Radiographer-led Review

Statistically, prostate cancer is the most common male cancer in the UK. Patients with a prostate cancer diagnosis often have a number of treatment options available to them which include surgery in the form of a radical prostatectomy, brachytherapy or external beam radiotherapy (EBRT). All treatment options usually involve hormone therapy before and after.

Statistics in Northern Ireland show an increase in the incidence of prostate cancer diagnosis this increase inevitably leads to an increase in patients opting for radiotherapy. With large demands on ClinicalOncologists time as it is, time for consenting patients, completing treatment plans, reviewing patients during radiotherapy and reviewing patients after radiotherapy as well as managing the care of inpatients is hard to find. These time constraints highlight the importance of role development and role extension for radiographers.

A radiographer-led review is just one of the ways in which radiographers can extend their role as an allied health professional. Much of the knowledge and skills gained as radiographers transfer to this role perfectly as a natural progression from normal daily interactions with patients.

Cancer research1 reports that over the last decade, prostate cancer incidence rates have increased by 6% and another rise is projected at 12% by 2035. This makes prostate cancer the second most common cancer in the UK. In 2014 the national institute for Health and Care and Excellence (NICE)2 reported that 35% of all prostate cancer patients underwent external beam radiotherapy. With these statistics, it is inevitable that the number of patients opting for radiotherapy will also rise, in-turn putting pressure on an already pressured national health service.

The Transforming Your Care (TYC) report3 highlighted eleven reasons supporting a change to healthcare in Northern Ireland. These include the importance of patient-centered care, an increasing demand for all programmes of care, the need to deliver a high-quality service based on evidence and making the best use of resources available. Role development in the radiography workforce can help to tackle some of the aims of the TYC report by utilizing and developing existing experience and skills.

The radiographer-led review must cover a large amount of information with patients to maximize on the care they receive. The reviewer must offer advice on skin care, dietary management, other details or issues with receiving daily treatment such as traveling to appointments and any holistic measures that can be taken. They must clarify if the patient is on hormone therapy if appropriate and discuss any side effects of these. A large part of the review process is spent discussing treatment side effects with patients, this includes the monitoring of both gastrointestinal (GI) and genitourinary (GU) reactions to their treatment using the Radiation TherapyOncology Grading (RTOG) toxicity scale for bladder and bowel, toxicity must be carefully documented. During reviews, medications can be suggested to ease side effects if appropriate and so a high level of communication between the medical oncologist and the radiographer is extremely important. The radiographer should also offer information on other services available such as counseling and must liaise with other health care professionals such as social workers or radiotherapy nurses if appropriate, any referrals should also be documented.

On a daily basis, all therapy radiographers use their knowledge and skill to assess whether or not a patient is fit or not to continue on their radiotherapy treatment course. Patients are asked about their general wellbeing, any new side effects or how they are managing with their current side effects and any issues are dealt with as appropriate. The formalradiographer led-review qualification takes the attributes that radiographer already have ascertained and escalates these skills and depth of knowledge to allow for role development as a natural progression to advanced practice.

Whilst researching this literature review, it was found that the number of papers dealing with the topic of radiographer-led reviews was quite limited. Hopefully, the drive for role development into other areas such as information and support or supplementary prescribing will deepen the research and widen the literature available.

Role Development

The Belfast Trust’s corporate plan 2013-20164include some of the corporate objectives set to meet the health and social care needs of the people of Northern Ireland. Importantly these include -

“A Culture of Safety and Excellence - We will foster an open and learning culture, and put in place robust systems to provide assurance to our users and the public regarding the safety and quality of services.

Continuous Improvement - We will seek to be a leading-edge Trust through innovation at all levels in the organization

Our People - We will achieve excellence in the services we deliver through the efforts of a skilled, committed and engaged workforce

Resources – We will work to optimize the resources available to us to achieve shared goals.”

The trust fully supports role development through these objectives but also through other systems which help it to function safely on a daily basis such as clinical governance systems, professional regulatory bodies such as HCPC and through the promotion of lifelong learning through continuous professional development (CPD). As radiographers, these opportunities should be welcomed as the chances for role development has really changed over the last decade with the increase in cancer diagnoses and continuing shortage of medical staff. TheRadiographer Review Protocol5 from the radiotherapy department, Belfast Trust provides guidance for reviewing patients one of the principles of this protocol is to reduce the time constraints on consultants and registrars. Again this supports the use of resources of a skilled workforce in times where time is a large constraint.

Role extension/ development has been highlighted in a document by the Society and College of Radiographers (SoR)6 the expansion in the use of radiotherapy and development of new technology has generated more opportunities for therapeutic radiographers to develop roles within their scope of practice, an example of one of these extra roles is radiographer-led review of patients. This SCoR document, like TYC3agrees, that priorities should include the optimal use of skills and resources, the delivery of an excellent patient experience whilst also continually improving patient outcomes from treatment and recognizing that patients should have access to a specialist practitioner with advanced or consultant level knowledge and skills.

