Proffered papers

Cynthia Cowling, Australia – A comparative ethnographic analysis of the sociological practice of radiography in seven countries, related to advanced practice.

In 2008, M. Hardy et al. aspired to develop a global standard of advanced practice in radiography. In 2015, as part of a global study, ethnographic fieldwork was carried out in seven countries representing a wide variety of socio economic and socio cultural environments and work places (UK, USA, India, Trinidad and Tobago, Taiwan, Australia and UAE). Research questions asked were what socio economic and cultural factors impact the sociological practice of radiography and how do these factors affect the achievement of professional autonomy.

Data was collected from semi- structured interviews, participant observation and relevant documents. A reflective journal provided an opportunity for the insider researcher to consider experiences from the point of view of a radiographer. Initial manual transcription and coding of data was followed by an iterative, inductive and deductive process of thematic analysis where core themes were developed. Dominant themes that emerged related to the work of the radiographer, the role of the radiographer, the impact of technology, intra and inter professional relationships and country culture effects.

Preliminary findings indicate that both work culture and country culture have a profound effect on the role of the radiographer, the ability and interest of the practitioner to achieve full autonomy and expansion or extension to their scope of practice, even the perception of autonomy and what constitutes advanced practice. Presentation

Hardy, M., et al., The concept of advanced radiographic practice: An international perspective. Radiography, 2008. 14, Supplement 1(0). p. e15-e19

Karen Coleman, New Zealand – Establishing Advanced Practice in New Zealand for Medical Imaging and Radiation Therapy. The results of New Zealand surveys

Overview
This presentation will highlight the main findings from New Zealand surveys of Medical Radiation Technologists/Radiation Therapists (MRT/RTs). There will be discussion and recommendations of a potential way forward for the profession that allows flexibility with respect to the diversity of clinical areas of expertise and perceived need in departments across the country, and also in supporting academic structures within New Zealand universities.

Method/Results
Electronic surveys were distributed to senior MRTs in large hospitals and private practices, across a range of specialisations, and to all radiation therapists in New Zealand, to gain feedback on potential advanced practice profiles and criteria. The perceived advantages and barriers of implementing advanced practice were also explored.

Results indicated that there is significant support within medical imaging and radiation therapy departments in New Zealand for formalised Advanced Practice roles. A diverse range of perceived advantages for the profession were identified, however many in the profession expressed concerns around accountability, acknowledgment and support.

MRTs supported the implementation of AP roles in New Zealand and the requirement of a Master’s degree qualification to underpin clinical knowledge.

Future Development
The authors recommend the development of one scope of practice titled ‘advanced practitioner’ with generic and specialist criteria for each profile as the future career pathway.  Systems for approval of the overall criteria package for any individual Advanced Practitioner profile, audit and continuing professional development requirements need to be established to meet the local needs of clinical departments.  Presentation

References
1. Jasperse M, Herst P, Coleman K. (2010). Evaluation of an ‘In House’, RT-led treatment review programme. Shadows 53 (2) 4-7.
2. Coleman K, Jasperse M, Herst P, Yielder J. (2014). Establishing radiation therapy advanced practice in New Zealand. J Med Rad Sci 61: 38-44
3. Yielder J, Young A, Park S, Coleman K. (2014). Establishing advanced practice for medical imaging in New Zealand. J Med Rad Sci 61: 14-21
4. Yielder J, Sinclair T, Murphy, F. (2008). Role development and career progression for New Zealand medical radiation technology: a research report. Auckland. NZIMRT

Kristie Matthews, Australia – Australian Radiation Therapy Advanced Practice. A Focus Group Study

Introduction
The implementation of advanced practitioners in radiation therapy in Australia has not been as readily achieved when compared to published international initiatives.  The few examples that have been reported reveal inconsistencies relative to expectations, and variation in outcomes1-4.  This paper will present the preliminary results of a doctoral research study intended to explore the influencing factors shaping the implementation of radiation therapy advanced practice in Australia.

Method
Using a grounded theory methodology5, a series of online focus groups were facilitated with radiation therapists, radiation oncologists, and radiation oncology medical physicists from a range of clinical and administrative experiences, geographic locations, and clinical organisation types.  The aim of the focus group phase was to explore the perceptions and assumptions of participants regarding the status of radiation therapy advanced practice in Australia, and the factors that may be influencing this status.

Results
The online focus group data revealed that multiple issues are perceived to underlie the limited implementation of radiation therapy advanced practitioners in Australia, including cultural, organisational, and financial.

