Review Reports - Evidence-Based Practice in Psychosocial Oncology from the Perspective of Canadian Service Directors

Round 1

Reviewer 1 Report

It's an interesting piece of work. The language expression and methodological process of the article are relatively smooth and normative. As a less common qualitative study in this field, its findings deserve to be considered for publication.

My suggestion is to describe the process of the snowball sampling in more detail, that is, whether the distribution of participants (particularly by the type of institution) results from objective probability or deliberate selection. In addition, this article can be made more vivid by presenting more narrative material.

There are some errors on typesetting need to be corrected.

Author Response

Dear reviewer,

We wish to thank you for the feedback and for taking the time to review our manuscript. We hope that we have addressed all your comments satisfactory. We feel that attending diligently to your recommendations made this a much better manuscript.

Merci!

Reviewer 1

Authors have detailed the process of snowball sampling in the present study under procedures. It now reads “The distribution of participants resulted from objective probability and deliberate selection. An online advertisement was posted in the monthly newsletter of the Canadian Association of Psychosocial Oncology. Researchers also shared the advertisement with psychosocial oncology services identified though online searches to ensure the inclusion of service providers from various provinces and to reach potential interviewees from geographical regions that had not yet been represented in the study sample.”

In addition, this article can be made more vivid by presenting more narrative material.

Authors added the following narrative material from participants. We tried to keep quotes to a minimum for the sake of brevity.

Client feedback: “Patient satisfaction surveys around practical and emotional needs have been really important for us to monitor how we’re doing. With this we can look at what actions we can we take to address identified needs or concerns.”

Autonomy Level: “The fact that we don’t have the red tape of bureaucracy helps us respond a little bit faster. There aren’t many people at our organization – so we can, for example, offer an additional cancer support group when we notice big waitlists.”

Financial Resources: “Our source of funding is from [Provincial Cancer Care Organization]–they give us funds for each patient receiving a radiation or systemic therapy. Our cancer program also has some patients that only go the surgical route, and are not eligible for our services because we don’t get any funding from that activity. Patients are also only eligible for mental health support up to one year after the end of their treatment. So once it comes to the survivorship or even the bereavement phases, we don’t tend to get involved with those patients. We just don’t have the capacity.”

Administration and Technology: “Our program has upwards of 2500 hours each month. So when participants come in and register, they’re assigned a wellness guide with all the different programs they can take. Every month a new calendar comes out and they select their wishlist and a team actually assigns each participants based on their wishes.”

Research Accessibility: “One of the largest barriers for us is that individual clinicians, including me as clinical lead and our manager, no longer have direct access to the university library system – they deleted our library. So if we want to go and utilize searches in the library, you have to by hook or by crook, find somebody who has access. I used to do it with my daughter, but she doesn’t go to university anymore. So I can’t look up or follow up on something unless I jump through hoops […] one of our staff member’s husband is doing a PhD. Well, you know that’s not good enough. So that’s a big deal. That’s a real barrier.”

There are some errors on typesetting need to be corrected.

We have carefully reviewed the manuscript and corrected typesetting errors.

Reviewer 2 Report

Thanks for inviting me to review this paper. This study adopted a qualitative design to explore the evidence-based practice in Canadian psychosocial oncology services from the perspective of service directors. Study findings are presented clearly and comprehensively and are helpful to inform evidence-based practice in clinical psychosocial practice and interventions. I have some minor comments for the authors’ consideration.

The title reads like a review or commentary paper; I would suggest adding the study design to the title.
I noticed that there are many abbreviations in this paper. Some of them, like PM and DS, are not commonly used. Also, unnecessary abbreviations for organizations' names could be avoided.
What are the professions of the study participants? Such as physicians or nurses. Only administrative titles are presented.

Author Response

Dear reviewer,

Merci!

Reviewer 2

1. The title reads like a review or commentary paper; I would suggest adding the study design to the title.

We have revised the title as follows:

Evidence-based practice in psychosocial oncology from the perspective of service directors

2. I noticed that there are many abbreviations in this paper. Some of them, like PM and DS, are not commonly used. Also, unnecessary abbreviations for organizations' names could be avoided.

