Advanced practice perspectives in radiation therapy

Journal of Radiotherapy in Practice

Journal of Radiotherapy in Practice 2004 4, 57–65 © Cambridge University Press, 2005

Original Article

Advanced practice perspectives in radiation therapy A. Bolderston Princess Margaret Hospital, University Health Network,Toronto, Ontario

Abstract Roles for radiation therapists are currently in a period of rapid global change. Technological advancement, increased entry-level education and the growing specialisation and professionalisation of many non-physician clinician groups are all significant drivers for change. There has been considerable interest in the Province of Ontario in “advanced practice” roles for therapists. This literature review identifies some of the background issues involved from a local and global perspective.

Keywords Role extension; role development; international; radiotherapy

INTRODUCTION There is no doubt that radiation therapists today are pushing the boundaries of their profession. In a few years we have seen technological advances in treatment machines leading to conformal, intensity modulated and high-dose treatment. A therapist working in planning may need skills in computerised tomography (CT) such as crosssectional anatomy to delineate critical structures, positron emission tomography (PET) imaging for co-registered CT-PET planning and even ultrasonography for departments performing prostate implants. Patient care roles (such as weekly review clinics, specialist patient education positions and palliative care) as well as research skills are also becoming increasingly important. There is also an increasing demand for therapists’ professional skills. As cancer incidence grows1 so

Correspondence to: A. Bolderston MRT(T), MSc, Clinical Education Manager, Radiation Medicine Program, Princess Margaret Hospital, University Health Network, 610 University Avenue, Toronto, Ontario M5G 2M9, Canada. E-mail: [email protected]

does the demand for radiotherapy services. In many parts of the world chronic staff shortages place a mounting emphasis on radiotherapy recruitment and retention. While steps have been taken to recruit additional therapists, increase intake numbers at training establishments and address wage concerns, less effort has been made to provide expanded career opportunities and enrich the work environment.2 Staff satisfaction surveys consistently reveal dissatisfaction with professional advancement opportunities, poor relationships with medical staff and a desire for increasing autonomy.3–7 Thus the move towards an enhanced or advanced practice role for radiation therapists is based in part on technological advancements but also political and societal trends. This literature review examines some of the factors influencing the professional move towards advanced practice in Ontario, Canada and the rest of the world. In addition, advanced practice is intrinsically linked with many other professional, personal and political issues such as the development of expertise, job modeling and the general trend upwards in radiography entry-level standards.

Journal of Radiotherapy in Practice Vol.4 Nos.2–3 © Cambridge University Press, 2005

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Advanced practice perspectives in radiation therapy

Gradient from subordination to autonomy Supervision → Delegation → Collaboration Physician involvement mandated Adjunctive clinical roles Primary care services Case management Patient education Physician reimbursement

Nurse practitioners & physician assistants

Independent practice Expanded scope of practice Prescriptive privileges Deferral of tasks by physicians Referral of patients to npcs Independent reimbursement

Figure 1. Moving from subordination to autonomy for health professions.8

As this is relatively new field of enquiry, there is little background literature specifically related to the subject of Ontario (or Canadian) therapists’ advancing practice. However the impetus for advanced roles for radiation therapists has been partly due to the development in this area by the nursing profession. Other health care professions are also attempting to expand their traditional roles, with varying degrees of success. Where relevant, issues arising from other areas of practice are discussed. An additional rich source of information is the recent rapid expansion of diagnostic and therapeutic radiography roles in the United Kingdom (UK). Some information is also presented from the United States (US), Australia and other radiation therapy communities.

CHANGES IN THE HEALTH CARE WORKFORCE Professionalisation and collaborative practice An emerging trend in many countries is the drive for professionalisation by numerous occupations. This often takes the form of seeking self-regulation, developing exclusive scopes of practice and defining entry to practice qualifications. Cooper8 has shown that this push for specialisation is part of an established path for many of the health professions (see Figure 1). While professionally there would seem to be many advantages to professionalisation, there are also drawbacks such as inter-professional turf battles and inefficient use of personnel.9 New professions are constantly emerging, but established professions may also splinter and divide.10 For example, the professions of Medical 58

Optometrists Nurse anaesthetists Podiatrists

Clinical nurse specialists

PHYSICIANS Psychologists Clin. social workers Psychiatric nurses Counsellors/Therapists

