Symptom Management Guideline Implementation Among Nurses in Cancer-Specific Outpatient Settings: A Scoping Review of Barriers, Facilitators, and Implementation Strategies.

METHODS
This scoping review was conducted following current Joanna Briggs Institute methodological guidelines19 and is reported following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews checklist.20 A protocol paper with detailed methods has been published21 and is summarized below.

Eligibility Criteria

Participants
Projects must have included nurses (eg, registered nurses [RNs], licensed practical nurses, registered practical nurses) and/or advanced practice nurses (APNs) (ie, clinical nurse specialists [CNSs], nurse practitioners [NPs]) caring for adult patients with cancer. Projects with multidisciplinary providers were eligible if findings for nurses were reported separately.

Concept
Projects must have reported on (1) factors influencing (or perceived to influence) the adoption (initial uptake), implementation (routine use), and/or sustainability (continued use)22 of cancer symptom management guidelines (ie, barriers and/or facilitators), and/or (2) the components of strategies that have been used to enhance symptom management guideline implementation. Symptom management guidelines were operationally defined as clinical practice guidelines providing patient care recommendations informed by systematic evidence synthesis and assessment of benefits/harms (including evidence-based care protocols, bundles, pathways, and/or checklists) for the management of any physical and/or psychological cancer-related symptom.2324 Articles focused exclusively on the implementation of standardized symptom screening tools/patient-reported outcome measures, medical management of diagnoses (eg, neutropenia), or management of adverse clinical events (eg, infusion reactions) without a clear component of symptom management were excluded. Articles focused on broader symptom management, survivorship, and/or palliative care interventions were included if symptom management guidelines were implemented as part of the intervention.

Context
Cancer-specific outpatient settings (eg, cancer clinics, ambulatory cancer services, cancer-specific urgent care) were eligible. Projects were excluded if they took place in institutionalized settings (eg, inpatient units) or non–cancer-specific outpatient settings (eg, home care).

Information Sources
Published and unpublished primary studies, quality improvement projects, theses/dissertations, and reports from the gray literature of any design were eligible. Reviews, conference abstracts, and editorial/position papers alone were excluded. Due to resource limitations, only articles published in English were eligible.

Search Strategy
A health sciences research librarian provided guidance on the development of the search strategy, which included a combination of MeSH headings and keywords (Appendix A, Supplemental Digital Content available at http://links.lww.com/CN/A253). The CINAHL (EBSCO), EMBASE (Ovid), EMCARE (Ovid), and MEDLINE (Ovid) databases were searched. The search was limited to articles published in the year 2000 or later, as efforts to develop relevant evidence-based guidelines for cancer symptom management have primarily occurred over the last 15 to 20 years.25 Targeted searches of relevant journals were performed, including Canadian Oncology Nursing Journal, Cancer Nursing, Clinical Journal of Oncology Nursing, European Journal of Oncology Nursing, Implementation Science, Journal of Pain and Symptom Management, and Oncology Nursing Forum.
Gray literature sources were also searched, including the OpenGrey and ProQuest Dissertations and Theses Global databases and websites of relevant nursing organizations (ie, Canadian Association of Nurses in Oncology, Oncology Nursing Society, International Society of Nurses in Cancer Care). Conference proceedings for the Canadian Association of Nurses in Oncology Annual Conference, Oncology Nursing Society Congress, and International Conference on Cancer Nursing were screened. Given resource limitations, this screening was limited to conference proceedings from the last 5 years. The reference lists of reviews were screened for relevant single studies, and authors of potentially relevant conference abstracts were contacted in an attempt to locate full reports, either published or unpublished. The electronic databases were searched until March 30, 2022, and the targeted hand search of relevant journals and gray literature sources included publications until August 31, 2023.

Selection of Sources of Evidence
Citations were imported into Covidence (Veritas Health Innovation, Melbourne, Australia), and duplicates were removed. Predetermined eligibility criteria were used to screen the titles and abstracts of all imported citations for relevance. The full texts of potentially relevant articles were retrieved and screened for inclusion. All levels of screening were performed by 2 independent reviewers. Conflicts were resolved through discussion or with the input of a third reviewer.

