Challenges, Strengths and Opportunities Related to Implementing Comprehensive Evidence-Based Guidelines on Breast Cancer Survivorship Care by Primary Care Physicians and Nurse Practitioners in Southeastern Ontario

Background Many breast cancer survivors continue to have a broad range of physical and psychosocial problems after breast cancer treatment. As cancer centres move forward with earlier discharge of stable breast cancer survivors to primary care follow-up it is important that comprehensive evidence-based breast cancer survivorship care is implemented to effectively address these needs. Research suggests primary care providers are willing to provide breast cancer survivorship care but many lack the knowledge and confidence to provide evidence-based care. Purpose The overall purpose of this thesis was to determine the challenges, strengths and opportunities related to implementing comprehensive evidence-based breast cancer survivorship guidelines by primary care physicians and nurse practitioners in southeastern Ontario. Methods This mixed-methods research was conducted in three phases: (1) synthesis and appraisal of clinical practice guidelines relevant to provision of breast cancer survivorship care within the primary care practice setting; (2) a brief quantitative survey of primary care providers to determine actual practices related to provision of evidence-based breast cancer survivorship care; and (3) individual interviews with primary care providers about the challenges, strengths and opportunities related to provision of comprehensive evidence-based breast cancer survivorship care. Results and Conclusions In the first phase, a comprehensive clinical practice framework was created to guide provision of breast cancer survivorship care and consisted of a one-page checklist outlining breast cancer survivorship issues relevant to primary care, a three-page summary of key recommendations, and a one-page list of guideline sources. The second phase identified several knowledge and practice gaps, and it was determined that guideline implementation rates were higher for recommendations related to prevention and surveillance aspects of survivorship care and lowest related to screening for and management of long-term effects. The third phase identified three major challenges to providing breast cancer survivorship care: inconsistent educational preparation, provider anxieties, and primary care burden; and three major strengths or opportunities to facilitate implementation of survivorship care guidelines: tools and technology, empowering survivors, and optimizing nursing roles. A better understanding of these challenges, strengths and opportunities will inform development of targeted knowledge translation interventions to provide support and education to primary care providers.

Effects of introspection on meta and structural attitude bases

Introspection is the process by which individuals question their attitudes; either questioning why they hold their attitudes (Why introspection), or how they feel about a particular attitude object (How introspection). Previous research has suggested that Why-introspection induces attitude change, and that Why and How introspection influence attitude-behaviour consistency,persuasion, and other effects. Generally, psychologists have assumed that affective and cognitive attitude bases are the mechanism by which introspection leads to these effects. Leading perspectives originating from these findings suggest that either Why introspection changes the content of cognitive attitude bases (the skewness hypothesis), or increases the salience of cognitive attitude bases (the dominance hypothesis); whereas How introspection may increase the salience of affective attitude bases (another part of the dominance hypothesis). However, direct evidence for these mechanisms is lacking, and the distinction between structural and meta bases has not been considered. Two studies investigated this gap in the existing literature. Both studies measured undergraduate students’ attitudes and attitude bases (both structural and meta, affective and cognitive) before and after engaging in an introspection manipulation (Why introspection / How introspection / control), and after reading a (affective / cognitive) persuasive passage about the attitude object. No evidence was found supporting either the skewness or dominance hypotheses. Furthermore, previous introspection effects were not replicated in the present data. Possible reasons for these null findings are proposed, and several unexpected effects are examined.