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Ensuring a high-quality response to screening for Distress dataSystematic knowledge translation is needed to improve patient experienceby Doris Howell, RN, PhD; Barry Bultz, PhD, CPsych; Margaret Fitch RN, PhD; Shannon Groff, BSc; Andrea Williams, BA; Laura Cleghorn, MA

Doris Howell RN, PhD is RBC Chair, Oncology Nursing Research and Education at Princess Margaret Hospital in toronto, ON and Lead, guidelines and standards, Cancer Journey Portfolio, Canadian Partnership Against Cancer (CPAC); Barry Bultz, PhD, CPsych is Director of the Department of Psychosocial Resources at the tom Baker Cancer Centre, university of Calgary and Lead, screening for Distress, Cancer Journey Portfolio, CPAC; Margaret Fitch RN, PhD is Head of Oncology Nursing and Co-Director of the Patient and Family support Program, Odette Cancer Centre, sunnybrook Health sciences Centre, toronto; Shannon Groff, BSc is Coordinator, screening for Distress, Cancer Journey Portfolio, CPAC; Andrea Williams, BA is Project Assistant, screening for Distress, Cancer Journey Portfolio, CPAC. Laura Cleghorn, MA, is a consultant with Cardinal Consultants in toronto.

ABStRACt

A cross Canada, efforts are underway to implement Screening for Distress as the 6th Vital Sign as part of routine cancer care. Significant progress has

been made in recognizing the need for a programmatic approach to the implementation of Screening for Distress. Additionally, there is acknowledgement of the importance of preparing front-line clinicians in the active management of distress, and pan-Canadian guidelines and algorithms have been developed to support this effort. However, there is an urgent need to understand the case for knowl-edge translation to be integrated as an essential element of a programmatic approach to Screening for Distress, to ensure a high-quality response to distress data based on

the evidence in these guidelines. In this paper, we describe some of the essential steps in translating guideline evidence into action based on the Knowledge-to-Action framework, as well as key learning from a pan-Canadian knowledge translation workshop. A programmatic approach requires that healthcare organizations focus equal attention on knowledge translation to ensure a high-quality front-line clinical response to Screening for Distress data, if improve-ment of the patient experience of cancer and health out-comes is to be realized.

Key words: distress, 6th Vital Sign, screening, knowl-edge translation, implementation, best practices

INtRoDuCtIoNRoutine Screening for Distress as the 6th Vital Sign1 is now standard of care for Canadian cancer organizations,2 to ensure recognition of the psychosocial, practical and physical conse-quences of cancer and treatment that contribute to distress, as well as early identification of those patients in need of more intensive interventions.3 The Cancer Journey Portfolio of the Canadian Partnership Against Cancer (CPAC) has been supporting 9 jurisdictions across Canada to implement a programmatic approach to Screening for Distress as the 6th Vital Sign to enhance person-centred care and ultimately improve health-related quality of life.4 It is recommended that a programmatic approach encompass care processes, inclu-

sive of therapeutic communication to ascertain the person’s perspective of the problem, and a focused assessment to guide the selection of relevant and appropriate evidence-based interventions to ensure an effective response to Screening for Distress data (Figure 1). Naturally, a programmatic approach would also include education for patients about the need for screening and engagement of organizational leaders and clinical teams to recognize the imperative for routine screening. Without this approach, there is little high-quality evidence to suggest that routine collection of patient-reported screening data will improve health outcomes,5-8 with the exception of patients with depressive symptoms referred for specialist intervention.9 Even though clinicians value screening data in overall patient assessment, the way these data are used in routine clinical practice and the effectiveness of the response to screening data is critical if health outcomes are to be realized.10 The purpose of this paper is to highlight the case for knowledge translation as an essential element of a pro-grammatic approach to Screening for Distress as the 6th Vital Sign, and the steps that are necessary if such an approach is to improve patient outcomes and experience of cancer.

LINkING CLINICAL PRACtICe to SCReeNING FoR DIStReSS DAtAIn order to ensure a high-quality response to Screening for Distress data, clinical practice guidelines and algorithms with care pathways were developed under the auspices of the

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Figure 2: responding to distress: guideline and algorithm framework

Green ZoneScore 1-3

Yellow ZoneScore 4-6

Red ZoneScore 7-10

This zone is considered a mild level: the patient is managing the problem and has

low symptoms or emotional distress.