Pharmacists

Acupuncturists Primary care Nurses practitioners Nursemidwives Physician assistants

Naturopaths

Chiropractors

Figure 2. Overlapping scopes of practice for non-physician clinicians.8

Resonance Imaging technologist and Ultrasonographer have emerged in parallel with the development of new imaging equipment but they are also “offshoots” of the diagnostic radiography profession. As a consequence, the ratio of these “non-physician clinicians” (NPCs) to medical personnel continues to rise (see Figure 2). In the US the shift to NPCs has been driven to a large extent by economic factors such as managed health care11,12 and the non-physician provider in an oncology/radiotherapy setting is usually a nurse practitioner (NP), clinical nurse specialist (CNS) or a physician assistant (also a nursing role).These practitioners usually work in collaboration and under the supervision of physicians. Interestingly, a study revealed that a small number of these practitioners independently write and sign treatment prescriptions, participate in dosimetry (with supervision) and verify patient set-ups, thus performing the traditional roles of the radiation therapist.13 These roles have been found to have a high level of acceptance by patients (as well as medical colleagues who can subsequently increase their caseload). NPCs face markedly increased responsibility and the role often necessitates a closer working relationship with physicians and other health care personnel. Collaborative practice (working in a cooperative, team-based and less hierarchical structure) is theoretically more patient-focused as all members of the team contribute their professional services and scopes-of-practice may be blurred. Collaborative or multidisciplinary practice is often



cited as the best model for contemporary patient care.14 Barriers to a more collaborative model of practice include “tradition and professionalism and progressive concern about practice boundaries”.15 Teams whose members believe their goals are aligned are more effective and exhibit less interdisciplinary conflict. In addition, members are more satisfied when they feel their skills are valued and remunerated appropriately. Bush and Watters16 described a collaborative team model as one that values professional expertise and supports areas of practice overlap resulting in an atmosphere of cooperation and communication.

Increased entry-level education In the last decade several countries (such as Australia, Norway, Israel, Hong Kong and the UK) have introduced a baccalaureate degree standard as the entrylevel requirement for radiation therapy.17 In Canada, the Canadian Association of Medical Radiation Technologists (CAMRT) has supported a degree requirement to practice for radiographers in all provinces from 2005.18 Graduate therapists are entering the profession with skills and expectations that may be different from those of diplomate professionals, including higher levels of professional judgement, critical thinking and decision making and thus are possibly better able to adapt to the rapidly evolving world of their chosen profession.19 A higher entry educational level has been strongly correlated to increased professionalism, clinical autonomy and credibility as well as subsequent participation in research and continuing education activities.18 Role upgrading by nurses, radiographers and pharmacists in the UK has been explicitly linked to increased entry-level requirements as well as a shift from hospital-based training to university-based schemes.20 However, two major professional regulatory bodies, the American Registry of Radiological Technicians (ARRT) and the College of Medical Radiation Technologists of Ontario (CMRTO), have recently countered this view.The ARRT conducted six studies over the course of two years and subsequently announced that a baccalaureate degree was not necessary for entry-level certification in radiation therapy.21 This was contrary to the position taken by the professions’ membership society, the American Society of Radiologic Technologists (ASRT), who have been strongly advocating for a radiotherapy degree program. Taking a similar

position, the CMRTO have recently questioned the need for a degree for entry-level practice that has been recommended by the CAMRT, citing: “The link is not self-evident between the competencies needed to practice medical radiation technology and the general education requirements of a degree”.22 Both the CMRTO and the ARRT claim that raising the bar for entry-level practice will exacerbate current staff shortages.The CMRTO contend that there may be a degree of hesitation from its members about the move to a degree, demonstrated in a survey of all college members. It is worth mentioning that of the members questioned, radiation therapists felt the most positive about the degree initiative with 51% believing that it would have a positive impact on their profession.

Examples of advance practice roles Nursing “A nurse who is an advanced practitioner will have advanced academic preparation and advanced clinical skills”.23 The American Nursing Association/Oncology Nursing Society (ONS) have defined Advanced Oncology Nursing Practice as “expert competency and leadership in the provision of care to individuals with an actual or potential diagnosis of cancer”.24 The basic requirement for advanced nursing practice is a Master’s degree. The ONS further defines four advanced practice roles, the CNS, Educator, Researcher and Administrator. There are extensive professional practice standards associated with all four roles.The CNS is perhaps the closest model for an advanced position for therapists and includes medication prescription, physical examinations, psychosocial support and patient education.

