Advanced practice roles amongst Therapeutic Radiographers/Radiation Therapists (TR/RTTs) across Europe

• Autores: Celeste Margarida Gomes Marques de Oliveira
• Directores de la Tesis: Helen Anne McNair (dir. tes.), Ricardo Nyi Mynn Khine (dir. tes.)
• Lectura: En la Universidade de Vigo ( España ) en 2024
• Idioma: inglés
• Tribunal Calificador de la Tesis: Julie Michelle Nightingale (presid.), Diana Valverde Pérez (secret.), Jonathan Robert McConnell (voc.)
• Programa de doctorado: Programa de Doctorado en Biotecnología Avanzada por la Universidad de A Coruña y la Universidad de Vigo
• Materias:
  • Ciencias médicas
    • Ciencias clínicas
      • Radioterapia
• Enlaces
  • Tesis en acceso abierto en: Investigo
• Resumen

  • The healthcare challenges that Europe is facing highlight the need for informed policy making based on evidence. It has been estimated that, in 2040, 3.25 million new cancer cases will be diagnosed, and 1.63 million deaths will occur due to this disease across Europe. These statistics will cause pressure on healthcare systems, especially in oncology services. Radiation therapy (RT) is required in more than 50% of cancer patients, resulting in 40% of cancer cures, resulting in a high demand for this treatment modality. One in four patients who need RT do not receive it, and RT capacity will be insufficient by 2025. Therefore, a considerable gap exists between the actual and optimal utilisation of RT across European countries.

    As members of the multi-professional team (MPT) in RT departments, therapeutic radiographers/radiation therapists (TR/RTTs) collaborate with medical doctors (MDs), medical physicists (MPs), oncology nurses, and other healthcare professionals. TR/RTTs are vital members of the oncology workforce with the professional responsibility for delivering RT treatments, ensuring patient care, and performing pre-treatment procedures such as treatment planning and image acquisition. In some countries, TR/RTT is an independent profession; in others, it encompasses additional specialisms beyond RT, such as medical imaging and nuclear medicine. In the remaining countries, the TR/RTT profession has yet to be officially recognized, with no formal education programmes from higher education institutions or registration processes in place. The heterogeneity in the TR/RTT profession contributes to the variation in RT quality standards across countries.

    Currently, RT is characterised by great complexity of technology and techniques, and the role of the TR/RTT and its associated level of responsibility is continually evolving and expanding. Therefore, advanced TR/RTTs are highly specialised professionals that practise at an advanced level with a pivotal role in the patient journey, from the referral, treatment coordination, follow-up, and liaison with the oncology team. Advanced practitioners (APs), experienced healthcare professionals with additional education, operate within the framework of the four AP pillars: clinical practice, leadership and management, education, and research. In the field of RT, APs spearhead the adoption of new treatment techniques, overseeing their implementation locally, educating both professionals and patients, and advocating for evidence-based practices. Whilst acknowledging that there are differences in the profession across countries, this study aims to provide a European landscape of these APs due to the European-wide market where TR/RTTs can practice in a different country from the country they trained.

    This research aims to explore advanced practice (AP) in RT and examine educational needs to underpin this level of practice among TR/RTTs across Europe. Therefore, the following research questions were considered during the three phases of this research:

    - What are the AP roles in RT? Which are the associated advanced activities? - What impact does this level of practice have on clinical, organisational, and professional outcomes? - How is AP level implemented in current practice across Europe? - Are there educational or training gaps in AP for TR/RTTs? - What is the current profile of APs in RT? Does the profile include the four AP pillars in current practice and education programmes? - What are the challenges to AP implementation and sustainability? - Which advanced skills and capabilities can enhance the work across all pillars? - What will be the future AP roles in RT? In phase I, a systematic literature review was conducted to synthesize the published evidence regarding AP roles in RT. This included characterizing the scope of practice concerning clinical practice areas and associated advanced activities. This literature review followed the Preferred Reporting Items for Systematic and Meta-Analyses protocol (PRISMA), with a three-part search strategy using the Population, Intervention, Comparison and Outcomes (PICO) framework, omitting the comparison (standard practice). TR/RTTs professionals and the RT field were the population; AP or APs were the intervention; and level of practice or roles were the outcomes. Several electronic databases were used: three major health-specific databases, one education-specific database, and two multidisciplinary databases. A hand search of RT key peer-reviewed journals and a literature review snowballing was conducted. The systematic search was performed by two independent reviewers and, the first reviewer exported citations to reference management software. All selected and in-doubt articles were checked independently by two other reviewers.