Data Extraction
A standardized data extraction form was pilot-tested and used to extract data in duplicate.21 The form included characteristics of the included projects, population, context, and symptom management guidelines. When reported, factors influencing implementation were extracted into the 5 domains of the Consolidated Framework for Implementation Research (CFIR).17 Of note, a revised version of the CFIR was published while the scoping review was underway.18 Although data were extracted based on the original CFIR domains, we adopted the revised CFIR during data analysis and mapped data to the updated domains (ie, innovation, outer setting, inner setting, individuals—roles/characteristics, and implementation process).18 Implementation strategy components were extracted using the criteria described by Proctor and colleagues (ie, actor(s), action(s), target(s), temporality, dose, justification, and outcomes reported).2226 The data extraction was performed by 2 independent reviewers, and conflicts were resolved through discussion or with the input of a third reviewer. Consistent with scoping review methodology and the aims of this review,19 critical appraisals of articles were not performed.

Data Analysis
A descriptive approach to analysis was used, with data presented using tables, figures, and narrative summary. Data concerning factors influencing implementation were uploaded into NVivo (Lumivero, Denver, Colorado) for content analysis to further categorize facilitators and barriers into relevant CFIR constructs18 using a deductive approach. Coding was performed by one analyst and checked by another; changes were made through discussion and input from the research team. The Expert Recommendations for Implementing Change (ERIC) taxonomy27 was used to categorize discrete implementation strategies based on the descriptions extracted. Strategies were then mapped to the 9 corresponding clusters identified by Waltz et al, including (1) adapt and tailor to context, (2) change infrastructure, (3) develop stakeholder interrelationships, (4) engage consumers, (5) provide interactive assistance, (6) support clinicians, (7) train and educate stakeholders, (8) use evaluative and iterative strategies, and (9) utilize financial strategies.28 Clustering the implementation strategies within these categories was not outlined in the published protocol. However, given the large number of discrete implementation strategies identified, there was a need to further categorize discrete strategies as part of data synthesis. Although our protocol also described mapping any CFIR-identified barriers to corresponding ERIC implementation strategies to compare and contrast strategies with expert recommendations,29 our decision to adopt the most current version of the CFIR precluded this level of analysis as the revised constructs have not yet been mapped to the ERIC taxonomy.

