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From Challenges to Resources

A Qualitative Study of Cancer Coordinators' Experiences of Barriers and Facilitators to Enacting Their System-Focused Tasks

Lie, Nataskja-Elena Kersting MSc; Solvang, Per Koren PhD; Hauken, May Aasebø PhD

doi: 10.1097/NCC.0000000000000617
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Background Cancer coordinators (CCs) operate at both patient and system levels in order to provide patients with tailored and coordinated services. In common with international CCs, Norwegian CCs denote notable progress in their patient-focused work, while reporting ongoing challenges in carrying out system-focused tasks. However, little is known about the barriers and facilitators for CCs' system-level work.

Objective The aim of this study was to explore Norwegian CCs' experiences of barriers and facilitators for enacting system-focused tasks.

Methods The study applies a qualitative method, conducting an interpretative data inquiry of semistructured in-depth interviews with 26 Norwegian CCs. The data were analyzed using thematic analysis and discussed in light of previous research and salutogenic theory.

Results The analyses revealed 3 main themes: (1) “understanding the role and local cancer care,” (2) “systems for care delivery in primary healthcare,” and (3) “commitment to collaboration.” Where present, the themes could represent important facilitators, whereas their absence could depict notable challenges to CCs system-focused work. Over time, as CCs were able to mobilize resources, they were able to gradually turn initial challenges into facilitators in the context of system-level work.

Conclusions Cancer coordinators encounter cognitive, practical, and relational topics that impact their system-focused activities. Adopting a salutogenic focus can help CCs mobilize resources needed to turn challenges into facilitators for system-level work.

Implications for Practice Cancer care coordination cannot be undertaken by CCs alone. Cancer coordinators' embedding in multidisciplinary teams, common systems for care provision, meaningful work relations, and professionals' commitment to cancer care represent important facilitators for CCs' system-focused tasks.

Author Affiliations: Department of Physiotherapy, Faculty of Health Sciences, OsloMet – Oslo Metropolitan University, Oslo (Ms Lie and Dr Solvang); and Center for Crisis Psychology, University of Bergen, Bergen (Dr Hauken), Norway.

The authors have no funding or conflicts of interest to disclose.

Correspondence: Nataskja-Elena Kersting Lie, MSc, Department of Physiotherapy, Faculty of Health Sciences, Oslo and Akershus University College of Applied Sciences, PO Box 4, St Olavs plass, 0130 Oslo, Norway (nataskja.lie@oslomet.no).

Accepted for publication March 21, 2018.

Online date: June 22, 2018

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Introduction

Cancer can be a complex disease, and its treatment can require a broad range of multidisciplinary actors and services.1–3 To meet the growing need for patient-centered, coordinated cancer care, professionals in a navigating function have been introduced in several countries.4–9 In Norway, the role, which is a novel part of primary healthcare services, is referred to as cancer coordinator (CC).10–14 In line with existing functions elsewhere, Norwegian CCs adopt a dual work focus, including both patient- and system-oriented tasks to help cancer patients overcome barriers to coordinated care.2,3,6,12 To date, CCs in Norway and other countries denote notable progress in terms of their patient-focused work, while reporting ongoing challenges in carrying out system-level aspects of their role.4,5,13 In response to calls for more research into the CC role, this study explores CCs' experiences of barriers and facilitators for their system-focused tasks. Such insights can provide valuable information for achieving coordinated care with the help of CCs.2,3

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Previous Research

Professionals in navigating functions have been established on an international basis, interchangeably referred to as coordinators, navigators, or similar terms.4,6–9,15 To facilitate adequate actions in the different settings, most CC positions are context bound and characterized by a flexibility to adapt the role and its tasks to the needs of the local setting.3,12 In Norway, the establishment of CCs has been initiated by the Cancer Society, providing municipalities with funding for up to 75% of the wages of CCs in primary healthcare over a period of 1 to 4 years.10,12 The underlying idea for Norwegian CCs aligns with the vision for existing functions elsewhere and aims to provide patients and municipalities with a resource to support a better tailoring and coordination of cancer care trajectories across sectors and disciplines.4,6,7,12 However, nationally and internationally, no standard definition exists for the role. Hence, CCs have to find their place among various actors in cancer care and determine adequate ways to operate in their particular context.3,13 This has given rise to great diversity in how CCs enact their role and a widespread request for research into the CC role in order to enhance understanding of the role.5,7,12