Conclusion
According to focus group participants, ‘making a place’ for advanced practice within a clinical service is not readily achievable.  This key concept will be explored further in a series of national case studies as the second stage of the research project.  It is intended the outcome of the research will provide a theory on the influencing factors that may be inhibiting the realisation of advanced practitioners in Australia, to better inform future implementation strategies.  Presentation

References
1. Job M. To assess the ability of a radiation therapist to delineate simple palliative radiation therapy fields. Paper presented at: CSM Melbourne; 2014.
2. Rivett M. RT-Lead Post-Radiotherapy Treatment Reviews in Rural and Remote Settings. Paper presented at: ASMMIRT Sydney; 2012.
3. Toikka C. Breast advance practice role implementation: our experience. Paper presented at: ASMMIRT Hobart; 2013.
4. Matthews K. Evaluation of Specialist Practitioner Radiation Therapist Roles at the Peter MacCallum Cancer Centre. Peter MacCallum Cancer Centre. Produced for the Department of Health, Victoria; 2012. (unpublished report)
5. Charmaz K. Constructing Grounded Theory. London: SAGE Publications; 2014

Laura D’Alimonte, Canada – Navigating the System. The Role of the Clinical Specialist Radiation Therapist (CSRT) in Delivering Person-Centred Care across the Cancer Continuum

Overview of role/service
Patient navigation roles were developed to help reduce gaps in care by improving access to and timeliness of cancer services (1). A primary activity of the CSRT at the Odette Cancer Centre (OCC) is to serve as a navigator for ‘complex’ patients. Complexity is defined not only by the treatment but also the anticipated needs of the patient identified within distinct disease sites. The spectrum of navigation includes support through care coordination, patient education and meeting the psychosocial needs of the patients both proactively and during the course of treatment.

Implementation of role/service
There are currently five CSRT roles at the OCC each aligned with a disease site or program; Skin, Palliative/CNS, Brachytherapy, Stereotactic Body Radiation Therapy (SBRT), and Supportive Care/Sexual Health. As part of the systematic approach to implementation, the current processes were reviewed to identify gaps in service delivery including support for patients. Within each position, the review identified the need for navigational roles for each CSRT that would, upon integration, not only drive greater efficiency within the system but moreover improve the patient experience.

Relevance/Impact on service delivery
The CSRT as navigator has helped stream line the patient journey through the cancer treatment trajectory by providing coordinated, evidence-based, person-centred care. Early data, both anecdotal and quantitative will be shown that supports the benefit of integrating this within the portfolio of the CSRT as they are equipped to provide all requirements of this navigation activity.

Future development of role/service
An internal organizational review of the staff and patient experience has identified the ‘want’ and ‘need’ for more navigational roles within the system. This is particularly amplified given the very complex treatment protocols within radiation medicine. Traditionally, these roles have been filled by our nursing colleagues, however, the CSRT is positioned well through the acquisition of advanced knowledge, skill and judgement leveraging their full scope and maximizing their role. Presentation

References
1. Riley S, Riley C. The Role of Patient Navigation in Improving the Value of Oncology Care. Journal of Clinical Pathways 2016; 2(1). 41-47

Ann-Marie Culpan, UK – The evolving role of radiographers in symptomatic mammography image interpretation.

In a study which explored the roles of radiographers interpreting and reporting mammography images in UK symptomatic breast clinics two models of practice were identified – blended and holistic care. In both models responsibility for interpreting mammograms was transferred from radiologists to radiographers. Each model had different ‘triggering’ circumstances and different consequences.

In the blended model, patients met multiple radiographers during their clinic visit and practitioners worked collectively to co-ordinate patient care and transfer information along the chain of diagnosis. Blended care was triggered where radiographers were skilled in only one advanced breast imaging technique – a typical feature of early ‘advanced practice’ career development.

In the holistic model, a single multiskilled radiographer performed all imaging investigations for an individual patient, providing direct continuity of care and communication. Holistic practice was triggered where radiographers had dedicated their practice to the ‘breast’ clinical domain and acquired expertise across the full range of advanced practice techniques over an extended period of time –  a typical feature of the experienced advanced or consultant radiographer practitioner.  Multiskilled radiographers had a similar holistic overview of the patient’s diagnostic journey to that of a radiologist which enabled them to substitute1,2 for radiologists in the diagnostic breast MDT.

Involving advanced practitioner and consultant radiographers in mammography image interpretation and reporting in symptomatic breast clinics could release radiologists for other duties, in the symptomatic breast or wider imaging service. Inter-professional (radiographer- radiologist) working3 in symptomatic breast clinics was considered an effective strategy for maintaining and / or increasing imaging service provision. Presentation

References
1. Sibbald, B. et al. 2004. Changing the skill-mix of the health care workforce. Journal of Health Services Research & Policy, 9(suppl 1), pp.28-38.
3 Nancarrow, S. A. and A. M. Borthwick. 2005. Dynamic professional boundaries in the healthcare workforce. Sociol Health Illn, 27(7), pp.897-919.
2. Hoskins, R. 2012. Interprofessional working or role substitution? A discussion of the emerging roles in emergency care. J Adv Nurs, 68(8), pp.1894-903

Dean Harper, Ireland – The development of an RTT led treatment delivery service for patients undergoing SABR for peripherally located tumours of the lung.

Stereotactic ablative radiotherapy (SABR) for patients with peripherally located early stage lung tumours was introduced in the St. Lukes Radiation Oncology Centre at St. James Hospital in March 2014. The successful implementation of the programme was the result of the strategic efforts of a core multi-disciplinary team which has remained in place in accordance with UK consortium guidelines.

The complex pathway from initial referral to treatment completion is extremely resource intensive and the demands on the service are set to intensify through expansion of the current programme to include oligometastatic and centrally located lesions. In particular there is an increased burden placed on the consultant radiation oncologist with the requirement for consultant approval at the treatment verification stage.