RESULTS

Characteristics of Included Projects
The search identified 5281 references (Figure 1). After duplicates were removed, 1994 records were screened at the title/abstract level, and 545 full texts were assessed for eligibility. A total of 36 projects (described across 46 articles or reports) published between 2004 and 2023 were included (Table 1). The term “projects” was adopted to describe the included literature as some implementation initiatives included multiple types of publications and/or gray literature reports, and not all were classified as research studies. Most projects took place in the United States (n = 22, 61%),32333536404142434445495154585960626371747576 followed by Canada (n = 8, 22%),3148535557676973 Australia (n = 2, 6%),5052 Scotland (n = 1, 3%),56 the Netherlands (n = 1, 3%),72 Switzerland (n = 1, 3%),39 or multiple countries (ie, Switzerland, Germany, and Finland) (n = 1, 3%).61
Of the included projects, 14 (39%)3240434451545860626369737576 were classified as quality improvement (ie, activities to develop, implement, and/or assess evidence-based practices to improve local processes).77 Ten (28%)31495052535556596167 were quasi-experimental (ie, interventional studies lacking randomization, such as interrupted time series and pretest/posttest designs), 7 (19%)33394142577174 were observational studies (ie, descriptive, correlational, cross-sectional), 4 (11%)35364572 used a randomized controlled trial design, and 1 (3%)48 was a program evaluation. Four of these projects (11%)39415667 additionally included a qualitative component through a mixed-method and/or multimethod design. Most projects (n = 33, 92%) described and/or evaluated the process of planning for implementation, engaging stakeholders, executing the implementation plan, and/or reflecting on the process. Two projects (6%)4271 focused on assessing barriers and facilitators only, and 1 project (3%)72 was a protocol paper that described implementation planning only.
The characteristics of oncology nurses were not consistently described (Table 1). Several projects (n = 12, 33%)314243444954586063677176 included a mix of nurses (RNs and/or “nurses” not specified) and APNs (NPs, CNSs, and/or “APNs” not specified) together, whereas others included RNs alone (n = 9, 25%)333641485355575969 or NPs (n = 2, 6%)3562 alone. Many projects (n = 13, 36%)32394045505152566172737475 included oncology nurses in a variety of roles (eg, clinical trials nurses, chemotherapy nurses, staff nurses) but did not specify their professional designations. The number of nurses included in each project ranged from 259 to 56342 (median, 22). The percentage of oncology-certified nurses was reported in 10 projects31425355586267697176 and ranged from 16%62 to 100%535876 of the sample (median, 71%).
Cancer-specific outpatient settings were primarily ambulatory cancer services (within or outside of hospital) (n = 19, 53%)33354244485051535556606267697172747576 or cancer clinics (n = 15, 42%)313236394041434549545758596164 that provided various oncology services (eg, radiation, chemotherapy, immunotherapy, symptom management, remote telephone support). Other settings included cancer-specific urgent care73 and a private outpatient oncology care service.52 When cancer types were reported, symptom management guideline implementation most often occurred in the context of medical oncology populations, such as breast, lung, gastrointestinal, head and neck, genitourinary, and/or gynecologic cancers (n = 16, 44%).32353640495051545658606169747576 Some projects (n = 7, 19%)39414347525364 included both medical and hematology/oncology patient populations, and 1 (3%)59 focused on patients with hematologic cancers only. The remaining 12 projects (33%) focused on implementing symptom management guidelines for patients with cancer but did not specify the cancer types.
When specific symptom targets were reported, symptom management guidelines were most frequently implemented to address anxiety, depression, and/or distress (n = 17); pain (n = 15); fatigue (n = 13); nausea (n = 9); vomiting (n = 8); constipation (n = 6); diarrhea (n = 6); and/or skin conditions (n = 6). Most projects targeted multiple cancer-related symptoms at the same time (Table 1). The most common guideline sources included the National Comprehensive Cancer Network (n = 15),353639424345495155565961627176 Oncology Nursing Society (n = 11),3132333536424449546074 Pan-Canadian Oncology Symptom Triage and Remote Support group (n = 6),414853676973 and Multinational Association of Supportive Care in Cancer (n = 4).35405075 Several projects implemented guidelines from multiple sources in the same initiative.35364042495355586176
Regarding implementation targets, there were 3 main types of projects that targeted (1) nurses’ knowledge, skills, and/or awareness of symptom management guidelines (n = 15, 44%)313233364045484952565762636772; (2) nurses’ behaviors related to the adoption, implementation, and/or sustainability of guidelines (n = 30, 88%)3135394041434445495051525354555657585960616267697273747576; and/or (3) patients’ uptake of guideline recommendations as a result of evidence-informed nursing practice changes (n = 6, 18%).323944496176 Eleven projects (31%) cited implementation science or evidence-based practice theories, models, or frameworks, including Rogers’ Diffusion of Innovations,42,63,71 the Knowledge-to-Action Framework,67,69 Iowa Model,40,49 Lewin’s Change Theory,56 Estabrooks’ Conceptual Structure of Research Utilization,31 Science and Practice Aligned Within Nursing model,74 and Melnyk’s Evidence-Based Practice approach.60

Factors Influencing Symptom Management Guideline Adoption, Implementation, and/or Sustainability
Several barriers and facilitators to symptom management guideline adoption, implementation, and/or sustainability among oncology nurses in cancer-specific outpatient settings were reported. These factors were determined through formal preimplementation/postimplementation assessments or through the authors’ discussion about the implementation process (eg, in descriptive reports). A compilation of these factors mapped to operationally defined CFIR domains and constructs is provided in Appendix B. These factors are displayed in Figure 2 and summarized below.

Innovation Domain
Most factors related to the innovation being implemented18 (ie, symptom management guidelines) were classified as facilitators within the innovation source, evidence base, relative advantage, adaptability, complexity, and design constructs (Figure 2). Symptom management guidelines were generally perceived as trusted, credible, and acceptable, containing up-to-date information, and offering a systematic and comprehensive approach to allow earlier detection and better management of patients’ symptoms.35,41,42,57,61,67,69 Facilitators included guidelines that are compact, simple, and easily accessible at the point of care and can be tailored to fit local context or needs.43,53,56,61,63,67,69 A potential barrier to guideline sustainability was related to the evidence base, where it was noted that some guidelines may lack comprehensive guidance (eg, optimal time point to discuss certain symptoms within the cancer trajectory)39 or have diminished applicability over time when the recommended strategies have been exhausted, but the symptoms persist (eg, self-management strategies for peripheral neuropathy).41