This article is the second study of a larger research project investigating the CC role in the context of Norwegian primary healthcare. The findings from the first study16 brought to light that, while CCs reported notable progress in their patient-focused work, most of them outlined system-focused tasks to be side-tracked and challenging to carry out. International literature identifies similar challenges in the achievement of CCs' system-focused tasks, indicating, among others, difficulties concerning external role comprehension and collaboration with professionals.5,7,12 Cancer coordinators may be contested in achieving coordinated care across sectors, especially when actors are not used to collaborating.2,17 In turn, CCs who succeed in operating at the system level are acknowledged as a vital resource in cancer care among other professionals.4,14 However, current knowledge on contextual factors that impact CCs in achieving the full potential of their function remains scant.2,3,18 To fill this research gap, this study explores CCs' perceived barriers to and facilitators for their system-focused tasks.

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Theoretical Background

This study applies salutogenesis as a theoretical framework to discuss the findings. The salutogenic theory, coined by Aaron Antonovsky,19,20 is best known as a framework for investigating resources that individuals apply in order to constructively cope and stay healthy under challenging circumstances. However, researchers have emphasized the transferability of the framework to the system level in order to explore factors that affect community-based or organizational health.21–24 In this context, health is viewed in terms of the productivity or output of a setting and the well-being of its actors.25 Salutogenesis supplies a problem-oriented approach to organizational health with a focus on resources in interventions or systems.22,25 The resources are termed general resistant resources (GRRs), which can be any internal or external factors that enable a constructive approach to managing stress-causing events.19,20 Knowledge, experience, money, support, and traditions are examples of GRRs.22 General resistant resources can enhance comprehensibility, manageability, and meaningfulness of a situation. Comprehensibility is “the extent to which one perceives the stimuli that confront one (…) as making cognitive sense, as information that is ordered, consistent, structured, and clear.”20(pp16,17) Manageability describes a perception of “resources are at one's disposal that are adequate to meet the demands posed by stimuli that bombard one.”20(p17) Meaningfulness is a notion that demands are “worth investing energy in, are worthy of commitment and engagement.”20(p17) These 3 components deploy a sense of coherence (SOC), a perceived consistency of demands, and resources that can enable coping.19,20 The SOC is the personal or collective driving force to utilize the given resources to achieve positive outcomes.26,27 In turn, general resource deficits can result in adverse reactions to stress and negative health outcomes and hinder a positive development.28 In this study, the framework is used to explore CCs' experiences of barriers and facilitators in their system-focused tasks.

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Study Aim

This study aimed to identify which factors Norwegian CCs perceive as affecting them in carrying out system-level work to deliver coordinated care. It addresses the research question: “What do CCs experience as barriers to and facilitators for operationalizing system-focused tasks?”

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Methods

The present study applies a qualitative method, by carrying out an interpretative data inquiry inspired by the work of Gadamer.29,30 Taking the ontological stance that no single independent truth about a phenomenon exists, understanding is generated by a dialectical process, which is also referred to as a hermeneutic circle. The hermeneutic circle is entered via a dialogue, in which the informants' accounts and the investigators' interpretations constantly interact and compare, until the different horizons merge into a shared, co-constructed understanding of reality.30,31 Such a constructivist epistemology anticipates that interpretations are affected by historical and cultural context, subjective experiences, and prior knowledge.29 However, methodological rigor can be ensured when accounting for how preunderstandings have influenced the analytical process.32 All of the present authors have prior experience with qualitative health research. The first author is educated in health promotion and psychology, the second author has a background in sociology, and the third author has a background in cancer nursing. This has yielded diverse perspectives and discussion and helped us pursue a reflexive process regarding our preunderstandings in order to approach the phenomenon faithfully.32,33

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Sampling Procedure and Informants

