Patient perceptions of advanced practice radiation therapists prescribing medication in radiation therapy.

INTRODUCTION: The purpose of this study was to determine patient perceptions of an advanced practice radiation therapist (APRT) prescribing medication for radiation therapy treatment-related side effects. By comprehending patient perceptions, it is important to implement change in order to improve patients' quality of life. METHODS: A literature review was conducted on advanced practice (AP) roles in Canada and world-wide; the roles searched were: APRT, nurse practitioner and pharmacist. The search focused on evidence demonstrating improvements made to patient care due to the implementation of these roles. Based on this review and input from a team of experts a qualitative semi-structured interview survey was designed, and pilot tested. The survey consisted of five open-ended questions, which were designed to determine patient satisfaction of an APRT prescribing medication over the course of their radiation therapy treatments. Patients undergoing head and neck radiation therapy treatments at a large, academic cancer centre were invited to participate. Six patients who had a head and neck APRT involved in their treatment were interviewed. A comprehensive thematic analysis was then conducted using the transcripts created from these interviews, which was followed by two independent blinded analyses to ensure validity of the results. DISCUSSION: The thematic analysis produced four salient themes which were: side effect management, care provided by the APRT in comparison to other healthcare workers, patients' access to care, and overall patient satisfaction. Common medications for head and neck radiation therapy treatment related side effects were discussed and these were: Magic Mouthwash, Xylocaine, Nystatin, Benadryl, Advil, Tylenol, Dexamethasone, Tantum, Biotene, Mucaine, Flamazine, Hydrocortisone, Ondansetron, Senokot, and narcotics. CONCLUSION: This study was valuable to understand patient experiences and provide evidence to change processes in order to improve quality of patient centered care. The study revealed that although patients were happy with the process of prescribing medication, they all agreed that having an advanced practice radiation therapist prescribe would improve care. Patient responses further demonstrated the need for future research in regards to side effect management as a whole by APRTs as well as how role clarification can impact patient perceptions of APRTs.

To prescribe or not to prescribe? Perceptions of radiation therapists prescribing medications for common radiation therapy side effects.

BACKGROUND: During radiation therapy treatments patients may require medications to manage radiation toxicities. Since patients are assessed daily by Radiation Therapists (RTs) it would be optimal and timely for patients to receive medication prescriptions for relief of common radiation side effects from the RTs. OBJECTIVES: The purpose of this study was to determine the perceptions that RTs and Radiation Oncologists (ROs) have of frontline treatment RTs prescribing medications to patients for treatment-related side effects. METHODS: A qualitative and quantitative survey consisting of twenty-five questions on a five-point Likert scale, one open-ended question, and three demographic questions was designed. While the survey sought to examine the perceptions that RTs and ROs have of RTs prescribing medications, the survey also proposed eight different medications that RTs could potentially prescribe. The medications that were proposed are commonly prescribed to radiation therapy patients and included anti-emetic, topical anti-bacterial, hydrocortisone cream, topical anaesthetic, anti-diarrheal, anti-spasmodic, urinary analgesic and anti-fungal medications. After the survey was approved by the Research Ethics Board, RTs and ROs at a large, academic cancer centre were invited to complete the survey. To analyze the survey results, several statistical tests were performed separately for the RTs' surveys and the ROs' surveys. The chi-squared test was used to determine if the sample RT and RO populations were representative of the actual RT and RO populations (p < 0.05). Additionally, the Sign test for medians was used to analyze statistically the responses to the Likert scale questions (p < 0.05), while the Kruskal-Wallis test was used to compare the responses to the Likert scale questions across the demographic groups identified in the demographic questions (p < 0.05). RESULTS: The response rate was 34% (31/90) for the RT population and 42% (10/24) for the RO population. The statistical analysis of the RT population's surveys showed that the majority of the RTs shared positive perceptions towards having RTs prescribe medications, while some respondents highlighted negative perceptions in the open-ended qualitative question. The majority of the RTs agreed that RTs should prescribe five of the eight proposed medications, excluding anti-spasmodic, urinary analgesic, and anti-fungal medications. In contrast to the RTs, there was no statistically significant consensus from the ROs on RTs prescribing medications. Furthermore, the ROs had varying opinions on RTs prescribing the eight proposed medications. CONCLUSIONS: Although the sample size in this study was small, the results from the RT population's surveys supported RTs prescribing medications. The positive results from the RTs and the equivocal response from the ROs suggest that future research should be conducted. Additionally, a future pilot study could be implemented where RTs prescribe one or more of the five medications that were supported to prescribe by the RTs. By having RTs prescribe medications to patients in a pilot study, the effectiveness on patient care could be measured.