Outer Setting Domain
Fewer factors were mapped to the outer setting domain, defined as the broader hospitals, systems, and networks in which cancer-specific outpatient settings are situated.18 Most outer setting factors were reported as barriers within the “critical incidents,” “local conditions,” and “policies and laws” constructs (Figure 2). Outer setting factors that negatively influenced symptom management guideline adoption, implementation, and/or sustainability included the COVID-19 pandemic,44 economic conditions within the healthcare system,31 variations in NP scope of practice by region,35 and variable insurance coverage of guideline-recommended medications.35 External policies such as accreditation were noted as a potential facilitator to drive symptom management guideline implementation and resource allocation.52

Inner Setting Domain
The inner setting was defined as the cancer-specific outpatient settings in which symptom management guidelines are implemented.18 Several inner setting factors were categorized as barriers and facilitators to implementation, most often within the constructs of “compatibility,” “information technology infrastructure,” and “work infrastructure” (Figure 2). The lack of compatibility (ie, the degree to which guidelines fit within current systems) between symptom management guidelines and current nursing workflows or cancer-specific outpatient setting processes was noted as a barrier.3654585967 Inadequate staffing, high nursing workload, and multiple competing pressures on nurses’ time were reported to impede nurses from engaging in evidence-informed practice and providing symptom management interventions.31,36,55,59,67,69,74 Adjusting staffing models to reduce nursing burden,36,59,69 incorporating guidelines into existing practice models and workflows,49,67 and implementing guidelines in a way that allows the work of the unit to continue with minimal disruption33,44 were reported as facilitators. Integrating guidelines into the electronic health record and nursing documentation can prompt nurses to provide symptom management interventions based on screening scores,51,60,67 whereas a lack of appropriate and integrated documentation can hinder guideline implementation.35,50,61,67
Additional inner setting factors included “mission alignment,” “relative priority,” “available resources,” and “physical infrastructure” (Figure 2). Organizational policies supporting change and evidence-based practices were reported to facilitate implementation.42,71 For example, nurses were more likely to adopt pain and fatigue guidelines in organizations that had philosophies and goals supporting guideline adoption.42 Conversely, a lack of clear organizational mandates to support symptom management guideline use within cancer programs and competing change initiatives were reported as potential barriers.67 The availability of resources to enact guideline recommendations also influenced implementation (eg, supervised exercise programs for cancer-related fatigue or psychosocial supports when referral is needed).39,49,71 Regarding physical infrastructure, a lack of dedicated space to implement guidelines when providing telephone symptom support, specifically, was identified as a challenge.41,67,69

Individuals Domain (Roles And Characteristics)
Most of the determinants across projects were mapped to the individuals domain, defined as the roles and characteristics of people involved in implementing symptom management guidelines18 (Figure 2). Within the high-level and mid-level leaders constructs, factors supporting implementation and resource allocation included leadership buy-in and enthusiasm.33,36,40,43,74 Conversely, unsupportive managers or turnover of influential managers who previously supported the adoption of evidence-based practices hindered implementation.40,55
Most factors within this domain were mapped to the “innovation deliverers” construct, defined as oncology nurses in this review. Factors related to oncology nurses’ roles were further mapped to the constructs of capability, opportunity, and motivation. Within capability, barriers included a lack of awareness, education, knowledge, experience, and comfort among oncology nurses with symptom management guidelines and/or evidence-based practice.42,43,58,62,67,74 Oncology nurses with advanced education, years of experience, and oncology certification were noted to have greater awareness and use of symptom management guidelines.31,42,53,62,71 Within opportunity, barriers were insufficient and unprotected time allocation within the nursing role to engage in evidence-based practice and provide symptom support using guidelines.313643596267697174 Facilitators were sufficient allocation of dedicated time for nurses to learn about and implement guidelines,335559 as well as establishing dedicated roles where consistent nurses have protected time to meet with patients and comprehensively address their supportive care needs.36,40,58,59,67 Some projects reported fewer barriers and higher rates of guideline adoption among nurses with increased role autonomy and agency (eg, APNs, navigators).31,42,55 Within motivation, barriers included staff reluctance/resistance to change,35,42,54 as well as issues related to nurses’ professional role identity, where the traditional role of nurses providing direct patient care may be viewed as more task-oriented than evidence-based.36,74 In one case, oncology nurses were reported to place limited value on ongoing education opportunities related to symptom management.55 Nurses with a more positive perception of symptom management guidelines and who considered guidelines to be necessary and useful for improving patient care were more likely to implement guidelines in their practice.42,43,58,59,61,67 APNs and nurses who self-select to participate in improvement projects were reported to be more motivated.55,71 APNs and nurses who are opinion leaders can facilitate guideline adoption among nursing staff by lending credibility and ongoing support to champion practice change.40,42,56
Factors were also categorized within the “innovation recipients” construct (ie, the capability, opportunity, and motivation of adult patients with cancer to enact guideline recommendations as recipients of evidence-informed nursing practice changes). Within capability, barriers were limited patient education, health literacy, and understanding of symptom management and self-management strategies.32,50,54,67,76 Within opportunity, it was noted that the unpredictable nature of cancer and socioeconomic factors can limit patient adherence to self-management strategies.32,59 Concerning motivation, a lack of patient motivation to engage with strategies (eg, exercise, medication changes) was reported.39,59,62 Developing and providing patient education resources that reflect symptom management guidelines67,76 and empowering patients with tools (eg, digital monitoring) to feel more in control of managing their symptoms61 were reported as factors that may facilitate implementation.