Based on the inclusion criterion “being a Cancer Society–funded CC in Norway,” we conducted purposeful maximum variation sampling,32 aiming to recruit a diverse sample with regard to CCs' professional background, terms of employment, age, and gender, as well as demographic variables of their municipalities. The sampling procedure was informed by a prior mapping of the whole population (n = 130 CCs), through which relevant information was systematically collected from the Web sites of the Norwegian Cancer Society, the Web sites of the Norwegian municipalities, and Statistics Norway.15,34 The first author contacted the selected CCs via e-mail with study information and an invitation to participate. All approached CCs gave their consent and were subsequently contacted by telephone to discuss further details and set an interview date. The sampling procedure was finalized when the range of the aforementioned variables was covered by the CCs in the study sample and has also been described in the first study of this research project.35 The final sample included 26 Norwegian CCs (Table 1).

Table 1

Table 1

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Interview Procedure

The first author conducted 26 qualitative interviews with the informants. Eighteen face-to-face interviews were undertaken at the CCs' workplaces, whereas a further 8 interviews were conducted by telephone because of long distances. The interviews were semistructured and based on an interview guide with open-ended questions (Table 2). The questions were informed by prior research, addressing CCs' experiences in executing system-level aspects of their role. Follow-up questions aimed at encouraging the CCs to elaborate on hindering and facilitating factors as well as raise additional topics, if needed. We conducted 3 pilot interviews that confirmed the suitability of the interview guide. These were included into the sample. The interviews lasted 60 to 120 minutes and were recorded and transcribed verbatim.

Table 2

Table 2

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Ethical Considerations

The Oslo and Akershus University College of Applied Sciences and the Norwegian Centre for Research Data approved the conduct of our study. The study was carried out in compliance with the Helsinki Declaration and data processing requirements.36 Study participation was voluntary and based on informed and written consent from all participants. Recognizable data on the identity of CCs or municipalities were anonymized in the transcripts and remain so in this article.

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Data Analysis

The study applied a thematic analysis of the data as proposed by Braun and Clarke,37 using the NVivo38 software to aid the organization of the rich data material. The steps involved the researchers' familiarization with the data and a subsequent open coding and labeling of relevant data extracts. In an iterative process, codes were refined and organized as themes and subthemes to capture important aspects of the phenomenon. The codes and themes were reorganized and relabeled several times. This procedure continued until all researchers considered the themes and subthemes as providing a rich, consistent picture of CCs' accounts.37

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Findings

The analyses revealed 3 main themes and several subthemes that the CCs encountered in the system-focused aspects of their role. The first theme was “understanding the role and local cancer care,” elaborated by 2 subthemes: “clarity of the CC role” and “cancer-related knowledgeability of collaborating partners.” The second theme was “systems for care delivery,” comprising 4 subthemes: “integration of the CC role,” “common procedures, “communication across sectors and disciplines,” and “local resources.” The third theme was “commitment to collaboration,” including 2 subthemes: “acknowledging work relations” “shared ownership and responsibilities.” Instead of depicting distinct sets of challenges or facilitators, the themes could represent both. Where present, the themes could represent important facilitators for CCs' system work. Their absence, in turn, could depict a barrier to the system-focused tasks. The analysis indicated a positive trend over time, as CCs were able to mobilize resources, which helped to gradually turn initial challenges into facilitators in the context of system-level work.

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Theme 1: Understanding the Role and Local Cancer Care

Cancer coordinators experienced the extent to which other professionals understood the CC role and patients' needs and services in local cancer care as affecting their opportunities for system-focused work. The subthemes are elaborated on in the following:

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SUBTHEME 1A: CLARITY OF THE CC ROLE

The CCs delineated that a clear positioning of the CC role in cancer care was a vital prerequisite for them to carry out system-focused work. This included a clear position description and initial role orientation, so that other professionals in primary healthcare would understand and differentiate the role from other actors in cancer care, such as cancer nurses, home care teams, or coordinators in specialist care. In a comparable way, many CCs themselves seemed to initially lack clarity concerning their intended tasks, as most municipalities had not provided them with a role description or orientation. Consequently, the CCs described that the role often was inadequately promoted in primary and specialized services, reinforcing challenges concerning role recognition.

