3.2 Implementation strategies
Strategies to implement CRISP into practice are briefly covered in table 3.
Table 3. A list of implementation strategies.

The practice staff suggested methods for introducing the CRISP into practice. The most popular method was to use CRISP during preventive health checks and chronic disease management consultations. The nurses often used these consultations to check on preventive health care such as cancer screening and found CRISP a useful tool to include in those sessions. A senior nurse accepted the responsibility of practice champion to lead the implementation of the CRISP. This senior nurse was also responsible for bowel screening in the practice, and so CRISP was within her established job domain. We discussed developing an alert to remind nurses that a patient booked for an appointment was eligible for a CRISP consultation, and we placed notices in the waiting room to inform patients about our research.
Strategies for implementing CRISP included how it could be incorporated into current consultations using Medicare Benefits Schedule (MBS) items, i.e., medical services that can be charged to the MBS, Australia’s national healthcare scheme. Opportunistic and targeted methods were considered so that people eligible for colorectal screening could have a CRISP consultation when they attended the clinic for reasons other than a screening consultation.
To increase opportunistic and targeted ways to book an appointment for a CRISP consultation, practice nurses described and adapted methods to identify patients who were eligible for CRC screening. The nurses completed the CRISP tool with patients, printed out the results, provided the tool’s output, and discussed the screening recommendations prior to the patient seeing their GP. The patients followed up the CRISP results with their GP who made the final clinical decision about how, or if, the patient should be screened for CRC.
We met with the pathology providers and ascertained that FIT kits were available. However, we found that the FIT usage instructions in the clinic were outdated and not relevant to the new immunochemical FIT kits. We also discussed the accessibility of colonoscopies and found that they were not always readily available, sometimes resulting in a prolonged waiting period.
Many ideas to integrate CRISP tool with the practice’s Electronic Medical Record (EMR) system were discussed, including auto-populating data from the patient’s EMR and auto-populating risk scores back into a patient’s EMR, and having the tool accessible within the EMR. These were out of our budget and time frame, and consequently we were unable to pursue this work.
3.3 Evaluation
We evaluated implementation strategies using interviews that adhered to the CFIR framework.
The results are described using the five CFIR domains to explain the emergent themes in the context of implementation barriers and facilitators (see Table 4).
Table 4
A summary of results of themes from interviews with; practice staff, including GPs and practice nurses mapped onto the Consolidated Framework for Implementation Research.
Characteristics of Intervention
|
Inner Setting
|
Outer Setting
|
Individuals Involved
|
Implementation Process
|
-CRISP was a valuable intervention and prompted them to discuss bowel cancer screening
-As CRISP is a website, the nurses had trouble using the desktop shortcuts after the tool was updated
-It was suggested that CRISP should be embedded within the electronic medical records
- CRISP took time to complete and auto-populating fields from the electronic medical records would save time
|
- The general practice where CRISP was implemented changed a lot over the duration of the study
- During flu season it was hard for practice nurses to find time to use CRISP
-Nurses identified opportunities to use CRISP i.e. during cervical screening appointments
-The clinic’s billing system changed, and some patients had to pay out of pocket
|
- CRISP encouraged participation in the National Bowel Cancer Screening Program
- As there are long waiting times for colonoscopic screening in the public system, CRISP decreased the need for unnecessary ones
- CRISP increased risk appropriate screening, so more the right people used the right screening methods
|
- The nurses were unaware of the risk factors for colorectal cancer that were presented in CRISP, so ongoing training was essential for its appropriate use
- GPs were pressed for time and felt overwhelmed by having to discuss the CRISP recommendations with their patients who often presented with multiple health concerns
|
- The clinic is a teaching clinic and they were incredibly flexible and open to change which may not be the same for other clinics
- The nurses were comfortable using the Fidelity Checklist, presented in Table 2, with their patients during consultations
- CRISP was well received by the practice and patients during consultations
|
3.3.1 Characteristics of the intervention (CRISP)
Interviews provided an opportunity for practice nurses to discuss how the CRISP tool worked as part of their clinical practice and suggest ways to improve the tool.
The practice staff recognised CRISP as a valuable intervention that could improve their clinical practice. Specifically, the practice nurses liked that CRISP prompted them to talk about bowel cancer screening easily, but also helped facilitate discussions about other healthy lifestyle changes their patients could make (Quotation 1a and 1b).
1a “I think the tool itself is really good because it also helps us to focus on their diet and lifestyle, and it’s making people think more about proactive help.” (Practice nurse)
1b “Well it’s sort of like quit smoking, if we ask the question, we’re not necessarily asking them to quit smoking, but it’s raising awareness to their health issues. It’s the same with Pap smears and testicular screening. It’s just raising awareness. I think more and more people are becoming more educated about their health.” (Practice nurse)
In practice, CRISP is hosted on an external website, and to make it easier to access, the practice staff created a shortcut to the website on their desktop. However, when CRISP was updated on the website, the shortcut had to be manually updated which occasionally caused problems (Quotation 1c).
