Participants
Twenty-two clinicians from the tertiary cancer centre were invited to participate in the research and 14 consented to participate in semi-structured interviews. Eight clinicians did not respond to the invitation. All clinicians who consented were interviewed, including six allied health professionals, four nurse consultants, and four haematologists. There were 10 females and four males with a range of 1–25 years of clinical experience at the institution. Interviews that examined one behaviour ranged in length between 20 and 43 minutes, whilst interviews that examined two behaviours ranged between 24 and 62 minutes.
High priority themes identified as enablers
A total of 50 enablers related to the behaviours for individual disciplines were identified across 13 domains of the TDF (Supplementary file 5): 23 were related to referring patients to the service and 20 were specific to prehabilitation delivery, 7 enablers related to both. Twenty-six enablers were classified as high priority as highlighted in Table 2. Domains with the largest numbers of high-priority enablers also contained the highest number of enablers: Social professional role and identity; Beliefs about consequences; Memory, attention and decision processes; Environmental context and resources as detailed in Fig. 1.
Table 2
Domain | Theme | Percentage of participants (n)* | Quote [participant] |
Social /professional role and identity | We work as a multidisciplinary team to action referrals If one of us forgets to refer our colleagues will prompt us Our nurse consultants help us refer Nurse 1 does the referrals for us or in collaboration with us Referring or delivery of prehabilitation is our role and responsibility. | 100% (8) 88% (7) 75% (3) 71% (5) 71% (9) | ‘We work as a multidisciplinary team, there's quite close involvement between the doctors… and the myeloma nurse consultants’. [HE2] ‘But that's why we have a team ‘cause if I forget someone else will remember’. [HE3] ‘we've got very efficient and very good coordinators [consultants]…they are the main portal of us referring the patients’. [HE1] ‘[nurse1] does the referrals to be honest, which is pretty unique’. [HE3] It’s just something that we do’. [NC1] |
Beliefs about Consequences | Patients will benefit from allied health prehabilitation If patients are not referred to prehabilitation it could impact their ability to proceed to transplant Assessment is essential If patients don't engage well with psychology, they may be less likely to engage with other disciplines | 93% (13) 83% (5) 75% (3) 100% (2) | ‘The purpose is to get a better outcome for patients from auto transplant… is the main reason we would refer’. [HE4] ‘if they're malnourished and they continue to be malnourished.. potentially they're gonna delay getting their stem cell transplant’. [AH1] ‘It's essential to get a baseline of the patient's function’. [AH4] ‘If some factors aren't addressed as well, they're probably more likely to not engage as well with some of their other goals with other allied health’. [AH6] |
Memory, attention and decision processes | We try and refer as early as possible Decision about intervention, follow up appointments (if any), and mode of follow up is based on assessment. I would never forget to provide assessment. | 75% (6) 83% (5) 75% (3) | ‘So we try and make that decision early so the patients get the best bang for buck out of the process’. [HE4] ‘would have a different level of follow up based upon how patients go on their initial testing’. [AH3] ‘No, very structured and regimented into my routine [laughs]’. [AH4] |
Environmental context and resources | Electronic medical records are an enabler Enabler to referring: Multidisciplinary team Enablers for exercise intervention: • exercise class • working in a gym • exercise prescription software Face to Face: Best mode of prehabilitation delivery | 79% (11) 75% (6) 100% (2) 100% (6) | Oh yeah, I think EPIC’s amazing so I'm very happy [laughs], made my life much easier’ [HE3] ‘it's not just me looking after the patients, there are multiple members of the team and if I don't get to the referral somebody else may prompt it’. [HE2] ‘We have dedicated supervised class time where we can book in to see multiple patients at once’. [AH3] ‘if you can get an initial assessment done face to face then it gives you so much more information about the patient’. [AH4] |
*Percentage of relevant participants who discussed the theme; (n) number of relevant participants who discussed theme |
Footnote: |
HE: haematologist participant |
NC: nurse consultant participant |
AH: Allied health participant |
Figure 1. Number of enabler themes in each domain.