Consultant radiation oncologists were attending each of the 3-5 treatment fractions in order to verify the image guided localisation of the target on both pre and mid treatment CBCT. A review of the planned expansion to include patients with centrally located tumours which are treated with 8 fractions identified that current practice was unsustainable in this regard.

In January 2016 a training programme was developed in order to expand the role of the SABR trained clinical specialists to allow RTT approval of tumour localisation for non-first fraction treatments. In February 2016 the first candidate successfully completed the programme. An overview of this initiative including challenges of implementing the programme and the benefits gained will form the basis of this presentation. Presentation

Caitlin Gillan, Canada – Where there’s a will, there’s a way. Development and piloting of the oral examination phase of a national advanced practice certification process for radiation therapists in Canada

An advanced practice (AP) certification process for radiation therapists (RTTs) was piloted by the Canadian Association for Medical Radiation Technologists. Involving three phases; professional portfolio, patient case log, and competency-based oral examination, the process culminates in AP designation. This process, as well as a standardized AP competency profile, were refined through externally-facilitated blue-printing and national validation exercises.

The objective of the oral examination was to assess competency across all clinical, technical, and professional competency domains. It was case-based and tailored to the candidate’s area of specialty. ‘Real’ anonymized data maximized clinical fidelity and facilitated evaluation of real-time navigation of clinic notes, imaging, treatment plans etc to inform clinical reasoning and decision-making.

Three subject expert examiners were recruited for each examination, one each from radiation oncology, medical physics, and RTT professional organizations. Examiners were consulted to ensure accuracy and relevance of developed cases and inform answer keys based on the standard expected of an AP RTT, set at that of a senior medical resident.

The exam involved two blocks; a single major case run from presentation through treatment and follow-up, and a series of secondary cases evaluating competencies not well-addressed in the first block. Assessment of professional competencies, such as research, continuous quality improvement, and mentorship was integrated throughout. Examinations were designed to be conducted virtually over web conference, to avoid unnecessary costs, with case materials and other resources built into an eLearning platform. Standardized scoring rubrics were used, and an examiner debrief followed each exam.

Three pilot examinations are to be conducted in June 2016. Presentation

Darby Erler, Canada – Taking Advanced Practice Skills Full Circle

Overview of role
The Stereotactic Body Radiation Therapy (SBRT) program at the Odette Cancer Centre has rapidly grown in both anatomic sites and patient numbers since 2008; treating over 600 patients last year to sites including lung, liver, spine, prostate, kidney, pancreas, head and neck and miscellaneous oligometastases. With such a rapidly expanding program, an advanced practice radiation therapy (APRT) position was created in 2012 to ensure quality patient care across the program. An initial area of focus was to have the APRT assume responsibility of approval of day 1 cone beam computed tomography (CBCT) registrations in place of the radiation oncologist (RO).

Implementation of role/service
The APRT attained competence through a combination of didactic and practical instruction. Concordance between the APRT and RO with respect to CBCT registration assessment was evaluated and the APRT demonstrated a concordance rate of 100% for clinically acceptable agreement for 44 cases evaluated.

Relevance/impact on service delivery
Since implementation, the APRT has approved on average 16 CBCT registrations (range 7-22) per month, which increases efficiency in workflow and translates into a time savings of approximately 4 hours per month for the RO to allocate towards more complex discipline-specific tasks as well as benefits to the patients and treatment unit staff.

Future development of role/service.
As the department’s experience in certain sites of SBRT matures, specific clinical scenarios have been identified where, with training, treatment therapists could independently approve day 1 CBCT images for SBRT patients. The APRT will develop a competency profile for performance of this task in the identified situations. Presentation

Joan Sweeney, UK  – Are we robbing Peter to pay Paul? Review radiographers should complement and not replace the skills of the wider team

Overview of service
The review radiographer role has developed and expanded since it first evolved in the 1990s raising the profile of therapy radiographers within the MDT. The success of the radiographer led on- treatment review service at the host department has increased in demand making it unsustainable in its’ current form. This was compounded by treatment radiographer’s inability to carry out simple reviews. To quantify and address the concern, an evaluation was followed by the development of a toxicity triage tool and refresher training programme for all staff.

Impact on service
A critical evaluation of the review radiographers’ role and levels of intervention in review clinics were undertaken. Informal discussions with treatment radiographers examined the wider skills mix and determined how best to utilise these more efficiently. Meetings were held with Oncologists and managers to determine how the service could be developed.

The clinical activity demonstrated a 37% increase of radiographer review in one year. Reviews were retrospectively graded by levels of intervention as per publication by Webber. All patients were scheduled 10min appointments despite the complexity level which was unrealistic. Treatment staff felt de-skilled so a training programme was developed with the addition of a ‘Treatment Toxicity Assessment Triage Tool’

Implementation of service and future developments
The success of the training programme and the Triage tool has ensured that the review service skills complement and enhance those of the treatment radiographers. Patients now receive more appropriate levels of care to meet their needs, and future developments will concentrate on patient self management. Presentation