    This comprehensive review, which included studies (n=87) with a focus on AP of TR/RTTs reported in peer-reviewed articles, provided an overview of the evolution, development, and implementation of AP roles in RT within the practice of TR/RTTs globally. The data from these studies was extracted and synthesised using Excel and thematically analysed using NVivo. Studies were clustered into four groups according to focus: Role evaluation and development, Task congruence,Role implementation and stakeholders insights, and Educational programmes. The thematic analysis aggregated all reported advanced activities from AP roles into seven dimensions and 27 sub-dimensions. Also, advanced TR/RTTs were characterised by clinical practice area or disease site-specific role or scope of practice. The resulting list of reported AP roles and advanced activities was validated and reorganised by an RT expert panel from the SAFE EUROPE consortium representing different European countries and areas of RT. The most studied AP site-specific role was breast cancer, reporting activities such as target delineation and comprehensive care with psychosocial interventions. The most investigated AP clinical area was palliative care, describing activities such as referral and triage, patient assessment and screening, treatment prescription, support with continuity of care, and liaison with palliative care teams. Also, a summary of the existing evidence on the impact of this level of practice on RT was categorised by clinical, organisational, and professional significance with associated impact indicators and metrics based on the Gerrish et al. (2013) toolkit adapted by Snaith et al. (2018). The three most reported AP outcomes were enhanced service capacity, higher patient satisfaction, and safety maintenance. In this review, education and training for AP in RT varied considerably and were often not described. Therefore, no robust published evidence exists about standardised AP programmes at the master's degree level. This gap denotes non-strategic educational pathways at national levels, directly affecting the standardisation of AP roles, regulation, and protection for APs and patients.

    In phase II, a cross-sectional study using an anonymous survey examined AP roles in TR/RTTs' practice regarding regulation, governance, education, and training support to identify any educational and training gaps to underpin this advanced-level practice in the European setting. The survey was developed and distributed online to TR/RTTs working in European countries at AP (official or informal). The tool was designed using previous research findings triangulated with grey literature. It was a three-section survey including one section divided into two sub-parts to capture formal and informal AP. The online survey, designed in English using Microsoft Forms, included closed and open questions. An external pre-test validated the survey with RT experts from the SAFE EUROPE consortium and piloted with an external group of APs or TR/RTTs working in AP roles to perform the reliability test in the two survey versions. Two weeks apart, the same TR/RTTs performed the test-retest to check if the survey produced similar results in different circumstances. This group of TR/RTTs represented different European working countries, several areas of RT professional practice, with varying years of professional practice. Convenience sampling used multiple strategies to maximise the dissemination of the survey, including collaboration with national professional organisations and a European-wide professional organisation. The quantitative data was analysed using Excel and IBM SPSS for descriptive statistics and the qualitative data was exported to NVivo for thematic analysis. Survey data was analysed separately, triangulated, and interpreted.