This zone is considered a moderate level: the patient is struggling to manage the problem. Targeted intervention is

needed to get the patient back into the green zone.

This zone is considered a severe level: Patient problem is out of control and placing them at serious risk. Urgent

response by the clinic team or a referral is demanded.

For all groups the following should take place:

1. Acknowledged scores in open dialogue with patient.2. Ask patient about the impact of the problem from their perspective and the most distressing problem(s).

3. Provide psychosocial and supportive care to all patients as part of a therapeutic relationship.4. Establish shared goals of care and action plan.5. Follow through on action plan and document.

Figure 1: Steps following screening

Open a dialogue with the patient; initiate a therapeutic relationship Ascertain patient perception of problem and negotiate a relevant plan of care

Screening for symptoms and distress Assessment of risk factors and focused assessment of problem Select appropriate interventions based on best evidence

Cancer Journey Portfolio, in partnership with the Canadian Association of Psychosocial Oncology (CAPO).11 These guide-lines provide a synthesis of the evidence base for effective assessment and management of the psychosocial, practical and physical symptoms that contribute to distress. The scores derived for 9 common symptoms as measured by the Edmonton Symptom Assessment System (ESAS)12 were linked to evi-dence-based algorithms and care pathways for intervention based on cutoff scores designated as green (1–3), yellow (4–6) and red (7–10) in Figure 2. This algorithm template was adopted by other organizations such as Cancer Care Ontario and was the basis for the pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS) protocols for remote telephone nursing practice to ensure a standardized practice guideline product for Canadian use. The linking of patient-reported outcome data and guidelines for best practice is recommended to improve the quality of clinician response to outcome data.13 This was considered a critical step to increase the usability of the guidelines, as this is shown to be an important element in uptake by clinicians.14

Unfortunately, a large body of literature has shown that, despite widespread dissemination efforts, evidence from guidelines is rarely implemented in clinical practice.15 For routine collection of Screening for Distress data to lead to better health or improve quality of life, equal attention must be paid to translating knowledge from guidelines into rou-tine practice. This is particularly important since the majority of cancer patients will experience moderate distress in response to cancer and its treatment16 and could benefit from inter-vention from front-line clinicians. A significantly smaller proportion of patients (20%–50%) will have clinical depression and/or adjustment disorders requiring specialist intervention by psychologists or psychiatrists.17

tRANSLAtING kNoWLeDGe INto ACtIoNProviding evidence in clinical guidelines is not enough to ensure the provision of optimal care.18 Putting this knowledge into action is a complex process that requires an understand-ing of knowledge translation, attention to the multifactorial barriers to practice change, and the use of a systematic imple-

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Table 1: Clinical guideline implementation for screening for distress programs: the essential steps

a. PrePare FOr iMPleMeNTaTiON STePS TO TaKe TiPS raTiONale

1. Increase awareness of the guideline.

INCITE PASSION FOR THE CHANGE• Dotheyknowabouttheguideline?• Dotheytrusttheevidence?• Dotheyhaveleadershipsupportforchange?• Doestheguidelineneedtobetailored?• Doyouhavesupportfromthetop?

a. Familiarize yourself with the evidence embedded in the guideline algorithm.b. Prepare a brief re: urgency of problem and need to address to improve care quality and patient/family experience (use prevalence data from your ESAS for the population and impact from current literature).c. Engage your target population disease site team/clinicians in dialogue to create awareness of the guideline.d. Provide an opportunity for clinicians to discuss current practice and the changes needed, along with the barriers and enablers to a different practice.e. Promote discussion of how the guideline might need to be tailored to local context.f. Engage key stakeholders across the organization and get commitment of senior leaders.

a. Acknowledge the hard work done in getting red-flag ESAS screening in place.b. Emphasize that the hard work of improving outcomes and patient experience will be challenging but they already have made initial steps (i.e. teamwork; new processes or screening uptake).c. Provide various educational opportunities to diverse target audiences to orient to symptom/problem and role of guidelines in improving care quality.d. Bring in an expert/respected authority to discuss the symptom/problem and the evidence in the guideline.e. Identify a team that is passionate to work with you to move this forward from within the practices.f. Donotgetstuckononedisciplineorpersonwhois resistant, but engage early responders.