References
Alfieri, F., Le Mottee, MA., Arifuddin, A., et al:  Radiation therapist-led weekly patient treatment reviews. (2009) Australian Institute of Radiography.  56 (3), p44-48.
Benner P: From novice to expert, excellence and power in clinical practice. (1984)  Menlo Park, California. Addison-Wesley
Ellis T., Ashmore L., Bray D Multidisciplinary radiographer led review clinics-an example of implementation. (2006) Journal of radiotherapy in Practice 5,87-95
Lees. L., The role of the ‘on treatment’ review radiographer: what are the requirements? (2008) Journal of Radiotherapy in Practice, vol. 7, pp113 – 131
Monk C.M., Wrightson S.J., Smith T.N., An exploration of the feasibility of radiation therapist participation in treatment reviews. Journal of Medical Radiation Sciences 60 (2013) 100–107
UK Oncology Nursing Society (UKONS). 24 Hour Triage-Rapid assessment and access toolkit. Cancer Nursing Practice June 2010 | Volume 9 | Number 5

Kirstie Smith, UK – ‘Integrating CBCT into Radiotherapy verification. Experiences from a medium-sized Radiotherapy Centre’

Introduction
Cone-beam CT allows for greater precision in IGRT and allows for Adaptive Radiotherapy. Experiences of Advanced Practitioners in a medium-sized centre integrating CBCT into imaging protocols is discussed.

Overview
Historically imaging protocols were as per On Target (2008). CBCT was utilised only for geometric precision when orthogonal KV imaging were considered inadequate. Since introduction of RapidArc treatment the smaller margins has meant a greater importance of accuracy in treatment delivery.

Implementation
Advanced Practitioners worked closely with other MDT members to aid the integration of CBCT into treatment. CBCT was introduced alongside RapidArc as follows

• Prostate
• Head and Neck
• Lung/SABR
• Gynae
• Anal Canal
• Oesophagus

Imaging protocols included KV for portions where bony anatomy was deemed an adequate surrogate in areas where PTV length extended longer than CBCT field-of-view.

Impact
D Anatomy training was undertaken however it was normative anatomy and there was a lack of confidence in image interpretation leading to initial CBCTs being time-consuming. Advanced Practitioners developed decision trees for Radiographers and aided in image interpretation on-set. Weekly multidisciplinary imaging groups by anatomical site were undertaken. Activity tasks on Aria helped identify patients/scans for discussion and all were invited to attend. Amendments were common initially but as confidence grew decision trees stabilised.

Future development
Challenges in CBCT include preparatory and continuous work to implement. The new IGRT specialist role will focus on ensuring training is fit-for-purpose. Our experience shows all Advanced Practitioners working together using their skills and expertise helps integration of CBCT into daily practice smoother to benefit patients and radiographers. Presentation

References
RCR, IPEM, SCoR, On Target: Ensuring Geometric Accuracy in Radiotherapy, 2008
National Cancer Action Team, NRIG Report. IGRT Guidance for implementation and use, 2012

Lori Holden, Canada – Enhancing roles, Increasing Responsibilities. The Clinical Specialist Radiation Therapist led interprofessional care clinic.

A Clinical Specialist Radiation Therapist (CSRT) is a registered medical radiation technologist in the specialty of radiation therapy who brings advanced clinical, technical and professional radiation therapy competencies to the existing inter-professional health care team. With the proper complement of knowledge, skills and judgment, CSRTs are now successfully leading and coordinating multidisciplinary clinics within our oncology program. The acquired skill set is transferable, in that the practicing CSRT is able to respond to the changing demands of a centre, and implement the role in other sites in response to changing strategic priorities.

Implementation of a new role occurs in a step wise systematic fashion. Beginning with shadowing a radiation oncologist (RO), then moving on to performing tasks while supervised, and finally performing tasks on their own, the CSRT not only acquires the competency, but also builds clinical expertise, and inherently garners the trust of the interprofessional team along the way. This ensures a smooth implementation of the role, and aids in its sustainability.

The CSRT’s impact not only enhances the patient care experience, but as well, impacts directly on the cancer program. By assuming activities traditionally held by other specialties, such as patient triage, obtaining patient histories and consent, and contouring target volumes, to name a few, time pressure felt by ROs is relieved thus enabling them to deal with more emerging complex situations. This presentation will show how having a CSRT lead a multidisciplinary clinic can improve patient throughput, decrease inappropriate referrals and increase efficiencies, all leading to an increased patient and staff experience. Presentation

Lisa Di Prospero, Canada – Sustaining the Clinical Specialist Radiation Therapist (CSRT) Role. Adaptability, prioritization and alignment to the organization strategy

Overview of role/service
Beginning in the early 2000s, the Clinical Specialist Radiation Therapy (CSRT) project was approved by the Ministry of Health in Ontario to investigate a new model for radiation treatment (RT) delivery. Our organization successfully implemented five positions that ranged from focus on technical complexities to supportive care. A detailed sustainability plan was created to ensure that the positions met program priorities both for our patients and the program.

Implementation of role/service
The sustainability plan required linkage to strategic priorities of the CSRT role at 3 levels of governance: program, hospital and provincial. Evidence was gathered to illustrate improvements in care that each position addresses using both quality and quantity measures. The positions also needed to demonstrate flexibility in the transfer of skills between the CSRTs and programs to meet gaps as identified.

