Nurse-led virtual prostate cancer clinic for survivorship care: Qualitative study of healthcare professional experiences and needs

doi:10.21203/rs.3.rs-2924582/v1

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Nurse-led virtual prostate cancer clinic for survivorship care: Qualitative study of healthcare professional experiences and needs

https://doi.org/10.21203/rs.3.rs-2924582/v1

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published 02 Nov, 2023

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Background: Approximately one in eight Canadian males will be diagnosed with prostate cancer. Longer survivorship horizons and resource constraints are leading to increasing strain on current models of specialist-led follow-up care delivery. Nurse-led digital health innovations can reduce demand on specialists if co-designed with health care professionals (HCPs).

Methods: Using human-centred design, the purpose of this exploratory qualitative study with ten HCPs was to characterize their experiences with prostate cancer (PCa) follow-up and virtual care to optimally situate a nurse-led clinic within this ecosystem.

Results: HCPs highlight how current follow-up care can be fragmented, so the scope of a nurse-led clinic should focus on the management of care with referral as needed. Despite an ambivalence for telemedicine arising from its implementation during the COVID-19 pandemic, HCPs see potential for improved care through digital health but note several concerns. Burn-out, weakened patient-provider relationships, and creeping scope of responsibilities were identified as pain points. We provide a health ecosystem readiness checklist to improve odds of acceptability, appropriateness, and feasibility synthesized from six HCP-defined facilitators mapped onto Proctor’s outcomes. Facilitators include: functionality testing (acceptability), technical support and usability (adoption), expectation management (appropriateness), resource allocation (cost), staff readiness (feasibility), and staff training (penetration).

Conclusion: Intentional and empathetic co-design with HCPs during the development of digital health innovations, such as digital therapeutics, is necessary to ensure that HCPs can benefit from, instead of being burdened from, the rising tide of digital health in their clinical responsibilities.

Health sciences/Health care/Health services

Health sciences/Urology/Prostate

digital health

healthcare personnel

nurses

physicians

professional practice

quality of healthcare

delivery of health care

prostate cancer

cancer survivorship

human-centred design

implementation

service design

supportive care

technology

symptom management

interprofessional relations

Prostate cancer (PCa) survivors in Canada receive follow-up care through a specialist-led model, which is straining to meet needs. Digital health innovations co-designed with healthcare professionals (HCPs) providing follow-up care may alleviate this strain. This study used human-centred design exploring ten HCPs’ experiences and perceptions of digital health and nurse-led care to inform the design of a nurse-led virtual clinic (“Ned Nurse”). Our results describe HCPs concerns resulting from mixed experiences with telemedicine during the COVID-19 pandemic. However, they see Ned Nurse providing benefit through supporting increased patient access to resources, better coordination of care, and faster responses to unmet patient needs. Co-design with HCPs may help bridge wider system concerns by incorporating HCPs’ lived experiences into digital health innovations.

In Canada, approximately one in eight males will be diagnosed with prostate cancer ^1,2. PCa care is complex and encompasses widely varying symptoms, treatments, and side effects. For example, clinicians are tasked with the challenge of identifying clinically significant disease, without over-diagnosing or over-treating indolent disease ³. This complexity continues in determining which treatment strategies are most likely to result in the best clinical outcomes for a patient, each with their own host of side effects ⁴. With these side effects comes the risk for heightened psychological distress and reduced quality of life for survivors ^5,6. To address this complexity, clinical PCa care teams are often multidisciplinary ⁷, aiming to facilitate sustainable PCa follow-up care and overcome adverse long-term outcomes ⁸.

The scope of follow-up care for PCa post-treatment in Canada generally comprises monitoring for recurrence, management of side-effects, and wellbeing maintenance⁹. Visits are scheduled at increasingly spaced-out intervals once a patient has completed curative-intent treatment ¹⁰. In traditional models, care is highly reliant on specialist physicians ^11,12. Notably, through advances in treatment and diagnosis, a growing number of Canadians are entering cancer survivorship, resulting in high-volume clinics and significant time burdens for oncology providers ^13,14. Recent clinical guidelines and research efforts have proposed new models of PCa follow-up care led by nurses, family practitioners, and patients, or a combination of multiple personnel beyond this mode ¹³. In particular, the nurse-led model has accumulated evidence on aspects of safety ¹⁵, effectiveness ¹⁶, and satisfaction¹⁷ through both in-person or virtual modalities ^18,19.

