service and an ability to access this at any time. Some participants reported having used the service, whilst for others there had been no need. Participants who accessed the service were positive about this strategy and reported it was easy to access and that the ADAPT Team were approachable, “readily available” (E_PSYCH_S10P04T0) and responded quickly. The ADAPT Support Service helped participants to implement the CP and troubleshoot issues as they arose.

“If I had to email about something or I’d queried something, it’s been immediate, they’ve come back… they’ve been supportive and they’re wanting this to work and wanting to work with us. So, I’ve felt that has really set the standard for me that, you know, this is a relationship and I’m sure that we can make this work.” (C_PSYCH_S01P03T0)