Staffing Levels and Workload for Radiation Therapists in Canada.

PURPOSE: The safe delivery of radiation therapy is dependent in part on the provision and organization of oncology professionals. General recommendations for staffing of radiation oncologists, medical physicists, and radiation therapists have been published, but most of these provide little detail, especially in the case of radiation therapists (RTs). In Canada, there are no guidelines or national standards for the staffing of RTs, and there is a paucity of Canadian data on the existing staffing levels of RTs and the models used to establish these levels. This project sought to identify and compare the staffing models used for Canadian RTs, and the staffing levels and workload resulting from these models. METHODS AND MATERIALS: In January 2016, a survey was sent to managers of the 46 radiation treatment centres in Canada. This survey sought information on a range of staffing and practice variables for the fiscal year 2014/2015. Respondents were requested to provide the staffing model used for RTs at each centre and enough additional information to calculate the staffing levels and workload resulting from their staffing model. The survey included further variables that had the potential to influence staffing levels and workload, and centres were compared to establish if these variables did indeed impact staffing. RESULTS: Of the 46 centres contacted, 37 centres responded, representing an 80.4% response rate. Survey results showed there are a variety of ways used to determine staffing across the country. Twenty of the 37 responding centres include some type of workload measurement in their staffing model, whereas 17 centres base staffing solely on historic levels or operating funds. There is a great deal of variation in the staffing levels and workload of RTs in Canada, with staff at some centres planning and treating twice the number of patients as RTs at other centres. Radiation therapist staffing levels at most radiation treatment centres in Canada are below the level recommended in recent publications. Differences in staffing levels or workload could not be accounted for by treatment complexity, number of specialty programs, use of relief staff, or number of RTs working in specialty nontreatment roles. CONCLUSIONS: A high degree of variability in staffing levels and workload exists for RTs in Canada, which is not explained by differences in patterns of practice. It is likely that workload for RTs exceed safe levels at some Canadian centres. It is recommended that treatment centres use an up-to-date staffing model for RTs and continue to review staffing levels at regular intervals.

Salicylate enhances the response of prostate cancer to radiotherapy.

BACKGROUND: Radiotherapy (RT) is a key therapeutic modality for prostate cancer (PrCa), but RT resistance necessitates dose-escalation, often causing bladder and rectal toxicity. Aspirin, a prodrug of salicylate (SAL), has been associated with improved RT response in clinical PrCa cases, but the potential mechanism mediating this effect is unknown. SAL activates the metabolic stress sensor AMP-activated protein kinase (AMPK), which inhibits de novo lipogenesis, and protein synthesis via inhibition of Acetyl-CoA Carboxylase (ACC), and the mammalian Target of Rapamycin (mTOR), respectively. RT also activates AMPK through a mechanism distinctly different from SAL. Therefore, combining these two therapies may have synergistic effects on suppressing PrCa. Here, we examined the potential of SAL to enhance the response of human PrCa cells and tumors to RT. METHODS: Androgen-insensitive (PC3) and -sensitive (LNCaP) PrCa cells were subjected to proliferation and clonogenic survival assays after treatment with clinically relevant doses of SAL and RT. Balb/c nude mice with PC3 xenografts were fed standard chow diet or chow diet supplemented with 2.5 g/kg salsalate (SAL pro-drug dimer) one week prior to a single dose of 0 or 10 Gy RT. Immunoblotting analysis of signaling events in the DNA repair and AMPK-mTOR pathways and lipogenesis were assessed in cells treated with SAL and RT. RESULTS: SAL inhibited proliferation and clonogenic survival in PrCa cells and enhanced the inhibition mediated by RT. Salsalate, added to diet, enhanced the anti-tumor effects of RT in PC3 tumor xenografts. RT activated genotoxic stress markers and the activity of mTOR pathway and AMPK and mediated inhibitory phosphorylation of ACC. Interestingly, SAL enhanced the effects of RT on AMPK and ACC but blocked markers of mTOR activation. CONCLUSIONS: Our results show that SAL can enhance RT responses in PrCa. Salsalate is a promising agent to investigate this concept in prospective clinical trials of PrCa in combination with RT.