High priority enablers from within these domains are elaborated below. Table 2 provides a list of these with exemplar quotes.
Table 2. High priority enablers
Social professional role and identity: A common theme across multiple domains was the importance of the multidisciplinary team as an enabler for referring patients and delivering interventions (domains: Social profession role and identity; Environmental context and resources). This was also highlighted in the Social influences domain with 86% of participants stating that colleagues support them in referring or delivering prehabilitation. Nurses and haematologists also reported that ‘If one of us forgets to refer our colleagues will prompt us’ [Heamatologist2] and that having nurse consultants to prompt and complete referrals, especially ‘Nurse 1’ [name withheld] was extremely helpful. ‘Nurse 1’ was mentioned by allied health, nurses and haematologists as a key advocate and facilitator of prehabilitation referrals and discussions. All disciplines reported that the behaviour/s discussed during the interview was their role and responsibility.
Beliefs about consequences
The overwhelming belief stated by 93% of participants was that patients will benefit from allied health prehabilitation. Participants reported that prehabilitation would improve patient outcomes pre- and post-transplant, optimise psychological and physiological functioning, improve health related quality of life, and reduce length of stay. Additionally, 83% of allied health participants reported that if the patient did not receive prehabilitation it could negatively impact their ability to proceed to transplant.
Memory, attention and decision processes
Haematology and nursing participants stated that they always try and refer as early as possible ‘so the patients get the best bang for buck out of the process’ [Heamatologist4].
Environmental context and resources
There were consistent views that since the introduction of electronic medical records in August 2020 referrals and providing prehabilitation was easier, more time efficient and improved communication between disciplines (79% of participants). Exercise physiologists reported that supervised exercise class (face to face or virtual) as well as exercise prescription software and easy access to equipment assisted in providing assessments and interventions. The mode of intervention was discussed by all allied health participants with the consensus being that face-to-face appointments were preferred by participants for building rapport, accurate assessments, and individualised intervention. However, it was acknowledged by some clinicians that telehealth (videoconference or phone) appointments were seen to improve accessibility to overwhelmed, fatigued and rural patients.
High priority themes identified as barriers
There were 29 barriers identified across 9 domains of the TDF (Supplementary file 6), 16 were related to referring patients to the service and 11 were specific to prehabilitation delivery, 2 barriers were related to both. Sixteen of these themes were classified as high priority as highlighted in Table 3. Domains with the largest numbers of high priority barriers also contained the highest number of barriers identified: Memory, attention and decision processes; Environmental context and resources; Social influences; Emotions as detailed in Fig. 2.
Table 3
Domain | Theme | Percentage of participants (n)* or conflicting belief (CB) | Quote [participant] |
Memory, attention and decision processes | Not all patients/all patients should be referred I sometimes (or never) forget to refer There is no objective tool to advise who should be referred to service | CB CB CB | ‘There are some patients where you make a judgement call that because of their age or lack of comorbidities… that they may not require prehab’. [HE2] ‘All patients going to transplant will be offered the prehab program’. [NC3] ‘I’m sure I forget all the time. [laughs]’. [HE2] ‘I don't think I've ever missed referring on early’. [NC1] ‘We have to have some sort of basic objective tool saying if patients fit these criteria, they automatically should be referred to prehab’. [HE1] |
Environmental context and resources | Barrier to referral and delivery is time and workload pressures. Not having reliable room accessibility (nutrition and psychology) Phone appointments are a barrier: • Not a good audience Videoconferencing can be a barrier: • Assessments are not validated • Harder to connect with patient | 100% (14) 100% (4) 100% (6) 100% (6) | ‘I think the main barrier at the moment is probably like time/patient load’. [HE2] ‘I guess staffing and time would be an issue…I just don't have the capacity’ [AH4] ‘Having reliable access to a room and a computer.… it can be challenging’[AH2] ‘You've got a better audience if it's face to face over telehealth or in person as opposed to over the phone’. [AH1] ‘I think those emotional concerns… are a little bit easier to speak about in person. And I think over telehealth sometimes it feels to them a bit more like a medical appointment’. [AH6] |
Social influences | Patients can be barrier to referral Patient can be a barrier to prehabilitation delivery | 88% (7) 83% (5) | ‘There have been some people where there's been a little bit of pushback’. [HE2] ‘We can't provide psychological treatment to someone if the patient doesn't want that and isn't motivated to engage’. [AH2] |
Emotion | Patients’ emotions may: • delay referral or discussion about prehabilitation • affect delivery | 71% (10) | ‘So if they’re pretty upset with the diagnosis we'll probably not discuss it at that particular moment and defer it to a second appointment’. [HE4] ‘There have been occasions where my patients’ feelings have affected me completing the assessment’. [AH5] |
*Percentage of relevant participants who discussed the theme; (n) number of relevant participants who discussed theme |
Footnote: |
HE: haematologist participant |
NC: nurse consultant participant |
AH: Allied health participant |
Figure 2. Number of barrier themes in each domain
High priority barriers within these domains are elaborated below and Table 3 provides a list of these with exemplar quotes.
