This article examines how clinicians working in outpatient cancer care adapted to the co-location of a novel community support service, Improving the Cancer Journey (ICJ), which is designed to meet the holistic concerns of every cancer patient in Glasgow (Box 1). Since its inception in 2014, ICJ has supported more than 4000 people, especially those most in need due to social deprivation (Snowden et al, 2018). ICJ is offered to all people newly diagnosed with cancer via letter, but it is also available to people with existing cancers at any stage of their illness or recovery. To widen access, in 2016 ICJ was situated within outpatient services in local hospitals in Glasgow. The positive impact ICJ has had on patients has been documented (Young and Snowden, 2019). This article focuses on understanding how being newly co-located with ICJ affected the way clinicians worked. This is important to understand because it is a working example of integrating health and social care, a long-standing aim worldwide that has proved historically difficult (Heenan and Birrell, 2006).
Integrating health and social care is the best way to deliver safe, effective, person-centred cancer care (Nancarrow et al, 2013; Scottish Government, 2016). Indeed, interprofessional working across professions and sectors is a goal of international health policy. However, creating and sustaining a joined-up, functioning interprofessional team is difficult (Øvretveit, 1997). Common impediments include poor communication and threats to professional identity (Stull and Blue, 2016). When multidisciplinary team members do not understand or value each other's roles and responsibilities, constructive working relationships deteriorate. On the positive side, a better understanding of other team member's roles leads to better working relationships, lower risk of burnout and better organisation of care (Birkeland et al, 2017). It is unsurprising therefore that Xyrichis and Lowton (2008) found that geographical proximity of team members and smaller team size were more likely to lead to successful interprofessional working. Conversely, geographical separation of disciplines sustains professional boundaries (King et al, 2012), so a key factor supporting the likely success of interdisciplinary teams is co-location (Wener and Woodgate, 2016).
As a result, when health and local authority care partners in Scotland wanted to improve access to ICJ they took the service into outpatient clinics in Glasgow. In practical terms this meant that cancer specialist nurses and doctors worked alongside link officers, non-health cancer specialists from the local authority (Box 1), for the first time. The unknown was how this move would change clinicians' working practices. A common challenge for health practitioners is that, despite having the will, they do not have the time or skills to support patients with complex social and practical needs, such as helping them navigate the financial options available to them (West et al, 2005). If a non-clinical expert can support patients with their social and practical concerns instead, this should improve the system by allowing clinicians to focus on their own specialities, with positive implications for both time and resources (Trevatt and Leary, 2010).
Witnessing this should have a positive impact on the way clinicians engage with both ICJ workers and patients, but this was not known before the study. It depends on outcomes being visibly positive to all. In addition, although it is intuitive to imagine that a helpful service would be well received, busy clinicians may instead perceive the project as unwanted extra work. Any change, no matter how well intentioned, is known to create discomfort and potential disengagement (Snowden and Young, 2017). Therefore, the way these clinicians engaged with the service could be important transferable knowledge for those attempting to understand and introduce similar schemes in future.
Study aims
Method
Design
The study adopted a qualitative exploratory approach using convenience sampling. Thematic analysis following Braun and Clarke's (2012) guidelines were used to analyse the data. The Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines were used to report findings (Tong et al, 2007).
Participants and setting
Twelve clinicians were approached by email. The reason they were approached was because they have an established association with ICJ; that is, they either work alongside the link officer, as in the lung team, or they make referrals into ICJ. All participants work for an NHS hospital within the NHS Greater Glasgow and Clyde health board in Scotland.
Interviews were conducted by one researcher (JY) between September 2018 and January 2019 in a private room in the participants' workplaces. A semistructured interview schedule was used to explore each participant's perceptions of ICJ. This included: motivations for collaborating with the service, what difference it has made to their practice, and what benefits this collaboration may have for their patients. However, the schedule was used flexibly to allow participants to describe their experiences of engaging with the service in their own words.
