Relatively little is understood about real-world provision of oncology care in ambulatory outpatient clinics (OPCs). This study aimed to: 1) develop an understanding of behaviours and practices inherent in the delivery of cancer services in OPC common areas by characterising the organisation and implementation of this care; and 2) identify barriers to, and facilitators of, the delivery of this care in OPC common areas.A purpose-designed ethnographic study was employed in four public hospital OPCs. Informal field scoping activities were followed by in-situ observations, key informant interviews and document review. A view of OPCs as complex adaptive systems was used as a scaffold for the data collection and interpretation, with the intent of understanding ‘work as done’. Data were analysed using an adapted “Qualitative Rapid Appraisal, Rigorous Analysis” approach.Field observations were conducted over 135 h, interviews over 6.5 h and documents were reviewed. Analysis found six themes. Staff working in OPCs see themselves as part of small local teams and as part of a broader multidisciplinary care team. Professional role boundaries could be unclear in practice, as duties expanded to meet demand or to stop patients “falling through the cracks.” Formal care processes in OPCs were supported by relationships, social capital and informal, but invaluable, institutional expertise. Features of the clinic layout, such as the proximity of departments, affected professional interactions. Staff were aware of inter- and intra-service communication difficulties and employed strategies to minimise negative impacts on patients. We found that complexity, coordination, culture and capacity underpin the themes that characterise this care provision.The study advances understanding of how multidisciplinary care is delivered in ambulatory settings and the factors which promote or inhibit effective care practice. Time pressures, communication challenges and competing priorities can pose barriers to care delivery. OPC care is facilitated by: self-organisation of participants; professional acumen; institutional knowledge; social ties and relationships between and within professional groups; and commitment to patient-centred care. An understanding of the realities of ‘work-as-done’ may help OPCs to sustain high-quality care in the face of escalating service demand. Multidisciplinary care (MDC) is considered best practice in the delivery of services to cancer patients –4. A ranSome understanding of MDC has been derived from the study of multidisciplinary team meetings (MDTMs) - formal mechanisms for diagnosis, care planning and management, usually organised around a tumour stream . This work reveals potential benefits, such as learning together, teamwork and promoting adherence to evidence-based guidelines –15, and We know comparatively little, however, about how aspects of MDC coordination and cooperation occurs as part of day-to-day care provision in ambulatory settings. Outpatient clinics (OPCs) are important sites for the provision of cancer care. Not all patient cases are discussed at MDTMs or return to formal discussion at an MDTM after initial diagnosis and treatment planning. OPCs offer an opportunity for clinicians to modify treatment plans and introduce new partners in the provision of MDC by, for example, identifying emergent or hitherto unrecognised needs and responding to them directly or by third party referral. Moreover, and unlike most MDTMs, these settings deliver consultation and treatment services with the patient, necessarily, present.A high-level of coordination is needed to actualise MDC , which hdevelop an understanding of behaviours and practices inherent in the delivery of cancer services in OPC common areas by characterising the organisation and implementation of care; andidentify general barriers to, and facilitators of, the provision of care in OPC common areas.Complexity science offers a valuable framework for examining oncology OPCs, conceptualising them as self-adapting, multi-faceted systems embedded within a complex mesh of relationships, including other health services. Such systems follow their own internalised rules (not necessarily those prescribed by top-down authorities) and respond to internal and external disruptions . Agents A focused, purpose-designed, multi-site, multi-method ethnography was undertaken , 33. EthFour cancer OPCs, situated within two metropolitan health districts in Sydney, Australia, participated. Collectively, the OPCs offer extensive consultation and outpatient treatment services. As shown in Table Observations were undertaken of a range of professionals at the study sites, including nursing, care coordination, allied health, medical, clinical research, administrative and management staff. Formal navigator interviews were undertaken with cancer nursing and care coordination staff. Malterud, Siersma and Guassora’s (2016)  model foPublicly-available local reports and cancer plans were analysed to generate an initial description of the cancer services at each hospital. These profiles were used to map key areas for data collection. Scoping discussions with managers and key staff were held to understand the study sites, and input was sought from oncology service management to ensure local relevance and the feasibility of the proposed methods.Information about the research, including contact details and participant information sheets, was disseminated by email, posters, and via information sessions for target professional groups at each site. OPC management was consulted and access granted.Unstructured observations of the delivery of care were undertaken in OPC areas associated with consultation, waiting and treatment, but not within consultation rooms or treatment bays. This included observing planned and ad hoc collaboration between professionals from differing disciplines during the care delivery process and informal discussions between researchers and professionals. Handwritten fieldnotes recorded observations and reflections. Observations were undertaken primarily by one researcher (BNGE) who is trained in ethnographic research practice, with some observations undertaken by two fellow team members: a senior research fellow (GA) and a research assistant (TW), both of whom were trained by BNGE to enhance data compatibility. This facilitated the sharing and discussion of unfolding understandings.Formal, semi-structured interviews were undertaken with ‘navigators’, staff members with an overview of care pathways  . InterviRelevant documents, identified during fieldwork, including unpublished policies and professional guidelines, were gathered and reviewed on an ongoing basis.Data were managed in accordance with ethical practice, as previously reported . RevieweA number of strategies appropriate to the methods were applied to safeguard quality, credibility and trustworthiness in the interpretation of the data. This involved verification and sampling of the coding strategy by experienced research team members and ongoing discussion of emerging interpretations within the team. Preliminary analysis was undertaken by one team member trained and experienced with this approach (BNGE), who developed a coding strategy which included coded data, interpretations and five suggested themes. Two experienced qualitative researchers (KL and DF-P) reviewed and verified the coding strategy to generate more nuanced understandings and facilitate revisions. One researcher (BNGE) further clustered the interpretations and consolidated the codes into six overarching themes, and assigned succinct phrases to the themes, in ongoing dialogue with the research team. Analysis was finalized in a team forum that did not alter the number of themes and factors identified, but which helped to develop greater conceptual definition between themes and refine the naming of the themes.All methods were carried out in accordance with relevant guidelines and regulations. Informed consent was obtained from interviewees in written format. In adherence with the National Statement on Ethical Conduct in Human Research (2018) information about the observations was disseminated to target professional groups at each site by OPC authorities and via on-site briefings provided by members of the research team, prior to the data collection. As per the guideline, this information was provided in plain language, included study team contact details, instructions on how to opt-out of the observation and details about the secure management and use of data. Informational posters advised of the study and how to opt-out at any point up until the observation was completed. Written permission to observe was granted by authorities responsible for OPCs. Approval for the study was granted by a Local Health District Human Research Ethics Committee (no. 18/207).n = 135 h approximately). These common (non-private) areas are primarily serviced by nursing staff but can act as a hub for many different professional groups. Ad hoc, unsolicited discussions with professionals occurred naturally during this fieldwork. Care coordinators, tumour-specific specialist nurses, cancer nurse specialists and senior clinical staff participated in formal navigator interviews (n = 13), totalling six and a half hours. Notably, many of these key informants had worked across more than one of the hospitals, and in various roles such as multi-tumour or tumour-specialised care coordination and oncology nursing.The research was conducted over a 9-month period with observations undertaken in chemotherapy treatment areas, waiting rooms, consultation and other multipurpose areas ). The concept of “team” was at times taken to refer to a local professional disciplinary grouping  or to a cluster of different professionals working in a specific location.The idea of flexible team membership was often discussed in relation to MDTMs. In response to issues that arose, staff members self-organised into teams comprising clinical and non-clinical professionals needed to best address the issue presented.Administrative staff and other non-clinical staff, such as interpreters, frequently support care delivery, acting as communicators between nursing staff and doctors and in some cases even making efforts to advocate on behalf of patients. (Fieldnote p47), “We educate them …” KI9), but was also used to direct cross-disciplinary collaboration:In discussions, “team” was quite a fluid concept, especially where “we” and “they”  was used to identify oneself and others. “We” was not only employed to identify acts by the professional area of expertise (e.g.we’ll do is… [tasks for the nursing staff to undertake].” (Fieldnote p92)The doctor was sent for, due to issues arising during pre-chemotherapy checks. The doctor comes to the nursing station and immediately begins speaking: “Right, what we’re a very close team” (KI2). “They” terms were often heard in situations where boundaries and responsibilities were negotiated, such as when a senior nurse discussed a patient with colleagues: “he [patient] is not supposed to be there—they put him here because they needed the space. Phone them.” (Fieldnote p280).These terms also highlighted distinctions between professional groups or groups with specific roles: “we have a psychologist, who is great” KI12), and to present a united approach:Notably, the representation of “team” was carefully enunciated in patient-facing interactions (discussion with or in front of the patient). “We” was used to extend the local team to encompass a broader multidisciplinary expertise . (Fieldnote p256)Oncology nurse: “In patient-facing interactions “we” appeared to aid a sense of continuity across professionals and offer reassurance. Staff members attempted to shield patients from conflicting information or concerns about the continuity of care. Where there was potential for discord in this united approach, this was cautiously explored, often involving gentle probing for further information:Where a patient complains about an ongoing side effect of treatment and felt it was not being taken seriously, the oncology nurse looks concerned and responds: “Did you tell the doctor? What did he say?” The oncology nurse confirms that the date of their next appointment with the doctor is soon and guides the patient on how to raise this issue with them again. (Fieldnote p174)Professional identity, scope of practice and how individuals negotiate these issues with their colleagues emerged as salient for understanding MDC. Interviewees’ descriptions of their roles, their sense of identity, the associated professional values, as well as the passion they had, was expressed in the comment: “I love what I do, love the patients that I work with” (KI11). The application of professional expertise was observed even in the rare departure from the united approach often presented to patients:The oncology nurse takes the decision not to administer chemotherapy and the patient voices their dissatisfaction. The nurse responds “you’ll need to go to [hospital], this is not safe anymore. I’ll talk to [doctor]. We are not comfortable to give you this.” (Fieldnote p98)The respective roles and duties of differing professional groups tended to be cited in the context of potential conflicts. On occasion, a lack of mutual understanding of roles was noted.While professional remit and duties may have been clear in theory, the scope and boundaries became less so in practice. The desire to prevent patients from “falling through the cracks” (KI13) appeared to contribute to staff members taking on duties which they did not believe was in their job description. This included where other services were overloaded, as illustrated: “I mean it should go totally to them [referring to a service outside of the hospital]. It doesn’t work that way though, it hasn’t for a long time because their staffing is so poor.” (KI5). In many cases the roles of staff members and teams appeared to adapt in response to the capacities of others and the demands made of them:In response to the needs of the clinic, flexibility in clinicians’ tasks and role was observed. This appeared to be commonplace and expected. Further, staff were observed to go beyond their roles to facilitate care delivery, often becoming involved in other areas such as pharmacy, or even helping with parking issues. (Fieldnote p65)This adaptability of roles and scope of practice illustrates the potential gap between work-as-imagined and work-as-done in the ambulatory setting.In addition to professional expertise, a complementary form of “institutional expertise” was observed. Comprising organisational, cultural and social knowledge, this was a valuable resource, often deployed to navigate difficult situations:Senior nursing staff who had worked in the district or the hospital for a number of years were often called upon where there was uncertainty or an issue. Their memory, history and experience were drawn upon to help navigate challenges. For example, where a patient might need to be admitted, the experienced staff would source information about the status of beds on wards and identify which specific staff members were occupying gatekeeping positions at that time. This was followed by negotiation and sometimes compromise with the relevant stakeholders/parties. (Fieldnote p122)Because of professional and departmental interdependence, ‘bridges’, or staff who were familiar with or who moved between different areas of strategic importance, relayed information between the settings. These staff members (often senior or managing clinicians) were relied upon to relay status updates and real-time information, which informed near-term planning. As noted:An experienced oncology nurse worked between the OPC and the ward. They were able to report on how busy other departments were, if there were any issues and the whereabouts/availability of key staff members who might be needed. This information was then factored into decision-making around securing staffing levels and patient transitions between areas. (Fieldnote p220)Social capital  formed another resource for front-line practice. This proved beneficial for navigating cross-disciplinary and interdepartmental issues and was most readily seen where senior nurses were approached by junior colleagues for help. For example:The oncology nurse reported to the senior nurse that they had been waiting quite a long time for a surgical consultant to visit the patient and could not proceed until this happened. The senior nurse then phoned the consultant, and this request was framed within a humorous exchange, with the senior nurse declaring that the consultant owed the nursing staff coffee at the end of the call. (Fieldnote p256)Relationships were recognised as vital in MDC practice, with staff members from across disciplinary areas investing in forming and sustaining interpersonal dynamics. At times, this simply involved an explicit commitment to cooperation, such as when a consultant confirmed to a senior nurse: “If he [patient] wants to see me again, page me and I will come down.” (Fieldnote p234).These efforts could also be seen in the management of potentially tense situations, for example where a doctor was not satisfied with the way in which a nursing colleague had completed a form:Oncology nurse: “With the form, do we need to fill out another?”it’s the strictest thing, so we have got to make sure it’s perfect. Maybe hand do it.”Doctor: “Yes, Oncology nurse: “Thanks [nickname for doctor].” (Fieldnote p134)Maintenance of relationships, judicious deployment of social capital and the employment of institutional expertise supported formal care processes, and appeared vital for mitigating and resolving issues.Multi-site research permitted exploration of services with different treatment capacity , on-site services , and location of services such as allied health and oncology pharmacy. Features in the design and layout of OPCs emerged as important contextual mediators of MDC.Sole and multi-purpose treatment areas created different opportunities for MDC interactions. In one OPC, the space and resources were organised to reflect the steps involved in chemotherapy preparation and administration; over the course of the observations, interactions with inter-professional colleagues were less frequently observed in this setting. In contrast, another OPC with a similar number of chemotherapy treatment spaces contained overlapping functional areas  and parts of this space were thoroughfares to the ward and offices. Consequently, this OPC served as a meeting point to share information, find staff members and discuss concerns.In the two smaller OPCs with multipurpose spaces, it appeared easier for allied health, treating physicians and other professional disciplines to casually visit patients while they were attending the clinic. This led to introductions, informal chats and consultations being undertaken while patients were waiting for or undergoing treatment (Fieldnote p57). In reality, even where spaces were not obviously multipurpose, they often functioned as such. For example, nurses working at the station of the chemotherapy treatment area were observed to field questions about a wide range of coordination issues, such as explaining parking and giving directions.Where space was limited, staff adapted and used available free areas, including corridors and waiting areas; during fieldwork it became apparent that attempts to map key locations for multidisciplinary interaction in OPCs was futile as it occurred wherever staff met. Some staff members recognised the difficulties of working within limited space: “it is just that the work environment is quite small so it can be difficult to see patients and to deal with things that are coming up and changing” (KI8). Staff also highlighted the ways in which they tended to anticipate each other and act proactively to ensure consistent workflow given the confines of a small space.The physical co-location of services and professionals influenced access to various expertise and input, as well as workflow in the chemotherapy treatment area. This was best seen in the interaction between pharmacy and chemotherapy staff. In one OPC, nursing staff could “just pop your head through” (Fieldnote p101), for immediate, in-person discussion with the pharmacist; this was valuable where there were schedule changes or when less common drugs were involved.While at first glance the potential immediate access to inter-professional colleagues could be highly beneficial, a distinction was made between staff members being “present” and being “available” (KI9). For example, a common source of delay occurred where input from a doctor was needed to advise on whether chemotherapy should proceed, but the physician was not immediately available . Sometimes nursing or administrative staff spent time trying to track down the doctor in person. There was a recognition that doctors were attempting to prioritise and manage their, often multi-location, workloads. As one oncology nurse put it “you don’t own their time” (KI9).