Two abbreviations which appear frequently and are central to this research were retained: evidence-based practice (EBP) and psychosocial oncology (PSO).

Authors have removed the abbreviations for progress monitoring (PM) as well as distress screening (DS). Authors have also removed the following association abbreviations: American Psychological Association (APA), Canadian Psychological Association (CPA), Interprofessional Psychosocial Oncology Distance Education (IPODE) and Cancer Care Ontario (CCO) and the Public Health Agency of Canada (PHAC). Two additional abbreviations were removed: full-time equivalent (FTE).

Initials detailing procedures and data analysis under method were kept due to being consistent with the formatting and style of other qualitative papers.

3. What are the professions of the study participants? Such as physicians or nurses. Only administrative titles are presented.

We have added a table with sociodemographic characteristics of the sample.

The field of training is presented in the first of two paragraphs under participants. The professions of study participants were 40% social workers, 27% psychologists, and other fields of training included Nursing, Occupational Therapy, Kinesiology and Psychiatry. The following line was included to detail the directors non-administrative roles: “The professions of study participants, in addition to social work and psychology, also included Nursing, Occupational Therapy, Kinesiology and Psychiatry.”

Reviewer 3 Report

The paper could benefit from being more concise and easier to follow, as it currently contains unnecessary information and may be difficult for some readers to fully understand the points being made.

Abstract

The abstract uses the terms "evidence based practice" and "science informed practice" interchangeably without explaining the difference or using consistent language. The results in the abstract do not clearly follow from the study objectives, and it is not clear how they address the objectives.

Introduction

While the Introduction provides some useful information, it could be clearer in distinguishing between "evidence based practice" and "science-informed clinical practice." The Challenges to Evidence-Based Practice section does not provide sufficient context for the barriers discussed, and it is unclear whether these barriers are at the system or practice level. Additionally, this section seems out of place in the Introduction.

The Evidence-Based Practice in Psychosocial Oncology section provides too much detail and does not give a clear overview of evidence-based practice in this field. It is also not clear if the Stepped Care model is an example of evidence-based practice in psychosocial oncology. It would be helpful to have more information on the alternatives to evidence-based practice and a broader overview of the different evidence-based practices in this field.

The Research Objectives section again uses "science informed practice" and "evidence-based practice" interchangeably without explaining the difference.

Results

The Results section lacks clarity in how the five major themes inform the research objectives, and it is not clear if "best practices" refers to evidence-based practice or science-informed clinical practice. The Results section is also difficult to follow and could be improved by explicitly linking the results to the aim of the study.

Overall, the paper would benefit from clearer language, a more concise structure, and a better alignment of the results with the study objectives.

Author Response

Dear reviewer,

Merci!

Reviewer 3

The paper could benefit from being more concise and easier to follow, as it currently contains unnecessary information and may be difficult for some readers to fully understand the points being made.

Abstract

The abstract uses the terms "evidence-based practice" and "science-informed practice" interchangeably without explaining the difference or using consistent language. The results in the abstract do not clearly follow from the study objectives, and it is not clear how they address the objectives.

Introduction

While the Introduction provides some useful information, it could be clearer in distinguishing between "evidence based practice" and "science-informed clinical practice."

We have clarified these terms in the manuscript and ensured their accurate use throughout the text. The results presented in the abstracts have been revised.

“Science-informed practice” means to consistently apply the best available scientific evidence to inform all aspects of clinical practice.

“Evidence-based practice” has been defined by the Canadian Psychological Association as follows:

“Evidence-based practice of psychological treatments involves the conscientious, explicit, and judicious use of the best available research evidence to inform each stage of clinical decision-making and service delivery. This requires that mental health professionals apply their knowledge of the best available research in the context of specific patient characteristics, cultural backgrounds, and treatment preferences” (Dozois et al. 2014)

The American Psychological Association basically provides the same definition https://www.apa.org/practice/resources/evidence/: “Evidence-based practice is the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences.”