After completing the tenth interview data saturation was reached (Mills et al, 2008). This was deemed to have occurred because no new themes were identified from the data. Interviews lasted 35–50 minutes, were audiorecorded and then transcribed verbatim. Finally, once the data had been analysed, in June 2019, the results were discussed with the participants to find out whether they resonated with their experience. All participants thought that their perceptions and experiences had been captured meaningfully within the researchers' interpretation.
Ethical approval
Ethical approval for the study was obtained from the West of Scotland Research Ethics Committee and the Edinburgh Napier University ethics committee.
Analysis
The data were analysed following Braun and Clarke's (2012) thematic analysis. This involves identifying, analysing and reporting patterns or themes across the dataset. Both authors read the transcripts and independently generated line-by-line codes. They then met to discuss early interpretations and reconcile any differences. The researchers then constructed themes from the codes to create an accurate representation of the whole.
Results
Ten clinicians agreed to be interviewed on their perceptions of an integrated ICJ service. The two who did not take part did not reply to the email request for participation. The majority (n=6) were from lung cancer teams and the remaining were from breast, gastrointestinal and head and neck specialties located in clinics in district general hospitals within Glasgow. The majority (n=8) were cancer nurse specialists (CNSs) and the remainder were medical oncologists (n=2). Nine were female and one was male. Clinical experience ranged from 1 to 15 years. The more experienced professionals contrasted their working practices before and after their collaboration with ICJ (n=8). Those who were newer in post reflected on their current practice (n=2).
Four themes were identified from the data, each representing a different phase of integration (Figure 1). They were: ‘The conversation’, ‘A better experience’, ‘Freedom to focus’; and ‘Working hand in hand’.
The first theme, ‘The conversation’ shows how a new way of working needs to be managed sensitively for it to be effective.
Theme 1. The conversation
The point at which ICJ is introduced to the patient was emphasised as being a significant moment. Participants referred to it as ‘the conversation’, with some expressing hesitation about getting it right:
‘I think something we can work harder on and I think it's just difficult sometimes trying to work out having the conversation at the right time and catching the patient at the right time.’
Emphasising that it has to be done ‘at the right time’ suggests that it was initially perceived as a sensitive, or difficult, topic. There was consequently some reluctance to engage, because some participants viewed ICJ as an additional layer of complexity, a burden to those with already challenging lives and needs:
‘When it first started I had a little trouble thinking, “How do I put this to people who've got enough to cope with?”.’
However, once it became evident that ICJ could provide relevant support for their patients, confidence and trust developed and ‘the conversation’ became easier. For participant 4 the benefit had to be personally experienced:
‘It was just a confidence thing. I didn't want to promise something I hadn't experienced, but then patients are coming back and saying, “Can I get it for my friend?”, and then you're seeing it—it gives you much more confidence to say, “I can sell this service”.’
The next theme considers that, as participants began to report appreciation of the new service, they were more comfortable expressing that to their patients.
Theme 2. A better experience
The interviewees stated that by supporting non-clinical concerns the link officers were improving the patient experience:
‘They sort out all the things that can make for a stressful life. I often say in my job, you can't change the outcome but you can change the experience. And I think that is how their job is too.’
This is a significant quote because it demonstrates that this collaboration is providing the mechanisms to provide a more holistic experience for this patient. Observing the positive impact that this additional support had on their patient's quality of life reinforced views on the value of this interprofessional collaboration. What is more, it was recognised that taking collective responsibility for their patients' holistic needs would help to connect the professionals, develop trust and respect for each other, and positively shape patient perceptions:
‘We made the decision to very much include ICJ as part of the team, so it felt to be a routine package of care that we offer everyone. It was very much, we were very determined that it was seen as a coordinated, synchronised package.’
Integrating knowledge and skills across the professions is essential for improved patient outcomes. For example, the clinicians reflected on how their patient's physical, psychological and practical needs are commonly intertwined:
‘If someone isn't supported practically, it has a psychological impact on them. And then it manifests itself physically, and then you're dealing with someone who's really not in a good place and going downhill pretty fast. Whereas, if they are supported in the community, they're a lot happier, they feel supported.’