[Discussing the delay that occurs when input is needed from a doctor to progress chemotherapy]KI10: “Yeah. I guess a pager, but we don’t page them.”Interviewer: “Is that because it's easier just to try and grab their attention?”KI10: “I’m not sure. I’ve just been told just find them. If they are not there, just wait. I guess if they're in a meeting or with a patient you would only page them if it was an emergency.”Co-location of consultation, treatment and other service areas was viewed as aiding communication “because you have all those prompts that you wouldn’t normally have” (KI13). This enabled opportunistic conversations, which staff found useful in situations “where you just need a quick, ‘yep that’s fine’” (KI13). Pursuing ad hoc communication, facilitated by physical co-location, was carefully exercised, taking into account urgency and appropriateness. Staff members were attuned to particular nuances, such as catching the doctor “between patients” or only calling in when the “door was ajar” (KI11). Unwritten/informal rules shaped communication practices:Drawing on institutional knowledge, methods of communication were often individually tailored, for example: “no, she won’t check that for ages, email her, she’s quick on that” (KI6).It was not possible to observe electronic communication, such as emails or the oncology information system firsthand in the fieldwork; nevertheless, as this was a frequent topic of conversation, these discussions are pertinent in this theme. The potential benefits of centralised and shared oncology information systems for MDC were recognised by staff members. As one professional put it: “the psychologist will have documented that [they’ve] seen the patient and different things that need to be noted around that and we can pop in and we can see that” (KI8). Conversely, electronic documentation was noted as not always being well-integrated in the workflow. As one staff member reported: “So you might go, ok everyone is actually okay, so I’m going to… I will quickly sneak in [to the electronic system] and do this and catch up with the documentation that’s required” (KI8).Electronic documentation could also provide a sense of protection for staff by providing a record of events: “if something were to happen, I need to provide that evidence [in order] to say, ‘no hold on, this is the communication trail’” (KI3). However, electronic communication was viewed as cumbersome and unreliable at times, especially when information was needed immediately, as one staff member expressed: “I’d rather pick up the phone than e-mail” (KI5). Staff members did not always appear confident about whether the information was up to date, as indicated by staff double-checking the information verbally and cross-checking with colleagues whether this “sounded right” (Fieldnote p167).Staff members were very aware of potential communication issues and took steps to mitigate the risk of possible pitfalls:Following the deterioration of a patient, the oncology nurse involved in their care discussed their status with a senior nurse. The senior nurse asked the oncology nurse whether they might be available to switch shifts, so that they could be there when the consultant arrived, to handover and liaise the following day. (Fieldnote p72)Points of transition in care appeared to be of particular concern, and this included transitions between services in the same district, as noted:“it's okay to go, we'll treat the patient here and then treat them over there …but it's about continuity of care. And, again, I may know something and if, [that service] doesn't know  might potentially miss something.” (KI12)“we've had to say, unless [it is clear the patient has been informed], we're not touching it […] I've said ‘hi my name is [name] I’m the [role] at [hospital]’ and it’s literally, ‘do I have cancer? Nobody told me. How come no one told me?’” (KI2)Coherent with the patient-facing approach described earlier, staff were vigilant about the potential negative impacts that communication issues could have on patients, and attempted to carefully manage this:Staff members invest time in attempting to untangle confusing and conflicting information from sources such as caregivers, interpreters, electronic systems and other staff members in order to clarify events and ensure continuity of care for the patient.MDC occurred in many areas in the OPC, but nowhere was patient-centred care better exemplified, in the areas observed, than when the patient was in the chemotherapy suite:The oncology nurse shows the patient in and prepares them for treatment, they conduct an assessment , ask about any issues and follow up with ongoing concerns. Following discussion with a patient, the oncology nurse states: “yep, yep, still no good, let me just…”. The oncology nurse pages the dietician who arrives about 20 minutes later to speak to patient. (Fieldnote p287)There was a “while you are here” (KI6) approach taken, as various professionals used this time for impromptu consultations. In some cases, it appeared opportune for several separate patient needs to be addressed when the patient attended the clinic. While there are alternative forums for engagement, this approach appeared to overcome barriers, including for patients for whom English language proficiency is a barrier:“I must admit, if it is a post op patient that I haven't met, I often won't call them [beforehand]. I wait till they are on the ward, arrange an interpreter or see them in clinic when I know the interpreters are there because it's too difficult to have a three-way conversation.” (KI7)Interaction between staff and patients was frequently typified by humour, empathy and familiarity, as illustrated in the interaction between an oncology nurse and a patient: “oh yes that’s right, and what was it, what is he called again, your fish?” [Discussion about a patient’s pet fish]. (Fieldnote p101).Staff members negotiated a tension between the time taken to provide this care and competing demands on the clinic. As captured by one interviewee:“It’s also the high patient load, it is really difficult. Sometimes you can see that a patient has been sitting in the waiting room for like 45 minutes. Then you bring them in and they wait another 30 minutes. Then you still can’t check the chemo [two oncology nurses need to review the information prior to chemotherapy administration] … and it sucks because you know they don’t want to be here, and they are having a [bad] day just from being here.” (KI10)To this end, staff members within nursing teams sought to work together optimally, but were concerned about short-staffing, and worried about the implications if they took leave. In day-to-day practice staff members sought to shield patients from this tension and ensure the preservation of patient dignity:Upon discovering that a patient had become confused and not taken a medication required in advance of chemotherapy treatment, the oncology nurse consulted the senior nurse, who organised it so that the patient could receive the drug intravenously (lengthening their time in the chair and impacting the schedule). While explaining the adaption to their care, the nursing staff minimised the issue and joked with the patient about being a “trouble-maker” who kept them on their toes, as after all, someone needed to. (Fieldnote p234)The four Cs—complexity, coordination, culture and capacity—were identified as key characteristics of MDC in ambulatory care settings, acting as threads that bind the themes. From this synthesis, factors which serve as barriers or facilitators were derived.Staff variously navigate the complexity, or manoeuvre within it, in an attempt to make their way in organisational settings and coordinate their own and others’ activities. The delivery of MDC relies on coordinated and timely input from various professionals, each responsible for managing their workloads; misalignment of their respective priorities may present a barrier. Here, individual acumen is an asset, where team members make decisions about the ongoing allocation of their time, including assessing costs associated with participating in ad hoc collaboration and care. The self-organisation of staff, often across professional boundaries with shared superordinate goals, helps to tackle issues which require a multidisciplinary response. This was observed where administrative staff helped to coordinate between doctors, managers, pharmacists and chemotherapy nurses to secure appropriate approvals and obtain a newly-approved drug available via a compassionate access scheme. While cross-department collaboration was challenging at times, bridges linking these networks and the benefit of institutional knowledge helped staff to predict responses and informed forward planning.The complexities of cancer care pose coordination challenges for staff, patients and their caregivers. OPC observations offer a glimpse into the plethora of services and professionals involved at a time point in the patient journey. While many aspects of care coordination are anticipated and planned, we noted the emergence of issues at the point of care. Descriptions of the themes provide examples of how staff members responsively adapt , sometimes aided by co-location, prioritisation and flexibility in staff members’ time and roles, as well as the fluidity of team membership. There was an awareness among staff about the potential pitfalls in coordination within and between services, and staff deployed institutional knowledge and flexibility in their roles to anticipate and address gaps . There was a concerted effort to preserve continuity of care for patients, with staff shielding patients from failures of communication or coordination.MDC necessitates interdependent input from individuals each with their own respective professional identities and values. An appreciation of a colleague’s expertise, time constraints  and boundaries can enable collaboration. However, even where this appreciation was evident, misaligned priorities or pressure could potentially strain these relationships, forming barriers to MDC delivery. Social ties across disciplines provided channels for information flow, promoted cooperation and helped to dissipate tension. Often the social capital and institutional expertise of senior staff was called upon, offering an opportunity for junior colleagues to learn about the informal social conventions employed to sustain harmony and navigate difficulties. Striving for patient-centred care was core to professional identity, and connectedly the impetus to go “above and beyond” (K7) to achieve this appeared deeply ingrained within the culture.A range of supports and resources are needed to facilitate practice in ambulatory settings. A key tool for