Doc menu

11. Analysis and Evaluation of Qualitative Data

11.1 As described in 7.2 above, facilitated workshops were held to enrich the survey data with qualitative information from practitioners already in post. The workshop topics had been pre-identified by the project team to obtain participants’ views about their specific role in the care and treatment pathway for men with prostate cancer, using the domains of advanced/consultant practice. 

11.2 The chance was also taken to identify particular expertise and resources that might contribute to a sustainable online forum. At the end, existing prostate/urology specialists were asked for their thoughts about what the service would lose if their role did not exist. 

11.3 Table 7. Workshop attendances 

Date

Number Invited

Number Attended

Number of Centres represented

04.03.15 (London)

10

10

9

17.03.15 (Manchester)

11

7

5

26.03.15 (Information, support & review forum, London)

13

13

12

Total

34

30

 

11.4 Key relationships

The multi-disciplinary team (MDT) approach to managing and optimising patients’ care and treatment pathways has become embedded in cancer services. Therefore the workshop participants were asked about which relationships they perceived to be vital in making the specialist role work. The team heard that the prostate/urology specialist radiographer role tends to be quite unique; the post holder has to work independently and may feel isolated from time to time. The following professionals were identified as those with whom prostate/urology specialist radiographers have or may need to form sound relationships:

  • Clinical nurse specialists (CNSs)

Relationships with CNSs were seen as key and complementary. The CNS role is well-established and they were viewed as allies and sources of knowledge and expertise. However, participants were of the view that not all CNSs understand the full impact of radiotherapy and so there are opportunities for mutual educational support. It was agreed that this relationship works best when respective roles are clearly defined and mutually understood. 

  • Consultant oncologists

Initially clinical oncologists were the key personnel because their support for undertaking specialist role development was vital since these were delegated clinical roles. Those specialist therapeutic radiographers in post stated that the roles are strongly supported by their oncologists particularly as they are beneficial in freeing up oncologist time.  

  • Oncology registrars  

Participants felt somewhat ambivalent about the presence of oncology registrars with whom they may compete for oncologists’ tutorial time at the same time as making a significant contribution to registrars’ education and development with both technical support and the provision of advice for patient management. Some prostate/urology specialists also support medical students’ clinical education.

  • Professional supervisor 

Despite SCoR advice about its importance to developing autonomous roles, few practitioners received professional supervision and most were ambivalent about the value of it. There was no engagement with additional academic supervision within the groups. Some individuals felt that professional supervision would not impact positively on their practice, however consultant practitioners present did engage with this process.

  • Pharmacy manager

Prostate/urology specialist radiographers identified their need for a sound relationship with the pharmacy manager in terms of implementing patient group directions, supplementary prescribing and prescribing policy.

  • Other hospital departments

These were also seen as sources of advice and expertise; for example, gastro-enterology for patients with long term malabsorption conditions or where proctitis endoscopy is indicated.

  • Primary Care

General practitioners are the primary carers of men with prostate cancer during their patient journey and beyond. In addition, practice nurses undertake much routine monitoring of patients in the community. Forging links with primary care to support the education of these professionals and to advise on patient management for all aspects of radiotherapy was seen as important but the majority of participants felt that their primary role was taking up most of their time and that they were too busy to look beyond the cancer centre to form external relationships.

  • Specialist charities 

Resources, support and services from the charitable sector such as Prostate Cancer UK and Macmillan were mentioned by participants as valuable sources of support for informing and preparing patients for treatment.

  • Service users

Participants recognised both the value and the difficulties involved in engaging service users in an authentic way in cancer service evaluation and development. A couple of participants mentioned having a patient representative for meetings and dialogue with the local cancer service users group.  Another specific example was given of ‘Macmillan Volunteers’ active within the clinical environment and trained to NVQ – level 4. 

While the research phase did incorporate a number of interviews with other key professionals eg a clinical nurse specialist and clinical oncologist, the study focused primarily on the views of therapeutic radiographers. A follow-up piece of work to help understand the role and value of these site-specialists could be carried out to examine how other professionals experience these roles and what they believe they bring.