Theme 3. Freedom to focus
This theme captures participant views on how directing their patients to ICJ for a range of non-clinical support has allowed them to regain a clinical focus within their consultations:
‘My clinical role is changing quite a lot. With new and developing treatments we're becoming quite involved in this part of things. So, I think our role as a whole has changed and linking with ICJ has given us the space to let this happen.’
‘I'm now able to concentrate on my part of the job. I can concentrate on the part that is mine, building from what the medics have said, knowing that the other part is going to be taken care of and to a much better, higher standard.’
There is recognition of the need to support patients with all of their concerns, combined with the acknowledgement that they may not have the expertise and time to adequately deal with these non-clinical issues. Previous attempts to do so had stretched their workload to the limit and, while they were providing some level of service, it was recognised that it was not always optimal:
‘When we did have to deal with the social issues, it was very time-consuming and took us away from the clinical work. We didn't have the knowledge, so patients were getting a really raw, a really bad deal.’
As a result of this collaboration with ICJ, a number of the clinicians described a considerable contrast between their old and this current way of working.
‘I think for us it enhances our job satisfaction … before, the way we were working, we were aware that there were bits we weren't dealing with, but we knew we had only so many balls that we can juggle. But now I don't think we feel there is anything left unturned.’
Consequently, realising that they can now refocus on their clinical role was seen to have a positive impact on staff morale and wellbeing. Most participants reported feeling less worried, less pressured and less guilty, knowing they can now easily refer patients for further support:
‘I think, because you feel that burden is taken off you and someone has taken it, you do feel overall we're doing a better job and we are better addressing the needs of the patient.’
Theme 4. Working hand in hand
‘If we can improve the patient's quality of life and we can do it with the least amount of inconvenience for them, then that is success … and that pretty much has been the CNS with ICJ sort of holding hands, is how I view it.’
The final theme encapsulates comments pertaining to the close working relationship that has emerged, both geographically and clinically. As in the literature, geographical proximity was singled out as an important element in the development of this partnership because it reinforced the idea of professionals physically working together. When the link officer was co-located within the clinic, patients could seamlessly move through appointments. Being situated together also had a positive effect on communication—in particular, the ability to have face-to face interactions ensured that queries could be dealt with quickly:
‘I think the fact that they're here. So if there's any issues we can just run down and speak to them. And, if we have someone who needs to see them, we can just get them booked in straight away.’
‘It's one service, a health and social care service. One stop. That's how I have it in my head, it's teamwork, and plus it's not an extra visit because they are here anyway.’
This theme also captures how mutually reliant the two services had become: participants viewed their roles as co-dependent and as working towards one purpose:
‘In terms of their expert knowledge, I'm learning from that. I'm learning about things in the community that we can refer patients to that I didn't know existed. So it's a learning curve for us all. And just to know the patients are having a more improved service from anything I could have offered is fantastic.’
Discussion
The aim of this study was to explore the impact of co-locating a non-health professional within clinical practice. The findings largely aligned with the literature of interdisciplinary working discussed at the start of this paper. First came the difficulties of adapting to new ways of working, at which point the service appeared more complex than it had done before the initiative. This was followed by clinicians witnessing the benefit of having the service co-located, quite quickly followed by clinicians identifying positive changes in their own practice as the service unburdened them of tasks they would have previously attempted, but were not appropriately skilled to manage. This, in turn, led to a much better division of labour, as each professional came to better understand the role and function of the other, at which point the two services became one. The discussion now examines this process to identify whether there is any transferable knowledge.
In the first phase, clinicians explained why they did not want to engage. They saw the new service as extra work and a burden not only to themselves, but particularly the patients. They saw their role as protecting patients from having to deal with something else when they were particularly vulnerable. In addition, because some participants lacked confidence in explaining what the service entailed (‘the conversation’), they struggled to discuss it at all. This chimes with a study where similar language was used by nurses explaining why they struggled to engage with research in a hospice environment (Snowden and Young, 2017). They lacked confidence in explaining the study protocol and feared burdening their patients.