Initiatives from the score have provided a framework in which they can pursue support and guidance for role development within the radiography workforce, the knowledge and skills required to support role development in radiotherapy have been agreed and published in its Education and Career Framework for the RadiographyWorkforce7. In these current time, the only drawback of role development for ourselves as radiographers is that while we are freeing up time for doctors to focus on other aspects of patients’ treatment who is filling the role on the treatment unit or are our colleagues being stretched to let these extended roles be covered.

Whilst redevelopment should be primarily to benefit patients and improve a service, Shi**demonstrated that having a radiographer-led review role led to a greater job satisfaction for radiographers, this, in turn, leads to a higher staff morale and to improved retention of staff.

The department of health’s white paper, Liberating the NHS: greater choice and control* is based on patients being at the heart of decision-making. “No decision about me without me” should be a principle throughout the delivery of all our treatments whether it be hormone therapy, EBRT or brachytherapy. It is critical that as radiographers we have adequate communication skills to support patients when making decisions about their care. During reviews with patients, it is important to offer all the information and leave the final decision with the patient, for example, if a patient has increasing nocturia, it is important to make them aware that there may be medication which can help but they are by no means obligated to start taking it. Often in a few days or another week, the patient will either request the medication or just be happy to know its available should they decide they can no longer manage the symptoms themselves.

The largest part of the role of radiographer-led review is based on communication, and the ability to communicate well and adapting your communication style to support patient-centered care is important. The majority of the aims and objectives of the Radiographer Review Protocol** are based on communicating, showing the need for excellence in this skill. These include ensuring the patient understands all written information with regards to preparation, to provide advice for skin care reactions, to provide advice for GI and GU side effects, to clarifyhormone compliance and to ensure that patients continue to receive information and support during their treatment.

In a study by byBolerston, Lewis and Chai** therapy radiographers were conscious that they were in a position to establish a relationship with the patients that went beyond their radiotherapy treatment. Choosing the profession was seen as a commitment to patient care because of the additional support required by the patient type. It also reported that effective communication can alleviate problems such as stress and anxiety and the establishment of relationships allowed patients to gain the information than needed during their treatment experience.

NICE2guides us to offer men individualized information tailored to their needs, the review session lends itself very well to this as we can give patients information relevant to their needs at the point of the review. They are often offered further information and support through the post of information and support radiographer, patients can also be referred for psychosexual support if required. NICE recommend that men and partners/carers are adequately informed of the effects of prostate cancer on their sexual function, physical appearance, continence and other aspects of masculinity and that we support them in decision making, taking into account the effects on quality of life as well as survival. As one of the treatment options for men with prostate cancer will be a course of hormones this guidance is key. Some of the side effects of hormones can be of a sensitive nature and not all patients will want to discuss these symptoms. It is important for patients and their partners to be aware of all side effects and to know that help is available if they decide to avail.

Patient Centred Care Radiographer–led review can help to ensure patient-centered care by using their experience and skills. One of the purposes of The Radiographer Review Protocol** states“As allied health care professionals we recognise the principles of skill mix will apply to ensure effective, efficient and safe care of patients, ensuring that our individual skills complement each other in order to maximise the benefits to patient care and optimise the use of resources”.

In the nice clinical guideline The Patient experience in adult NHS services: improving the experience of care for people using adult NHS services** it is explained and advised that treatment and care should take into account individual needs and preferences. It is suggested that patients should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals.

With time constraints on clinics, it is important to try to get to know patients as individuals, patients value this acknowledgment as their individual needs can vary greatly and also the way in which each person can experience a condition differently can impact lives differently.

Whilst providing clinical information and support for side effects, another support is also offered if appropriate such as counseling, help with expenses transport. NICE explains how we should ask patients about their domestic, social and work situation and consider how each of these might be impacted by a diagnosis or treatment and how it may affect their ability to make decisions about their care or how they might self-manage. This also brings back the issue of patients making decisions for themselves and deciding at which point they need to accept support if at all.

The department of health produced a framework which outlines elements which are important to patients’ experience of the NHS. The NHS Patient Experience framework**. Respect for patient-centered values, preferences, and needs. These include cultural issues, the dignity, privacy and independence of patients, an awareness of quality-of-life issues and the importance of shared decision making. It is import to ensure patients have information, communication links, and educational progress, prognosis, and processes of care in order to facilitate autonomy,self-care and health promotion. We should welcome the involvement of family and friends who patients rely on for decision making. Patients should all have access to attentive care, for example, we should be aware of placing a patient in the waiting room and the waiting time for the radiographer-led reviews.