1c “The tool crashed on the GP as he had an older version [of the shortcut] on his desktop.” (Practice nurse)
To overcome this, the nurses suggested embedding CRISP into the patient EMR software as they had with other risk calculators (Quotation 1d). They also felt this would encourage them to use it more regularly as well.
1d “Just wondered if there’s some way of putting it into the EMR software so you could actually remember it like the geriatric depression thing…and things that you can just take down” (Practice nurse)
CRISP sessions also took a non-trivial amount of time to complete in the context of consultations which often required other clinical activities. The nurses identified opportunities to save time including auto-populating patient details from the practice’s EMR system (Quotation 1e).
1e “So, we were talking about how having the tool autofill some things. I know it’s been possible with us in the other program we were using so maybe we can try that? It would save a few minutes.” (Practice nurse)
3.3.2 Inner setting
The general practice was continually adjusting their priorities which impacted the use of CRISP. Despite the tool being designed to take about five minutes to complete, competing demands on practice staff’s time limited their capacity to use CRISP regularly (Quotations 2a, 2b). This was especially obvious during ‘flu vaccination season, during which vaccination consultation was prioritised over a CRISP consultation. Practice nurses did not have shifts covered when they went on annual leave, so at times the practice was not all full capacity, adding further workload pressure.
2a “...not gone off our radar at all or enthusiasm, it’s simply not been able to fit this in.” (Practice nurse)
2b “There could have been people we missed out on, if I was travelling well for time then I could use the CRISP tool with the patients but no I didn’t catch everyone, sometimes it is impossible to fit something extra into a consultation.” (Practice nurse)
Practice nurses were constantly thinking of ways to identify opportunities to use CRISP during patient visits to overcome the time barrier (Quotation 2c and 2d).
2c “Cervical screening because my nurse team usually have 30 minutes for cervical screening, usually. That’s probably been an opportunity where we really have been able to do it at the CRISP tool.” (Practice nurse)
2d “The care plans [chronic disease management plans], you know 30 minutes is very tight if you know the client well and the paperwork is fairly well organised, you could possibly fit it in there.” (Practice nurse)
Throughout the duration of the project, the clinic experienced substantial internal changes that affected their use of CRISP. The clinic transitioned from being a fully bulk-billing clinic to charging patients out-of-pocket fees for many services (Quotation 2e and 2f). While preventative health checks continued to be bulk-billed, the billing change resulted in it not being used as frequently as it could have been.
2e “[We have a] new billing system - some patients will be charged an out-of-pocket fee of $20” (Practice nurse)
2f “Patients who aren’t on a care plan must pay out of pocket for their visit to [the practice] now, they may be hard to recruit” (Practice nurse)
Although the practice faced many changes, the general culture of the staff was positive - they remained flexible and agile, and continued to be open to change (Quotation 2g).
2g “All four [of the nurses] have been championing this... They’ve been absolutely on board with it” (Practice nurse)
3.3.3 Outer setting
CRISP has been designed to increase risk appropriate screening, and this includes encouraging average risk patients to screen with the National Bowel Cancer Screening FIT kit rather than undergo unnecessary colonoscopies. The nurses recognised this was a benefit to using the tool as it not only provided individualised risk but also methods for communicating recommended screening advice (Quotation3a). Also, nurses were aware of the long waiting periods to access colonoscopies through the Australian public healthcare system (Quotation 3b). They understood that CRISP’s ability to steer average-risk patents towards FIT also had the potential to reduce the pressure on the public healthcare system by preventing unnecessary colonoscopies.
3a “I find it helpful in terms of trying to dial people away from colonoscopies because we have a lot who are captured by specialists who.. . they’ve had a colonoscopy and are immediately booked in for another one.” (Practice nurse)
3b “They want to know are they iron deficient, are they anaemic, and that’s how they are prioritising so the referral’s going to enter the public system and face a lengthy wait and if you’re raising with the patient, “based on your history we think colonoscopy is the way to go but you may have to wait 9 months to a year for an interval colonoscopy” ” (Practice nurse)
The CRISP tool and discussions about CRC screening prompted patients to participate in the National Bowel Cancer Screening program (NBCSP); (Quotation 3c).
3c “.. . people throw the NBCSP kit in the bin, so I do think this will be useful once we start approaching more people and people get used to being asked questions about it...” (Practice nurse)
Practice nurses also wanted NBCSP FIT kits to help explain their use to patients and further promote CRC screening uptake. Researchers SM and JM ordered sample kits from the NBCSP for each of the practice nurses (Quotation 3d).