Case Study 3 – Amanda Ford

I qualified 33 years ago as a therapeutic radiographer at a large dedicated oncology hospital in the north of England with a state of the art radiotherapy department. Moving regularly during my career has provided varied roles, a wealth of experience and some amazing opportunities, including becoming superintendent of a newly-built, small department at the age of 25. I have also managed a brachytherapy department, a mould room, been superintendent of planning and research and development.

In 2001 I took up my current role as a Macmillan information and support radiographer, later called Macmillan radiotherapy specialist. I have two passions; patients, including patient experience care and communication, and raising the profile of therapeutic radiographers and educating others about their capabilities in supporting and caring for cancer patients. This role gives me the opportunity to pursue both.

My new Macmillan role was a blank page; developing multi-disciplinary teams, patient pathways and meeting huge unmet needs for both patients and the service were (and still are) the order of the day. This has involved collaborative working with many newly appointed CNS nursing colleagues and multi-disciplinary teams (MDTs).

I identify my patients at MDT meetings; any patient who is going to be offered radiotherapy as a treatment option. I see them at first diagnosis, support them through the decision making process and, if they do opt for radiotherapy, support them through the treatment and on into survivorship. Giving patients the knowledge and confidence to understand, be involved, take control and self-manage is an amazing reward.

Obtaining recognition and respect as an allied health professional in this field has been an ongoing challenge. Being told I couldn’t do something because I wasn’t a nurse has only served to drive me forward. I truly believe it’s not where we come from or our label but the underpinning knowledge and skills we obtain along the way and our capabilities that count.

11.5 Scope of practice and service development 

11.5.1 Participants were next asked to articulate their views about the scope of their roles and opportunities for role and service development. The project team heard that all workshop participants occupied substantive posts with detailed job descriptions, which they regarded as essential to the success of the role. They identified strongly with the need for specialist radiographers to have clearly defined roles linked to a specific job grade/pay band and with job plans that include a proactive training programme.  Participants also identified the need for clearly defined inter-professional boundaries. 

11.5.2 Prostate/urology specialists are designated as advanced or, in some cases, consultant practitioners and are (being) educated to master’s level. Although job content is variable and tends to be in response to service need, the core functions of the role were unanimously agreed by all; the clinical aspect of which is as the key worker for men with prostate cancer having complex, advanced radiotherapy within a multi-disciplinary pathway. 

11.5.3 Practitioners were concerned about a perceived lack of succession planning, including managing the day-to-day issue of cover if post holders were sick or on annual leave. The role-holders typically work independently and there is generally no WTE built in for sickness or annual leave and no one to cover these standard absences. This can mean that the patient is left unseen, clinics and appointments are delayed or postponed, or support comes in the form of a non-specialist. It also results in the post holder experiencing a challenging increase in their workload before and after these periods.

11.5.4 Sustainability for new role development is vital yet there was no concrete evidence that succession planning for prostate/urology specialist roles is being undertaken. If the prostate/urology specialist radiographer role is to become as widely accepted as the clinical nurse specialist, then this needs to be addressed urgently by those who are responsible for workforce planning and staffing profiles in cancer centres.  

11.5.5 The ability to prescribe medicines was seen as necessary in relation to the current scope of practice, in the interests of efficiency, to optimise patients’ experience of the treatment pathway and for their own job satisfaction. However, most practitioners were content with patient group directions (PGDs) or supplementary prescribing and were ambivalent about becoming independent prescribers although they saw advantages of timeliness and efficiency in becoming supplementary prescribers, provided that the infrastructure and educational frameworks were in place to support this development. Consultant practitioners present could see the advantages of independent prescribing. The outcome of the NHS England Allied Health Professions project on independent prescribing, which includes radiographers, is awaited.25

11.5.6 Where the prostate/urology specialist role should begin and end was also disputed. Not all the practitioners were able to attend the multi-disciplinary team (MDT) meeting, but those who did were in no doubt of its value and importance as the starting point of the specialist key worker role. Participants agreed that the ideal beginning point should be attendance at the MDT meeting where the patients’ treatment plan is decided. This would give the opportunity for continuity and relationship building. However, not all participants were afforded this opportunity.