As radiographers, there is documentation in place to protect ourselves practitioners but also to protect patients as users of the service we provide. The score Code of Professional Conduct** places an expectation upon us to practice in a manner that is based on respect, empowerment, empathy, trustworthiness, integrity, and justice. It also places an importance on us to maintain the public’s trust and confidence in our profession.

Legally there are also many aspects to consider and autonomy and scope of practice are discussed throughout the document and are useful in supporting radiographerswishing to attain the radiographer-led review competency. Section one of the code refers to providing the best care for patients based on up to date evidence, this highlights the importance of evidence-based practice and is why the radiotherapy service develops at the rate which it does with roles such a review radiographer.

Section2 of the code of conduct highlights the importance of working within your scope of practice with current legal, ethical, professional and governance frameworks pertaining to role and workplace, one example of this would be the Health andCare Professions Council (HCPC). For HCPC registration it is essential to provide evidence of continuous professional development (CPD) if required, this provides a means for assessing competency to practice. Working within the scope of practice should also bring an awareness of limitations in a particular role. Knowing limitations when reviewing patients is important in order to deliver patient-centered care but also to be working in a safe manner and seeking help when necessary.

Section3 discusses the need to keep records current and accurate and ensure that they are completed honestly. One of the aims/objectives of the radiographer reviewprotocol5 is to document all details from the consultation clearly. Documenting information from reviews can be seen as just a communication tool between staff or the wider MDT but actually is much more important than that, annotations can protect the patient and prevent them from coming to any harm but conversely, it can protect the reviewer. All things discussed should be annotated, this is extremely important when the radiographer may review over twenty patients in a session, it would be nearly impossible to remember all the details of each individual reviewer.

As mentioned before, the increasing incidence of cancer diagnosis’ has led to an increase in the number of patients requiring or opting for radiotherapy. The older on-treatment review protocols no longer met the standards expected, the needs of patients or the radiotherapy service and now current on-treatment review systems are being stretched to meet increasing needs. This shows a need for more radiographers to be put through a formal training program and be qualified to review patients as per departmental protocols.

Having more staff trained in radiographer-led review comes in line with role development/ extension as well as CPD as expected by CPC, this role can then be further developed for example with the role of supplementary prescribing.

The current government healthcare policies on cancer care all strive for staff to deliver a service of excellence and that patients receive optimum management of their disease. Radiographer-led review aids the radiotherapy department in meeting the corporate objectives set by the Belfast trust and the TYC document by using the knowledge and skills of radiographers and developing them through post-graduate qualifications. It also means we can streamline the patient's care pathway and provides a high-quality service with a high level of patient-centered care. Continuity of care is easily implemented in the radiotherapy department too due to the forward planning of staff rotas and the continuity of clinic rotas.

At the moment in the Northern Ireland Cancer Centre, patients who opt for prostate brachytherapy are followed up with a phone-call three months after treatment. Considering the PSA level is ultimately what is used for monitoring patients, these post review phonecalls might be something which could be implemented for radiotherapy patients in the future. In turn, this might help to reduce long waits for oncology review appointments post treatment and will again alleviate the time and pressure constraints on our oncologists.

As mentioned in the discussion, communication plays a large part in the overall radiographer-led review process. Information is continually passed from staff to patient for treatment preparation, any expected treatment reactions and information on hormone therapy and the side effects of these. Communication in this situation is a two-way street and it's important that the patient feels comfortable and confident to discuss any problems they are having in relation to any aspect of their treatment. Empathy and approachability are great skills to develop further and patients appreciate that we may have more time to spend with them than an oncologist. When issues arise with patients which are outside the scope of practice of a radiographercompetent in reviewing patients, it is necessary to be confident in communicating clearly with other healthcare professionals and oncologists. Knowing when to refer a patient to another member of the multi-disciplinary team such as the information and support radiographer is vital.

Currently, in the Belfast Trust, it is necessary to undertake a post-graduate module in radiographer-led review in order to become competent to carry our reviews. This is not the case in all departments across the UK, but it is a good standard to adhere to. As state of the art cancer treatments is continually being researched and developed to allow for dose escalation such as the move from conformal radiotherapy to IMRT and now to VMAT, we are continually updating our scientific and practical knowledge in line with these modernizations and attend various courses and information session to aide further development.

Prostate and breast cancer patients are currently the only sites which are covered by a radiographer-led review in Belfast but a long-term goal would be for the in-house training program be rolled out fourth and to cover other sites such as lower gastrointestinal cancers. This would again aim to reduce the pressure on clinical oncologists and would help to streamline the service whilst providing a high-class service and further continuity of care.