Moving guidelines into action: a report from Cancer Care Ontario’s event Let’s Get Moving: Exercise and Rehabilitation for Cancer Patients

Meeting Report


Moving guidelines into action: a report from Cancer Care Ontario’s event Let’s Get Moving: Exercise and Rehabilitation for Cancer Patients


J.R. Tomasone, PhD*, C. Zwaal, MSc, G. Kim, BHSc, D. Yuen, MPH§, J. Sussman, MD, R. Segal, MD#, on behalf of the Psychosocial Oncology and Survivorship Programs at Cancer Care Ontario


doi: https://doi.org/10.3747/co.24.3422


ABSTRACT

The need for an improved understanding of the rehabilitation services landscape in Ontario and for promotion of Cancer Care Ontario’s newly developed Exercise for People with Cancer guideline brought Cancer Care Ontario’s Psychosocial Oncology and Survivorship Programs together to host a knowledge translation and exchange event. The primary objectives of the event were to understand recommendations from Cancer Care Ontario’s new exercise guideline, to discuss key considerations and determine strategies for the implementation of the guideline recommendations, and to explore the current state and future directions of cancer rehabilitation in Ontario.

The event was attended by 124 stakeholders, including clinicians, allied health care professionals, administrators, patients, community partners, and academics representing each of the 13 regional cancer programs in Ontario. Attendees participated in two small-group activities that focused on determining the best approach for implementing the guideline recommendations into practice and discussing current barriers and the future state of cancer rehabilitation in Ontario. The activities allowed for networking and collaboration between attendees. The event provided an opportunity for the Psychosocial Oncology and Survivorship Programs to learn about the types of goals and plans that could be feasible in implementing the guideline in each region, and about ways to prioritize gaps in access to rehabilitation services and the types of implementation strategies that might be used to address the gaps. Overall, attendees were highly satisfied with the event, and the findings are being used to help inform research and practice activities with respect to guideline implementation and rehabilitation practice.

KEYWORDS: Exercise, rehabilitation services, guideline implementation, knowledge translation, knowledge exchange

INTRODUCTION

People with cancer look to rehabilitation services for strategies to cope with impairments resulting from cancer and its treatments, including changes in physical and cognitive abilities, independence and activities of daily living, and physical activity participation levels1. As survival rates improve, cancer rehabilitation continues to play a critical role in optimizing health and quality of life for survivors. However, Ontario currently lacks a coordinated cancer rehabilitation system, and inpatient and outpatient services both vary widely in terms of availability, expertise, and patient access. Cancer rehabilitation has therefore been identified as a strategic area of focus in the Ontario Cancer Plan IV: 2015–20192, calling for Cancer Care Ontario’s Psychosocial Oncology and Survivorship Programs to explore and identify opportunities to improve the delivery of rehabilitation services.

The need to better understand the rehabilitation services landscape in Ontario aligns with the launch of Cancer Care Ontario’s newly developed guideline, Exercise for People with Cancer3. Exercise has been shown to be a safe, cost-effective means to prevent and mitigate many of the secondary complications associated with cancer treatments and to enhance quality4 and quantity5,6 of life for cancer survivors. Given those benefits, exercise is a key modality in cancer rehabilitation. However, in the absence of a more comprehensive implementation strategy, simple publication of guidelines does not ensure uptake7,8.

The need to better understand the rehabilitation services landscape in Ontario and to promote the new exercise guideline within rehabilitation settings brought Cancer Care Ontario’s Psychosocial Oncology and Survivorship Programs together to host a knowledge translation and exchange event. The event, Let’s Get Moving: Exercise and Rehabilitation for Cancer Patients, was hosted in Toronto on 19 November 2015. The primary objectives of the event were to

  • ■ understand recommendations from Cancer Care Ontario’s newly developed Exercise for People with Cancer guideline (hereafter referred to as the guideline).

  • ■ discuss key considerations and determine strategies for implementation of the guideline recommendations.

  • ■ explore the current state and future directions of cancer rehabilitation in Ontario.

