Frameworks are models to systematically develop, manage, and evaluate interventions. In contrast, theories support the understanding of inter-related concepts to explain relationships between variables. Frameworks and theories can also be called models - especially when they are visualised in graphic or picture format (61).
The Medical Research Council (MRC) framework for complex interventions (62) defines four phases for development, feasibility/piloting, evaluation and dissemination of complex interventions. We decided to use different theoretical frameworks for completing the development phase, structuring the feasibility/piloting and the evaluation phases. The three frameworks used for the Symptom Navi Pilot Study were: the COM-B (Capability Opportunity Motivation – Behaviour) model (6), the Reach Effectiveness – Adoption Implementation Maintenance (RE-AIM) framework (3), and the Theory of Symptom Self-Management (TSSM) (63, 64).
We identified the need for a model to structure the nurse training to ensure consistent SNP application at each participating centre and supporting behaviour change of nurses and fidelity with the SMS training manual. The COM-B model was employed to standardise and evaluate the nurse training to complete the development of the SNP. Therefore, the COM-B model was applied to facilitate first behaviour change on nursing level to empower nurses in supporting patient behaviour change to self-manage symptoms. The RE-AIM framework was employed to evaluate the SNP implementation process including feasibility and piloting as well as exploring the impact of the programme on patient reported outcomes. The strength of this framework is to consider outcomes on individual and organisational level for a comprehensive evaluation of multiple factors potentially impacting the implementation process. The SNP is based on advanced nursing skills to tailor SMS interventions (e.g. semi-structured nurse-led consultations) to patient’s needs. The aim of the SNP is to support symptom self-management by using appropriate information leaflets (SN-Flyers) in at least two semi-structured consultations to facilitate patient’s perceived efficacy for self-management (8). To operationalise patient-reported outcomes related to symptom experience, perceived self-efficacy, and patient self-management behaviour, the RE-AIM framework was complemented with the TSSM. All applied frameworks are summarised in the following paragraphs.
Capability Opportunity Motivation – Behaviour (COM-B) Model
The COM-B model identifies four correlated dimensions (capability, opportunity, motivation, and behaviour) that are crucial for behaviour change (6). The model posits that motivation is influenced by individual capabilities and opportunities that are defined by social and group norms (67).
Therefore, motivation is a moderator for individual behaviour. Capabilities and opportunities influence behaviour achievement directly as well as indirectly (via motivation) (see Figure 5, second article, page 36). Capabilities, opportunities, and motivation are targets for changing behaviour. An individual’s psychological and physical capacity to perform an activity comprise the capability dimension, whereas opportunities (i.e. social and physical factors) may support or hinder behaviour respectively. Motivation is a moderator and is influenced by individual capacity and contextual opportunities. Motivation incorporates reflective and automatic processes inherent in analytical decision-making as well as emotional responses (6). The COM-B model consider successful behaviour change depends on involved individuals and environmental factors that support/hinder a specific behaviour. The Theoretical Domains Framework (TDF) complements the COM-B model to facilitate intervention development and reporting (68).
We used COM-B components and TDF constructs to guide the structure of the nurse training procedures and content. The synthesis aims to support nurses in adopting the SNP (i.e. six key elements of semi-structured consultations) and to consider potential adaptations needed to meet workflows at participating centres (Table 4).
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Physical Skills Not applicable
Opportunity
Social Social influences Acknowledge local competencies
Physical Environmental context and resources Place where consultations will be employed, collaboration in nursing team
Motivation
Reflective Social / professional role & identity Beliefs about capabilities
Automatic Social / professional role & identity Optimism
Reinforcement Emotion
Follow-up training based on nurses’
questions / concerns on feasibility and acceptability of the SNP
Abbreviations: COM-B, capability, opportunity, motivation, behaviour; SN-Flyers, Symptom Navi Flyers; SNP, Symptom Navi Programme; TDF, Theoretical Domains Framework
The COM-B model is applicable for structuring the necessary procedures (i.e. nurse SNP training) to implement a new intervention at different cancer outpatient centres. However, to define and operationalise the outcomes for every RE-AIM dimension requires a third framework – the Theory of Symptom Self-Management.
Reach Effectiveness – Adoption Implementation Maintenance (RE-AIM) framework
Implementing a complex intervention in different clinical settings demands iterative procedures - starting with an accurate description of the intervention and identified components which may need to be adapted in different settings (62, 65). It is also important to evaluate the implementation process to recognise how components work in real life and what adaptations nurses make apply when delivering the intervention. Successful implementation depends on serval factors. Health care providers must find the intervention acceptable and be willing to deliver it as intended. Additionally, effective implementation also depends on a benevolent and supportive environment.
The RE-AIM framework includes five dimensions for a comprehensive evaluation of the implementation process and has been used widely for nearly 20 years (66). Reach and effectiveness dimensions operate at the individual level meaning the people who potentially benefit from the intervention. The other dimensions (adoption, implementation, and maintenance) focus on staff and setting of the intervention (66). Table 3 provides definitions of the five RE-AIM dimensions in relation to the SNP. An overview of the outcomes based on the RE-AIM framework is included in the study protocol (7).