There was a confusion (…) [among the professionals. In terms of] what she was doing, what I was doing, what the contact nurse was doing (…) we actually didn't know. CC2

To enhance clarity concerning the CC role, the CCs had to resolve which work tasks would best suit their municipality and how they could promote the role locally. However, most CCs received little management support and supervision, as well as investing much time and effort in determining and communicating their tasks to collaborating partners and the patients.

I used a lot of time (…) to develop a system of what I would do and how I would promote [the CC role]. I have a lot of knowledge now (…) that makes it easier. CC5

To orient themselves toward their work, many CCs described consulting with local professionals or other CCs as helpful. Some CCs were part of a project group or had created their own project plan with goals and tasks for their role. These CCs perceived their role to be more clearly defined, promoted, and understood and reported fewer difficulties in professional collaboration.

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SUBTHEME 1B: CANCER-RELATED KNOWLEDGEABILITY OF COLLABORATING PARTNERS

The analysis revealed that local professionals' cancer-related expertise and skills affected CCs' system-focused activities. Cancer coordinators perceived several actors to lack knowledge of cancer care and patients' physical, psychosocial, occupational, or financial needs. This yielded separate service provision, rather than a holistic approach to patients' biopsychosocial needs.

I think there is little holistic thinking and too much focus on “You need cortisone, I'll write a prescription” (…) There is nothing more, such as “How are you? (…) Do you need support at home?” They leave that to others or might not even think about it. CC1

Further, many CCs regarded services across sectors to be disconnected and lacking transparency, such that professionals had little overview of patients' entire treatment course or knowledge of existing services and relevant actors involved in cancer care. Thus, CCs emphasized their efforts to train local actors via education, competence building, tutoring, or guidance in procedures. Other CCs used informal arenas, for example, lunch meetings, to facilitate knowledge exchanges.

We have [multidisciplinary] lunches (…) every second week (…) To learn what is going on in the field, what services there are. Very smart, because (…) you hear about services you didn't even know existed in the municipality, and I can forward it to my patients. CC3

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Theme 2: Systems for Care Delivery

The analysis illuminated that CCs experienced the prevailing systems for care delivery in primary healthcare as another major topic. This was elaborated in terms of 4 subthemes, presented below.

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SUBTHEME 2A: INTEGRATION OF THE CC ROLE

The analysis revealed that proper integration and visibility of the CCs' role in existing systems had a major impact on their ability to execute their system-focused tasks. Many CCs explained that the management had no planned approach to the implementation of the role. Hence, CCs described a seemingly random or unfavorable organization of the role and localization of CCs' offices, in terms of inadequate access to professional work arenas and databases. This could deter CCs from cooperating with other professionals, resulting in many CCs working in isolation. The visibility of the role in healthcare systems and settings was of concern regarding hospitals, as several interchanging actors needed to be informed and reminded of involving CCs in their work.

The bigger the hospital, the more difficult it gets. Because so many are involved (…) [They don't] always contact us when releasing patients who may need to see us. CC13

As CCs perceived themselves to have little influence on information technology (IT) systems, many of them focused on other ways to improve the integration of their role, for example, by adding their details to contact lists for staff in specialized and primary services. Several CCs had their office relocated to facilitate better access to and availability for, for example, home care teams, administration staff, general practitioners, or nurses. This helped to enhance their visibility and interaction with other professionals.

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SUBTHEME 2B: COMMON PROCEDURES IN CANCER CARE

The CCs highlighted that routines for cooperation as well as common standards and procedures in cancer care across sectors had notable impact on their ability to carry out system-focused tasks. Several CCs explained that professionals could struggle with adopting and sustaining new routines in their often hectic workdays. In addition, many professionals were used to working via case-to-case approaches, rather than standardized care procedures.

Everyone has distinct approaches (…), and the information provided often differs. CC4

However, several CCs were aware that more systematic professional collaboration and common care procedures across sectors could be facilitated via standardized tools, for example, checklists, written procedures, or training, which supported establishing, conducting, and maintaining new routines.