Large-scale passive education/written materials are not effective in practice change but can increase initial awareness as part of a marketing plan (NICE, 2007).

Guideline will achieve only small effects unless successfully integrated into clinical settings using a systematic and managed change plan (Kingston et al, 2010).

** Identifying barriers is critical as your implementation strategies must be tailored to address these barriers.

2. Create a sense of urgency about the problem as a quality-of-care problem.

ENGAGEHEARTSANDMINDS• Dotheybelievetheguidelinewillachieve betterpatientoutcomes?• Aretheyexcitedabouttheroletheycanplay toimprovepatientexperienceandcarequality?• Dotheyhavetheresourcesneededanddo theyfeelvalued?

a. You will experience resistance to “yet another guideline.”b. Prepare a fact sheet on the urgency of the problem from prevalence statistics combined with data re: patient experience and the difference from interventions embedded in the guideline.c. Use ESAS data already collected to show the extent of the problem scores over time.d. Tell stories about the impact of other programs using the evidence in the guideline: use a patient/family member and data from other case examples (engage their hearts and minds).

a. Remember that change also incites fear and strong emotional reactions in people.b. Communicate your vision relentlessly using marketing strategies and multiple methods.c. Show how other agencies have been able to make changes and achieve success (what processes and how: what should work here).d. Use examples that are local and that practitioners can identify within their organization.

** Stories from patients and families are a powerful motivator for change

3. Understand the situation before you start in order to design a targeted action plan.

START WHERE THE PRACTICE IS NOW/ENGAGE INDIAGNOSIS• Aretheycurrentlyusingvalidassessmenttools?• Dotheyteachpatient-specificself-management skillstomanagetheproblem?• Aretherepatienteducationresourcesfor thisproblem?• Dotheyunderstandtheproblemandknow howtoacttochangeit?• Arethereadoptersalreadywhocanmodel behaviour?• Aretherelevantstakeholderswhowillneed tochangetheirpracticeinvolved?

a. Understand the current practice by complete a gap analysis. You can create a quick audit checklist based on the expected care in the guideline or use an existing tool.b. Assess knowledge, attitudes, skills of potential adopters focused to the problem using surveys/focus groups and observing practice in action.c. Askforspecificexamplesoftheactionsalready being taken.d. Use multiple methods as above to identify barriers to adopting guideline recommendations that must be addressed to design new ways of working.e. Identify resources that already exist (i.e. skilled APN).f. Avoid reinvention by using educational packages or training videos already available internally or externally

a. Donotmakeassumptionsaboutpractice—attitudes or barriers can interfere with doing the right thing.b. Consider running a baseline assessment against the recommendations to identify where change is required, and ensure that everyone can see the results or, even better, helps with the audit, to foster buy-in.c. Engage clinicians in generating solutions to barriers andtailoringifguidelineisneededtofitcare processes.d. Generateaspecificplantoaddressidentifiedbarriers in your implementation strategy.e. Need a detailed road map to navigate through change and its complexity.

Thereisasignificantvariationinuseofthebestevidenceinpractice(IOM,2008).

Implementation strategies are more effective when targeted to existing barriers (Logan&Graham,1998).

Barriers exist at multiple levels (organization, disease site teams, individuals)(Legareetal,2008).

Identifying the gaps is the starting point of implementing knowledge and analysis should involve use of rigorous methods and engage relevant stakeholders (Kitson et al, 2009).

b. iMPleMeNTaTiON STraTegieS STePS TO TaKe TiPS raTiONale

4. Customize/tailor the guideline for your organization.

SIMPLIFYTHEEXPECTEDACTIONSTOBETAKEN• Dotheresourcesexisttoimplementthe guideline?• Haveyouengagedallrelevantstakeholders inneedfortailoringtheguideline?• Whatprocessesneedtobechangedto achieveoutcomes?

a. Determinewhowillneedtotakeactionbasedon evidence in the guideline (organize the care team).b. Identify if there are some recommendations that need to be tailored to local context as to how the action can be taken (match intensity of clinical resources to problem).c. Establishaspecificactionplantoaddresstheareas needing improvement (i.e. team communication; lack of knowledge and skills; patient-mediated approaches, etc).d. Integrate with other change initiatives whenever possible.

a. Turn the recommendations in the guideline into a documentation tool.b. Simplify by creating an algorithm of expected care processes (who, what, when, where).c. Link recommendation to explicit care processes already existing (i.e. drop down focused assessment tools for red flag scores >3).d. Implementing changes in new care processes takes time and systematic planning linked to desired outcome.