11.5.7 There was anxiety about where the role should end. Most see the natural end point as discharge from radiotherapy, although they recognise that survivorship issues and the way in which cancer has become a long term condition mean that their skills and expertise could be extended beyond discharge from the service. The question was asked whether support beyond the end of radiotherapy is sustainable in practice. It was also pointed out that this is likely to depend on the working practices and staffing profile of individual cancer centres. There is scope for further exploration of this issue and who is best placed to provide follow-up care.

11.5.8 There is a natural human desire to have control over one’s work and the open-ended possibilities of engaging with community-based services provoked anxiety about sustainability of the role. However, the key worker role entails co-ordination of professionals and services around the needs of patients and, given the paucity of knowledge about radiotherapy outside the profession, this is a key issue for the specialist workforce to address, particularly when considering management of problems such as late effects of pelvic radiation.

11.5.9 The widely held negative view of the value of professional supervision among the practitioners who attended the workshops is of professional concern. The radiography profession has long felt that, once qualified, practitioners do not need further supervision and it has mainly been resistant to appreciating the benefits that other professions value. Despite having professional guidance since 2003, updated in 2013,26 the SCoR has made little impact on this. Yet, with continuing professional role development and a scope of professional practice that does not define specific limits, there is little doubt that radiographers would benefit from regular, professional supervision. Those who receive it generally recognise its value, which suggests that the SCoR should take this forward.

11.5.10 In summary, this analysis of the scope of professional practice of those present at the workshops, together with job descriptions submitted by service managers, could be used to develop a model role descriptor to assist centres with making a successful business case for having a prostate/urology specialist role.  It would also enable the potential for a more uniform approach to the development of the roles and their easier introduction while recognising that there needs to be scope for tailoring to meet local need and service set-up.

11.6 Education and training 

11.6.1 Participants discussed educational and training needs necessary to support and develop practitioners in undertaking their roles, both in terms of developing their own expertise and the need to be a clinical leader and resource for others.  However, the team learned that the need to identify and prioritise sources of funding for further training and development of the role at a time of severe financial constraints was problematic.  This was linked by those present to the need to identify measurable outcomes and evaluate the benefits of the service being provided.

11.6.2 The following education and training issues were discussed:

  • Provision of prostate/urology specific MSc or relevant modules. It was reported that funding is generally available for individual M-level modules that meet service need rather than the complete MSc award.
  • A mixed provision for review and consent modules, with a combination of in-house and HEI programmes was highlighted as a good model. The opportunity to undertake in-house content and achieve academic credit through work-based learning modules was favoured by participants. 
  • As clinical leaders in their fields, prostate/urology specialist radiographers need to share their knowledge and expertise within cancer centres and out into the community. This can be a challenge due to time and resource pressures. 
  • Opportunities for targeted higher education masterclasses were proposed. 
  • A prescribing qualification would be beneficial, if not essential for all specialist role holders.

11.7 Opportunities for research

11.7.1 Research is a core domain of advanced and consultant practice. Prostate/urology specialist practitioners are in advanced or consultant posts and are required to seek opportunities to undertake or become involved with research about prostate cancer, including making the role  of prostate/urology specialist practitioner as effective as possible.  While the need for research is well understood, it seems that opportunities are not being grasped. 

11.7.2 There is an urgent and specific need to evaluate the impact of the role. The main reasons for implementation of posts were described in 8.7. They were; to improve service quality, manage the increasing workload, improve skills mix, provide radiographer development opportunities and provide a more efficient service. At the present time, there is little or no evidence that any of these important aims are being realised. In addition, prostate/urology specialist radiographers are ideally placed to lead research that is focussed on the development of radiotherapy practice, both technical and relating to patient experience. Where roles are funded externally, there can be more impetus on recording evidence of impact; the Prostate Cancer UK funded post will report back on completion of the project.  

11.7.3 Specialist practitioners must be able to demonstrate their value and the online community forum should make addressing this a priority. 