Relevance/Impact on service delivery
The intentional linkage to strategic priorities and the ability to adapt to the continually changing needs of the program have been critical in creating a viable sustainability plan. The view that CSRTs are experts in one clinical area is not practical and does not align with the complexity and changing needs of RT

Future development of role service
Although initially implemented to meet a specific gap, the CSRT portfolio must be responsive to program needs as they arise to ensure sustainability. This requires additional skills and the flexibility to leverage knowledge and expertise that is transferable and adaptable. Presentation

Rita Borgen, UK – Establishing of a Radiographer Led Vacuum Assisted Breast Biopsy (VAB) within the Breast Unit at ELHT

Purpose
To introduce a VAB service that is managed and led by Advanced Radiographer Practitioners.
Introducing this new service will benefit the patient by increasing the accuracy of preoperative diagnosis, provide an alternative to surgical excision for screen detected B3 lesions and provide extended scope of practice for Radiographer practitioners.

Background
The technique of vacuum assisted biopsy (VAB) was developed in the late 1990’s and can be used in conjunction with stereotactic, ultrasound and MRI image guidance.
Unlike other biopsy units VAB systems use needles with a lateral aperture into which tissue is pulled in by negative pressure. A cutting cylinder extracts a sample of tissue using 8 or 11gauge needles. This sampling method allows for increased tissue retrieval and therefore increased pre operative diagnostic accuracy
Today the optimal management of screen detected breast cancer requires pre-operative assessment with image guided needle biopsy to obtain a non-operative diagnosis in upto 95% of cases.
The new guidelines (NHSBSP No 49) include recommendations for the use of vacuum assisted core biopsy (VAB), reflecting its increased use in tissue sampling.
In addition to the potential diagnosis of invasive components within an area of DCIS VAB is considered the sampling method of choice in the following situations.

• Following a B1/B3/B4 results at 14gauge biopsy
• Diagnostic excision of papillary lesions and radial scar/CSL without atypia diagnosed by core biopsy
• Assessing microcalcification if non are retrieved in the initial 14gauge biopsy
• Diffusely spread microcalcification which may be difficult to sample with conventional 14 gauge biopsy
• Very small <5mm clusters of microcalcification which may be difficult to sample.

Outcome
The VAB service was introduced into the Breast Unit in April 2012. Since then Advanced Radiographer Practitioners have undergone training and are able to undertake the procedure. To date 165 procedures have been performed.
77% of patients undergoing VAB have been discharged, 25 additional cancers were diagnosed in patient with B3 lesions and 12 cancers were confirmed in patients with previously diagnosed cases of DCIS or B4 outcomes.
The introduction of this service has led to

• A significant reduction in open surgical biopsies saving unnecessary surgical intervention
• Appropriate surgical intervention following cancer diagnosis
• A cost saving in theatre time
• A reduction in procedural costs
• Minimal clinical risk.

Presentation

Katie Cooper, UK – The role of the Advanced Practitioner in developing a Radiographer led brachytherapy service.

Innovation and modernisation have been high on the agenda for the Department of Health during the last decade, with emphasis being placed on radiotherapy departments developing novel ways of working and breaking down traditionally held professional boundaries to improve service delivery and patient care¹ ².

This paper will describe how successful service redesign, in the form of a Radiographer led vaginal vault brachytherapy service has been implemented at the Norfolk and Norwich Hospital. This has enabled the Advanced Practitioner to undertake initial vaginal assessment, treatment planning and approval, patient review and clinical follow up and discharge. It will highlight how all role extension has been underpinned with relevant MSc modules, competency programmes and with the support and supervision of clinical oncologists. It has also been initiated under clearly defined scope of practice guidelines as recommended by SCoR³ and HCPC4, thus allowing for greater responsibility, autonomy and increased job satisfaction whilst maintaining a duty of care to all patients.

It will demonstrate how undertaking roles previously held by the clinical oncologist and physicist has enabled greater patient throughput, better equipment utlilisation, improved patient continuity and improved quality of care, whilst also discussing the challenges and barriers encountered and how they have been overcome to implement a new way of working. Presentation

References
1. National radiotherapy advisory group (2007) Radiotherapy: developing a world class service for England. NRAG
2. James, S., Beardmore, C. & Dumbleton, C. (2012). A survey on the progress with implementation of the radiography profession’s career progression framework in the UK radiotherapy centres. Radiography, 18, 153-159. Doi:10.1016/j.radi.2012.03.002
3. The Society of Radiographers. (2013). Scope of practice. London. SCoR
4. Health & Care Professions Council. (2016). Standards of conduct, performance and ethics. London. HCPC

Kristie Matthews, Australia – Advanced Practice at Peter MacCallum Cancer Centre: An Evolving Concept

Overview
Peter MacCallum Cancer Centre (Peter Mac) has been proactive in the development and implementation of advanced practitioner radiation therapists to improve coordination of patient care, productivity and job satisfaction1.  Two advanced practitioner roles are currently present within the radiation therapy service: namely breast advanced practitioners and imaging advanced practitioners. However, changes in models of care and the structure of the workplace have altered the way the roles are utilised within the service, and the outcomes the practitioners are enabled to achieve.  This paper will present the evolution of the advanced practitioner roles at Peter Mac over the last decade.