EVENT SUMMARY

The event was attended by 124 stakeholders representing each of the 13 regional cancer programs in Ontarioa. Stakeholders included clinicians (physicians, oncologists), allied health care professionals (nurses, physiotherapists, occupational therapists, exercise professionals), administrators (cancer centre program directors or managers), patient and family representatives, community partners (exercise or support program staff), academics (researchers, trainees), and Cancer Care Ontario directors and staff.

The day included a variety of presentations, breakout activities, and discussions that were presented or facilitated by a range of clinicians, allied health care providers, academics, community-members, and cancer survivors (Table i). In brief, after opening remarks and a patient story, the remainder of the morning session focused on the newly released Exercise for People with Cancer guideline.

TABLE I Session details for the Let’s Get Moving: Exercise and Rehabilitation for Cancer Patients event

 

The lead author of the guideline, Dr. Roanne Segal, began by delivering a series of presentations highlighting the importance of exercise in oncology care, the rigorous process that was used to develop the guideline9, and specifics about the guideline recommendations. After a stretch-and-nutrition break, implications for practice and key considerations for guideline implementation were discussed to set the stage for the first small-group activity. After lunch, the afternoon session focused on the current state and future directions of cancer rehabilitation in Ontario. From Dr. Eugene Chang’s overview of the importance of rehabilitation in the cancer journey, to Dr. Jonathan Sussman’s review of the results from a survey examining the current state of cancer rehabilitation in Ontario, to a multidisciplinary discussion panel that provided perspectives and experiences in cancer rehabilitation, attendees were provided with the information and insights necessary to complete the second small-group activity. The day concluded with an event summary and a call for attendees to continue the discussions in their regional cancer programs so that exercise and rehabilitation services for cancer survivors are optimized.

Small Group Activity 1: Exercise Guideline Goal-Setting and Action Planning

Unfortunately, without targeted dissemination activities and implementation interventions, the presence of a guideline does not guarantee the guideline’s use in practice10. Moreover, although guideline dissemination activities such as the Let’s Get Moving event and publication of the guideline on the Cancer Care Ontario Web site are important for creating awareness, dissemination alone is insufficient to change practice11,12. Implementation of the guideline will require both understanding and overcoming individual, organizational, and systematic barriers to guideline use13; targeted knowledge translation interventions are required. However, barriers are likely to differ depending on the local context and resources available at the 13 regional cancer programs in Ontario.

In consultation with the event planning committee, which comprised multidisciplinary stakeholders, a researcher with expertise in exercise behaviour change (JRT) designed an action-oriented small-group activity. The activity incorporated 2 behaviour-change techniques— goal-setting and action planning—that have been shown to be effective for changing behaviour in a number of contexts (behaviours as diverse as patient self-management to provider clinical practice) and at a number of levels (change at the individual, organizational, or systems level)14,15.

Attendees were allocated to small groups according to the regional cancer program in which they practiced, researched, or resided. Each group was tasked with the overall objective of determining the best approach for implementing the guideline recommendations into practice by developing a goal and an action plan for their regional cancer program. Each group was given a template that guided them through two tasks, with two examples of each task being used to generate the initial discussion and idea generationb. Groups were asked to record their thoughts on chart paper and the provided templates, which were collected at the end of the activity. Members of the event planning committee circulated between the groups during the activity to answer questions.

Groups were asked to spend 15 minutes formulating an objective or mini-goal that would help their regional cancer program achieve the overall goal of implementing the guideline recommendations in practice. The groups were asked to formulate goals that aligned with the smart principle16 so that their goals would be specific (presented in detail rather than in generalities), measurable (having outcomes that can be measured in a practice setting), attainable (being actually achievable), realistic (fit to the region’s current policies, practices, and resources), and timely (conducted within a period that aligns with other initiatives in the region).

Groups were then asked to spend 15 minutes on the second task, which focused on generating an action plan for implementing the group’s objective or mini-goal. Using the principles of action planning14, the groups were asked to specify who would be responsible for accomplishing the objective, what specific tasks would have to be accomplished, when the tasks would have to be completed (or for how long), where the tasks would take place or the outcomes be measured, and how the plan would be carried out in light of potential barriers or enablers in the local context.

Table ii summarizes the goals and action plans generated by the groups. Some of the common objectives and potential implementation strategies discussed by the groups were to

  • ■ increase provider awareness and knowledge of the guideline by discussing it at physician, allied health, and professional meetings.