One might argue that being “science-informed” solely refers to acquiring or consuming scientific knowledge and as such, only represents point 1 of the definition of “evidence-based practice”, i.e., using the best research.

However, “science-informed PRACTICE” goes beyond being knowledgeable. It means to apply scientific knowledge to clinical practice; and applying science to practice is no mechanistic cookbook process. Using science to inform one’s practice requires clinical expertise and taking the patient and context factors into account when making clinical decisions.

Thus, it is our perspective that “science-informed practice” means the same as “evidence-based practice”. The difference seems to be that “evidence-based practice” has a clearer, more operationalized definition, is promoted by both North American psychological associations, and might be the more popular term nowadays.

We have revised the manuscript to mainly used the term “evidence-based practice”. We kept the term “science-informed practice” when it was used by the study participants, and we also used the term “science-informed” (without “practice”) when solely referring to keeping one’s scientific knowledge up to date.

The Challenges to Evidence-Based Practice section does not provide sufficient context for the barriers discussed, and it is unclear whether these barriers are at the system or practice level. Additionally, this section seems out of place in the Introduction.

Authors have removed the section “Challenges to Evidence-Based Practice” from the introduction and integrated key ideas, e.g., practitioner challenges to maintaining science-informed practice where this is introduced, elsewhere in the introduction while elaborating on those challenges within the discussion and conclusions.

In the discussion, barriers and facilitators now specify if they are at the system or the practice level whenever this distinction deemed to be relevant.

The introduction to evidence-based practice in the field of psychosocial oncology has been revised to be more concise. We have ensured to provide an overview of evidence-based practices in psychosocial oncology, which includes the science-informed need for 1) cancer patients’ psychosocial care across the cancer trajectory, 2) the stepped care model as one approach to use science to guide the selection of adequate interventions for each patient in a cost-effective manner, and 3) the usefulness of clinical practice guidelines as a means for services providers to rely on a synthesis of robust, current research findings to facilitate evidence-based practice.

The Research Objectives section again uses "science informed practice" and "evidence-based practice" interchangeably without explaining the difference.

The introduction now contains an explanation of the terms “science-informed practice” and “evidence-based practice”, which are used accordingly.

Results

We have clarified how the five major themes inform the research objectives. We have also included a table of the five major themes, the subthemes, and brief descriptions, which we hope will increase clarity for the reader.

The beginning of the results section now reads: “Interview results are presented according to the five major themes identified through qualitative analysis (please see table 2 for major themes and subthemes). The first three major themes – Best Practices, Clinical Expertise and Client-Centred Care – pertain to research question 1: how evidence-based practices in psychosocial oncology are being implemented in clinical care and how the service quality is monitored. The next two major themes – Program Structure and Diversity and Networking – depict responses to research question 2 regarding barriers and facilitators of evidence-based practice in Canadian psychosocial oncology services.”

Overall, the paper would benefit from clearer language, a more concise structure, and a better alignment of the results with the study objectives.

We have simplified vocabulary throughout the paper and have removed some results that were less aligned with the study objectives.

Round 2

Reviewer 3 Report

Thank you for your thoughtful and thorough comments and changes. They have made the paper much better. A few more minors comments:

1. I would remove the section in the introduction titled Introduction to Evidence-based Practice - it is still confusing the reader and I don't think it adds much

2. Page 3 line 77-80: I would delete the sentence "Jacobsen (2009) high- 77 lights that one reason for failing to address PSO needs of patients is the tendency of care 78 providers to “underestimate distress in patients and not to link patients to appropriate 79 services when needs are identified” [14] (p. 4421)."

3. Page 3 line 93-95: I would delete this "Clinical practice guide- 93 lines systematically evaluate and summarize the latest scientific evidence for specific 94 symptoms or conditions and synthesize findings into actionable recommendations for 95 clinical practice." This is common knowledge for the audience of current oncology.