staff is the electronic oncology information system, as this has capacity to centralise pertinent information, refer to colleagues  and to communicate changes. However, the doubts staff expressed about the recency of information suggest this system is not perceived as optimal, and potentially may be a barrier. Much of the ad hoc collaboration arising as a result of the identification of needs during clinic visits was made possible by the availability, proximity and workload adaptations of relevant staff members. Sufficient staffing was cited as an issue, with some professionals concerned about letting down colleagues, or in some cases resulting in limits on services offered .This study builds on the understanding of the provision of MDC in cancer services by developing an account of how, in practice, this care is delivered in ambulatory settings, mostly the chemotherapy consultation and treatment zones which were present in all four OPCs studied, and mostly delivered by nurses. Professionals endeavoured to provide holistic, patient-centred care, while simultaneously negotiating demands and pressure. Overwhelmingly, the main facilitator of the provision of quality care in these settings is the empathy of staff, their professional commitment to do their bit to optimise patient outcomes. The main barrier, resource constraint, acts directly to reduce care quality  and indirectly by creating tensions between staff and departments.We captured nuanced, behavioural examples of “work as done” and developed a framework for understanding the four key issues that shape the delivery of care across six key characteristics of OPC settings. Team composition is routinely reconfigured across professional group boundaries, and is informally formulated ad hoc to best address the issues faced by presenting patients. While we observed a degree of fluidity in team membership, this represents one of many possible models of team care that have been described –4. As obComplexity is an underpinning characteristic of OPC care. Care delivery relies on interaction between networks of semi-autonomous agents, for whom misalignment of priorities can pose a barrier to collaboration; time-pressures appear to be a major source of this misalignment. Self-organisation capability, the exercise of judgement and the presence of bridges across networks, facilitate care delivery and enable the coordination of activities. Culture is also a fundamental characteristic of MDC. Here, respect and understanding among professionals, the cultural transmission of institutional expertise and social conventions, as well as the sustaining of inter-professional relationships, served as enablers. From an economic perspective, future research could harness understanding of differences in organisational cultures and any strategies used to develop this culture, between sites, to identify possible avenues for investment. The necessity to go “above and beyond” was commonly observed in all settings, reflecting resource constraint or the frequency of non-standard presentations. Further, the capacity needed to support MDC delivery was understood to encompass the requisite staffing to enable ad hoc and patient-responsive care in the OPC.Care coordination has been previously highlighted as challenging to achieve across the patient journey, and this study extends the understanding of coordination in ambulatory settings , 40, 46.Professionals in the research not only sought to shield patients from disruptions to the continuity of their care but, as is congruent with best practice , to alsoNursing scholarship suggests that time and workload pressure can be a barrier to the provision of the relational aspects of care, including the detection of psychosocial, educational and medical needs, and in such circumstances, more visible, physical or task-oriented aspects of care are privileged , 47. TheFrom an improvement perspective, the findings from this paper suggest potential actions to advance the delivery of cancer services in OPCs. Figure Individual OPCs should consider the expected value of the above and other actions in their local context. Continued research on the costs and effects of actions to improve the safety and quality of outpatient clinic flows is also required.The study had limitations. The key informant sample comprised professionals from cancer nursing or care coordination backgrounds. While this was informative for learning about point of care processes for nurses, the perspectives of other professional groups involved in this care would have been beneficial. It was not possible to observe closed door consultations or consultations with doctors, which meant that the majority of the observations concerned outpatient waiting areas for radiation therapy and chemotherapy and chemotherapy treatment areas. Other relevant, and potentially connected, observations may have been missed.Moreover, some of the participating hospitals have cancer services separate from these generic treatment areas and these were not studied; for example, a small number of services are delivered through multidisciplinary clinics where a patient comes in to sequentially consult with multiple clinicians and perhaps participate in the MDTM. While this limits what could be observed, this was necessary to ensure patient privacy and confidentiality, and to minimise the burden of research on clinics. Further, it was not feasible incorporate the study of electronic health records in this ethnographic investigation which limits our analysis, given the importance of the modes of interaction in the course of practice and their implications for how staff manage their time. Observations concerning care for patients for whom English language proficiency is a barrier suggests that additional considerations and support are needed  in MDC delivery, and, as such, merits dedicated study. We also noted the way in which patient safety-promoting behaviours and interactions were threaded throughout the observational data collected; we did not include this as a specific interview prompt, which may have influenced the way themes emerged. Future research efforts could incorporate an explicit focus on behaviours and interactions which promote safety in these settings. Qualitative research does not seek to provide generalisations or quantifiable answers , 37, andApplication of multiple lenses through which to see the study, namely complexity, coordination, culture and capacity, prompts engagement beyond work-as-imagined to appreciate the processes and resources which support work-as-done. The value of social ties in helping to bridge networks and the employment of social capital to sustain performance, even under pressure, underscores the importance of attending to culture in the study of MDC. Moreover, it speaks to the need for health services to invest in building and supporting and coordinating these critical relationships. The precise nature of the social coordination, built on connections, including bridges across networks, represents as multiple social network analyses, whereby those who create the bridges are ‘boundary spanners’ .


N = 5607) was analyzed descriptively, and five focus groups were conducted, applying thematic analysis. Statistics showed that boys from the age of 14 use video games up to 5 times more than girls, while girls are much more on social media. From the focus groups, we found that boys did not view social media as socially significant as gaming and that there is a greater social acceptance of gaming among boys than among girls. Gender differences in video gaming are not necessarily a problem per se, as they may reflect gender-specific motivations and interests. However, the study also finds that girls feel less encouraged than boys to play video games due to different gender-related experiences of video gaming. Therefore, gendered barriers in video gaming must be explored in future research.Gaming is widespread among adolescents and has typically been viewed as an activity for boys. There are however a growing number of female gamers and we need to learn more about how gender affects gaming. The aim of this study is to both quantify gaming among Norwegian adolescents and explore how gender differences are perceived. A mixed method approach was used to capture gaming experiences among boys and girls. Survey data ( Video games have been played for decades, influencing the daily lives of people and relationship to technology. In the last 40 years, video games have moved from amusement arcades 1970s) to home consoles and computers (1980s–1990s), and more recently to mobile devices 2000s) and lastly to sports stadiums due to the popularity of electronic sport, eSports (2010s) [970s to h000s and As pointed out by Lobel et al. most research on video gaming has focused on its potential negative impacts, such as addiction, violence, depression, and other mental health issues . SimilarIn recent years, a significant body of studies has begun to investigate gaming’s potential positive side. Research has shown that gamers can experience considerable benefit, such as pleasure and enjoyment , meaningVideo gaming has long been perceived as mainly a territory for adolescents and males. A systematic review on gender differences in online gaming by Veltri et al.  reports Since video gaming is more prevalent among boys than girls ,16, the In this light, the purpose of this study is to explore gender differences in various aspects of video gaming. We believe that exploring gender disparities is vital because gender is a fundamental characteristic that inspires the behavior and societal roles of men and women. The present study aims to investigate  how gendOur study population was children and adolescents in Norway aged 11–19 years. We used a mixed-method approach, as we believe that using both qualitative and quantitative data would enable an exploration of how the two methodological approaches could complement and nuance each other in understanding adolescents. Quantitative data come from the Ungdata study, a national youth survey covering almost all municipalities in Norway (Ungdata.no). Qualitative data were collected by the author in focus groups conducted in secondary schools in Innlandet County. Both datasets were analyzed separately and then brought together for analysis and comparison.As Granic et al.  point ouUngdata is a standardized and quality assured survey covering various topics, such as school, health, family and friends, substance use, and leisure activities, including digital media use and video gaming. The Norwegian Social Research Institute (NOVA) administers Ungdata. The survey was first implemented in 2010 and is financed by the Norwegian Directorate of Health, Ministry of Children, Equality and Social Inclusion, and the Ministry of Justice and Public Security. Ungdata is available for grades 5–7 in elementary school (Ungdata junior) and for secondary school (Ungdata). The survey may be ordered free of charge every third year by municipalities. It comprises about 150 questions that are similar across all surveys. Schools may also choose an expanded version of the survey, with additional sets of questions on mental health, gaming behavior, and other topics. The students complete the self-reported digital questionnaire during one school lesson with a teacher present. Participation in Ungdata/Ungdata junior is voluntary and based on informed consent .N = 504,553.To show screen activity trends by age, we used the entire Ungdata junior and Ungdata sets used in 2010–2020. The analysis was restricted to participants with non-missing values in the variables of interest, which were gender, age, gaming on PC/console, gaming on smartphone/tablet and use of social media, with a total p-values <0.05 were considered statistically significant. All analyses were conducted in SPSS Statistics for Windows, Version 26.0. .To analyze gender differences in secondary school adolescents regarding screen activity, we used data from 5607 8th to 10th graders (aged 13–16) in Innlandet County who participated in the Ungdata survey in the beginning of March 2020 before the national confinement due to the COVID-19 pandemic. The convenience sample includes 2779 (50.4%) boys and 2731 (49.6%), which represents about 45% of the secondary school students in Innlandet County. Categorical data were presented as counts and percentages. We used Chi-square tests to assess gender differences. The qualitative data were collected using focus group interviews in September and October 2019. We focused on secondary school students aged 13–16 years, as this is the period when many girls lose interest in gaming while boys continue with it . We recrAn interview guide, including gaming-related questions from the Ungdata survey, directed the participants to talk about how they used video games, their experiences of friendship, intimacy, belonging, exclusion, or hate in gaming spaces, how gaming may support or constrain young people’s lives, their parents’ views on their video gaming, and the impact of gaming on their schoolwork, social relations, and mental health. The interview guide was pretested in a 9th grade class of 30 in a school where we did not conduct focus groups. The interview guide was modified after pretesting. Questions were not worded in a manner that directly targeted gender differences. The interview guide ensured consistency and flexibility in the approach to elicit the participants’ stories. Probes were open and specific to their comments.Both researchers were present during all focus group interviews. The second author led the interviews, while the first author took notes and asked some follow-up questions. The interviews lasted 30–45 min and took place in a private room in the school with only participants and interviewers present. Confidentiality was ensured at the outset by informing participants that all identifying information would be removed from the data. All interviews were audiotaped and transcribed verbatim by the first author. The interviewers had the impression that all students spoke freely, but some were less talkative and gave shorter responses.We conducted semistructured group interviews to generate interactive data and access everyday ways of talking about our research topics ,26. FocuQuantitative data were obtained from an established database collected anonymously in the Ungdata surveys, which was approved by the Norwegian Centre for Research Data (NSD). Consequently, separate ethics approval for the present study was unnecessary. Informed consent was obtained from all students and their parents prior to the online survey. Separate informed consent was collected from the students participating in the focus groups and their parents. Students were also given verbal information about the study aim and their rights as participants at the beginning of the group interviews. Ethical approval for the qualitative part of the study was granted by NSD (NSD no. 882453).The quantitative analysis shows that more boys than girls in all age groups spend an average of one hour or more per day playing video games on a computer or console. The gender difference varies between 40% and 54%, depending on age. At age 13, video gaming on computers and consoles decreased by about 20% in both genders . Gaming The analysis shows a gendered pattern in the adolescents’ use of social media . Betweenp < 0.001 for all categories).Ungdata participants were also asked about video games, social relations, and friendship . In UngdThe first theme reflected adolescents’ perceptions of how boys and girls were oriented towards different screen activities. In line with the survey findings, the participants associated video gaming with boys and social media with girls. One 9th grade boy said that boys and girls spend about the same amount of time on screen activities, but that boys spend most time on gaming and girls on social media. A girl in the 10th grade described how she and some friends used to text each other so much on social media that their parents had to make a rule forbidding the use of social media after 8.30 pm. She explained how video games and social media play different roles in her life: “I do think it’s fun to play video games, but now that I have Snapchat and stuff, I’ve kind of started talking a lot more with people there”. Both boys and girls mentioned using various social media platforms such as Facebook, Snapchat, and Instagram. Boys, however, did not view social media as socially significant as gaming. One boy in 8th grade stated: “I play a lot. That’s what I do most. I have social media too, but I’m not active there”.Many of the boys used the term “gamer” about themselves. In their perspective, a “gamer” is a person who has video gaming as a passionate hobby. One 9th grade boy, who referred to himself as a gamer, described how gaming was an integral part of his life: “I play every day. Just now, it’s a lot of Minecraft, Grand Theft Auto, CounterStrike. I play with people from my class and sometimes with people I have gotten to know online”. The boys described video gaming as a broad medium, ranging from mobile app games  to large open world games . However, some genres and titles were described as more authentic video games than others. Boys described playing on a console or computer as “real” and “hardcore” gaming and playing on a tablet or a smartphone as “casual” gaming. When one boy mentioned that some girls at school play a horse game (“Howrse”) on tablets, one of the biggest gaming enthusiasts protested loudly: “Hell no, that’s not a real video game!”.All of the girls we interviewed had some experience with video games. Most had one or more games on their smartphone or tablet, such as Candycrush, Roblox, Color Road, and Sims. Despite playing these games occasionally, the girls mainly expressed their relationship to gaming with comments like: “It’s just a pastime for me”; “It’s just something I occasionally do in vacations or when I’m traveling”; “I don’t sit down and do it for its own sake”; “You won’t find me sitting at a computer or Playstation”. Only one girl explicitly mentioned video games as her hobby. However, she expressed ambivalence towards video games and parts of gaming culture.The second theme related to how adolescents associated video gaming with different stages of life. Boys considered video gaming to be a central part of both childhood and youth culture. Many girls associated gaming primarily with childhood and younger children’s lifeworld. One 10th grade girl stated: “Many girls are insecure about themselves and can get affirmation that they’re good enough on social media. Some also think that gaming’s childish. Some games aren’t childish, of course, but on social media, you can talk more with friends”. Several girls reported having played more video games when they were younger, with friends or family members, but that their interest in gaming had gradually faded. One girl felt that video gaming was mostly about playing and having fun, but that social media was better suited to make and cultivate friendships. Some of the boys had noticed that the girls at school were more oriented towards social media and youth culture now than a few years ago. One boy in 9th grade explained: “Many of those typical ‘girl games’ aren’t so popular among the girls any longer. At age 9, or at least that’s what I think, all the girls want to be princesses, cute and stuff. But suddenly that stops, and they all want to be models on social media”.From the boys’ perspective, video gaming belonged to both childhood and youth culture. Unlike the girls, some boys reported spending more time gaming now than when they were younger. Most of them had always enjoyed gaming and they found it hard to visualize a life without video games. One boy in 10th grade said: “A normal day for me is like this: I come home from school, I go to the computer, and I play video games (...) I play lots with friends. I’ve played soccer before, but I’ve become a gamer. I’d probably survive without gaming, but it’s so cool!”