Radiography The US recently introduced a radiography advanced practitioner in the form of the radiologic assistant. This role has been created to improve departmental (and radiologist) productivity, patient care and patient access to imaging services (there is currently no equivalent position in


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radiation therapy).The role includes patient assessment and responsibility for expanded radiology procedures.25 The ARRT are currently in discussion with the member society, the ASRT about the possibility of developing a radiotherapy advanced practice level. The “Skills Mix Project in Radiography” (fourtier system) is a government-driven initiative in the UK that has developed several new roles.There are two “advanced” roles above the level of stateregistered radiographer, the advanced practitioner and the consultant.The advanced practitioner works autonomously in a specific area of expert clinical practice underpinned with appropriate education. The consultant role is associated with a higher level of professional development (up to a PhD) and provides clinical leadership in addition to specialist and expert clinical skills.The model has also introduced an assistant role below the level of state-registered radiographer.This position involves the completion of an accredited training course.The qualified assistant can care for and treat patients under the direct supervision of a state registered radiographer. All four-tiers of the UK model are associated with clinical practice and the project has four aims: 1. In a radiotherapy team, roles are assigned according to the individual’s skills and competencies rather than their profession. 2. Advanced roles are promoted to encourage life long learning. 3. Routes to enter the profession are widened to improve recruitment and retention. 4. Practice standards are developed as well as professionals’ inherent potential.26 In Canada there has also been a recent groundswell of interest in advanced practice. One of the major cancer centres in Toronto has introduced a new practice model for radiation therapists that aims to increase therapist involvement in research, education, quality assurance and standard setting by integrating clinical practice and other roles.2 In other centres, therapists are working in what might be deemed “advanced” positions in a more informal manner. There is currently no formal educational component associated with advanced roles in Canada (or indeed any standard definition of “advanced practice”). The CAMRT have an Advanced Certification program which aims “to 60

stimulate members to further their studies and to broaden their understanding of the art and science of the radiation technologies”.27 The program consists of a mixture of self-directed education and course work.There are no specific job roles associated with the CAMRT Advanced Certification, although some departments (and union agreements) match promotional opportunities and increased remuneration with the certificate.

Assistant roles Expanding the “top” of the profession is often accompanied by the introduction of assistant roles to take over routine tasks (with varying levels of supervision).This has been the case in nursing for many years, and in most countries the profession has a “nursing aide” type role below that of board registration (or equivalent). In the UK, the assistant practitioners’ role has been implemented to backfill positions left vacant by advancing roles. In turn this has led to the creation of a new career structure and pay scale.28 Roles for assistants can be wide ranging. In the United States (specifically in states such as Florida and California) assistants perform patient care functions; tackle paperwork and treat patients under the supervision of a registered radiation therapist.29 In remote areas of northern Ontario, there is a limited diagnostic “technician” class of worker in the Aboriginal/First Nations community (the Limited Practice Practitioner or Basic Radiological Technician). These technicians are graduates of a training program and work under the supervision of a registered radiographer, but can take X-rays independently. The introduction of “lower grades of staff ” has raised concerns that the subsequent redistribution of labour is driven by an imperative to trim budgets rather than other issues such as the desire to advance professional practice.30

THEORETICAL UNDERPINNING Issues of medical dominance Non-medical professionals seeking advanced or expanded roles can often upset the traditional balance or power relationship with their physician



colleagues.This is particularly true if the previous relationship was historically based on a professional hierarchy.

resentments and may be perceived as a lack of respect for the techs by the doctors”.38