The advancement of digital health innovations (DHI) has provided an opportunity to improve sustainable cancer survivorship care ²⁰. Nurse-led DHIs have been developed for PCa survivorship self-management, symptom telemonitoring, and psychosocial care ^21–24. These solutions have shown efficacy in educational, informational and psychosocial aspects by allowing users to access more holistic support. However, their design is rarely informed by health care providers (HCPs) in practice ²⁵. This may be because a lack of input from HCPs during the development of DHIs exacerbates an already-challenging implementation process, which has been posited to be the result of a combination of limited clinician time and a flood of such tools entering the market ^25,26. Existing literature highlights a disconnect, as HCP perspectives are not clearly discussed in the development of DHIs ²⁷. HCPs may therefore face extensive barriers to the sustained use of DHIs owing to: technical limitations, limited resources to improve technological skills or digital literacy, inefficient, non-user-friendly interfaces, and poor system design ^28,29.

To ameliorate the growing mismatch between PCa follow-up care needs and the capacity of current healthcare systems, the Ned (“No Evidence of Disease”) clinic was developed and implemented at the University Health Network (UHN) in Toronto ²¹. Ned was designed to optimize clinical care and patient self-management through asynchronous care delivery. It is considered a digital therapeutic, which is an “evidence-based, clinically evaluated software to treat, manage, and prevent a broad spectrum of diseases and disorders” ³⁰. Therefore, we refer to the Ned clinic as a digital therapeutic, the wider space as digital healthcare, and the interactions mediated by technology (e.g., person-to-person, app-to-person, person-to-app) as virtual care. The purpose of this study was to explore the care experiences of HCPs in PCa care and their needs in relation to the service design and development of a virtually-delivered nurse-led survivorship digital therapeutic (Ned Nurse clinic), as well as barriers and facilitators to virtual care in their professional practice. We explored HCPs’ role in follow-up care delivery, the multidisciplinary nature of HCP teams, and their experiences of technology use. Then, we investigated perceptions of nurse-led and virtual care in the context of acceptability, feasibility, and adoption strategies. By addressing these goals, this work aims to better understand the optimal design of a service model for a proposed nurse-led PCa follow-up care platform (Ned Nurse).

Conceptual frameworks

A pragmatic, human-centered design (HCD) approach was used to guide the overall study and design of the Ned Nurse (i.e., nurse-led Ned clinic) prototype ^31,32,33. HCD is an evidence-based, iterative process that involves and considers the needs of the end-user and perspectives of all stakeholders throughout the design process. The framework consists of three steps: (1) concept generation and ideation, (2) prototype design and system development, and (3) evaluation. This study describes phases one and two.

We adopt the stance that service design is equally as important and recursive to the technology and implementation processes that are critical to delivering and sustaining healthcare innovations into practice.³⁴ Here, we empathetically consider the challenges and desires that HCPs have described in their delivery of survivorship care. The Consolidated Framework for Implementation Research (CFIR, a determinant framework) and Proctor et al.’s implementation outcomes framework were applied to analyze these experiences.^35,36 This resulted in a readiness checklist that addresses service considerations and implementation determinants likely to lead to outcomes of implementation success for the Ned Nurse Clinic.

Study design

This study was conducted at the UHN. Data were collected between May 2021 and June 2021. Recruitment and data collection were conducted virtually, and approval was obtained through Clinical Trials Ontario with the UHN Research Ethics Board as the Board of Record (Project ID: 3238). This study used an exploratory qualitative description design³⁷ as part of a larger overall research programme for the development of a nurse-led PCa follow-up virtual care platform. This study is presented according to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines ³⁸.

Sampling

In order to achieve thematic saturation and to illustrate the future representative Ned Nurse HCP user, a total of 10 HCPs with experience delivering PCa survivorship care were interviewed ³⁹. Clinical leads at our participating sites in Ontario (University Health Network, Trillium Health Partners, and Niagara Health System) reached out to colleagues from a variety of healthcare professions who delivered PCa follow-up care and gauged their interest in providing formalized feedback. Interested HCPs were connected with the study team, who assessed eligibility, collected informed consent and interviewed participants. Interviews were completed through a secure video conferencing platform (Microsoft Teams) due to the ongoing COVID-19 pandemic. Demographic and non-participation data were not collected to protect the privacy and identity of each participant. Participants include a combination of oncologists and nurses from the three participating sites. Written and informed consent was obtained from all participants prior to interviews by the research team via REDCap.