Implementation
Work-based training for breast and imaging advanced practitioners was supported by Monash University between 2005 and 20122, which resulted in thirty practicing graduates. Implementation of the roles was initiated in response to service need: to enhance the breast patient pathway, and the increasing use of advanced imaging technologies.

Impact
Positive outcomes in patient throughput, protocol developments and evidence based practice were clearly demonstrated during the earlier years post-implementation. However, a subsequent formal evaluation, service restructure, and the release of professional body and academic frameworks3 for advanced practice have prompted alteration to the title and utilisation of the practitioners.

Future Developments
The advanced practitioners continue to provide an essential service within the organisation; however the evolution of the roles has negatively impacted on the number of practitioners willing to continue to be credentialed to practice.  Future developments will require strategic consideration of required outcomes against role satisfaction and possible attrition. Presentation

References
1. Matthews K. Evaluation of Specialist Practitioner Radiation Therapist Roles at the Peter MacCallum Cancer Centre. Peter MacCallum Cancer Centre. Produced for the Department of Health, Victoria; 2012.(unpublished report)
2. Matthews K, Wright C, Osborne C. Blending work-integrated learning with distance education in an Australian radiation therapy advanced practice curriculum. Radiography. 2014;20(3):277-282.
3. Australian Institute of Radiography. Pathway to Advanced Practice. 2014.

 Angela Turner, Canada – The Development of a Clinical Specialist Radiation Therapist (CSRT) Role through a Systematic Framework: The Odette Cancer Centre Experience

Overview of role/service
Beginning in the early 2000s, the CSRT project was approved by the Ministry of Health in Ontario as part of a project to investigate a new model for health care delivery. The aims were to provide optimum access to care and improve the quality of care provided to cancer patients. Our institutional priorities are aligned with the province and the CSRT role has been integrated into interprofessional practice with great success. Provincial reports from patient satisfaction surveys as well as institutional data identified areas for improvement in the delivery in both technical and clinical areas of unmet need for cancer patients.

Implementation of role/service
The process of developing this CSRT role utilized an established framework (Participatory Evidence informed Patient centered Process for APN role) (PEPPA) which had been developed to support the introduction and implementation of Advanced Practice Nurse (APN) roles. Gaps in care were investigated through an environmental scan of both provincial and institutional reports and documents. A literature search to identify published research to support the data was also carried out. Practice areas where RTs were currently not represented were identified. A Formal Proposal was developed which highlighted the CSRT role and it’s alignment with program needs, key priorities provincially and locally. The evidence provided was linked to published literature. The support of key stakeholders was established.

Relevance/Impact on service delivery
The impact of the CSRT role is ongoing. Established metrics e.g. patient satisfaction, stakeholder satisfaction, improved access to services amongst, as well as other pertinent documentation continues to be collected to evaluate the roles.

Relevance/Impact on service deliver/future development of role service
The development of novel CSRT roles is possible using standardized frameworks. Investigating service models with formal processes may result in the identification of innovative non traditional roles which expand the boundaries of RT practice. Modifications of the framework have been adopted organizationally for potential implementation of other advanced practice roles across the health professions. Presentation

Kirstie Smith, UK – ‘Research Therapy Radiographer. Early experiences in a new role’

Introduction
Involving radiotherapy patients in clinical trials is important (Cancer Research UK, 2014; SCOR, 2015). The experiences of implementing a new Advanced Practice role in a medium-sized department are discussed.

Overview
In 2015 a new Research Radiographer role was introduced. Responsibilities include

• Increasing the number of patients in trials
• Facilitating setup/smooth-running of NIHR portfolio trials
• Liaising with wider MDT and Trials Physicist
• Co-ordinating and support Radiographers in setting up in-house trials

Implementation
The role developed from departmental goals for research and development. Initial focus on education regarding current NIHR portfolio trials. It was important to liaise with other Advanced Practitioners and to delegate some tasks appropriately. Challenges included integrating with existing services.

Impact on Service
Education sessions reduced trial protocol deviations to the benefit of patients. The inclusion of an experienced Radiographer aids in participating in appropriate NIHR Portfolio trials, the setting of realistic recruitment targets and enables tackling of barriers to recruitment. Goal is to have 3% of Radiotherapy patients in trials, currently Q1-Q3 2015/16 = 2.69% due to some trial closures, aim to increase and improve on this.

Future Development
All Radiographers will undertake Good Clinical Practice training. Future goals include

• Undertaking and supporting others in undertaking in-house research for publication
• Horizon-scan for NIHR portfolio trials
• Involving students and Radiographers
• Shift focus from portfolio trials already undertaken to build capacity for own trials
• Continuing to develop a positive research culture

Conclusions
Benefits and challenges in implementing a Research Radiographer role exist. Prioritisation and time management are essential. It is important to consider the department itself and to share our knowledge and experience. Presentaion

References
SCOR 2015 Research Strategy 2016-2021

Cancer Research UK NHS England 2014, Vision for Radiotherapy 2014-2024

Amanda Bolderston, Canada Mapping the way. A participatory, evidence-informed, patient-centred framework for establishing advanced practice roles

Radiography advanced practice (AP) roles have been developed internationally using a number of different approaches and frameworks (1). Regardless of the implementation methodology there are often challenges to the effective operationalizing of AP roles, some of which could be minimised through improved pre-role planning and better stakeholder understanding of the intended positions (2). The participatory, evidence-informed, patient-centred framework (PEPPA framework) was originally developed to address implementation challenges in AP nursing using the principles of participatory action research but has been used by other health provider groups such as physiotherapists (3). It has been successfully adapted and utilized by Cancer Care Ontario’s Clinical Specialist Radiation Therapist initiative to introduce AP radiation therapist roles to Ontario, Canada (4). The framework has recently been taken up by the British Columbia Cancer Agency to investigate the feasibility of an AP role specialising in palliative care. This talk will discuss the steps involved in the framework, how the BCCA has carried out the implementation phase of PEPPA (steps one through 6) and evaluate the role development progress so far.

