Advanced Practice radiation therapy roles: where is the evidence?

This month’s blog is a response by Amanda Bolderston to October’s paper by Hilder et al.  Amanda is a faculty member at the University of Alberta’s Radiation Therapy Program and has been involved in the development of Canadian advanced practice (AP) roles in radiation therapy for longer than she cares to remember.

AP roles have developed in several countries, including the UK, Australia and Canada*. Hilder, Vandam and Doherty’s JMRS paper outlines the Australian context for AP roles – defined in the paper as “working beyond one’s traditional scope of practice underpinned by expert evidence based knowledge” (p. 138).

There are several commonalities between the countries in terms of principles of practice. In the UK Advanced Clinical Practice is defined by Health Education England (HEE) as “four pillars of clinical practice, leadership and management, education and research, with demonstration of core capabilities and area specific clinical competence”.  The four elements of the radiographer advanced practice and consultant roles (defined by the Society and College of Radiographers/Department of Health) are expert clinical practice, professional leadership and consultancy, education training and development and practice and service development, research and evaluation.

The Canadian definition doesn’t refer to “pillars” but looks at “principles” of improved patient outcomes, critical thinking, complex decision making, autonomy of role and leadership. The Canadian Association for Medical Radiation Technologists (CAMRT) AP competency profile is based on clinical and technical expertise, leadership, research and evidence based practice and education. Australia’s seven “dimensions of practice” are expert communication, internal and external collaboration, high level of professionalism, advanced clinical expertise, high level of scholarship and teaching, professional judgement based on evaluation of evidence and clinical situation and clinical leadership.

Hilder, Vandam and Doherty’s JMRS paper provides a useful scoping exercise of the last 12 years of about 50 papers, conference abstracts and reports related to the Australian advanced practice radiation therapist role.

It would be useful to carry out a similar scoping review for the UK and Canadian context but for a (VERY) rough comparison a search was conducted for published journal articles and conference abstracts using “advanced practice” in the title, abstract or keywords. JMIRS (Canada) indicates 18 radiation therapy  papers, mostly single-institution studies. There were very few papers about AP in diagnostic imaging. For Radiography (UK) using the same search boundaries there are many more papers about diagnostic imaging AP roles, and only four identified about radiation therapy specifically (but about 20 broader papers looking at AP frameworks, research or education in general).

While this approach is obviously flawed and subjective (looking at titles only) it demonstrates a number of common issues. Actual evidence for radiotherapy roles is fairly sparse – and mainly limited to conference abstracts, not published papers.

This is worrying for a few reasons. One is that research is embedded in all AP roles in all three countries. Rachel Harris’s doctoral work has demonstrated the difficulty many AP practitioners have in actualizing their research roles and it is very well documented that ALL practitioners aspiring to research face barriers in terms of time away from clinical duties. Another cause for concern is that we need research to show the impact of these kinds of roles, both for the profession and for individuals and departments looking to implement them.

There may be a few more reasons why the literature doesn’t demonstrate fully “that the gaps in service have been addressed, that service delivery, and patient care has been improved” (Hilder, Vandam and Doherty, 2018, p. 145):

1. Lack of an academic professional culture – our radiation therapy education has only fairly recently moved to an undergraduate degree, Masters level education is relatively new (depending on the country) and doctorally prepared radiation therapists are still quite sparse. It takes decades to change a professional culture and embed scholarly competence. In addition, we need to grow necessary infrastructure (peer reviewed meetings, journals, etc.) that along with our professional growth.
2. Much of the work that we do is essentially “unfunded” in that we may have dedicated funding to accomplish something clinical, but there isn’t much dedicated time to conduct research or write up findings. We don’t often attain high level research grants that cover publication and dissemination costs.
3. We rely mainly on single institution studies – we tend to be quite silo’d (both within our own countries and internationally). Most of studies that we do to demonstrate results of these roles are “one off” studies. These isolated results can rarely show the success of an individual in a particular role in a specific centre. It’s very difficult to influence decision makers with that kind of evidence.  What we need to do is collaborate better, adopt/adapt consistent methodologies and develop multi-institutional projects.

So, despite decades of work on advanced practice roles we still have pretty limited evidence to support them. We know they work! Let’s get publishing!

*Other countries have AP roles but I am looking at these three for convenience

Thank you to Nicole Harnett for her input into this blog – particularly the last section on radiation therapist scholarly competency etc.

She’ll be expanding on this at LTWRAP as the Canadian keynote speaker in her talk “The advanced practice journey in Canada: how old am I anyway?”

 

 

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