Implementation Process Domain
The implementation process domain grouped factors related to the activities used to implement symptom management guidelines.18 Most factors fell within the “teaming” construct (ie, collaborative efforts to implement symptom management guidelines) (Figure 2). Across projects, teaming was a consistent facilitator. Early engagement of nurses as end-users can inform adaptations to support guideline adoption.35,67 Including diverse perspectives (ie, patients, families, nurses, managers, prescribing clinicians) facilitated implementation,33,36,39,43,59,67,74 as did fostering shared leadership, group decision-making, good communication, and teamwork.43,44,49,57 Additional facilitators included providing clear expectations about nurses’ responsibilities related to symptom management guidelines in advance51,67,69 and providing accessible, practical, and dynamic nursing education.36,40,43,48,49,55,67 The importance of reflecting on and evaluating the process through regular audits, check-ins, and performance feedback was reported to influence guideline sustainability among nursing teams.36,40,43,51,53,55,67

Implementation Strategies
Across the 34 projects that reported on implementation strategies, 30 discrete strategies were identified using the ERIC taxonomy27 (Table 2). All projects used a combination of strategies (median 4 discrete strategies per initiative; range, 2-11; Table 1). The most common discrete strategies were “conduct educational meetings” (n = 20, 56%),3140434448495051545657585960616367697273 “distribute educational materials” (n = 19, 53%),31323336404344454849505759616263676972 “use advisory boards and workgroups” (n = 16, 44%),35363940434451555758606167737476 “conduct ongoing training” (n = 14, 39%),3236414748505254555657596773 and “change record systems” (n = 11, 31%).40,41,50,53,58,60,67,69,73,75,76
The discrete strategies were mapped to their corresponding categories28 (Table 2). Most projects used strategies from multiple categories within the same initiative (median 3 categories per project; range, 1-6; Table 1). The most common category was “train and educate stakeholders” (n = 29, 85%).3132333640414344474849505152545556575859606162636769727376 Educational strategies were typically developed and delivered by APNs, nurse educators, research nurses, and/or nurses with content expertise (eg, in nursing education or managing specific symptoms). Educational intervention dose was highly variable, as reported in 10 projects.31,33,36,41,43,48,56,58,59,67 Some projects delivered between one and five 30- to 60-minute educational sessions,31,43,56,58,67 whereas others delivered training over multiple hours or days.33,36,41,48,59 Other common categories included “develop stakeholder interrelationships” (n = 20, 59%)3335363940434449515355565758606167737476 and “use evaluative and iterative strategies” (n = 17, 50%).3536394044474849505354555960626775 No projects reported strategies aligned with the “utilize financial strategies” cluster. A summary of implementation actions taken within each category is provided in Table 2.