. Video gaming was emphasized as fun and entertaining by several of the boys. One boy in 10th grade used to phrase “digital playing” to describe his relationship to gaming and mentioned the popular video game Minecraft, which he described as “Lego on the screen”.Some boys also explained that gaming was more than pure play and fun: they connected gaming to learning, education, and careers. Several boys envisioned a future where video games would be part of their lives, not solely as a passionate pastime but also as a possible career, such as a professional video gamer (eSports athlete), streamer, or game developer. The boys mentioned several schools that offered gaming programs. Some boys were deeply interested in eSports, and they thought it was cool that Fortnite had a Norwegian world champion.The third theme related to video game content and characters. Both boys and girls were critical of gender representation in video games. One 9th grade girl expressed it this way: “The characters in video games are mostly guys. There are lots of war games. I don’t play any video games where the main character is a man”. Although she described gaming as her hobby, she was ambivalent about video games because she felt that there were so few “good female characters”. Another girl commented that female characters are often portrayed as helpless and in need of being rescued, mentioning the princess character in the Super Mario Bros games.Both girls and boys felt that video games were addressed more to males than females. One 10th grade boy explained: “It’s nice to have a choice. Then maybe girls will feel more welcome in video gaming (...) I play a female character in Destiny 2. All the male characters in the game look completely hopeless. They all look like they’re in a midlife crisis.” The interviewees wanted more nuanced and varied game characters. They thought more gender balance would improve the games and that the introduction of more female characters could make girls feel more attached to gaming.The fourth theme concerned the greater social acceptance and higher status of gaming among boys than among girls. The boys described how gaming was an essential setting for experiences of togetherness in free time and school time. One 10th grade boy said: “I play with classmates and sometimes with people I’ve got to know online (…) We have an iPad at school, and it’s tempting to play a game in class. You get a black mark if the teacher catches you, but my friends and I take that risk”. Several boys said that they got to know others better and made friends in online games. Some mentioned that they kept in touch with family members and former neighbors or classmates by playing online together. “In games like Minecraft or Super Mario Maker, you can build something together while talking about other things”, one of the boys explained. Another boy said that he and some classmates used to play Minecraft after school. He added: “I’d have felt left out if I couldn’t play with my friends”.Besides enjoying playing video games themselves, several boys reported often spending time on YouTube and Twitch watching others play video games. They found this just as natural and meaningful as watching soccer or other sports on TV. The most popular games among boys included World of Warcraft Classic, Fortnite, FIFA, Call of Duty, and Counter Strike. When we asked if they sometimes played with or met girls in these games, one boy answered: “I’d be amazed if I met a girl in CounterStrike. There are really not that many girls in those games”. For the girls, social media had greater social significance than video games in the peer community. One girl described how she began to think twice about gaming when she was 12: “When people say gamer, I think mostly of boys really (...) I used to play a boxing game. That was before I got social media. Every time I got a visit, I tried to get them to play, but (...)”. This lack of interest in video gaming from her friends colored her view of video games. Girls found it difficult to find other girls to play with or talk to about games.Our study found pronounced gender differences in the screen activity of adolescence. The statistical analysis showed that boys spent significantly more time than girls in all age groups playing video games on consoles or computers. Regarding online gaming, most boys reported playing at least once in the past week, compared to 23% of girls. This finding concurs with other studies from Norway , GermanyFurther, the analysis showed that the adolescent boys and girls had different views on playing and gaming. Previous studies have reported that teenage girls are often keen  to creatAnother factor that the adolescents eagerly discussed as a gender barrier in gaming was the predominantly male/masculine orientation of many video games. It is well documented that there are far more male than female game characters  and thatFor many young people today, especially boys, gaming occupies most of their waking hours out of school. For many of the boys, video games were a crucial aspect of their social life. They emphasized that gaming was deeply integrated into their friendship and peer groups. Playing video games with friends allowed boys to communicate their thoughts, feelings, and worries in a play-like context. For some boys, video games were also a way to keep in touch with former classmates or distant relatives, as also described in other research .The quantitative analysis supports the interviews in finding that gaming is an essential social tool in male adolescents’ lives. Gaming is a way to connect with friends and find like-minded peers, especially for boys. It is important not to underestimate or condemn virtual friendship as less real and genuine. Although the use of digital tools that mediate our social interactions, such as online gaming and social media, help to maintain communication during breaks in physical presence , researcThis study focused on gaming an understanding of gaming behavior in adolescents in a gender perspective. We applied a mixed methods approach to obtain a broad picture of adolescents’ video gaming practices and experiences. There are several important limitations to the study findings to be addressed. Firstly, one challenge that can emerge when applying a gender perspective is to overemphasize gender differences. Gender and other social identities, such as age, ethnicity, sexuality, religion, and class, form part of a complex interrelationship . Our intBesides these limitations, our study also possesses some strengths. It focused on the gender perspective of gaming behavior in adolescents, which has been absent in much previous research . While tThe present study found significant gender differences in the video gaming of Norwegian 11–19-year-olds. The quantitative part showed a high proportion of gamers among boys regardless of age, but less gaming among girls with increased age. The qualitative part identified four themes that may explain how gender effects adolescents’ practices and gaming experiences. Gender differences in gaming behavior and experiences are not necessarily problematic. However, our study found that adolescent girls have a more limited scope in gaming. The finding of gendered barriers to participation in gaming activities must be explored further in a larger population.


Although children’s intake of fruit and vegetables has seen a recent rise, almost half of adolescents do not eat even one piece of fruit or vegetables per day. One way to address this problem is through interventions that provide fruit and vegetables directly to children in kindergartens and schools. For such interventions to meet their intended goals, what is important to consider in addition to impact is implementation. Our objective is to systematically review qualitative results reporting on the determinants (barriers and facilitators) to implementation of interventions that entail direct provision of fruit and vegetables in kindergarten and school settings and conduct a framework analysis of those results using the Consolidated Framework for Implementation Research (CFIR).Implementation Science was completed. Screening of titles and abstracts (n = 5427) and full texts (n = 227), led to 14 included articles. Coding and analysis were done using the framework method and CFIR.A systematic search was designed and run in November 2019 for: MEDLINE (Ovid), Embase (Ovid), PsychINFO (Ovid), ERIC (Ovid), Cochrane Library Reviews and Cochrane Library Trials. A keyword search of the journal intervention characteristics domain: ‘design quality and packaging’, ‘adaptability’ ‘cost’; 2) outer setting: ‘cosmopolitanism’, ‘external policy and incentives’ ‘patients’ needs and resources’; 3) inner setting: ‘implementation climate’, ‘readiness for implementation’ and ‘structural characteristics’; 4) characteristics of individuals: ‘individual stage of change’, ‘knowledge and beliefs about the intervention’ 5) process: ‘engaging’, ‘executing’ and ‘reflecting and evaluating’. The review stresses the dual role of parents as both supporting the implementation and targets of the intervention, which could have implications for the design and implementation of future fruit and vegetables interventions. Positive child perceptions of the value of the intervention and perceived behavior change due to the intervention were reported as relevant facilitators to implementation across several studies, and should be taken into consideration in future design efforts.The following CFIR constructs were found relevant: 1) CFIR offers a systematic way to identify and organize barriers and facilitators to implementation of interventions in the kindergarten and school setting. Revisions are encouraged to allow adequate space for perceptions of various implementation actors and the target group.CRD42020167697.The online version contains supplementary material available at 10.1186/s12966-022-01246-8. A higher fruit and vegetables consumption is significantly associated with lower risk of all-cause mortality . NonetheOne way to address this issue is through interventions that provide fruit and vegetables directly to children in kindergartens and schools, as the settings where many children may be reached. In the context of this article, interventions are understood as any policy, programme or environmental change that aims to promote certain health behaviors . A systeResearch in the field of implementation science has made significant progress, laying the groundwork in regard to theory . In partOur objective is to systematically review qualitative results reporting on the determinants (barriers and facilitators) to implementation of interventions that entail the action of direct provision of fruit and vegetables in kindergarten and school settings and conduct a framework analysis of those results using the CFIR.A protocol for this systematic review has been published in PROSPERO (registration number: CRD42020167697).Implementation Science was completed July 2020, producing 156 records. In addition, a manual search was completed of reference lists from 30 studies included in the Micha et al., 2018 systematic review, that were identified as reporting on the impact of direct fruit and vegetables provision interventions [The search strategy was developed by an advisor at the Medical Library, University of Oslo for the following databases: MEDLINE (Ovid), Embase (Ovid), PsychINFO (Ovid), ERIC (Ovid), Cochrane Library Reviews and Cochrane Library Trials  and conflicts were resolved through discussion and consensus. Records that evaluated the impact and/or implementation of interventions providing fresh fruit and vegetables to children on school property, at any time during the school day were included for