4. Page 3 line 81-90: I would move this to the discussion

5. Page 3 line 111-114: The objectives listed here should match the objectives in the abstract. There are some slight word differences that make it confusing for the reader. Although these could be considered synonyms and really mean the same thing, I think it is best to have consistency in something as fundamental as the research objectives.

6. Page 3 line 118: You use the term psychosocial oncology previously in the text but only define the acronym here. I would define the acronym the first time you use this term. Confirm this for all acronyms as well.

7. Page 5 line 170: I don't think I saw any mention of how the coding manual was developed. Please clarify.

8. Page 5: Any strategies taken to enhance trustworthiness of the results? Member checking etc? Please clarify

9. Page 7 Table 2: Are these participant quotes verbatim? I think it would be helpful to have some quotes to support the trustworthiness of your results.

10. Page 7 line 206: I think it would be helpful to include the two major research questions followed by the themes identified for each so that for example section 3.1 is "Implementation and Service Quality Monitoring of Evidence-Based Practices in PSO" and then section 3.1.1 is "Best Practices".

11. Page 8 line 226-237: When you present the results that address your first research question, I would keep paragraphs focused to the two things you are trying to speak to (i.e., Implementation and Service Quality Monitoring). This will help the reader follow why you are presenting these results as the results section is very long right now and it is easy to get lost in the point you are trying to make.

12. Overall comment on the results section: This needs to be much more succinct. There are too many words being used to describe the same thing right now and it makes it very hard for the reader to follow. I would not subdivide each theme further in the actual text. Table 2 is redundant with the text right now. I would use it to include participant quotes to demonstrate trustworthiness of results.

13. As a reader with interest in this area, one thing I would like to see if this is available from your results is what the actual structure of these PSO programs or practices were. You present bits and pieces of the programs and practices in a disaggregated fashion, but it would be helpful to have a higher-level overview of what each person reported having at their institution. In particular, how these services are managed, organized and funded and a comparison across geography and institution type would be very valuable.

14. Page 18 line 677: Please keep your study objectives exactly the same throughout the entire article. I think this is foundational to rigorous scientific research as even a slight change in study objectives can mean a lot regarding methods and reporting of results.

15. Page 18 line 680-682: "Since the current state of evidence-based clinical practice is closely intertwined with barriers and facilitators of applying science to clinical practice, the discussion will focus on the interconnection and interdependence of the identified themes in response to both research questions." This sentence isn't necessary. Show the reader instead of telling the reader. I would include a few high-level takeaways in this first paragraph in the discussion that you will expand on further in the discussion. These high-level takeaways should be the overall conclusions you are making about your research objectives.

16. Page 18 line 691: I am confused as to where the Stepped Care Model fits in here. Is this suppose to be the "gold standard" model for PSO that should be followed? If so, I would include the part in the introduction in the discussion and then discuss the implications of your findings and how they measure to that. The way the stepped care model is included in the article as it stands makes it sound like one option for PSO, but I am thinking this is viewed as the gold standard? is that correct? are there other models? might be good to include some information on this in the discussion for readers as an anchor to discuss the implications of your findings and how they measure up to these models.

17. I think the discussion needs to be reformatted to speak to the implications of these findings. These are very important results and need to be published. However, the major takeaways are lost right now. This is an important area of great need across Canada. The discussion right now does not speak to the objectives of the research in a way that is easy for the reader to follow. I would include paragraphs that speak to each of the following research objectives: implementation of EBP, quality monitoring of EBP, barriers of EBP, facilitators of EBP. I think you are well positioned to speak to recommendations for how we can advance in each of these areas in Canada and what the next steps should be. I would really like to see this spelled out for readers and it would be incredibly valuable for us to have this to bring to our own cancer agencies to advocate for more resources to this important work.

Author Response

Please see the attachment.

Author Response File: Author Response.docx

Round 3

Reviewer 3 Report

The authors have satisfactorily addressed all my comments. I support this article for publication. I have no further comments.