Topham C. Advanced Medical Radiation Technologist Practice and the Canadian Association of Medical Radiation Technologists: History and Perspective. Journal of Medical Imaging and Radiation Sciences. 2014, 45 (4); 348–351

Lockhart E, Gutierrez E, Warde P, Bak K, Zychla L, Bolderston A, Lewis D, Smoke M, Wenz J, Nagata L, Ang M, Harnett N. A new model of care: An advanced practice radiation therapy role. 2014 ASCO Quality Care Symposium. J Clin Oncol 32, 2014 (suppl 30; abstr 131).

Bryant-Lukosius DE. Designing Innovative Cancer Services and Advanced Practice Nursing Roles: PEPPA Toolkit. Cancer Care Ontario, 2009.

Harnett N, Zychla L, Bak, K, Lockhart E.  The evidence-based development and implementation of an advanced role: the Clinical Specialist Radiation Therapist. Journal of Allied Health. 2014, 43(2); 110–116.

 

Rachel Bilton, UK – Setting priorities for a gastro-intestinal consultant radiographer: An exploration into the potential role based on local service need.

The investigation into gastro-intestinal (GI) consultant radiographer post came about through the convergence of several factors;

• increasing demands on diagnostic imaging services (DoH, 2007; Kelly, Piper and Nightingale, 2008; Masterson & Humphris, 2000).
• targets for reduction in waiting times (DoH, 2011a; DoH, 2011b).
• a national shortage of radiologists (RCR, 2002; RCR, 2015: Rimmer, 2015).

These are familiar issues for many radiology departments across the country, leaving many struggling to sustain services.

The creation of consultant radiographer posts endeavours to meet these challenges while recognising and rewarding the skills of the post holders (DoH, 2001; NHS, 2007). While these posts are aimed to be substantive, the role is often bestowed on staff already performing at this level (Forsyth & Maehle, 2010). The aim of this research was to establish what is required of the role, within the local setting, prior to appointment.

The nominal group technique (Delbecq, Van de Ven and Gustafson , 1975) was used as a method to generate ideas from a group of experts and attempt to achieve consensus on primary role descriptors for the post. Following the process a list of eight role descriptors was produced with a statistically significant level of consensus amongst the group (). These descriptors will be used to establish a substantive post with future direction within the local setting.

References

Delbecq, A L., van de Ven, A H., & Gustafson, D H. (1975) Group techniques for program planning: A guide to nominal and Delphi processes. Glenview, Illinois: Scott, Foresman and Company.

Department of Health. (2001). The advanced letter PAM (PTA)2/2001 arrangements for consultant posts. Retrieved from http://www.dh.gov.uk

Department of Health. (2007). The NHS cancer reform strategy. London: Stationary Office.

Department of Health. (2011a). The National Cancer Strategy.  Retrieved from https://www.gov.uk

 

Patrick Eastgate, Australia

Objectives: In 2013 the Royal Brisbane and Women’s Medical Imaging Department’s Peripherally Inserted Central Catheter (PICC) insertion team reviewed its service delivery, training and auditing. The PICC team set out to ensure it’s multidisciplinary approach was of the highest levels.

Methods: Following a review of the service a dedicated training package was developed and published that covered not only the insertion but also new and innovative practices not previously seen in PICC teams. Uniquely this team is lead by both radiographers and nurses with most roles being interchangeable. Following the implementation of the training package all insertions were auditted for success rate, number of attempts and infection control issues.

Result: The PICC team has a very high percentage of success and low number of attempts when compared to other PICC insertion teams. Monitoring of infection control issues still remains a challenge. New roles for the PICC team have been adopted including acquiring written patient consent, radiographers siging off on PICC tip position, a traffic light system for escalation to the Interventional Radiologists and a process to review PICCs of inpatients 72 h post insertion.

Conclusion: The development and implementation of an education package and innovative aspects of service delivery has resulted in a PICC service delivery team of the highest standards when compared globally.

 

Robert Milner, UK – A week in a radiographer reporting service

Background
Radiographer reporting is well established, but the wider opportunities associated with the implementation of a radiographer-led service are poorly understood. This study provides insight into the breadth of activities of a team of advanced and consultant radiographers within a general radiography service in a multi-site NHS Trust.

Method
The study utilised activity diaries over a period of one week. A coded framework was used to categorise the 4 domains of practice, namely clinical, research, leadership and consultancy and associated subgroups. Additional free text documentation was provided. Additional secondary data was drawn from the radiology information system to identify volume and scope of reporting activity. Analysis of the diaries was undertaken to identify the contribution to service delivery.