The therapist-radiation oncologist relationship is similar to the traditional nurse-physician relationship. This has been extensively analysed, as nurses seek to push the envelope of their professional practice they also seek more ways to work in harmony with their physician colleagues.31 Like radiation therapists, the majority of nurses are female and as most physicians are typically male, this has resulted historically in a “caste-like relationship of nurses and physicians”.32 In the past, autonomous practice, including critical thinking has not been encouraged in nurses who instead functioned in a modified parent-child relationship with physicians and acted in a subservient role rather than developing their own professional practice.32 This attitude has also been noted in the field of radiography. Radiographers are sometimes seen as “passive technicians, implementing the designs of others”.33 In radiotherapy, the doctor has legal responsibility for prescribing and (in most countries) “supervising” the treatment (and, by extension, the therapists who deliver the treatment as the doctor is in effect supervising their work). This is supported by a recent study investigating the impact of university and workplace cultures on lifelong learning in radiographers.34 One of the respondents commented, “many radiologists will still require radiographers who are willing to work under their direction”.34 The study found medical dominance was still a significant barrier to professional development.

Concept of “expert” The concept of “advanced” practice relies on the assumption that therapists can progress to a level of expert practice, enabling them to take up the greater job tasks or responsibilities. While there is little literature on the development of expert radiation therapists, there has been considerable research in this area from our nursing colleagues.

In addition, studies examining nurses’ job satisfaction consistently cite poor nurse-physician relationships to be one of the greatest sources of stress.35–37 This interdisciplinary discord has also been demonstrated in similar studies with therapists. Three studies from the USA indicated that poor relationships with medical staff were a significant factor in minimising job satisfaction for therapists.3–5 A more recent Canadian study also identified frustration with radiation oncologists to be an issue decreasing job satisfaction; this was especially true in Ontario.6 This often stems from the lack of control therapists have over many parts of their work lives: “Technologists may feel discounted and overruled by the decision of a physician. This can lead to deep

Various models for developing expertise can be found in the literature, for example the four-stage model of developing clinical expertise and the cognitive continuum theory.39 However, one that perhaps closely parallels therapists’ experience is the modified Dreyfus model of skill acquisition described by Benner.40 Benner analysed nurses’ expertise and identified five distinct stages of proficiency. These stages are novice, advanced beginner, competent, proficient and expert. According to her model the expert nurse possesses three aspects of skilled performance: 1. The nurse has an intuitive grasp of a situation based on her clinical experience and knowledge. This concept is perhaps similar to Schön’s41 idea of “knowing-in-action” where a practitioner uses tacit (or implicit) knowledge gathered through experience to solve everyday problems.This is seen every day in a radiotherapy department where experienced therapists can often intuitively assess and correct a difficult treatment. 2. The nurse expert can assess a situation and focus on the most important clinical aspects. Benner calls this “pattern recognition” and comments that this is particularly important in oncology nursing where subtle symptoms may indicate serious problems such as spinal cord compression. Again, this has obvious parallels with a therapist’s practice. 3. The expert nurse is involved in the situation, rather than apart from it.This is counter to the theory that nurses need to maintain a certain distance from patients to deliver the best care. Benner argues that involvement leads to deeper relationships with patients and a higher likelihood of noting a physical or emotional change


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in the patient, which may indicate progression in their disease. In a radiotherapy department, the relationship that develops with the therapist can often be very meaningful to the patient and can lead to a very individualised approach. This model has been criticised for not being “scientific” enough.42 In some respects this judgement is levelled because the model relies on “clinical and practice knowledge which has for so long been seen as inferior to theory”.43 Another criticism directed at this model is that practitioners rarely perform at the same level for all tasks; a therapist who is an expert in one area may perform as a novice in another.39 This assessment is somewhat valid; however, individuals function across a continuum of knowledge, skill and judgement. It would be a mistake to apply any model too rigidly. This model needs to be investigated further in regard to the development of an “expert” therapist but implies that we cannot define a therapist in terms of competencies or purely cognitive/psychomotor abilities that can be easily taught. It is clear that the “expert” or advanced practitioner is a complex mix of clinical and tacit knowledge, professional confidence and many other characteristics.

Job models and job satisfaction The subject of advanced practice for therapists leads to an analysis of how we model our current therapy positions and how an advanced role would be managed in an organisational development context.