3d “If I actually have a demonstration kit to show the patients how to use it I probably will but if I need to leave the consultation room to try and find one I might not use it or show them how to do it…this could be another barrier to implementation” (Practice nurse)
At the time of this study, the NBCSP had not been fully implemented as a biennial program. General practices were expected to use local pathology companies to provide FIT kits to patients who were not up to date with CRC screening. In discussions with the local pathology providers, we realised that the FIT kit instructions being offered by the practice nurses were written for the older guaiac-based test. That is, the instructions were not applicable to the immunochemical FIT kit being used. These instructions included dietary restrictions and a more complicated sample collection, which might have deterred patients from undertaking the test. The instructions for the immunochemical test were updated in the practice to eliminate this barrier to CRC screening.
3.3.4 Characteristics of individuals
Practice nurses were unaware that ‘risk factors’ in the CRISP tool included some factors that increased bowel cancer risk, but also others which reduced risk (Quotations 4a and 4b). Furthermore, there was some misunderstanding about which patients might not be suitable for CRISP due to additional risk factors such as inflammatory bowel disease. This highlighted the need for comprehensive information and training to ensure correct use of the tool. (Quotations 4c and 4d).
4a “Why is calcium a problem? I take calcium for my osteoporosis.. . I thought I better stop taking my calcium tablets if it will increase my risk.” (Practice nurse)
4b “So HRT increases your risk of breast cancer if you take it for a certain period of time and calcium has some risks as well. So that’s one thing that we clarified with you and also the more information when it comes to the analgesic stuff as well.” (Practice nurse)
4c “When you say NSAIDs, is Panadol an NSAID?” (Practice nurse)
4d “.. . if someone has had significant bowel disease, like ulcerative colitis and diverticulitis the tool shouldn’t be used for them, right? (Practice nurse) [Researcher response: “That’s actually a very good question. If someone has diverticulitis they can be included if it is not significant as it is very common].”
Nurses reported that there were barriers for GPs to discuss the CRISP recommendations when they received the printed CRISP report. They felt overwhelmed if their patients presented with significant/multiple health issues, and a discussion of bowel cancer screening was also expected (Quotation 4e and 4f). Time pressures felt by GPs prohibited them from fully embracing CRISP (Quotations 4g).
4e “I think we have to give them a bit of time to get their heads around this. One of the GPs who was overwhelmed copped two patients who had a history of polyps from me.” (Practice nurse)
4f “Because the GPs must dig in the patient’s records, they don’t feel they can manage this. Patients are booked for one item per consult, the GPs have said that they want the patients to come back.” (Practice nurse)
4g “...the GPs felt overwhelmed talking to the patients about the tool as they have very limited time to do so” (Practice nurse)
3.3.5 Process
The overall culture of the practice meant that practice staff were open to changing and adapting to the implementation of CRISP. As a teaching clinic, practice staff were familiar with exploring new methods. Nurses were motivated and enthusiastic but recognised that this might not be the case in every clinic (Quotation 5a). They were open to introducing the tool into existing processes and were very forthcoming with new to incorporate CRISP into their clinical workflow. This included, for example, flagging specific patients aged 50 to 74 years old who were eligible for screening, and incorporating CRISP into chronic disease patients’ care plan appointments, which are typically longer than other consultations (Quotation 5b).
The practice nurses were comfortable using the fidelity checklist alongside CRISP with their patients, and confident the tool was being used as it was intended (Quotation 5c).
Overall, the practice nurses thought that CRISP was easy to use, and they reported that patients enjoyed working through it because it raised awareness. (Quotation 5d and 5e).
5a “If you look at a lot of things that happen in our clinics, I think we’re probably fairly motivated here. Not that other nurses aren’t but it depends on what they’re doing with the.. . the quicker and the. .. simpler you make it, the easier it will be to continue to apply in the longer-term basis.” (Practice nurse)
5b “But you’re quite right, because we flag things on our care plan, particularly the breast screening, cervical screening, FIT, that is the time to flag and I thought to myself, I rebook for this, I give you the phone number for that, I’ve got time I’ll even do it on the phone in my room immediately.” (Practice nurse)
5c “We usually go through a bit of a fidelity checklist which I know we’ve done that with you before and it seems like that was all.. . everything was being used in the right way.” (Practice nurse)
5d “Mine have been fairly straight forward if I’m lucky.” (Practice nurse)
5e “I found that the patients I asked were very keen and liked going through the tool, it’s great at bringing awareness tool and gets people talking about their risk” (Practice nurse)