full text screening. Reviews, study protocols, comments, editorials and conference abstracts were excluded. A total of 5200 records were excluded, leaving 227 records for full text assessment. Quantitative studies reporting only on impact and/or implementation outcomes were excluded, as such results were not sufficient to identify barriers and facilitators to implementation. Full text eligibility evaluation was conducted independently by two teams of reviewers (B.M. and as a team—D.A.S. and J.W.) and conflicts were resolved through discussion and consensus. A total of 213 records were excluded with reason, leaving a final number of 14 articles to be included as part of this review. As 14 peer reviewed articles were identified for inclusion, dissertations and records which were not peer-reviewed were excluded. Grey literature was not searched and included  . HoweverThe 14 articles included in this review are based on research conducted in the United States (9), Canada (2), Denmark (2) and Australia, published in the period 2011–2019. For all studies, the school (with one focusing on preschool) was the main setting where implementation of the intervention/program took place. However, three articles also looked at the wider community context.The main methods for data collection were 1) individual face to face or telephone interviews, 2) focus groups and 3) observation. In two studies, questionnaires were used to collect qualitative data: Lin et al.  used quaFor the purpose of data extraction, we have followed the method of Malterud –22, thatfirst are interventions with a limited time frame, implemented once and discontinued upon completion. In addition to providing fruit and vegetables, these interventions have an educational component, and may entail actions that aim to involve groups other than children, such as parents. These are the Boost intervention, Denmark [second type of interventions are those based on national level government policy, that once introduced are then continued on a yearly basis. The main purpose of these interventions is the provision of fresh fruit and vegetables, and they may or may not have additional components. These are the Northern fruit and vegetable program, Canada [third type of interventions are farm to school, USA [The 14 papers included in this review , 25–36 a Denmark , 36; Sna Denmark ; Cooking Denmark  and the  Denmark . The sec, Canada  and the , Canada , 31. Finool, USA , 33–35 aool, USA . They arool, USA .Table 1CThe quality assessment was done independently by two authors (B.M. and M.S.). As all papers were evaluated positively on at least seven (13 of the 14 papers on at least nine) checklist points, the overall conclusion that all 14 articles were of sufficient methodological quality to be included in the review was made through consensus of the two authors. Some general remarks can be made based on the assessment. Papers were found to be especially weak in regard to ‘reflexivity’ and ‘theoretical framework’. In particular, both authors agreed that only two out of the 14 papers had a theoretical frame of reference. Namely, Jørgensen et al.  used theFigure Additional file Additionalfile intervention characteristics domain, was ‘design quality and packaging’. Different aspects of this construct were discussed in 13 out of the 14 papers. Studies emphasized the importance of the quality of the fruit and vegetables provided [The construct most widely addressed across papers and coded with greatest intensity overall as well as within the provided , 33, 36 provided  and textprovided . Vegetabprovided  and dipsprovided , 27, 31.provided , 27 whilprovided , 31, 36 provided , 25 in tprovided , 36. Finprovided .adaptability’, the findings based on the Boost intervention are particularly worth highlighting [Cost’ was a relevant determinant in two particular respects. Studies emphasized the importance of fruit and vegetables which are free, as that was found to be helpful for children of lower socio-economic background in particular [Two other constructs within this domain which were also widely present across papers were ‘adaptability’ and ‘cost’. In regard to ‘lighting . The intrticular , 31. In rticular , 35 thisrticular .complexity’, which overall was not widely addressed across papers compared to ‘design quality and packaging’, ‘adaptability’ and ‘cost’. Some interventions required specific ways of packaging the fruit and vegetables, which for some suppliers meant more effort in order to comply [The perspective of suppliers is worth highlighting as evident under the construct of ‘o comply . Overallo comply , 32.outer setting were ‘cosmopolitanism’ (8 out of 14 papers) and ‘external policy and incentives’ (7 out of 14 papers). When reporting on ‘cosmopolitanism’, the most commonly found barriers and facilitators were linked to the relationship between the school and the farm/producers/suppliers/delivery service [External policy and incentives’ was another outer setting construct often addressed in papers. Whereas the availability of external funding was found to be a facilitator to implementation for schools [The most widely present constructs from the  service , 34, 36. service , 33, 36. service . ‘Extern schools , 30, 35  schools . Studies schools , 32 howepatient needs and resources’ (in the context of this study ‘patient’ refers to the primary target group-children) was present in 5 of the 14 papers reviewed. When the intervention was perceived to address the needs of children in regard to their overall health – mental and physical, it facilitated the implementation [Text linked to the construct ‘entation . Howeverentation . Anotherentation .peer pressure’ was found to be a relevant construct in only one of the included studies, and it is worth noting, as it primarily represents the views of distributors [Finally, ‘ributors . Namely,ributors .inner setting were found to be ‘implementation climate’ (9 out of 14 papers) and ‘readiness for implementation’ (8 out of 14 papers). Within the ‘implementation climate’ construct, the sub-construct most often addressed was compatibility [relative priority was often a barrier, as teachers had a tendency to prioritize other, often curriculum related obligations [organizational incentives and rewards, one study emphasized the importance of celebrating the overall success of the children, due to the intervention, as such a celebration was found to be a strong motivating factor for teachers [goals and feedback, emphasized the importance for teachers to clearly understand the objectives of the intervention [Highly prevalent constructs of the tibility , 31, 32 tibility , 35, 36 tibility , 35. Texteachers . The samteachers . Anotherrvention .‘readiness for implementation’, mostly belonged to the sub-construct available resources [access to knowledge and information sub-construct [leadership engagement, serving as a motivating factor for teachers and their own commitment to intervention implementation [Text linked to the construct esources , 34–36. onstruct . Finallyentation , 32.inner setting, which although not as prevalent as ‘implementation climate’ and ‘readiness for implementation’, were nonetheless present – ‘structural characteristics’ (6 out of 14 papers) and ‘networks and communications’ (4 out of 14 papers). Under ‘structural characteristics’, findings emphasized the importance of storage space, kitchen space, having containers, utensils and refrigerators but also the location of the school as important, as more distant schools were a challenge for distributors to reach [networks and communication’, in particular among teachers, administrators and kitchen/food service staff within the school was also identified as important across studies [Two additional constructs are also worth noting within the to reach , 33, 36. studies , 32, 34.characteristics of individuals domain, text pertaining to ‘stage of change’ (9 out of 14) and ‘knowledge and beliefs about the intervention’ (8 out of 14) were most present among the included papers. Text linked to ‘stages of change’ was common, but superficial, primarily emphasizing the importance of staff ‘buy in’ as a facilitator and important for success of the intervention [Among the constructs related to the rvention . Educatirvention , 34. Exprvention . Distribrvention .knowledge and beliefs about the intervention’, from the perspective of persons involved in the implementation of the intervention, most commonly teachers [Perceptions of behavior change were expressed under ‘teachers , 33, 34.teachers , 30, 33 teachers , 31 deveteachers .individual identification with the organization’ [self-efficacy’ related text was indicated by teachers taking part in the Boost intervention, as they found teaching unfamiliar topics was a familiar task, and thus facilitating implementation, while their ability to control the classroom even when food fights occurred also showed to be important for implementation [Two papers had content in regard to the construct ‘ization’ , 33. Teaization’  while prentation , 36.process domain was ‘engagement’ (12 out of 14), followed by ‘executing’ (6 out of 14), ‘reflecting and evaluating’ (6 out of 14) and finally ‘planning’ (4 out of 14). Within ‘engaging’ papers referred most often to the sub-construct of external change agents, in particular, parents [opinion leaders [internal implementation leaders was another facilitator [champion for the success of implementation, identified to be someone from the school staff or an industry contact [The dominant construct of the  parents , 32, 35  parents , 35 comm parents . For ins parents  but also parents . One stu parents , while a parents , 29 ment leaders , 30, 34 ilitator . Finally contact , 35.executing’, the most common barrier identified was the delivery time, or altogether lack of delivery of the fruit and vegetables [Within the construct of ‘getables , 31, 36.getables , 31, 35.