We developed a standard trajectory, with checklists, to provide comprehensive care to the patients (…) [such as] routines for collaboration (…) and knowledge dissemination. CC21

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SUBTHEME 2C: COMMUNICATION ACROSS SECTORS AND DISCIPLINES

While communication systems across sectors and disciplines were outlined as an important feature of system-focused work, most CCs pointed out a lack of meeting points and shared electronic systems. This hampered information exchanges within primary healthcare and across sectors, mostly regarding patient transfers from hospital to the municipalities.

Various epicrises signed by different doctors (…) Verbal transferals (…) The hospital thinks the general practitioner follows up (…), but he has not received an update (…) They don't communicate, as they don't have a shared electronic journal system. CC4

To improve cross-sectoral communication, most CCs are engaged in regular contact and information exchanges with relevant actors, for example, via e-mails or by telephone, visiting them at work, joining existing network groups, or establishing multidisciplinary teams. However, narrow time frames or significant distances could impact CCs' ability to gather all professionals together.

We don't have a common workplace (…), so we have fixed weekly meetings (…) But, it is a hassle (…) It would be so much easier if we had a shared workplace. CC20

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SUBTHEME 2D: LOCAL RESOURCES IN CANCER CARE

Most CCs outlined local political commitment as well as sufficient resources and service offers in cancer care, which affected their opportunities for system-level action. Only a few CCs worked in municipalities that had established, for example, a local or regional cancer care plan or mobilized external funding for developing local cancer care. Most CCs, however, described limited political prioritization and little available resources for cancer care. As a result, some CCs worked to increase local budgets via external funding. However, many CCs sought to better utilize the given resources, for example, by including their patients in local offers for other patient groups. Other CCs allied with neighboring municipalities, patient associations, or volunteers to enhance services.

Collaborating with others… various organizations (…) is what is needed to manage to establish [local service] offers [in cancer care] (…) Otherwise, we couldn't do it. CC21

All CCs emphasized the embedding of their role in local structures as a crucial factor in the manageability of system-level tasks in cancer care. Most CCs had no mandate for decision making or budgeting, while reporting very limited management support for system-level action, such as implementing routines or enhancing local services. While several CCs noted that such circumstances impeded their system-focused work, some CCs found solutions in allying themselves with local professionals, stating common action could facilitate a bottom-up implementation of routines.

We allied ourselves with general practitioners to design a common procedure, which got approved by a steering group, then got disseminated to all the departments. CC22

A few CCs pointed to increased cooperation with their management over time, which resulted in considerable support in terms of forwarding CCs' inputs at a system level.

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Theme 3: Commitment to Collaboration

The analysis illuminated commitment to collaboration as a third major topic. This was elaborated on by 2 subthemes, presented in the following.

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SUBTHEME 3A: ACKNOWLEDGING WORK RELATIONS

All CCs stated that acknowledging work relations was a key factor associated with other professionals' commitment to collaborations with CCs and CCs' system-focused activities. To begin with, some CCs experienced skepticism or reluctance to accept their role among local professionals, who appeared to be protective of their fields and unwilling to change familiar routines. Other actors, in turn, seemed hesitant toward collaborating with CCs as they expected an additional workload. To overcome initial barriers, CCs worked to build up trusting interpersonal relations via an ongoing dialogue and mutual support in their interaction with professionals, in which they clarified the intention of the role as being supplementary to, rather than competing with, existing roles.

It could have been a problem if I had joined in with a new role, walking all over their work (…) So, we [discussed and] reached an agreement, and it works well. CC1

Cancer coordinators also emphasized the value of multidisciplinary team meetings, giving members the opportunity to discuss cases and share competencies, information, and skills in a common space.