A number of factors influence uptake including: perceptionofbenefitofchangetothepractice(cost, risk, quality, culture), extent to which the changes required are compatible with existing care processes, and to what extent local practices are allowed to adapt centrally designed recommendations (Berwick et al, 2003).

**Mustensureintailoringtolocalpracticethat processes still fall within guidelines.

5. Engage opinion leaders and champions at every level to spread enthusiasm.

• Haveyouengagedarespectedopinionleader?• Isthechampionanexcellentfacilitator?• Aretherightpractitionerstargetedforpractice change?• Haveyouempowereddirectcareteams?

a. Project leadership: change must be strategically supported and managed effectively.b. Identify a local opinion leader to highlight the importance andbenefitsofthechangesforpatients,andencourage healthcare professionals to want to make changes.c. Opinion leaders and champions are often different individuals.d. Identify a local disease site champion (i.e. APN) to facilitate change. Consider leadership training for selected champions.

a. Empower direct care teams to take action: maximize their full scope of capabilities and respective roles.b. Opinion leaders/champions motivate and inspire clinicians to achieve best possible care, often acting as role models.c. Champions are best chosen within local teams and, depending on the practice change target within the discipline needing to change (e.g. APN working with nurses to change approach to dyspnea).d. Identify implementation team.

Opinion leaders have been shown to have mixed effects or positive effects (Bero et al, 1999). The mixed effects may be due to the choice of opinion leader and if the practice is responsive to this type of approach, and how they engage practitioners.

** Local champions must be skilled in effective facilitationwithstronginterpersonalskills—choose wisely.

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Table 1 continued: Clinical guideline implementation for screening for distress programs: the essential steps

b. iMPleMeNTaTiON STraTegieS STePS TO TaKe TiPS raTiONale

6. Use a multifaceted approach to foster practice change.

COMBINEARTISTRYWITHKNOWNEFFECTIVEAPPROACHESTOIMPLEMENTATION• Dotheyknowhowtoimplementchanges andwhen?• Dotheyhavetimetodevelopnewskills?• Istherightinfrastructure/toolsinplace toenablepractice?• Haveyouusedinnovationinyourapproach?• Haveyouengagedcommunitypartners?

a. Prepare and educate all clinicians, building on initial awarenesswithspecificeducationtargetedtothose who will deliver the intervention. Use interactive educational approaches and multimedia.b. Patient-mediated interventions should be part of implementation as they are responsible for day-to-day management of problems.c. Reminders: tailored reminders can help to continually foster and reinforce change.d. Audit and feedback: reporting of retrospective information to teams about practice is likely more effective when data is trusted and the format is based on pragmatic factors and local circumstances (Grimshaw et al, 2004).e. Educational outreach visits (also called academic detailing) and small-scale meetings are more effective that didactic methods (Grol, 2001).f. Identify good examples of local practices to share across your organization and consider other ways that healthcare professionals could learn from one another, for example peer-to-peer coaching or individual academic detailing.

a. Clearly designate who will take responsibility for specificrecommendationsintheguideline.b. Identifyandbrainstormspecificsolutionstobarriers and multifaceted implementatio approaches to address different barriers to change.c. Choice of implementation strategies must be based on barriers and practice setting. For instance, audit and feedback may be too labor intensive unless data and tailoring is needed (i.e. ESAS scores declining over time).d. Theories of change can guide change processes (i.e. social cognition theories focus on perceptions).e. Implementation theories can help to ensure a systematic approach to change.

**Rapid-cycle change uses an audit and feedback processwithinthePDSAcyclesandcanbeusedforsmalltestsofprocesschangetoreachafinalpracticechange goal.

Thirteen systematic reviews found passive information dissemination ineffective (Alvanzo et al., 2003; Bauchner et al, 2001; Bero et al, 1998;Freemantle,2006;Grimshawetal,2001; 2004; Grol, 2000; Grol et al, 2003; O’Brien, 1997; 1999; 2001; Oxman et al, 1995; Smith 2000; Wensing et al, 2005a).