Table 3. High priority barriers
Memory attention and decision processes: There were conflicting views amongst nursing and haematology participants about which patients should be referred to the prehabilitation service. Seventy five percent of haematologists reported that ‘There are some patients where you make a judgement call that because of their age or lack of comorbidities… may not require prehab’ [Hematologist2] whilst 75% of nurses reported that ‘all patients going to transplant should be offered the prehab program’ [Nurse3]. This barrier was reinforced through other related themes reported by nurses and haematologists including: no objective tool to advise who should be referred to service (Memory, attention and decision processes), lack of formalised process for referring (Behavioural regulation), and a lack of understanding about who we can refer (Knowledge). Some nurses and haematologists reported that they might forget to refer a patient, whilst others stated ‘I don't think I've ever missed referring on early’ [Nurse1].
Environmental context and resources: The most frequent barrier reported by all participants was lack of time to complete referrals, assessments, and individualised interventions. This was stated in various ways by participants including: patient load, appointment time not long enough, patients running late creating time pressure, and not enough funding to meet the needs of the service. Phone appointments were widely viewed by allied health participants as ‘not ideal’ [Allied health2] and challenging. Videoconference appointments were considered better than phone appointments, but barriers included: assessments not being validated; some patients having technological difficulties and greater difficulty building rapport than face to face appointments.
Social influences
Patients’ views were discussed as a potential barrier to referral by 88% of haematologists and nurses who reported that some patients did not feel they needed the service or were too overwhelmed with their diagnosis or treatment. Eighty four percent of allied health participants also discussed patients’ responses as a barrier to delivery. They reported that patients may refuse assessment due to ‘time, sometimes due to pain, sometimes due to not feeling well’ [Allied health3], and that patients’ motivation and preferences affect provision of the intervention. Patients who were coping well prior to transplant were reported to be more difficult to engage in the prehabilitation intervention as they ‘find it a little bit difficult to conceptualize’ [Allied health5] future struggles.
Emotions
Patients’ emotions were a barrier to completing referrals and delivery (stated by 71% of participants). Specifically, nurses and haematologists discussed delaying the prehabilitation referral if the patient was overwhelmed or upset.
Lower priority domains
Six domains were rated as a lower priority using the developed decision criteria: Knowledge; Skills; Beliefs about capabilities; Optimism; Reinforcement; and Intentions. Most allied health participants were aware of the evidence supporting multidisciplinary prehabilitation (Knowledge), and reported that assessments were simple, standardised and that they had received appropriate training to conduct them (Skills). All participants felt confident in their ability to appropriately refer patients or deliver prehabilitation (Beliefs about capabilities). When asked about Optimism, two participants hoped and assumed that their colleagues would submit referrals or be aware of the service. Two participants discussed how rewarding referring or delivering prehabilitation can be (Reinforcement), whilst all other participants reported they did not receive any rewards from completing their prehabilitation behaviour/s. The majority of nursing and haematology participants stated that they were determined to refer and educate patients as early as possible (Intentions).