    Eligible survey participants (n=189) from 21 European countries self-reported their professional profile: 57% were TR/RTTs working in AP role(s) without recognition as APs; 31% were APs in RT; 9% were undecided about the definition of their current level of working practice; and 3% were practitioners who considered working at a different level of practice (other definition). The participants had a median of 13 years of professional experience as TR/RTT and six years of professional experience in AP. The most common AP roles were disease site-specific roles, such as prostate and breast, and in clinical areas of practice, such as palliative care and practice development. Of the 27 listed advanced activities, the most common were the activities associated with image-guided RT/ adaptive RT (IGRT/ART), tasks regarding patient information and patient assessment. Job titles were varied and inconsistent both within and across countries, even in the APs group with some practitioners presenting multiple role titles. Most survey respondents (75%) had a job description for their current post, but a job plan was available only in 32% of APs. Focus on clinical practice was detected by mapping the percentage of working time by each AP pillar per respondent. 42% of respondents acknowledged the existence of minimum requirements of additional education to undertake AP roles at the local or national level; masters degree or master module were the most cited. One in four respondents recognised a minimum number of practice years required to perform AP roles in their departments; five years was the most reported number of required years. Only 32% of professionals responded that their AP is regulated by a professional society or regulatory body at the national level or by formal agreement at the local level for the practice of advanced activities in RT departments. Most APs stated that their AP posts had permanent funding, contrary to the TR/RTTs working in AP roles without recognition as APs, with a minority (14%) having financial compensation in the remuneration. 47% of respondents were involved in developing or implementing the AP role in the department with the main driver of new technologies or techniques implementation. Almost one in four participants (24%) indicated their AP role or advanced activity was evaluated. Appraisals were performed mainly through process evaluation, competence and capability assessment, and annual reports. 47% of TR/RTTs reported that their AP roles had demonstrated impact, namely through the following indicators: quality initiatives, patient and professional satisfaction, innovations, and time savings. Respondents with no AP role appraisal or impact assessment in their departments justified it mainly by organisational and professional issues, such as limited staff resources, lack of dedicated time, and departmental culture. The top three areas of knowledge appointed as necessary to improve current AP roles were IGRT/ART, multimodal imaging and technologies, and advanced treatment planning. Leadership, management, and tumour-specific or technique-dependent roles expertise were the top identified training needs to develop AP roles. 63% of respondents considered that new AP roles will emerge to meet future service needs in their countries. Some appointed future roles were associated with research, education, and management areas. Most TR/RTTs (52%) consider that there exist gaps in education and training for AP roles in their regions or countries.

    In phase III, a descriptive study ends the explanatory sequential multiphase of mix-method design with a qualitative interview to provide insights into the perceptions and experiences of key stakeholders across Europe about AP roles in RT. A range of stakeholders, including practitioners, educators, employers, students, regulators, and professional body representatives, were recruited to participate in this study. The interview guide was informed by the findings from previous phases with adaptation for each stakeholder group. The guide focused on the current and future AP roles in RT practice and current AP or RT-specific masters programmes from the perspective of the four AP pillars. The interview guide for practitioners was tested in two pilot interviews. A purposive sampling was performed, and the recruitment of participants used different strategies according to the stakeholder group being the sampling approach revisited throughout the study to ensure a reasonable representation across stakeholder groups. Participants (n=33), individuals working or studying in 16 European countries, were interviewed by the PhD researcher using TEAMS, in the English language, with audio and video recording. All transcriptions were audio-based, and full verbatim of the interviews content was independently transcribed and checked by the interviewer and interviewees using the positivist method of member checking. Braun and Clarke (2013)s seven steps guided the thematic analysis of the interview transcriptions to draw out the main themes and subthemes using NVivo. PhD researcher coded all the interviews transcriptions, and the other three researchers independently coded for cross-coding.

    After triangulation four overarching and interlinked themes emerged: AP drivers and outcomes,AP challenges vs enablers, current vs future AP, and becoming and being advanced practitioner. The theme AP drivers and outcomes denoted the rationale for AP roles in RT and related the AP drivers with the outcomes related to AP impact being the perceptions categorised according to their significance: clinical, professional, and organisational. The theme AP challenges vs enablers identified the challenges in implementing and maintaining AP roles and reported the enablers through the reported personal experiences of successful AP journeys, being categorised by four subthemes: governance and role development, workforce and organisation, practice across all pillars, and education & training. The theme current vs future AP described the past and current AP roles and the perspectives on future AP roles categorised by AP pillar. The theme becoming & being advanced practitioner explored the educational background and training maintenance to support advanced TR/RTTs, revealing common ground between the practitioners on becoming advanced practitioners being schematised in four stages, which co-occur in no particular order and feed back into each other to maintain the TR/RTT as an advanced practitioner: development of competence and capability, professional maturity, challenging professional boundaries, and pioneering innovation.