Data collection

We conducted semi-structured interviews to meet our exploratory and feasibility goals (see Table 1 for details). In reflection of the goals of the study, each interview consisted of several sections with corresponding questions. Interviews were audio-recorded with participant consent, then transcribed for analysis. Please refer to Appendix 1 for our interview guide.

Table 1

Semi-Structured Interview Goals and Sample Questions.
Goals	Example of question
Exploratory goals
1. HCPs’ role in the delivery of PCa follow-up care	Currently, could you describe how you deliver PCa survivorship care?
2. Understanding the composition and multidisciplinarity of PCa follow-up care team	What other healthcare providers are part of your clinical team, for supporting PCa survivors?
3. HCPs’ current technology use in clinical practice	What are your experiences with digital health tools or telemonitoring systems in your clinic?
Acceptability, feasibility, and adoption goals
1. Algorithm of the virtual nurse-led survivorship clinic (i.e., Ned)	One feature of Ned is having the system alert you when your patient may require attention. What type of information needs to be inputted into the system for such features?
2. Secondary care features of the Ned	What secondary care (i.e., psychosocial, rehabilitative, nutrition etc.) would be helpful to have indicators for?
3. Impression of nursing roles in the Ned	What direct care do you envision the nurse being able to deliver? What direct care should be triaged to the physician level?

Data analysis

Interview transcripts were independently analyzed by three members of the research team using content analysis ^40,41. Coders read each transcript to familiarize themselves with the data. A baseline codebook was developed using the interview guide as a scaffold. Patterns related to implementation were coded with elements of the Proctor et al. implementation outcomes framework salient to the pre- and early stages of implementation ³⁶. Three transcripts were collaboratively coded to establish consensus on code definitions and usage, then the remainder of the transcripts were coded separately. The codebook and final analysis were further refined through consensus debriefs and iterative discussion of emerging themes.

Positionality of the data analysis team

High-quality qualitative research is grounded in a number of elements, including sincerity ⁴², which is developed through continuous self-reflexivity by researchers. The authors unfolded their positionalities to elucidate how their backgrounds, experiences, and beliefs interacted with the data and its interpretation in service of the “researcher-as-instrument” ^43,44.

Author KY is a second-generation Canadian settler and cis woman of colour from a working-class background. She is a research trainee in health informatics with focus on the contexts and relationships that shape the design and implementation of health technologies. She did not complete any interviews during the data collection phase, and is only familiar with study participants to the extent that they provided personal details during their interviews.

Author DN acknowledged her standpoint as an upper-class, cis-gender woman of colour living in a large metropolitan area in Canada. She is a public health and health systems researcher, with a focus on patient experience and mobile health application adoption. She is a digital native with an excellent grasp of current technological trends. Prior to this study, she has not interacted or cared for any individuals living with PCa. As such, she cannot fully comprehend the experience of clinician participants who provide care to this population. She recruited and consented all study participants and observed their interviews.

Author TJ recognizes that she is a middle-class, cisgender woman in young adulthood. She has access to and is comfortable with technology. She received post-secondary education in the health and health informatics fields. She had previously worked in a clinical setting but had not taken care of, nor had a close connection to, anyone who lived/is living with PCa; therefore, she cannot fully grasp the challenges faced by this patient population or HCPs providing their care.

Our qualitative analysis aimed to explore HCP experiences with providing PCa follow-up care while contextualizing their perceptions of the acceptability, appropriateness, and adoption of a potential nurse-led PCa virtual follow-up care system to provide digital healthcare. This was grounded in HCPs’ qualitative self-assessment of their usage and comfort with digital health tools within their scope of practice. We first outline the complexity of PCa follow-up care from the HCP perspective. Then, we outline the technical and clinical expertise needed to deliver standard PCa follow-up care and insights into how a nurse-led model of care can be structured. Lastly, some key digital literacy considerations and clinical, technical, and implementation requirements identified by HCPs are introduced.