  • ■ increase patient awareness and knowledge of the guideline by hosting “lunch and learn” sessions and patient education classes, by distributing a variety of patient education resources (for example, pamphlets, promotional videos), and by creating a patient version of the guideline.

  • ■ include exercise recommendations or prescriptions as part of treatment plans for patients, regardless of whether the prescription is given by a physician or another health provider.

  • ■ facilitate greater awareness and use of exercise programs in the region, including the creation of a database of existing programs, and generate a process for referral to those programs.

TABLE II Responses for small-group activity 1, exercise guideline goal-setting and action planning, by Ontario regional cancer program


 

Although most of the groups were able to identify at least 1 action plan for their goal, most plans were not specific with respect to how the plan would be implemented; thus, further work is required to examine the context-specific barriers and facilitators to guideline implementation in each regional cancer program before knowledge translation strategies are designed. To respond to that gap in knowledge, an online questionnaire assessing barriers and resources to guideline implementation in each of the 13 regional cancer programs will be launched in 2017. Follow-up interviews or focus groups will help researchers to identify feasible knowledge translation strategies for bolstering guideline use in each regional cancer program.

Small Group Activity 2: Current and Future States of Cancer Rehabilitation

Results of Cancer Care Ontario’s survey examining the current state of cancer rehabilitation identified large variability with respect to cancer rehabilitation services and patient access across the province. However, four barriers hindering the delivery of cancer rehabilitation programs or services consistently emerged:

  • ■ Funding constraints

  • ■ Limited resources for service provision (for instance, space, personnel)

  • ■ Provider knowledge gaps with respect to cancer rehabilitation

  • ■ Lack of buy-in or a clear mandate (or both) for cancer rehabilitation

Those barriers served as the foundation for the second, action-oriented group activity that was designed by the planning committee.

The overall goal of the second activity was to discuss current barriers and the future state of cancer rehabilitation in Ontario by generating an understanding of the root causes of identified barriers and by discussing potential improvement strategies. This time, attendees were divided into groups based on their role in cancer care rather than on their regional cancer program affiliation, such that each group would have a broad representation of stakeholders (for example, physician, social worker, nurse, patient and family advisor, researcher, policymaker, and so on) and, thus, varied perspectives. Each group was a provided with a template that guided them through the task, and a Cancer Care Ontario staff member facilitated and recorded the group’s thoughts on chart paper that was collected at the end of the activity.

Groups were asked to select one of the four barriers identified in the “current state” survey (or an alternative barrier not listed) and to spend 20 minutes identifying the underlying reason for the barrier’s existence. “The 5 Whys,” a technique that is effective for uncovering the root of a problem in health care, was used to help guide the group’s thinking. For the chosen barrier, group members were asked “why” the barrier exists, which might uncover an additional barrier or problem for which they were once again asked to respond “why.” This iterative process was encouraged to continue until the group felt that they had reached the root cause of the problem. With a richer understanding of their particular selected barrier, the group was then asked to spend 20 minutes discussing potential strategies to improve the barrier to cancer rehabilitation.

Table iii presents a complete summary of the barriers identified and the improvement strategies proposed by the eleven small groups. Two of the groups discussed the barriers of funding constraints and limited resources for services (for example, space, personnel), six groups discussed provider knowledge gaps with respect to cancer rehabilitation, and three groups discussed lack of a clear buy-in or mandate for cancer rehabilitation. No groups identified barriers that could not be classified into the barriers identified in Cancer Care Ontario’s “current state” survey. The root cause of each barrier varied by group, and each group identified from 4 to 12 ideas for dealing with the barrier. Ideas for improving cancer rehabilitation that consistently emerged in the groups, regardless of the barrier discussed, included

  • ■ incorporating exercise for people with cancer and cancer rehabilitation into medical school, medical residency, and professional school curricula.

  • ■ surveying and leveraging existing exercise and cancer rehabilitation services, and having an inventory available that providers and patients can access.

  • ■ enhancing the capacity of patients for self-management with respect to accessing exercise and rehabilitation services.