Discussion
This scoping review uses the recently revised CFIR,18 a comprehensive implementation science framework, to synthesize factors influencing symptom management guideline implementation among nurses in cancer-specific outpatient settings. This theoretically informed understanding of barriers and facilitators helps identify relevant targets for future projects to support enhanced guideline implementation. Most factors influencing implementation were mapped to the inner setting (eg, compatibility, work infrastructure) and individuals—roles and characteristics (eg, oncology nurses’ capability, opportunity, and motivation) CFIR domains/constructs. The findings suggest that oncology nurses may face several implementation barriers related to a lack of symptom management guideline integration within current cancer-specific outpatient setting workflows.3654585967 Given the insufficient and unprotected time allocation reported within their roles to engage in evidence-informed practice,31364355596267697174 outpatient oncology nurses may currently have limited opportunity to implement symptom management guidelines. These findings are unsurprising given the current pressures afflicting the oncology nursing workforce, including challenges related to recruitment and retention, staffing shortages, rising cancer incidence and service demands, complex cancer treatment advancements, and burnout.78 Although most factors were mapped to the inner setting and individual domains, given that only 31% of projects cited an implementation science theory, model, or framework, it is possible that additional determinants related to the innovation, outer setting, and/or implementation process are not reflected based on how data were collected and reported across projects. However, our findings are generally consistent with determinants of evidence-informed nursing practice environments previously noted in the literature.111279
Using implementation science taxonomies, this scoping review also synthesizes the types of strategies that have been used to implement symptom management guidelines into outpatient oncology nursing practice to date. This can help inform the identification of strategies that may be useful to overcome reported barriers and leverage identified facilitators to support tailored guideline implementation. Most projects (85%) used educational strategies, such as delivering educational meetings and distributing educational materials. These findings are consistent with a systematic review that explored guideline implementation strategies among oncologists and nurses across inpatient and outpatient cancer care settings, which similarly identified strategies focused primarily on passive dissemination and education.80 Notably, almost all projects (88%) sought to target behavior change related to guideline use. Although educational interventions may be appropriate to address the capability barriers identified related to nurses’ knowledge and awareness, educational strategies alone are unlikely to sufficiently address the most commonly identified barriers related to guideline incompatibility and limited implementation opportunities within outpatient oncology nursing roles. This suggests that there is a need to move beyond educational strategies that primarily target nurses’ knowledge and awareness toward strategies that meaningfully target systemic barriers and support behavior change.
This review highlights the need for integrated strategies to implement compact and easily accessible symptom management guidelines within existing workflows and processes. Although used less often, implementation strategies identified within the “change infrastructure” and “support clinicians” categories (eg, “change record systems,” “facilitate relay of clinical data to providers,” and “remind clinicians”) may be helpful to achieve better integration by modifying electronic health records and nursing documentation systems to reflect evidence-based symptom screening, assessment, and management interventions. Some projects35,61 used clinical decision support systems, which are designed to process patient data through evidence-based algorithms and present recommendations at the point of care. Decision support systems have demonstrated effectiveness in improving symptom management among physicians and NPs in lung cancer.81
Further, implementation strategies within the “develop stakeholder interrelationships” and “use evaluative and iterative strategies” categories are likely important to support guideline integration. Partnering with nursing champions and opinion leaders can help implementation teams better understand current processes and determine how care delivery can be optimized to include symptom management guidelines. Although patient-related factors such as health literacy, socioeconomic status, and motivation were noted to influence the uptake of symptom management guideline recommendations, few projects (17%) actively involved patients and family members as consumers of evidence-informed nursing practice changes. Given that forming teams with key stakeholders (ie, patients, families, nurses, managers, prescribing clinicians) was widely reported as a facilitator to implementation,33,36,39,43,59,67,74 future projects should consider implementation strategies such as “use advisory boards and workgroups” that include the perspectives of patients and families, in addition to providers and administrators, to determine local barriers/facilitators, inform necessary adaptations, and codevelop tailored strategies that support adoption. These recommendations are supported by a recent review of the effectiveness of implementation strategies in healthcare, which called for the need to build more situated and relational knowledge to support research use in practice.82
There are several strengths and limitations of the scoping review process that should be considered. Although we identified 36 projects, we suspect there may be additional symptom management guideline implementation initiatives happening within local cancer care settings that are not published in the literature. A strength of this review was the inclusion of gray literature, such as conference presentations and organizational reports. Although we identified several conference abstracts that were potentially relevant, contacting authors to locate unpublished reports proved resource-intensive with limited return. Some abstract authors reported that further details of the implementation initiatives were not available, suggesting that there is a need for better reporting and evaluation of implementation strategies in oncology nursing. It is also worth noting that this review excluded articles involving interdisciplinary cancer care providers when findings for nurses were not reported separately. This decision was made given the different scopes of practice between oncology nurses and other cancer care providers (eg, oncologists) that may influence implementation determinants and strategies used. However, it is possible that we have not captured factors related to the interdisciplinary nature of practice in cancer care that may influence symptom management guideline use.
There are also some limitations related to the evidence included in this scoping review. Across projects, there was limited reporting of the population (eg, nursing roles, certification). Although we originally intended to include projects involving specialized and advanced oncology nurses specifically, these reporting limitations meant that very few articles would have been eligible. Thus, we opted to include projects involving any nurses working in cancer-specific outpatient settings. Further, many of the included projects were classified as quality improvement. Of the projects that used research designs, most were quasi-experimental or nonexperimental. These information sources are well-aligned with the objectives of this scoping review to identify factors influencing implementation and the types of strategies that have been used, rather than strategy effectiveness. Although we originally intended to map study designs and outcome measurements across projects to inform whether there is sufficient evidence to conduct a systematic review, through data analysis, we determined that the current evidence base is not amenable to a systematic review of intervention effectiveness based on study designs. As a result, the types of outcomes measured across projects were not mapped as planned.