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SUBTHEME 3B: SHARED OWNERSHIP AND RESPONSIBILITIES

The CCs outlined that a perception of shared ownership and responsibilities appeared to impact professionals' formal and informal commitment to collaboration with CCs and to their activities undertaken at a system level. Cancer coordinators noted a lower adherence to changes when other actors, for example, general practitioners or healthcare staff in hospitals, were encouraged to adopt new routines without having taken part in their development. Therefore, CCs engaged in collaboration with respected professionals or authority figures, for example, head nurses or team leaders, who could propose and promote routines and a sense of commitment among healthcare staff in their department. Similarly, the active involvement and participation of collaborating partners, for example, in formal networks or project groups, had a noteworthy influence on their commitment and enhanced a notion of shared ownership and responsibility, for example, about implementing new procedures.

When things come from the bottom up, from those who enact the services (…) are they much easier [to implement] than having me imposing procedures from outside. CC22

However, some CCs found that professionals signaled discomfort when taking on responsibilities in cancer care, as they lacked adequate expertise. Here, CCs' engagement in education, tutoring, or common procedures could help to motivate and secure professionals in providing cancer care.

I have the competence, maybe, that is needed to secure (…) health personnel. Providing [them with] information and skills, so that they feel more secure in a situation with cancer patients. Because, when you feel insecure about something, you avoid it.

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Discussion

The analysis revealed 3 main themes and several subthemes affecting CCs in undertaking system-focused work. The subthemes could both present facilitators, and, if missing, barriers to CCs' system-focused activities. The main findings will be discussed considering salutogenesis and prior research.

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Understanding the Role and Local Cancer Care

The CCs in the current study emphasized that the clarity of their role was a vital factor that impacted their system-focused tasks. However, most CCs stated that they had received inadequate role orientation and management support and had struggled with defining and communicating the scope of their role. Similarly, the literature4,5,12 indicates that an inadequate description and promotion of the CC role can pose ongoing challenges to the external role recognition. To enhance clarity of the role, our participants engaged in regular contact with other CCs or local actors to clarify and promote their role within the professional field. This was identified as the most common form of role orientation overseas7 and suggested as a means by which to raise external awareness of the CC role.5 However, our participants indicated the need for a systematic approach and management support to define and promote their role.

This study also identified health professionals' specialized expertise, familiarity with services in cancer care, and patients' complex needs as other vital comprehensibility aspects that affected CCs system-focused work. Thus, CCs concentrated on training local professionals, which has helped to educate and raise awareness of services in cancer teams overseas5,8 and can enhance health professionals' cancer-care related knowledgeability.26 However, competence building is time consuming and may limit CCs' capacity to engage in other aspects of their role.5 From a salutogenic perspective, the present theme and its subthemes can be viewed as cognitive features, thus the comprehensibility component influencing the ability of CCs and their coworkers to facilitate positive developments within local systems for cancer care. Considering this, the subthemes could depict important resources (GRRs) or general resource deficits that impact CCs in their system-focused work. Consequently, it may be suggested that providing adequate resources that can enhance the group-level comprehensibility of CCs' role and cancer care may facilitate CCs' system-focused activities. In particular, our study suggests a need for better support for CCs, for example, from the management, as important GRR to enhance role clarity and professionals' knowledgeability of cancer care. Overseas, the responsibility for clarifying the CC role and training local professionals has been assigned to a cancer network,8 a national nurse lead,39 or a head nurse,8 who has been shown to enhance personal and collective comprehensibility of professionals' work elsewhere.26 Other support for CCs could include the provision of an implementation tool kit or placing the state in charge of developing and offering educational programs for professionals in cancer care, as proposed in the United States.9

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Systems for Care Delivery in Primary Healthcare

The analysis showed the established systems for care delivery as a second main topic. This was elaborated in terms of the extent to which integration of the CC role had been undertaken and the degree of common procedures, communication across sectors and disciplines, and local resources in cancer care. From a salutogenic perspective, this theme and its subthemes could depict instrumental aspects pertaining to the manageability of executing system-focused aspects of the CC role. Most CCs outlined their role to be organized and located unfavorably to begin with, for example, lacking access to professional arenas and electronic databases, forcing them to work in isolation rather than in a team. This aligns with literature on CCs elsewhere5,39 and seemed to inhibit their opportunities to carry out the system-focused tasks of their role. Salutogenic research confirms that poor work frames and missing occasions to interact socially can deter the manageability of health professionals' work.26 Thus, the present study suggests the need to associate CCs with networks or cancer care teams in order to support their system-level tasks.