Multifacetedimplementationstrategiesarebest(Grol et al., 2003; Grimshaw et al, 2004).

Reminders and decision-support tools are likely to be effective (Wensing et al, 2009).

Materialsdisseminatedtopatientsareeffective in changing behaviours of health professionals (Grilli et al, 2002).

**Mindmapping(brainstorming)usingcomputer-based processes can help to map barriers to change.

7. Build ownership over the practice change in the clinical team at every opportunity.

a. Start small and show success. (i.e. two nurses do a trial run using new learned intervention techniques).b. Conduct monthly reviews to determine progress, to elicit learnings and provide positive reinforcement.

a.Usespecificstrategiestoworkwithtargetdiscipline needs but not a sole focus, as the whole team must act.b. Work with those who are willing and interested to work with you, rather than trying to change the most resistant.c. Targeted approaches may be needed to reach specificdisciplines.

Practice change improvement that is collaborative or in communities of practice comprised of different disciplines is effective in moving change forward (Nease et al, 2010).

C. MaiNTaiN SuCCeSS aND CelebraTe STePS TO TaKe TiPS raTiONale

1.Determinewhatsuccesslookslikeandmonitor over time.

GETTINGBEYONDGO-LIVE• Haveyouidentifiedthedesiredfuture?• Issomeoneskilledinevaluationand measurementonyourteam?• Haveyouembeddedchangesinpolicies/ standardofcare?• Haveyouestablishedbenchmarksof performance?

a. Identify the expected outcomes you will achieve.b. Engage someone skilled in evaluation and measurement as a member of your implementation team.c. Consider how you will measure improvement or success outcomes for patient.d. Use established indicators if available and engage the team in what indicators will be key to monitoring over time and routinely.

a. Rapid-cycle change can be used to quickly measure if required care processes are being implemented and need for midcourse corrections.b. Buy-in is vital for your personnel to take ownership of the success or failure of the project.c. Sustaining change requires a reward or accountability system to be in place.

Studies show that a return to baseline can occur within a few months if changes are notmaintained(Franckeetal,2008).

2.Trackchangesusingspecificdatacollection strategies.

a. Outcome-based assessment tools as part of assessment processes can ease data collection and continuous quality improvement.b. Engage local computer specialists to integrate outcome-based tools into medical records.

a. Establish benchmarks for keeping people on track in the short and long term.

3. Sustain the change by embedding it in routine practice.

MAKEITDIFFICULTTODOITWRONG

a. Ensure the changes are incorporated into local protocols, investigations and procedures.b. Consider adopting a computerized reminder system.c. Sharing your results with other organizations can help sustain interest.d. Encourage work to be submitted for publication in journals and for presentation at conferences.e. Encourage everyone to own the data and dissemination.

a. Creating sustained change involves: awareness of the need for change; acceptance of the responsibility to change; action to change (supported); adopting practices.b. Adoption of new practices takes time and a number of weeks to be adopted as a “habit.”c. Teams must move through three phases of change to achieve long-term sustainability: awareness; understanding; acceptance; commitment.

ESAS=EdmontonSymptomAssessmentSystem;APN=advancedpracticenurse;PDSA=Plan-Do-Study-Act.ontonSymptomAssessmentSystem;APN=advancedpracticenurse;PDSA=Plan-Do-Study-Act.

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mentation process that incorporates multifaceted change strategies known to be effective for translating evidence into effective care.19,20

Knowledge translation has been defined as “a dynamic and iterative process that includes synthesis, dis-semination, exchange and ethically sound application of knowledge to improve the health of Canadians, provide more effective health services and products and strengthen the healthcare system.”21 The prominent Knowledge-to-Action (KTA) framework can be used to guide planning and sys-tematize the implementation process (Figure 3).22 Based on the KTA frame-work, we adapted existing knowledge into practice guidelines and algorithms for use in a pan-Canadian health context. We used a guideline adaptation method-ology to develop our practice guideline products for use in Screening for Distress programs.23 In addition, we developed a toolkit to guide organizations in implementing guidelines in routine practice (available on the CPAC website: www.partnershipagainst cancer.ca). Table 1 summarizes some of the critical steps in translating guideline knowledge into action, based on the KTA framework and incorporates the evidence base for strategies that are known to be effective in promoting uptake.

translation plan to facilitate uptake of the guidelines in rou-tine clinical practice as part of a programmatic response to Screening for Distress. The overall purpose of the workshop was to increase understanding of knowledge translation and the most effective strategies for facilitating the uptake of the pan-Canadian distress management guidelines and algo-rithms into practice.