    This multiphase research increased the body of knowledge about AP in RT, with a European-wide perspective. A list of AP roles and advanced activities was identified in the literature and validated by a group of experts, and this list was updated with survey and interview data. It has been proven that AP roles among TR/RTTs enhance patient-focused care and streamline palliative care; in organisations optimise the capacity of the RT service, improve the use of existing resources, and maintain safety; in profession raises autonomy and job satisfaction of TR/RTTs and MPT members for improved time efficiency. From phase II and III findings, evidence shows that European countries were in different phases of AP implementation in RT. Some countries have had official AP roles implemented for several years, but in other countries AP roles are not official, being the performance of advanced activities protected by local agreements. Participants reported educational and training gaps for APs in RT due to several and varied reasons at the local, national, and international levels. The survey shows two current main profiles of professionals among TR/RTTs working in AP roles in European countries. Both profiles (advanced practitioner and advanced TR/RTT without recognition) work under a mixed bag of job titles. In both groups, it was found that their working time has a significant focus on the clinical practice pillar, neglecting the other three AP pillars. Regarding AP masters degrees, it was realised from the academic representatives and students interviewed in phase III that there exist masters programmes that cover the content needed to develop the skills and capabilities for students to become experts in the four pillars. However, some RT-specific AP masters programmes do not include leadership and management content. Regarding the AP challenges, in terms of governance, Europe needs more AP-level standardisation in RT, consistency of job titles and updated job descriptions for each level of practice. In terms of role development, some European countries face informal AP associated with unpaid advanced activities, no AP requirements in terms of educational and practice background, no options, or minimal opportunities for career progression among TR/RTTs, lack of AP evaluation or no impact assessment of AP roles, and ad hoc AP roles developed by service needs without national regulation. In the organisations, the challenges remain attached to the lack of AP roles understanding by the healthcare professionals, limited support from regulators, employers, and MPT members, the persistent professional boundaries that hinder the task shifting within the MPT, the institutional barriers and resistance to change, the professional isolation of advanced TR/RTT. Europe faces current healthcare staff shortages, namely in the TR/RTTs recruitment and retention, due to workload pressures, stressful work from the oncology setting, lack of staff motivation and low morale. The practice across all pillars is challenged due to a lack of agreed understanding of the pillars importance among stakeholders, non-existent job planning, no available staff for AP roles due to workload, no time allocation for education roles, departmental research barriers, and the persistent prioritisation of service clinical demands. Regarding education and training, Europe faces educational challenges due to the discrepancy between educational models to qualify TR/RTTs across countries and even within the same country. The lack of protected time for TR/RTT to undertake additional training, and the limited funding for AP education for TR/RTTs who want to progress in their career is a reality across many European countries such as the non-existent accreditation of AP pathways to recognise advanced TR/RTTs. Many countries do not have RT-specific masters degrees, and many departments have limited mentorship or supervision at the workplace and no CPD framework at the national level to support professionals in their careers. Stakeholders appointed several skills and capabilities for APs in RT, which were categorised by AP pillar, including also soft and hard skills for the high professionalism of APs in RT. Since the nature of the AP concept is dynamic, it was relevant to investigate the future AP roles in RT. According to participants, the site-specific roles will evolve, including activities such as new patient clinic acceptance, and the technique-specific roles will develop according to the technology innovation, being adapters a common role in the treatment units. Trends will be fast-tracking for palliative RT, care (or case) manager, research, and development roles, including experts in artificial intelligence to assist the MPT.

    The findings from this multiphase research have led to recommendations to address many of the identified challenges, listed by subthemes based on the enablers reported in the interviews triangulated with the literature. The growing body of evidence of AP roles and associated activities performed by advanced TR/RTTs illustrate the main areas that could be used to support academic or professional bodies, to conceptualise AP level and implement AP roles in RT with the assurance of the four AP pillars. The education and training gaps found in this research guided lecture plan design addressed in the RT webinar series of the SAFE EUROPE project, which promoted role development boosting AP awareness and understanding among TR/RTTs and other professionals. As the first large-scale research of current AP in RT across Europe, the findings highlight significant issues in the practice and education of TR/RTTs. Several challenges and barriers exist in the governance structure and role regulation to support this level. The creation or adaptation of educational programmes should be prioritised for the existing educational gaps in European countries and the training needs. Continuous updates of TR/RTTs curriculum aligned with current and future practice are crucial, as the harmonisation of the professional curriculum in the standard and advanced scope of practice positively impacts patient care.