Follow-up care can be fragmented and difficult to coordinate

All HCPs spoke to their specific tasks and domains of care during their interviews, which resulted in a clear pattern of provider follow-up tasks. Immediately post-treatment, care includes assessment of patient responses to their treatments, pain and symptom management, patient education, and psychosocial support. In the longer term, care proceeds according to specialist-designed surveillance protocols, and symptom assessment plays a major role in follow-up care. Care decisions were primarily made by assessing patient symptom severity. If these assessments were completed by non-physician HCPs, they were reported to physicians for further consultation with patients about treatment when appropriate.

“We have... a triage line that patients can call and it can be about anything, it could be about their appointments, it could be about any of the symptoms... they will speak to a nurse, report whatever is going on...then that message will get sent to the primary nurse and then the primary nurse will have to review the information. If she can answer on her own she’ll let the patient know. If she requires some sort of consultation from the physician she’ll get in contact with them.” (HCP001)

HCPs noted that the complexity of PCa follow-up care delivery necessitates a multidisciplinary care team led by a specialist. Team members can include physicians, physician assistants, nurses, physiotherapists, dietitians, social workers, genetic counselors, and patient care coordinators. Often, follow-up care is managed across specialties. One patient’s treatment and follow-up care may encompass surgery, radiation, and hormone therapy or chemotherapy. This complexity requires careful coordination and networking of care across these specialist teams and sometimes with external institutions, as not all hospitals are able to offer these services in one place. These patients are required to travel to other hospitals to receive treatment, which can complicate inter-provider communication and patient record-keeping.

Scoping a nurse-led clinic should be a focus on the management of care and referral as needed

HCPs judged a nurse-led follow-up care model for PCa to be an acceptable, feasible, and appropriate mode of delivering care. HCPs most often indicated that a Registered Nurse (RN) would have the appropriate scope of practice to act as the central point of contact for a virtual nurse-led survivorship platform. Some indicated a preference for an Advanced Practice Nurse (APN) or Nurse Practitioner (NP). However, these expressions were often accompanied by caveats regarding the amount of experience a provider might have delivering genitourinary oncology care. Above all, participants were clear that they viewed the scope of this role as one of assessment, management, coordination, and escalation. A nurse in this role would need to understand when to escalate care to the appropriate care provider, but would primarily manage all non-emergent situations.

“The nurse can definitely do an initial assessment... I think it is within our process to understand the main [providers]... involved. And also in terms of providing emotional support… this is something that the nurses can also be involved in. But anywhere where you would need…diagnostic measures, the testing or medications prescribed, that would something that would need to be escalated.” (HCP002)

Virtual care through a digital therapeutic: Assessing system readiness

Despite an ambivalence for current digital health tools, providers see the potential

HCPs perceived potential barriers to the further spread of digital health tools within their workplaces, many as a result of their prior experiences with virtual care. The pandemic ushered in a drastic shift towards delivering many services through virtual means very quickly, most often through telehealth modalities. The cognitive load of virtual care continued to be high. HCPs found themselves needing to provide support outside their scope of clinical care, such as technology support, to patients who were not comfortable with virtual care. These factors resulted in wariness towards these tools, as trust was not established with these HCP users during the initial implementation phase at the start of the pandemic. Furthermore, participants did not indicate that efforts were initiated to create this sense of trust after the use of these tools became standardized. Preserving the preferred level of work and life balance was more difficult because virtual care opened up access to work from home. Other participants expressed anxiety that moving towards a virtual model of care would fray the therapeutic relationship between provider and patient, resulting in decreased continuity of care.

“So using [virtual care tools]… talking and talking and talking and describing and making sure that they understand… speaking in layman terms and going over and over again, relaying results, making sure that the patient doesn’t freak out or get you know, super worried about something. It was just exhausting for me.” (HCP010)

However, participants also recognized the potential for virtual care to drastically restructure care, enhance care access, and improve patient experiences. Despite ambivalence towards their current use of these tools, HCPs noted that virtual care could provide benefits to patients, such as the ability to deliver mental health support to survivors and provide them with opportunities and flexibility to seek care when needed.