These perspectives changed when it became clear that the service often improved the patient experience and simultaneously allowed clinicians to focus more on their own specialties. This opinion was unanimous, leading to the view that care would be considered worse if the service were taken away.
There are many ways of conceptualising this process. Rogers' (2003) classic ‘theory of diffusion’, for example, describes the process through which an innovation spreads over time among members of a social system. Based on the normal distribution, it is essentially a description of a passive process, whereby people of different natures (early adopters, laggards and so on) are seen as likely to adopt the new idea based on their propensity for change. However, although a useful illustration of diffusion under normal conditions, the authors argue that a better theoretical fit in this case is the J curve (Figure 2).
Originally used to explain patterns of conforming behaviour such as punctuality (Allport, 1934; Dudycha, 1937), the J curve has subsequently been adopted by economists and business analysts to explain the diffusion of ideas in instances where initial resistance to change is apparent (Jelassi et al, 2017). The theory is that change is a function of motivation and time (Keefe, 2006). A period of disruption should be classed as normal behaviour because any innovation disrupts the usual routine (Viney, 2005; Kawulich, 2011). The J curve is therefore a useful starting point for any innovation because it builds in an expectation of an element of resistance.
Further, it is useful because much of the literature on leadership and the J curve focuses on navigating this ‘valley of despair’ (VoD) (Chase and Dickson, 2017). This therefore a useful way of understanding why a critical area of development has not happened (Markham et al, 2010), and this literature could therefore be very helpful for those interested in the transferability of the findings presented here. Innovations with a clear unambiguous advantage over an old way of working are more easily adopted (Greenhalgh et al, 2004), which is what happened here, yet even in these circumstances there was still an element of resistance in places.
Limitations
Most of the interviewees came from a single area. The ICJ link officer is physically located within the lung teams, therefore the authors prioritised recruiting a larger number of lung specialists in order to capture their perceptions of this unique collaboration.
However, as the service develops and expands, link officers will be situated in additional oncology teams representing different cancer types. Future research will seek the views of these clinicians.
A further limitation of the study is its relevance to other geographical settings and healthcare systems. For example, the west of Scotland has among the highest lung cancer incidence rates in the world (NHS National Services Scotland, 2020). There are also considerable areas of deprivation within Glasgow (Maantay, 2013). One of the main advantages of collaborating with ICJ is its ability to support patients' practical and financial concerns. However, the need for such a service may not be the same in other areas.
Finally, one of the main reasons the venture was successful may have been the level of knowledge already held by clinicians when ICJ was co-located. The service had been operating for about 18 months, so some participants may have already been convinced of its worth. Therefore, they did not need any extra training that may be necessary in other projects. In other words, the dip in the J curve may be much longer where an extended period of time is needed to convince others of the worth of a particular venture.
Conclusion
It is important to understand how new interprofessional ventures succeed or fail in response to the global need to make health care more holistic. Integrating any new service within an existing way of working can take time and sensitivity, so qualitative studies such as this are valuable because they provide a more detailed understanding of the range of factors that may help or hinder collaborative working. Despite some participants being aware of the positive impact ICJ had on some patients, this had happened at a distance and so most required tangible evidence that any change to their existing practice was going to be of benefit to patients. This evidence appeared first as hearsay from one or two local anecdotal reports, before colleagues witnessed the benefits to patients first hand. At this point, the benefit was accepted by the wider team who subsequently described their new colleagues as invaluable and irreplaceable.
Although explicable as a working example of the J-curve theory of innovation, it is important not to generalise too much from a single example. This venture succeeded mainly because it helped patients. It may seem like an obvious point, but many excellent ideas fail in the ‘valley of despair’ and, even though this particular venture came with a realistic degree of optimism, it initially still had to overcome antipathy. Consequently, the first and most important recommendation is that planners should ensure that all parties are aware of any and all potential positive impacts on patients as comprehensively as possible. Second, even if they succeed in getting staff onside, they should expect things to get worse before they get better. Be prepared for the valley of despair. Preparation will improve the chances of developing successful interprofessional care.