The specific learning outcomes for workshop participants are outlined in Table 2. Experts were invited to share their real-world case examples demonstrating lessons learned from implementing guideline evidence into routine practice. Application of key learnings to develop a systematic knowl-edge translation plan for participating organizations was facilitated in breakout sessions.

Healthcare professionals across various disciplines and representing 7 provinces in Canada attended the knowledge translation workshop held in Montreal, Québec in June 2011. Participants (n=46) attended as teams from each of the 8 jurisdictions implementing routine Screening for Distress programs in Canada (n=46). The KTA framework guided the selection of workshop topics and provided the structure for small-group activities based on the steps in the

Table 2: Knowledge translation workshop learning outcomes

1. Describetheessentialelementsandkeystepsinthetranslationofknowledge (guideline products) into action.

2.Discussthemostsuccessfulimplementationstrategiesinfacilitatinguptakeof guidelines into routine practice.

3.Applyskillsintheidentificationofbarrierstoguidelineuptakeandtheoptionsof tailoring implementation strategies to local contextual barriers.

4.Discussapproachthatcanbeusedtomonitortheuptakeofguidelinesintoroutine practice and the evaluation of impact on distress.

Figure 3: Knowledge to action cycle

From: Graham et al. Lost in Knowledge Translation: Time for a Map? www.jcehp.com/vol26/2601graham2006.pdf.

Monitorknowledgeuse

Select, tailor, implement

interventions

Assess barriers/supports to

knowledge use

Adapt knowledge to local context

Evaluate outcomes

Sustain knowledge

use

Identify problem

Identify, review, select knowledge

Knowledge creation

Knowledge inquiry

Synthesis

Product tools

Tailor

ing kn

owled

ge

FACILItAtING CHANGe: A kNoWLeDGe tRANSLAtIoN WoRkSHoPAdditionally, the Cancer Journey Distress Management Leadership Team hosted a national knowledge translation workshop entitled “Responding to Distress, the 6th Vital Sign: Implementing Guidelines and Algorithms into Routine Practice.” The aim was to engage national implementation teams from across Canada in the development of a knowledge

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framework. The sessions guided the teams through the steps of the KTA cycle and provided the building blocks for devel-oping a systematic approach for implementing the guidelines and algorithms into practice as part of their Screening for Distress programs. Table 3 summarizes the topics presented over the two days of the workshop and the breakout sessions.

Evaluation data from the knowledge translation work-shop provided insight into the benefits of the workshop or areas needing refinement. Of the 36 participants completing evaluation feedback forms, the majority (70%) rated pre-sentations by experts as better than average. Participants provided feedback on ways to improve the workshop and noted that more instruction was needed for assessing barriers to practice change and selecting approaches to address these barriers. Participants also expressed appreciation for the organization of the day, the opportunity to network with other professionals, and the real-life examples of knowledge translation that demonstrated the steps and strategies for guideline implementation to be successful. Most participants reported a need to conduct a more comprehensive assessment of barriers to practice change in order to understand how to proceed to guideline implementation. Barriers that were identified included:•staff time constraints and heavy workloads, and clinicians

not working to full scope of practice•difficulties in engaging patient and family and expectations

of care (e.g. patients not wishing for assistance)•lack of provincial collaboration and use of consistent

quality standards and monitoring

•mobilizing nurse roles and knowledge in management of distress

•lack of electronic data capture, technology resources and funding

Overall, participants reported beneficial learning outcomes from the workshop and felt better prepared to finalize their guideline implementation plans for their jurisdictions to support the uptake of best practices in distress management. Evaluations showed a high degree of satisfaction with the workshop topics and breakout activities. Participants noted that the workshop allowed the rare opportunity for healthcare teams to meet face-to-face and collectively build capacity in the knowledge and skills required for knowledge translation.

