title: Implementation of Symptom Protocols for Nurses Providing Telephone-Based Cancer Symptom Management: A Comparative Case Study.
abstract: BACKGROUND
  The pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS) team developed 13 evidence-informed protocols for symptom management.
  
  
  OBJECTIVE
  To build an effective and sustainable approach for implementing the COSTaRS protocols for nurses providing telephone-based symptom support to cancer patients.
  
  
  METHODS
  A comparative case study was guided by the Knowledge to Action Framework. Three cases were created for three Canadian oncology programs that have nurses providing telephone support. Teams of researchers and knowledge users: (a) assessed barriers and facilitators influencing protocol use, (b) adapted protocols for local use, (c) intervened to address barriers, (d) monitored use, and (e) assessed barriers and facilitators influencing sustained use. Analysis was within and across cases.
  
  
  RESULTS
  At baseline, >85% nurses rated protocols positively but barriers were identified (64-80% needed training). Patients and families identified similar barriers and thought protocols would enhance consistency among nurses teaching self-management. Twenty-two COSTaRS workshops reached 85% to 97% of targeted nurses (N = 119). Nurses felt more confident with symptom management and using the COSTaRS protocols (p < .01). Protocol adaptations addressed barriers (e.g., health records approval, creating pocket versions, distributing with telephone messages). Chart audits revealed that protocols used were documented for 11% to 47% of patient calls. Sustained use requires organizational alignment and ongoing leadership support.
  
  
  CONCLUSIONS
  Protocol uptake was similar to trials that have evaluated tailored interventions to improve professional practice by overcoming identified barriers. Collaborating with knowledge users facilitated interpretation of findings, aided protocol adaptation, and supported implementation. Protocol implementation in nursing requires a tailored approach. A multifaceted intervention approach increased nurses' use of evidence-informed protocols during telephone calls with patients about symptoms. Training and other interventions improved nurses' confidence with using COSTaRS protocols and their uptake was evident in some documented telephone calls. Protocols could be adapted for use by patients and nurses globally.
authors.affiliation: Professor, School of Nursing, University of Ottawa, and Scientist, Ottawa Hospital Research Institute, Ottawa, Canada.
authors.forename: Dawn
authors.initials: D
authors.lastname: Stacey
authors.affiliation: Director, Person Centred Perspective, Canadian Partnership Against Cancer, Toronto, Ontario, Canada.
authors.forename: Esther
authors.initials: E
authors.lastname: Green
authors.affiliation: Advance Practice Nurse, Palliative Care, Health Sciences North, Sudbury, Ontario, Canada.
authors.forename: Barbara
authors.initials: B
authors.lastname: Ballantyne
authors.affiliation: Health Services Manager, Ambulatory Oncology Clinics, Cancer Care Program, QEII Health Sciences Centre, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada.
authors.forename: Joy
authors.initials: J
authors.lastname: Tarasuk
authors.affiliation: Clinical Research Coordinator, Cancer Care Mission, McGill University Health Centre Research Institute, Montreal, Quebec, Canada.
authors.forename: Myriam
authors.initials: M
authors.lastname: Skrutkowski
authors.affiliation: Clinical Research Coordinator, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
authors.forename: Meg
authors.initials: M
authors.lastname: Carley
authors.affiliation: Clinical Nurse Specialist, Oncology, Horizon Health Network, Fredericton and Upper River Valley Area, Fredericton, New Brunswick, Canada.
authors.forename: Kim
authors.initials: K
authors.lastname: Chapman
authors.affiliation: Associate Professor, Director of Masters in Health Systems Program, Telfer School of Management, University of Ottawa, Ottawa, Ontario, Canada.
authors.forename: Craig
authors.initials: C
authors.lastname: Kuziemsky
authors.affiliation: Systemic Treatment Chemotherapy Nurse, Health Sciences North, Sudbury, Ontario, Canada.
authors.forename: Erin
authors.initials: E
authors.lastname: Kolari
authors.affiliation: Associate Professor & Associate Director, Undergraduate Nursing Program, Dalhousie University School of Nursing, Halifax, Nova Scotia, Canada.
authors.forename: Brenda
authors.initials: B
authors.lastname: Sabo
authors.affiliation: Director of Nursing, Montreal General Hospital, Montreal, Quebec, Canada.
authors.forename: Andréanne
authors.initials: A
authors.lastname: Saucier
authors.affiliation: Primary Care Nurse, Nova Scotia Cancer Center Clinic, QEII Health Sciences Centre, Halifax, Nova Scotia, Canada.
authors.forename: Tara
authors.initials: T
authors.lastname: Shaw
authors.affiliation: Faculty lecturer, McGill University, Associate Director of Nursing, Cancer Care Mission, McGill University Health Center, Montreal, Quebec, Canada.
authors.forename: Lucie
authors.initials: L
authors.lastname: Tardif
authors.affiliation: Doctoral Candidate, University of British Columbia, School of Nursing, Vancouver, British Columbia, Canada.
authors.forename: Tracy
authors.initials: T
authors.lastname: Truant
authors.affiliation: Centennial Professor, University of Alberta, and Professor, Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Greta G
authors.initials: GG
authors.lastname: Cummings
authors.affiliation: Senior Scientist, Oncology Nursing Research and Education, University Health Network, Toronto, Ontario, Canada.
authors.forename: Doris
authors.initials: D
authors.lastname: Howell
mesh_terms: D002170:Canada; D002985:Clinical Protocols / Q000592:standards*; D005260:Female; D015277:Hotlines / Q000592:standards* / Q000639:trends; D006801:Humans; D008297:Male; D009726:Nurses / Q000639:trends*; D009859:Oncology Nursing / Q000379:methods*; D016730:Program Development
keywords: cancer; case study; implementation; knowledge to action; knowledge translation tools; nursing; symptom management