Our participants referred to common procedures for care and collaboration as relevant factors when managing their system-focused tasks. Our findings indicate that hectic workdays and a high turnover of professionals in clinical settings could pose barriers to implementing and maintaining new routines. However, our study, supported by international surveys,3,5,8,39 showed that CCs were able to facilitate and support common routines across sectors by providing healthcare providers with training and standardized tools, for example, for referrals, screening, or care procedures. This emphasizes that cross-sectoral communication, for example, via electronic systems, has a noteworthy influence on CCs' opportunities to carry out system-level work. Similar to CCs in New Zealand,4,39 Norwegian CCs are often faced with inadequate IT infrastructure and support. As the latter's opportunities to exploit IT systems seemed to be limited, most of them focused on facilitating cross-sectoral communication via multidisciplinary team meetings. Previous research2,3,8,40 indicates that multidisciplinary teams can support communication and service alignment among healthcare providers. On the other hand, it is known that organizing multidisciplinary meetings can challenge CCs in terms of additional workload, a lack of local facilities, and difficulties in ensuring the attendance of all actors.2,40–42

Further, our participants suggested that local commitment and human and financial resources for cancer care affect their system-focused activities. The present study reinforces the findings reported in the literature,2,3,8,39 which show that CCs can be challenged by local resource shortages, poor management support, and a lack of any mandate for decision making or budgeting to enforce system-level action. Consequently, our participants were dependent on the support of local professionals to facilitate a bottom-up initiation of system-level action, which added to their regular workload. However, a systematic literature review43 found that resource downsizing, poor management support, and demands for increased productivity could negatively affect professionals' healthcare settings. Our findings suggest that a close collaboration between CCs and their superiors can be important resources to support the former in carrying out system-focused tasks. From a salutogenic perspective, the practical implications outlined in this section may depict GRRs that can enhance manageability of CCs system-focused tasks. The literature4,26 confirms that the manageability of health professionals' working conditions can be enhanced by ongoing communication with the management. Further, municipalities are suggested to allocate or recruit adequate resources and facilities to support collaborative action, which have previously been proposed to improve the manageability of health professionals' work.4,7,26

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Commitment to Collaboration

The current study found the other professionals' commitment to collaboration regarding CCs' system-focused work as the third major topic. This was elaborated in terms of how far the CCs and other professionals had engaged in acknowledging work relations and adopted a notion on shared ownership and responsibilities. Through the lens of salutogenesis, these features describe motivational aspects regarding system-focused action, associating to the meaningfulness concept in salutogenesis. Our findings show that CCs can experience interpersonal barriers to system-focused action in cancer care, particularly in terms of a lack of buy-in and collaboration with other health professionals, such as general practitioners or long-established nurses, who could be inclined to be protective about their fields. The literature confirms that CCs could be challenged by a lack of buy-in,2,3 highlighting that role conflicts or imbalance can be psychosocial risk factors that may affect the outcome of interventions in a community setting.43 To overcome these barriers, Norwegian CCs underscored creating trusting and acknowledging professional relations, which have previously benefited the work of coordinators overseas.4 Our findings reveal that professional work relations could be improved by facilitating an open dialogue between CCs and local professionals in order to clarify the CC role as a resource and support for local actors, as well as cocreate adequate ways for collaboration. Similarly, the American Association of Critical-Care Nurses44 emphasizes that soft issues of professional practice, for example, true collaboration, skilled communication, and meaningful recognition, can improve the quality of the work setting and healthcare practice and its outcomes. Regarding the hospital setting and busy working culture, the CCs found that building close working relations with all actors involved was almost impossible, such that alternative strategies were required to ensure commitment to new routines. Our study showed that CCs' collaboration with respected professionals, for example, head nurses, could facilitate communication and buy-in for new working procedures in the distinct divisions. The literature on the application of salutogenesis in organizations21 confirms that prevailing relationship and power structures can help to transfer planned action into practice.