[The Ned Nurse Clinic] could definitely help them feel like they are in control of their care. I feel like a lot of patients feel like they don’t know what’s going on…there’s always that behind the scenes that happens with the nurses and the doctors, but the patients aren’t always in that conversation... having that ability to have continuous care would give them the feeling that they are in control of their care. HCP003

…definitely improved access to care. Some people aren’t able to travel that quickly and, given the pandemic, people are scared to go places, especially people who have gone through chronic illness… travel can be difficult, especially for those that live somewhere more remote. So I feel it’s definitely improved access to care. It also makes it, you know, this goes along with that, but it makes it easier to follow up with a patient. HCP005

HCPs seek support for patient digital literacy to avoid barriers to care

Participants raised concerns regarding the feasibility and appropriateness of virtual care for patient populations. HCPs indicated that most PCa survivors are over the age of 50 and are unlikely to consider themselves digitally literate. Additionally, providers were concerned about the effect of the digital divide and the possible inaccessibility of a virtual care tool to some groups. Specific to the patient population, HCPs named concern that prostate cancer survivors are a group of older men placing them in the digital divide due to age and gender. However, they also expressed that with proper resources and support, they were confident that patients would be able to take on the responsibility of using digital healthcare.

“I think the patients who don’t really use that type of technology ... might not be so up to doing it that way without proper enforcement and helping them learn the ropes of how to do it ... but most patients are pretty receptive to doing things, in terms of reporting their symptoms because they know that it’s beneficial for their care.” (HCP001)

HCPs see the opportunity for improved continuity of care but are concerned about patient expectations and potential for burn-out

When speaking to the possible benefits of a digital health platform, HCPs identified two main considerations. First, HCPs described the requirement for potential technological capabilities to support their role, asking “will it make my job easier?” Second, they named ease of use: “is it intuitive and easy to use?” HCPs stressed the importance of ease of use for both providers and patients, with lack of usability identified as a common friction point.

HCPs shared that a digital health model can support strengthening of continuity of care and communication. Most survivors are given appointments with increasing intervals of time in-between, based on the amount of time elapsed post-treatment and symptom management experience. A follow-up platform that incorporated both scheduled check-ins and the ability for patients to contact their provider independently was identified as an optimal system. It would capture patients who might be symptomatic or are reticent to contact their provider outside of scheduled appointments. However, participants emphasized the need for any platform to provide appropriate training for patients to manage expectations and prevent provider burnout. This would include communicating and enforcing boundaries to ensure that patients understand the limitations of the platform and service. Examples include clarifying the Ned Nurse’s hours of availability, and ensuring that patients understand that responses to their queries are manually written by a person, not instantly generated.

“I see value in having scheduled video calls.... I think that that just helps situate patients [so] that they don’t fall through any cracks. They don’t get to the point where they need quick intervention if something’s caught early or if they’re proactively addressing concerns rather than having to be reactive.” (HCP006)

Principal findings

This study explored the care experiences of HCPs in PCa care and their needs in relation to the service design and development of a virtually-delivered nurse-led survivorship digital therapeutic, as well as barriers and facilitators to virtual care in their professional practice. HCPs describe five facilitators for sustainable use of digital health technologies: (1) ease of use, (2) patient expectation-setting and coaching, (3) proper training and provision of support toHCPs involved in providing services through the technology (4) adequate staffing, resourcing, and patient support, and (5) building trust in the platform for sustainable application of a digital health platform. These results have been echoed in studies examining HCP perspectives and involvement in the digital delivery of mental health therapies ^45,46, advocacy for patient use of digital health tools ^25,47, nurse-led telehealth prostate cancer supportive care ⁴⁸, digitally-mediated therapeutic adherence efforts ^49,50, and improving patient access and adherence to digital therapeutics ^51,52.

Our results show the complexity of providers’ clinical care domains and processes within multidisciplinary clinical teams to assess and manage PCa care. This is in line with existing findings across studies in other fields ^7,48,53 where HCPs have a broad scope of responsibilities.⁴⁸ Tailored care is fostered through multidisciplinary teams and shared decision-making between HCPs, patients, and their family. It also facilitates greater patient adherence to care plans, and higher-quality care.⁷ Involving HCPs throughout the early phases of mapping complex processes within current follow-up care models and soliciting feedback informs how to optimally situate a nurse-led clinic in this ecosystem. More specifically, HCPs both recommend and propose a specific scope for a nurse-led digital health intervention for PCa follow-up care. HCPs with expertise in PCa care acknowledge that this nurse role is significant, considering the specialist focus in current models of care. They indicate a nurse-led model is acceptable, appropriate, and feasible if positioned as a comprehensive platform to provide patient assessment, coordination, and management.