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fied. Psychologists such as Maslow,46 Herzberg47 and Alderfer48 have postulated that work needs to fulfil these higher-order needs. These needs have been called “self-actualisation” (Maslow), “motivational factors” such as achievement at work, advancement and responsibility (Herzberg) and simply “growth needs” (Alderfer). What all these models have in common is that the higher needs relate to using one’s skills to the fullest and the achievement of personal growth.While these models have been criticised for being simplistic and difficult to apply to many job situations49 they all demonstrate that a job needs to satisfy more than the need for money. A job needs to supply the opportunity for personal growth and self-esteem. From the 1950s onwards the “Quality of Work Life” movement has gradually replaced Taylorist approaches to job design in many places. This movement developed various methods of “humanising” the work place and increasing satisfaction. Both job rotation and enlargement add variety to a job by adding to the employee’s responsibilities. Job enrichment, on the other hand, provides depth to a job by adding additional motivators and attempts to satisfy the higher-order needs. In this approach employees are given more control and discretion over how their job is performed. It is important to note that not all employees will choose an enriched job if they have a choice, some people will always prefer the routine and simplicity of unenriched jobs.50 Five core dimensions have been identified in job enrichment:

One of the earliest job models is “Taylorism” (or “scientific management”). This approach has been used in offices, call centres, the food service industry and many other places. “Taylorism” has come to mean the division of labour into small subcomponents with the subsequent separation of “knowledge or conceptual work from the execution of the tasks”.44 This model is very efficient, tasks are completed quickly and training can be minimal but it can lead to boring and repetitive work.45

1. Skill variety – the job uses a high range of skills. 2. Task identity – the employee can perform a complete section of the work and so feels a sense of responsibility for the final product. 3. Task significance – the employee feels the job has intrinsic worth and is important for the organisation/society. 4. Autonomy – the employee has some control over their work and input into related decisions. 5. Feedback – the employee receives appropriate assessment and critique of their performance.51

With the scientific management approach socalled “higher-order” needs are also often unsatis-

Since the 1980s team-based approaches have played a large part in new organisational development



strategies. These “high-performance work systems” have extended the concept of increasing worker autonomy to the group or team in an attempt to increase organisational flexibility.49 These trends influence the way we look at the roles and responsibilities of the radiation therapist whose jobs are often a combination of systems. Therapists work within teams who manage a daily workload and are frequently self-managed to a certain extent. In this way they might emulate a “highperformance work system”.The job is sub-divided (depending on the size of the department) and several individuals/groups will be responsible for moving the patient from their first appointment in planning to their final treatment many weeks later. This work practice could be deemed Taylorist in that all participants are producing a small part of a whole “product” (a treated patient).Therapists’ roles are flexible in that they can move between different “work stations” (e.g. from planning/dosimetry to a treatment machine). However, in today’s environment it is increasingly difficult to keep all skill sets current thus any transition may involve a certain amount of retraining/upgrading. This fits with the Taylorist approach, productivity is higher if people are specialised but the benefits of rotation (job enrichment) are also important. Thus in a typical radiation therapy department staff scheduling is a balance between keeping experience where it is needed but allowing work to remain interesting and challenging by moving people periodically. An advanced role would lose some of this inherent flexibility, although the therapist would develop expertise in areas of practice that have been previously relatively unexplored. From this analysis we can see that an advanced practice role would fit most of the criteria of an enriched job. The role would involve increased autonomy, task significance and identity and the therapist would be using a wider range of skills than those utilised in a routine treatment position. The missing piece, feedback, would have to be provided by the organisation.This could involve the use of mentors, or structured support sessions with appropriate recommendations for improvement or change.

health care environment such as the move to collaborative practice and a general shift towards increased professionalism have raised expectations of greater responsibility and flexibility of practice. At the same time educational standards have changed and degree qualification has levelled the playing field somewhat between therapists and their nurse and physician co-workers. Advanced roles for therapists have been successful in several countries and are currently evolving in Ontario in line with some of these international models. The development of advanced practitioners happens within (often unarticulated) historical, organisational and sociological paradigms. These include the lingering influence of medical dominance in radiation therapy departments. The development of the therapist from novice to expert must also be considered. Research in this area would be helpful to allow us to map the pathway to excellence and identify some of the stages and signs along the way. Finally, administrators planning to introduce advanced roles need to reflect on how they fit within the department as an enriched job and how this might link with the rest of their organisational structure.

Acknowledgement This work forms part of an MSc project in Therapeutic Radiography and is published with the permission of Anglia Polytechnic University, United Kingdom.

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CONCLUSION

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