Aims
Chemotherapy-induced peripheral neuropathy (CIPN) is common yet under-recognised, and assessment, monitoring and referral vary widely. Knowing what the barriers are is not enough to act on them: strategies must be targeted to the point in care where each barrier operates. We aimed to identify factors affecting implementation of a co-designed CIPN care pathway and locate barriers and facilitators along that pathway, to improve implementation efficiencies through targeted strategy selection for a planned multi-site implementation trial.
Methods
We interviewed 31 clinicians (medical oncologists, nurses, allied health, pharmacists, neurologists) across four cancer services, with sampling continued until no new themes were identified in successive interviews. Transcripts were analysed using framework analysis and coded to Consolidated Framework for Implementation Research (CFIR) 2.0 domains and constructs, with each factor affecting implementation classified as barrier or enabler and anchored to one of 19 steps on our co-designed pathway process map. A concurrent medical record audit triangulates mapped barriers against documented practice.
Results
Barriers were unevenly distributed across the 19 pathway steps, and their character shifted with location. At symptom assessment and monitoring they were predominantly internal: absence of standardised assessment tools, variable clinician capability and confidence, and patient under-reporting (inner setting, individuals). At onward referral they were predominantly external: limited neurology and allied health access, funding, and specialist capacity (outer setting). Several barriers recurred at every referral point, indicating single strategies with multi-step, multi-site reach; a smaller set, time and unclear clinical ownership, spanned the entire pathway and requires system-level strategies.
Conclusions
Locating determinants on the care pathway converts a list of barriers into an actionable targeting plan: point-specific strategies where barriers are local, shared strategies where they recur, and system-level strategies where they are pervasive. The approach is transferable across cancer care pathways generally, and specifies the strategy package for the forthcoming trial.