Results
Analysis is ongoing but provisional results suggest that there is considerable breadth and depth to individuals’ roles. The majority of the radiographer’s role was focussed towards clinical expertise, including immediate and delayed reporting and the direct management of patients. All 4 domains were witnessed during the study period, with the radiographers impacting on the roles of other health professionals, through education and advice. Radiographers were actively engaged in the research domain through research and audit, although this varied between individuals.

Conclusion
Radiographers encountered in this study undertake a variety of activities as part of their roles, and appear to be working at a level commensurate with their titles.

References
Franks H. The contribution of nurse consultants in England to the public health leadership agenda. Journal of Clinical Nursing, 23, 3434–3448.
Hardy M, Snaith B, Smith T. Radiographer reporting of trauma images; United Kingdom experience and the implications for evolving international practice. The Radiographer 2008;55(1):16-19.
Harrison L, Nixon, G. Nursing activity in general intensive care. Journal of Clinical Nursing 2002; 11: 158–167.
Humphreys A, Richardson J, Stenhouse E,  Watkins M. Assessing the impact of nurse and allied health professional consultants: developing an activity diary. Journal of Clinical Nursing, 19, 2565–2573.
Snaith BA, Lewis EF, Hardy M. Radiographer reporting in the UK: A longitudinal analysis. Radiography 2015;21(2):119-123.

Johnathan Hewis, Australia – A hermeneutic phenomenological study of Australian medical imaging (radiography) practitioners’ perception towards the role of higher education in the context of developing ‘advanced practice’ in planar image interpretation.

Introduction
Recognition of advanced practice in radiography/medical imaging is still emerging in Australia compared to a more established frameworks in countries like the UnitedKingdom (1, 2). Within the context of Australian healthcare environment, the impetus andnature of formally recognised advanced practice has progressed slowly with a predominant focus on addressing local need, typically in a rural setting (3). Key barriers to advanced practice include a perceived lack of knowledge or skill, limited confidence, risk of litigation, radiology and health departments (3,4,5). In 2014, the AIR introduced a new framework for advanced practice (6), which includes a ‘Master’s by Coursework’ or a ‘Master’s by Research/Doctorate’ pathway.

Purpose
Identify the essence or essential meanings of the phenomena of higher education in relation to advanced practice in planar image interpretation from the perspective of postgraduate practitioners enrolled in a ‘Master’s by Coursework’.

Methodology
Data collection will be conducted using semi-structured in-depth telephone interviews of participants with a focus on their ‘lived experience’ (7,8). A purposeful sampling strategy will be employed to recruit participants who must be practicing clinically in Australia, be registered as a diagnostic radiographer with APHRA and be enrolled currently or recently in a coursework master’s of planar image interpretation at an Australian university.

References
1. Paul D. An Overview of Initiatives Relating to Advanced Practice Role Development for Radiological Technologists. J Med Imag Rad Sci 2009;40(3):90-99.
2. Hardy M, Snaith B, Smith T. Radiographer reporting of trauma images: United Kingdom experience
and the implications for evolving international practice. Radiographer 2008;55(1):16-19.
3. Smith, T., Brown, L & Cooper, R. (2009). A multi-disciplinary model of rural allied health clinical academic practice: A case study. Journal of Allied Health. 38:236-241.
4. Freckelton, I. (2012). Advanced Practice in Radiography & Radiation Therapy. Report from the Inter-professional Advisory Team.
5. Page, B., Bernoth, M. & Davidson, R. (2014). Factors influencing the development and implementation of advanced radiographer practice in Australia – a qualitative study using an interpretative phenomenological approach. Journal of Medical Radiation Sciences. 61;142-150.
6. Advanced Practice Advisory Panel. 2014. Pathway to Advanced Practice. Summary document and guidelines for application for accreditation. Australian Institute of Radiography.
7. Langdridge, D. (2007). Phenomenological psychology. Theory, research and methods. London. Pearson.
8. Smith JA. Hermeneutics, human sciences and health: linking theory and practice. Int J Qual Stud Health Well-being 2007; 2: 3–11.

Jonathan McConnell, UK – The impact of global work list working on radiographer reporting across a Scottish health board.

Scotland has been slow to develop reporting radiographers as a resource to help with the reporting crisis. However since their inception in Scotland’s most densely populated health board, global work lists enable the reporting radiographer to contribute across a range of plain radiograph reporting areas to help reduce the pressure on radiologists from anywhere within the country. The presentation discusses developmental change in the reporting radiographer team in Glasgow and Clyde across 3.5 years to show how global work lists impact on waiting times, trainee reporting radiographer education and identification of future potential scope of practice developments. From a small start of 20k exams in year 1 with 1.9 WTE reporting radiographers under close audit to a projected 70+K exams in year 4 with a 4.3 WTE team, implementation has been shown to be successful and widening across a greater scope of practice range.The talk will address issues of radiological governance under the umbrella of a widening of referral sources for radiological examinations from nursing and allied health professional colleagues. This is in the light of the 2016 integrated joint board initiative of NHS Scotland where the AHP National Delivery Plan of 2015 and the Scottish Government 20:20 vision continue to drive service development to meet the wider needs of the Scottish public who live in metropolitan and rural/remote environments.