HCP participants experience significant barriers to adopting digital health tools, especially in the context of the rapid pandemic-related introduction of most virtual care. We suspect this is because of their lack of interaction and input within the design of digital health tools, which is consistently a main barrier to implementation ^29,54. In true user-centred design form, targeted users should instead be involved in all stages of design, from conceptualization to feasibility testing and implementation ⁵⁵. It is clear that more supportive efforts are needed to galvanize the adoption and sustainability of digital health technologies within HCP scopes of practice. The immediate and rapid dissemination of telehealth into healthcare during the pandemic has left HCPs with a sense of ill preparation for the use of digital health tools. Moreover, it is evident that HCP guidance and endorsements are key to digital health adoption and sustainability within patient populations. Overlooking the involvement of HCPs in these processes has far-reaching consequences for the digital health ecosystem as a whole.

A checklist to assess an ecosystem’s readiness for virtual care

Existing care models for PCa and cancer survivorship primarily pursue the goal of improving clinical survivorship outcomes (e.g., survival), not patient-reported outcomes (e.g., quality of life).⁵⁶ We suggest that a digital health survivorship platform should effectively integrate perspectives from all affected stakeholders for better communication and resource management including HCPs, patients, policy makers, and designers. We synthesized HCPs facilitators into six aspects to support sustainable uptake of virtual care moving forward guided by HCPs perspectives and Proctor’s implementation outcomes ³⁶. Our six aspects (mapped onto Proctor outcomes) are as follows and expanded on in Table 2: (1) functionality testing (acceptability), (2) technical support and usability (adoption), (3) expectation management (appropriateness), (4) resource allocation (cost), (5) staff readiness (feasibility), (6) staff training (penetration). While additional service outcomes and client outcomes are central to the focus of more in-depth user testing, this readiness checklist can be used to assess the health ecosystem to understand where resources and support are needed for the early stage of digital therapeutic development and implementation. Ensuring ecosystem readiness for new digital therapeutics can improve the odds of implementation acceptability, appropriateness, and feasibility.

Table 2

HCP Facilitators for Proctor Outcomes - Readiness Checklist Assessment
Facilitator	Item	Description and designing for outcome
Functionality Testing Proctor Outcome: Acceptability	● Has the platform been user-tested for technical and clinical fit and function?	As a result of the broad and rushed transition to telemedicine during the COVID-19 pandemic, HCPs are wary of new digital therapeutics. However, they also recognize the potential for digital health tools to improve care - if designed and implemented properly. Functionality testing assessment could include methods such as think aloud usability testing and heuristic evaluations by technical and clinical experts (e.g., ^57,58).
Technical Support and Usability Proctor Outcome: Adoption	● Are patients and HCPs able to access technical support and information to guide their use of the platform?	HCPs were frustrated by a lack of technical and implementation support within their telemedicine experiences. Technical support can be assessed by usability testing with patients and HCPs via think-aloud and other user testing methods (e.g., ^57,59).
	● Has the platform been user-tested for ease of use?	HCPs felt that telemedicine modalities made their jobs more difficult during the pandemic, as a lack of technical support impacted their ability to care for patients. Usability assessment could include digital literacy evaluations, accessibility evaluations, or site-specific pilot implementations (e.g.,^60,61).
Expectation Management Proctor Outcome: Appropriateness	● Have appropriate use of the system and system boundaries been discussed with patients?	HCPs noted that the use of telemedicine and telework resulted in less work-life balance. Implementing direct contact with providers requires expectation management of: appropriate frequency of communication, and defining “timeliness” of expected response. This would be clinic/clinician specific. Some clinicians may support shorter or longer times for follow-up. Boundaries should be communicated to patients (e.g.,^62–65).
Resource Allocation Proctor Outcome: Cost	● Have specific resources and staffing been allocated to the platform to ensure that it is not resulting in an increased workload for providers?	HCPs were concerned that the introduction of a digital therapeutic would add more responsibilities into their role (“pain”) without much value (“gain”). Resource allocation assessment could include qualitative assessment of whether HCPs feel they have the capacity and resources to use this platform (e.g.,⁶⁶).
Staff Readiness Proctor Outcome: Feasibility	● Are staff ready to participate in implementing this change in practice?	HCPs were not prepared for the pandemic transition to telemedicine. Staff readiness assessment could include qualitative assessment of whether they feel empowered to participate in this practice change, and that their institutional culture supports this change (e.g., ^67,68).
Staff Training Proctor Outcome: Penetration	● Have staff been trained on this platform, and will they be able to access enhanced post-implementation support when using it?	Staff training assessment could include qualitative assessment of whether they feel adequately prepared to independently use the platform for its stated purpose (e.g., ^69,70).