Our study identified shared ownership and responsibilities as key features impacting CCs' system-level activities. The CCs highlighted that involving professionals in multidisciplinary networks or project groups could foster a sense of shared ownership and enhance professionals' commitment to system-level action. Networks can be a source for knowledge exchange, social support, and belonging,7,25,26 which are identified as resources (GRRs)20,27 to increase meaningfulness and can thus enhance people's motivation to act in order to achieve positive developments (the SOC) with regard to collaborative action. The literature7,45 confirms that integration, participation, and empowerment can promote a supportive psychosocial environment. However, some of the present CCs experienced ongoing difficulties in collaborating with local actors who lacked specialized skills and appeared to be uncomfortable with becoming involved in cancer care. Thus, CCs put their efforts into competence building and linking-up of professionals for knowledge exchange and learning. Coordinators overseas3,5 have reported similar strategies to enhance professionals' engagement in cancer care. The literature43,45 suggests that participation in collaborative cultures, mutual exchange, and support yield a positive attitude toward change processes and enhance professionals' occupational self-efficacy.

In line with national and international evaluations,5,11,12,39 our study observes that CCs experience a positive trend and better facilitation for their system-focused tasks over time. The present CCs displayed a salutogenic approach to overcoming barriers to system-level tasks as they mobilized the required assets to improve cancer care systems. The literature46,47 underlines that interventions with a salutogenic focus can enable self-optimization from within. In promoting strengths and resources, CCs seem to depict an example of a salutogenic intervention and may themselves be considered a GRR for achieving viable improvements in local cancer care.

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Limitations and Trustworthiness of the Study

Qualitative research always embraces a certain degree of subjectivity.30,31 To ensure rigor in the present study, we have provided a detailed account of the entire research process. The authors analyzed the data independently and discussed the findings subsequently. Regular discussions stimulated ongoing awareness of own presumptions and facilitated ongoing reflexivity in each of the researchers, in order to be as faithful to the data as possible.31,33 The external validity of the findings from in-depth interviews is difficult to assess.32 However, our diverse sample mirrored the variety in which the CC role has evolved and facilitated rich data on their experiences.

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Implications for Practice

The insights gained via the present study indicate that CCs need better support or guidelines to adjust their role and services to the context of their particular setting. Municipalities are advised to take a greater responsibility for facilitating CCs' system-level tasks, including the provision of a role orientation and the adequate integration of CCs into existing systems, for example, by facilitating their access to relevant professional settings and systems. There is a need to provide measures for increasing cancer care competencies among local professionals, for example, via seminars or courses. The establishment of local cancer care teams and regular team meetings are suggested to provide resources that will ensure professional commitment, collaboration, shared ownership, knowledge exchange, and service development. It is suggested that local management considers providing adequate technologies and additional resources to safeguard communication and collaboration between CCs and other professionals across sectors. The study showed that factors influencing CCs' work could be related to comprehensibility, manageability, and meaningfulness, which should be paramount when implementing the CC role in local systems.

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Conclusion

The present study identified 3 main themes and several subthemes influencing CCs in executing their system-focused tasks. The main topics encountered by the CCs included “understanding the role and local cancer care,” “systems for care delivery in primary healthcare,” and “commitment to collaboration.” Considering salutogenic theory, the topics in this study depicted central cognitive, practical, and relational resources for CCs' work, whose absence, in turn, appeared to impose barriers to CCs' system-focused tasks. The insights gained through this study emphasize that cancer navigation cannot be undertaken by CCs alone. The role must be understood and established as part of a local network. Management support is required to develop a position description and promote the role to collaborating partners. System-focused work task of CCs need to be undertaken in collaboration with multidisciplinary teams, in which common systems for care provision and communication, sufficient resources, acknowledging work relations, and shared ownership and responsibilities represent the pillars of local cancer care.

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Keywords:

Cancer care; Cancer care trajectories; Cancer coordination; Cancer coordinators; Cancer navigation; Coordinated care; Cross-sectoral collaboration; Primary healthcare; Qualitative research; Resources; Salutogenesis; System-level work

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