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Table 4: Definition of RE-AIM dimensions related to the SNP Dimension Focus at level Definition
Reach Individual The absolute number, proportion, and representativeness of patients willing to use the SNP
Effectiveness Individual The impact of the SNP on patient-reported outcomes and potential negative effects.
Adoption Organisational The absolute number, proportion, and representativeness of cancer centres and nurses willing to employ the SNP.
Implementation Organisational
The fidelity to the key-elements of the semi-structured consultations defined in the training manual; the consistency of delivery as intended, adaptations made, time used for consultations.
Maintenance (not included in pilot study)
Individual and organisational
At the individual level: The long-term effects of the SNP on outcomes after 6 or more months after the most recent semi-structured consultation.
At the organisational level: The extent to which the SNP becomes institutionalised or part of the routine practices.
In the Symptom Navi Pilot Study, the maintenance dimension of the RE-AIM framework was not included as it relates to long-term evaluation of the program what is not feasible within the context of a pilot study.
Theory of Symptom Self-Management (TSSM)
The effectiveness dimension of the RE-AIM framework aims to evaluate the impact of SNP at the patient individual level. The TSSM was chosen to operationalise patient reported outcomes because it integrates a nursing symptom management theory (Theory of Unpleasant Symptoms TOUS) and Bandura’s self-efficacy theory (58, 69) to measure perceived self-efficacy for self-managing fatigue.
The TOUS emphasises that symptoms are multidimensional, influenced by individual characteristics, and affect patient functional status (70). Bandura proposes that individuals who believe they can self-manage their symptoms (termed self-efficacy) achieve better functional outcomes. The mediating function of self-efficacy is central to the TSSM which suggests that SMS interventions should facilitate efficacy for a target behaviour. This position is consistent with the self-management education framework published by Howell and colleagues (22).
The TSSM assumes that patient self-management behaviour will be affected by his/her symptom severity and burden as well as perceived self-efficacy for self-management behaviour.
Consequently, patient physical status will be affected by co-morbidities, cancer treatment and self-management behaviour (58, 64). An initial evaluation of the TSSM investigated correlations between patient characteristics, cancer related fatigue (and other concomitant symptoms) and perceived self-efficacy for fatigue self-management. Analysis revealed that more comorbidities (t = -7.47), increased cancer-related fatigue severity (t = -5.30) and more symptoms (t = -2.71) predicted lower physical functional status (63).The observed relationship was re-tested confirming that perceived self-efficacy for fatigue self-management partially mediated the relationship between fatigue severity and physical functional status in patients affected by cancer (71). Several studies have used the TSSM to examine self-management behaviours including patients after surgery for lung cancer (64, 71-74).
The SNP was developed for patients with any cancer diagnosis, and therefore, evaluating its effectiveness cannot focus on a single symptom (i.e. fatigue). However, we assumed that a circular relationship exists between symptom severity, perceived self-efficacy, and self-management behaviour and these aspects will be important for any symptom self-management caused by cancer/treatment. Based on this assumption, we posit the SNP could affect the proposed circular relationship and ultimately improve patient physical functional status during active anticancer treatments (Figure 1).
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Figure 1: Model for operationalising the outcomes of the Symptom Navi Pilot Study based on the TSSM
Based on the RE-AIM framework, symptom self-management behaviour, and ultimately, patient physical functional status will depend on delivering the intervention as intended and therefore outcomes on individual and organisational level should be assessed and evaluated. The Methods chapter describes how the selected frameworks were applied in the pilot study.
Objectives of the doctoral thesis
By the end of 2015, several cancer outpatient centres expressed interest in implementing the SNP program at their centres. Initial evaluations showed the SNP was highly accepted and deemed helpful by patients and health care professionals in standardising SMS (1, 2, 75). Implementing the SNP is challenging for nurses as it demands behaviour change to tailor every intervention. Nurses are expected to shape interventions based on patient needs and the prescribed anticancer regimen while concurrently setting collaborative priorities and considering a variety of outcomes. According to the Medical Research Council (MRC), the SNP is considered a complex intervention because it integrates multiple interacting components, requires challenging behaviours, includes a variety of outcomes, and demands intervention tailoring. Accordingly, effectiveness and safety should be tested prior to disseminating a complex intervention into widespread practice (62).
Evidence suggests that implementing a new program into clinical practice requires stakeholders’
involvement and a systemic approach (76). Therefore, we designed a multi-method pilot study (Symptom Navi Pilot Study) to comprehensively evaluate the implementation process. This doctoral thesis focuses on four objectives decided at the intermediate thesis exam in March 2017:
1) Evaluate feasibility regarding patients’ accrual and retention rates, 2) Evaluate nurses training,
3) Test preliminary effectiveness of the SN©P, 4) Explore nurses’ fidelity to training manual.
Therefore, this doctoral thesis work informed a “go versus no go” decision for proceeding with a subsequent large, multinational study to formally test SNP effectiveness (77).
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