Implications for Practice, Education, and Policy
Clinical practice guidelines can optimize patient care by ensuring patients receive care that is informed by high-quality scientific evidence.23 Findings from this review suggest a need to standardize outpatient oncology nursing practice workflows to consistently assess and manage symptoms using an evidence-informed approach. This scoping review can be used to design tailored implementation strategies to support symptom management guideline use within local practice contexts, which can help reduce symptoms and suffering for patients. Oncology nursing leaders working with teams of diverse stakeholders can use these findings (eg, summary of barriers and facilitators in Figure 2, summary of implementation strategies in Table 2) in research and quality improvement projects to consider what strategies might be appropriate to select and test in local settings based on an understanding of contextual factors and available resources.
Findings suggest that APNs and nurses with increased role autonomy may have greater opportunities to implement symptom management guidelines. APNs acted as opinion leaders, promoting evidence-informed practice, leading implementation projects, and delivering education to nurses. As such, nursing graduate programs should ensure master’s degree–prepared nurses receive training in implementation science to prepare APNs to effectively lead this work. From a policy perspective, it is apparent that macrolevel strategies are necessary to address nursing workforce issues (eg, inadequate staffing, high workload) for oncology nurses to be able to regularly engage in evidence-informed symptom management care. Although these issues may not be easily addressed, a potential strategy may be to consider staffing nurses in dedicated symptom management roles with protected time to comprehensively address patients’ needs. Another notable finding for oncology nurses in leadership positions is that the commitment and support of high-level leaders (eg, directors) and mid-level leaders (eg, managers) can greatly influence implementation success.

Implications for Research
This body of literature could be improved through enhanced reporting of implementation strategies following established recommendations from the field of implementation science222627 and greater use of implementation science frameworks, which has previously been noted in this area of research.83 An encouraging finding was that symptom management guidelines were generally reported to be useful and well-received. However, it was noted that guidelines may lack relevant advice for all symptoms or have diminished applicability over time for persistent symptoms when management strategies have been exhausted. This suggests that more experimental studies of novel symptom management interventions may be needed to expand the recommendations available in clinical practice guidelines. Symptom management guideline developers should ensure simple and compact summaries of guideline recommendations are made available for oncology nurses to easily access and integrate at the point of care.

Conclusion
Outpatient oncology nurses may face several implementation barriers related to the lack of symptom management guideline integration within current cancer-specific outpatient setting workflows and may have limited opportunities to implement guidelines within their roles. Most projects used educational strategies, which alone may be insufficient to address reported barriers. Partnering with patients, families, nurses, managers, and prescribing clinicians in local contexts may facilitate the collaborative development of tailored, integrated strategies that address known barriers and leverage potential facilitators to implement symptom management guidelines within outpatient oncology nursing care. Supporting enhanced guideline implementation among oncology nurses can improve symptom management for patients living with cancer.