  • ■ enhancing use of technology to minimize transportation and space issues (for example, perhaps through the Ontario Telemedicine Network).

  • ■ creating mechanisms for enhancing communication between patients, providers, and regional cancer centres or regional cancer programs, as well as other types of rehabilitation programs (for example, cardiac rehabilitation and smoking cessation programs) to foster the sharing of lessons learned.

TABLE III Summary of responses for small-group activity 2: current and future states of cancer rehabilitation




 

Interestingly, a number of ideas for improvement identified in activity 2 mirrored the ideas for guideline implementation discussed in activity 1, including enhancing provider awareness or education and increasing awareness and use of existing programs in each regional cancer program.

Attendee Feedback

At the end of the day, attendees provided their feedback on an event evaluation form. Overall, attendees were highly satisfied with the event and strongly agreed that the event was worth attending. They indicated that the event met the stated objectives, that the small-group activities were worthwhile, and that they planned to share with their colleagues the information learned in the sessions. As one attendee said, “My favourite part was seeing how many people are so passionate about [exercise and cancer rehabilitation].”

CONCLUSIONS

Let’s Get Moving: Exercise and Rehabilitation for Cancer Patients presented a valuable opportunity for a group of multidisciplinary stakeholders to come together for an exploratory and action-oriented event focusing on exercise and rehabilitation for cancer patients. The small-group activities allowed for networking and collaboration between the various stakeholders that attended. The activities also provided an opportunity for the Psychosocial Oncology and Survivorship Programs at Cancer Care Ontario to learn about the types of goals and plans that might be feasible for implementing the Exercise for People with Cancer guideline in each region, and about ways to prioritize gaps in access to rehabilitation services and the types of implementation strategies that might address the gaps. Findings from the group activities are being used to help inform research and practice activities with respect to guideline implementation and rehabilitation practice into the future.

ACKNOWLEDGMENTS

The Let’s Get Moving: Exercise and Rehabilitation for Cancer Patients knowledge translation and exchange event was funded by Cancer Care Ontario’s Psychosocial Oncology and Survivorship Programs. The authors thank the additional members of the event planning committee, including Sari Greenwood, Holly Bradley, Kate Smith, Zahra Ismail, and Maria Grant for help with meeting preparation and organization. The authors also acknowledge the assistance of staff in Cancer Care Ontario’s Clinical Programs and Quality Initiatives division for facilitating discussion and note-taking during the second small-group activity. The Psychosocial Oncology and Survivorship Programs at Cancer Care Ontario thank all participants and speakers for attending this important event and for combining their knowledge and experiences to build connections and contribute to important discussions throughout the day.

CONFLICT OF INTEREST DISCLOSURES

We have read and understood Current Oncology’s policy on disclosing conflicts of interest, and we declare that we have none.

AUTHOR AFFILIATIONS

*School of Kinesiology and Health Studies, Queen’s University, Kingston;,
Program in Evidence-Based Care,,
Survivorship Program, and,
§Psychosocial Oncology Program, Cancer Care Ontario, Toronto;,
Juravinski Cancer Centre, Hamilton; and,
#The Ottawa Hospital Cancer Centre, Ottawa, ON..

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Correspondence to: Jennifer Tomasone, Program in Evidence-Based Care, Juravinski Hospital, 711 Concession Street, Hamilton, Ontario L8V 1C3. E-mail: ccopgi@mcmaster.ca

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aThe province of Ontario is divided into 13 regional cancer programs funded through Cancer Care Ontario. Regional cancer programs are responsible for implementing provincial standards and programs for cancer care, responding to local cancer issues, coordinating care between local and regional health care providers, and working to continually improve access to care, wait times, and quality (for more information, see the Cancer Care Ontario Web site: https://www.cancercare.on.ca/ocs/rcp). In general, each regional cancer program has 1 cancer centre; an exception is the Toronto Central Regional Cancer Program, which has 2 cancer centres (Princess Margaret Hospital and the Odette Cancer Centre). ( Return to Text )

bThe templates for the small-group activities are available from the first author upon request. ( Return to Text )


Current Oncology, VOLUME 24, NUMBER 1, February 2017







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ISSN: 1198-0052 (Print) ISSN: 1718-7729 (Online)