‘planning’, studies reported having a planning committee [In regard to ommittee  a scheduommittee  and a baommittee . Exampleommittee .reflecting and evaluating’, studies reported on formal evaluation results being fed back into the implementation of the intervention, [Finally, under the construct of ‘vention, , 36 but vention, , 34.children’s perceptions of value of the intervention and perception of personal behavior change due to the intervention. Although perceptions of behavior change from the perspective of teachers were presented as part of the ‘knowledge and beliefs’ construct, within the characteristics of individuals domain, the determination was made that this domain contains views of implementers rather than the target group. Thus, target group perceptions of behavior change could not be coded. Nonetheless, how the target group perceived changes to their behavior due to the intervention, in addition to their views on the content of the intervention , was highlighted as an important determinant of implementation by several papers, and thus, must be included [Through our review, we have come across texts which could not be coded under the current CFIR constructs, referring to one dominant theme – included , 31, 36.Participants perceptions of the free fruit and vegetable snacks: increased fruit and vegetable intake, tried new fruits and vegetables, changed fruit and vegetable preferences [ferences Students noted that the snacks helped prevent hunger if they skipped a meal or had lunch later in the day (…) appreciated the program because they felt it demonstrated that school staff cared about them [out them The pupils appreciated that the fruit and vegetable programme was for everyone and some pupils expressed that it became a habit to eat fruit and vegetable in class and that they affected each other’s eating habits [g habits We have taken the presented text reflecting perceptions of children as the primary target group as a facilitator (when children express positive perceptions) or barrier (when children express negative perceptions) to implementation.intervention characteristics domain: ‘design quality and packaging’, ‘adaptability’ and ‘cost’; 2) outer setting: ‘cosmopolitanism’, external policy and incentives’ and ‘patients’ needs and resources’; 3) inner setting: ‘implementation climate’, ‘readiness for implementation’ and ‘structural characteristics’; 4) characteristics of individuals: ‘individual stage of change’, ‘knowledge and beliefs about the intervention’ and finally of 5) process: ‘engaging’, ‘executing’ and ‘reflecting and evaluating’. The review stresses the dual role of parents as both supporting the implementation and targets of the intervention. Positive child perceptions of the value of the intervention and perceived behavior change due to the intervention were reported as relevant facilitators to implementation across several studies.This review highlights the importance of the following CFIR constructs, as determinants in the implementation of fruit and vegetables interventions in schools: 1) quality and variety of the fruit and vegetables is consistent with research looking at school level factors that may impact fruit and vegetables consumption in middle and high schools, where quality of fruit was significantly associated with a 44% increase in fruit consumption, and variety of vegetables in the form of salad bars with a 48% increase in vegetable consumption [adaptability in the context of our review was also found to be both a facilitator and barrier to implementation.The importance of sumption . Consistsumption , adaptabinner setting domain, the sub-constructs of compatibility, relative priority (implementation climate) and available resources (readiness for implementation), all point to the importance of teacher workload in regard to regular curriculum activities, and time pressures that teachers face when implementing fruit and vegetables interventions. This is consistent with findings on implementation of nutrition policies in schools generally, where training support and resources are found to be key facilitators while competing priorities and time consuming nature of implementing nutrition policies in schools are barriers [Within the barriers . The impbarriers , as wellbarriers .external change agents were found to have a dual role as supporters of implementation, but also secondary targets of the intervention. Consistent with our findings, Ismail and colleagues also highlight the importance of parental engagement for the success of school based dietary interventions [In the context of our review, parents, as ventions . Literatventions –44.intervention characteristics, and the construct ‘executing’ as part of the process; and, second, in lacking the prevalence of ‘complexity’ highlighted in Lobczowska and colleagues [One of the advantages of using CFIR for synthesis of results is that it enables comparison of findings across studies using the same framework . A recenlleagues . The reaHowever, CFIR is not without its shortcomings. It’s one-dimensionality, not only prevents a distinction of micro, meso and macro level factors, which other frameworks do offer , 47 but characteristics of individuals domain will reflect the perspectives of implementing actors only. The decision to do so was made after a thorough exploration of the domain and its constructs [characteristics of individuals domain would most adequately reflect the views and perceptions of implementers rather than the target group. The same process was followed when deciding to place the perceptions and views of parents in regard to the intervention, as well as parental behaviour change due to the intervention under the construct ‘engaging’. However, these were our choices, and a more thorough revision of CFIR may be needed to reflect the progress made in implementation science more widely.In the context of the current review, the authors did make the decision that constructs under the nstructs  and a superceptions of value of the intervention and perceptions of behavior change due to intervention by children as the primary target group. To the best of our knowledge, there is little input from literature up to date, emphasizing the importance of perceptions of value of an intervention, or perceptions of behavior change, by the target group, as a determinant of implementation. Although, the importance of children liking the fruit and vegetables intervention has been associated with the effect of the intervention reported on in both the Pro Children and PRO GREENS studies [Our decision to make a distinction between the views expressed by different actors relevant to implementation, also led us to introduce a new theme coded outside of CFIR, containing text that reflects the  studies , 53.perceptions of value and perceptions of behavior change. Further, neither ‘observability’, ‘attitude’ nor acceptability as such are included in CFIR. Thus, based on the current research, we would recommend a definition of ‘acceptability’ as an implementation determinant, which would be inclusive of concepts such as ‘observability’ and ‘attitudes’. This would be the closest we could identify to reflect our theme – perceptions of value of the intervention, and perceptions of behavior change due to the intervention. We would further recommend that any or all aforementioned concepts are defined in such a away, as to allow space for reflecting and clearly distinguishing the views of the target group, from those of implementing actors.Concepts close to the newly identified theme may be ‘observability’ and ‘attitude’, both of which could potentially link to ‘acceptability’. The concept of ‘observability’ –56 is deengaging’: key stakeholders and innovation participants. However, further consideration of actor roles, and specification of these constructs  are needed to guide reserachers when using the framework.Changes to CFIR in this direction may be upcoming, with latest (checked October 2021) references found in CFIR website  to a verThis paper has explored the determinants of implementation based on CFIR, that would be relevant to interventions providing fruit and vegetables in schools, as well as recommend possible amendments to the framework when applied to school settings, and in regard to direct provision interventions. However, there are several limitations to this research. Few of the included studies used an implementation framework to analyze their findings, thus the determination to place extracted text under each of the CFIR constructs was made by the authors, based on what the text segments implied as identified barriers or facilitators to implementation. CFIR poses the additional challenge, that it allows for double coding of text under its constructs. Although double coding was avoided by the authors, and decisions on placing text under each construct was performed on basis of consensus of at least two authors, other researchers may code the text differently. Finally, although CFIR does not make a distinction between target groups, it was our own decision to do so in the context of this work. The potential shortcomings may also be seen as its strengths. We have used a widely applied determinant framework from implementation science to synthesize results that now further offers the opportunity to compare findings on barriers and facilitators to implementation across studies from different fields. In doing so, we have highlighted which may be the most relevant constructs when looking at school based, direct provision of fruit and vegetables interventions, thus giving other researchers the opportunity to be more selective when conducting their own implementation evaluations of similar future interventions, in similar settings. Finally, we have identified ways in which CFIR can be revised and expanded, so as to keep up with the progress made in implementation science and be applicable to a variety of settings.Based on our findings, we propose the following recommendations:Use Fig. Consider the needs of different target groups during intervention design: children and parentsExplore acceptability of the intervention by all actors involved (in the implementation and as target groups): teachers, school administrators, children, parentsExplore what is possible and acceptable in regard to ‘design quality and packaging’ with teachers, target group(s) and those delivering the fruit and vegetablesConsidering the importance of ‘cosmopolitanism’ the relationship between those delivering the fruit and vegetables and those receiving it at the kindergarten/school deserves particular attention. Time and effort should be dedicated to establishing these relationships from the very beginning, and those relationships should be nurtured throughout implementation.We concluded that CFIR offers a systematic way to identify and organize barriers and facilitators to implementation of interventions in the kindergarten and school setting. Further, we have singled out the most relevant constructs Fig.  which idAdditional file 1. Documentation of literature search and data extraction and analysisAdditional file 2. Definitions and Coding ClarificationsAdditional file 3. Quality assessmentAdditional file 4. Quality assessment process notesAdditional file 5. Grid Overview tableAdditional file 6. Grid example