11.7.4 Specific potential research topics identified were: 

  • evaluating the impact of specialist therapeutic radiographers on the patient experience;
  • the opportunity for multi-centre audit on patient experience of interaction with radiotherapy services;
  • a cost benefit analysis of the specialist role to assess areas such as value for money, impact on clinical oncologists’ time, impact on staff development, introduction of new techniques. 

11.8 Professional accreditation 

Practitioners could identify and speak about their education and training needs at postgraduate level, their responsibilities in relation to the education and training of others, their role in leading clinical innovation and service development, and the need for research to underpin their professional practice. This information suggests that there is a significant opportunity for the SCoR to promote its professional accreditation process to this group of specialist practitioners as a means of embedding and sustaining role development and autonomous practice.

11.9 Challenges to further development of prostate/urology specialist radiographer posts 

Workshop participants were asked what they thought were the barriers to further development of posts to embed them in many more cancer centres. They identified the following issues as significant:

Lack of expertise in the successful development of the business case for specialist roles;

  • Production of PGDs in relation to effectively managing treatment- related toxicity;
  • Specialist posts can be seen as more costly. There is no reliable evidence but there is some anecdotal indication that there is a cost saving compared to a similar provision by oncologists;
  • Oncologists may be reluctant to undertake the necessary development of specialist radiographers alongside their commitment to registrar training;
  • Lack of succession planning for provision of the role at the planning and implementation stage;
  • Lack of engagement with the role from the wider radiotherapy team;
  • Workload pressure in cancer centres;
  • Demonstrating sufficient numbers of patients to justify the specialist role.

11.10 What would the service lose if your role no longer existed?

The study shows that there is a paucity of hard evidence to demonstrate impact but we asked practitioners what they thought about the value of these roles. In thinking about the benefits of their roles, practitioners were asked to consider what would be lost if their role did not exist. They listed the following, which can be grouped into two elements – patient experience and clinical expertise: 

  • expertise and compassion
  • relationship with patient
  • ‘accompaniment of patient along road’
  • patient advocacy
  • tools for audit / research
  • prevention of side effects
  • knowledge about the trajectory of late effects

11.12 Online forum

An important objective of the project is the establishment of a sustainable online community forum. Participants were asked what benefits this might bring and also what resources would be helpful. Post holders described some professional isolation and workload/caseload pressures. Some mentioned that these research events were the first time that they had been brought together with their peers in similar site specialist roles. Participants were enthusiastic about the creation of an online forum with virtual learning platform, supported by the SCoR.  They saw it as both a supportive community of practice and also a place where resources could be made available. There remained a desire to meet face-to-face periodically in order to network, share and discuss prostate work.

The groups specifically identified the following potential benefits and characteristics of the online space for prostate practitioners:

  • to give access to a toolkit of resources
  • to support the creation of shadowing opportunities
  • to enable a ‘buddy-up’ system for research opportunities
  • to provide access to virtual learning platforms – signposting as appropriate
  • to help develop and provide a competency framework, mapped to existing SCoR guidance
  • to provide a forum to identify issues and then propagate further discussion via face-to- face networking meetings
  • to hold guidelines and best practice
  • to share information about funding opportunities eg  Macmillan funding for brain and bone metastases specialist consultant roles
  • to hold information relating to prescribing and planning 
  • to provide an opportunity for members to reflect on and articulate the value of the service and their role within it
  • to include a Frequently Asked Questions (FAQ) section

11.13 Progress with implementation of the online forum 

The initial development of the online community forum is almost complete and due for launch at the same time as the project report. This will be password protected and reside on the SCoR members section of the website. It is currently being populated with useful resources, including sample job plans, education and development quick guides, patient experience tools and useful contacts. 

A facilitated blog to identify community functionality and key features will support the launch. There will also be a monthly guest blog to highlight relevant news from Prostate Cancer UK. The forum has undergone testing by ‘critical friends’ involved with the project prior to launch. 

This online solution is also customisable and enables teams and individuals to be members of one or many groups while keeping in touch with dynamic projects by means of instant notifications. A full audit trail of versions, updates and comments, tasks, discussions and other project information makes it easy for new members to join teams and have all the information easily accessible.

Content tools

Accessibility controls

Text size

AA A

Colour