CoNCLuSIoNEnsuring a high-quality response to Screening for Distress data is critical to improve patients’ experience of living with cancer and, ultimately, health-related quality of life. While the dissemination of pan-Canadian guidelines was an important step, Screening for Distress implementation teams still require practical training and “know-how” to translate this knowledge into routine clinical care, to ensure that the active manage-ment of distress becomes part of routine clinical care. It is incumbent on cancer organizations to take the additional steps necessary to ensure the uptake of best practices and care processes in the effective management of distress as part of a programmatic approach to Screening for Distress as the 6th Vital Sign.

Note: guidelines are available on the website of the Canadian Association of Psychosocial Oncology (www.capo.ca).

References1. Bultz BD, Carlson LE. Emotional distress: the sixth vital sign in cancer care.

J Clin Oncol 2005;23:6440-1.2. Qmentum Program, Cancer Care and Oncology Services. Accreditation Canada:

Ottawa, 2010. www.accredita tion.ca/accrediation-programs/qmentum/.3. Jacobsen PB, Donovan KA, Trask PC et al. 2005 Screening for psychological distress

in ambulatory cancer patients. Cancer 2005;103:1495-502.4. Screening for Distress Toolkit Working Group. Canadian Problem Checklist. In The

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5. Boyes A, Newell S, Girgis A et al. Does routine assessment and real-time feedback improve cancer patients’ psychosocial well-being? Eur J Cancer Care (Engl) 2006;15:163-71.

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Table 3: Workshop topics and breakout session

Topics covered in Day 1 breakout sessions: Day 1

1. Applying the Knowledge-to-Action- (KTA) cycle

Examine organizational readiness to change

2. Working with oncologists to change practice

Strategies to identify barriers to guideline implementation

3. Facilitating interprofessional collaboration using a practice change approach

Select and tailor implementation strategies to address barriers at multiple levels

4. Selecting strategies to support knowledge translation and to identify and address barriers to change

Topics covered in Day 2 breakout sessions Day 2

1. Improving pain management in neonates: lessons learned in implementing evidence

Solution-generating for addressing barriers to implementation

2.Developmentofaplannedapproachto improve dyspnea management by clinicians

Consolidating a plan for next steps to move the implementation of guidelines forward

3. Embedding better practices in clinical process redesign to improve distress response

4. Lessons learned from 12 years of implementing guidelines and strategies: evaluation and monitoring

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11. Howell D, Keller-Olaman S, Oliver TK et al. A Pan-Canadian Practice Guideline: Screening, Assessment and Care of Cancer-Related Fatigue in Adults with Cancer. Toronto: Canadian Partnership Against Cancer, Canadian Association of Psychosocial Oncology, 2010.

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13. Snyder CF, Aaronson NK. Use of patient-reported outcomes in clinical practice. Lancet 2009; 374:369-70.

14. Grol R. Successes and failures in the implementation of evidence-based guidelines for clinical practice. Med Care 2001;39(8 Supp2):II46-II54.

15. Jacobsen PB, Ransom S. Implementation of NCCN distress management guidelines by member institutions. J Natl Compr Canc Netw 2007;5:99-103.

16. Velikova G. Patient benefits from psychosocial care: screening for distress and models of care. J Clin Oncol 2010;28:4871-3.

17. Zabora J, Brintzenhofeszoc K, Curbow B et al. The prevalence of psychological distress by cancer site. Psychooncology 2001;10:19-28.

18. Davis D, Evans M, Jadad A et al. The case for knowledge translation: shortening the journey from evidence to effect. BMJ 2003;327:33-5.

19. Strauss SE, Tetroe J, Graham I. Defining knowledge translation. CMAJ 2009;181:165-8.

20. Graham ID, Logan J, Harrison MB et al. Lost in knowledge translation: time for a map? J Contin Educ Health Prof 2006;26:13-24.

21. Canadian Institute of Health Research (CIHR). About Knowledge Translation. Retrieved January 2011 from www.cihr-irsc.gc.ca/e/29418.html.

22. Bero L, Grilli R, Grimshaw JM et al. Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. BMJ 1998;317:465-8.

23. ADAPTE Collaboration (2007). ADAPTE Framework. Retrieved July 22, 2008 from www.adapte.org/www/rubrique/adapte-framework.php.

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