* patient readiness should be specified based on patient needs assessment.

Strengths and Limitations

Lessons from these provider-focused themes and pragmatic service design recommendations can be transferred to develop and implement future digital therapeutics for PCa survivorship. The focus of the HCP perspective of this study provides the “missing puzzle piece,” complementing patient-centred virtual care research facilitating holistic UCD for technology-based care.⁵⁵ These implications should be interpreted with the following considerations. The limited availability of practitioners and ethical concerns regarding the identification of participants restricted our ability to provide demographic information. Additionally, interviews were conducted in English at academic healthcare centres that are located in multicultural urban areas situated in an industrialized country. The HCPs interviewed in this sample are highly trained and work in a high-income country setting. Limited services and the potential inequitable allocation of healthcare resources across less-resourced communities, settings, and countries are beyond the scope of our discussion.⁷¹

Future directions

This study will inform an integrated care system that addresses both patients’ and HCPs’ needs via a digital, nurse-led PCa follow-up care platform. This study focuses specifically on the HCP perspective and includes their understanding of patient needs. While important, this does not necessarily represent the experience of patients, which should be specifically investigated from their perspective. Future research in the early stages of service design should investigate strategies to meet both comprehensive care goals while maintaining accessible design features.

Digital health solutions continue to experience challenges related to adoption and acceptance from HCPs. We designed a qualitative study to investigate the current experiences of HCPs in PCa follow-up care to inform the implementation and application of technology-based PCa survivorship management models. Our findings indicate that a nurse-led model of PCa follow-up care is generally acceptable to providers when positioned as a system that allows for patient assessment, management, and coordination of care by nurses. Although HCPs express ambivalence regarding the use of digital health tools within their current environments, they recognize the potential for a digital therapeutic leveraging virtual care to increase access to enhanced mental health support, community support, and patient resources. Involving HCPs in the design process and building a sense of trust during the development and implementation of such care tools is paramount to the sustainability and scale of digital therapeutics. In response to this need, we developed a health ecosystem readiness checklist for the implementation of virtual PCa care platforms that considers facilitators from the HCP perspective. Further validation of this checklist is warranted to show its efficacy as well as additional work to explore the patient perspective and specific user-informed design considerations to support user uptake.

Acknowledgements

The authors would like to acknowledge the time and effort contributed to this research by the patients, providers, and administrators who were involved in this research. We also recognise the Ned product team (project managers, analysts, designers, and software developers) at the Centre for Digital Therapeutics (UHN) for their commitment to delivering a digital therapeutic intervention through digital health for prostate cancer survivors and their circle of care. This includes contributions from Danny Wang, Ryan Ho, and Adam Badzynski who supported study set-up and data collection. The study was funded by the CIHR Canadian Cancer Society Survivorship Grant (CCS:706713; CIHR: 168606). The funding agencies were not involved in the design or analysis of this study.

Author Contributions

RL, DW, RH, AB, DN, and KY contributed to the conceptualization and study design for this project. RL, DW, RY, DN, TJ, and KY contributed to data collection and analysis. TX, KY, and KP led the manuscript writing. QP conceived the rationale method design and oversaw the study. Additional methodological contributions for the Ned Nurse Clinic were from AB, JLB, DB-L, AHF and JAC. CN and DN led the study set-up including REB. All authors contributed to, reviewed, and approved the manuscript.

Conflict of Interest

QP, JAC, AB, AF and University Health Network jointly own intellectual property rights to the Ned platforms (including Ned Nurse). Under the respective agreements with their organizations, these individuals are entitled to personally benefit from any commercial use of the intellectual property.

Data Availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request and with permission of the University Health Network Research Ethics Board.

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Yes there is potential Competing Interest. Drs. Quynh Pham, Joseph A. Cafazzo, Alejandro Berlin, Andrew Feifer, and the University Health Network jointly own intellectual property rights to the Ned platforms (including Ned Nurse). Under the respective agreements with their organizations, these individuals are entitled to personally benefit from any commercial use of the intellectual property.

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Nurse-led virtual prostate cancer clinic for survivorship care: Qualitative study of healthcare professional experiences and needs

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