Patterns of Practice in Canadian Radiation Treatment Centres: Results of a National Survey.

PURPOSE: Radiation therapy has changed rapidly over the past decade due to the application of technological advances. A survey was conducted of radiation treatment centres in Canada to establish current patterns of practice across the country. Areas of inquiry included treatment techniques and image verification, as well as roles and responsibilities of radiation therapists (RTs). METHODS AND MATERIALS: In January 2016, a survey was sent to managers of the 46 radiation treatment centres in Canada. This survey sought information on a range of staffing and practice variables for the fiscal year 2014/2015. RESULTS: Of the 46 centres contacted, 37 centres responded, representing an 80.4% response rate. Survey results showed that the use of volumetric arc therapy and intensity-modulated radiation therapy is common across Canada for several anatomic sites, as well as the use of daily pretreatment image verification. A high degree of variability exists for imaging modality (two dimensional vs. three dimensional) for some sites, including brain, head and neck, and lung. RTs' responsibilities have expanded uniformly across the country, with RTs involved in organ-at-risk contouring and on-treatment image approval at the majority of centres. Despite this role expansion, specialty roles in areas of quality and applications expertise are still rare. CONCLUSIONS: Radiation therapy in Canada has transitioned to high-technology treatment techniques with relative consistency across the country. There is, however, variation in the imaging modality used for daily verification. Canada may benefit from consensus guidelines on the application of three-dimensional imaging for treatment verification. While RTs have expanded their responsibilities, role definition for RTs working in supervisory or supporting positions has not kept pace at many centres and it is unclear if RTs are supported in their expanded accountabilities.

Virtually Certified: Development of an Online Oral Examination Phase for a National Advanced Practice Certification Model for Radiation Therapists in Canada.

Following development of a framework to establish the scope of advanced practice for radiation therapists (APRTs), a Canadian certification process was built. This involved three independently-assessed phases: professional portfolio, case submission, and oral examination. The oral examination was to test the candidate's knowledge and capacity for decision-making. Development and piloting involved 3 elements: 1) content development, including relevant case selection, with accompanying high-fidelity imaging and resources; 2) harnessing of technology and ensuing logistics, given the desire to offer the examination online, maximizing accessibility and minimizing resources; and 3) examiner recruitment and preparation, involving a national call for interprofessional examiners, to assess across the spectrum of competencies. Each element was approached systematically, with modifications made iteratively. Three overarching challenges required ongoing attention and consideration: resource-intensiveness of building and validating cases, ensuring applicability and relevance of case content and "answers" across practice environments, and preparation of non-radiation therapist (oncologist and physicist) examiners regarding APRT standards. The resultant examination model is thought to be a robust assessment tool, well-regarded by candidates and examiners as fair and transparent, and complementary to the other certification phases. A consultatory pilot process supported establishment of a robust framework that is believed to be defensible and preliminarily valid.

Preferences in Learning Styles and Modes of Information Delivery in Patients Receiving First-Day Education for Radiation Therapy.

PURPOSE: The primary objective of this study was to determine levels of patient satisfaction with current first-day teaching practices at a large, academic Canadian Radiation Therapy Department. A secondary objective was to investigate patient preferences in learning styles and modes of information delivery. METHODS: A literature review was conducted on learning styles, modes of information delivery, and patient education in radiation therapy. Based on this review, a quantitative survey was designed to evaluate patient preferences. Inclusion and exclusion criteria were generated to select participants. The study population included 21 patients with prostate cancer and 24 patients with breast cancer. The surveys were distributed for a 2-week period. The Sign Test and Kruskal-Wallis Test were used to analyze the data. RESULTS: The results revealed that patients significantly disagreed with the use of group sessions and strongly agreed with sit-down, one-on-one sessions and the use of supporting print material. Patients agreed with the use of a combination of teaching methods. Male participants more frequently strongly agreed with the use of videos to support educational practices. Significant results were found on preference for visual and kinesthetic learning. Overall, participants agreed that teaching sessions reduced anxiety. CONCLUSIONS: Radiation therapists are encouraged to continue with current teaching practices since patients reported high levels of satisfaction. The results of this study indicate that a combination of teaching methods including visual aids and videos for male patients may be of benefit. Therefore, to further strengthen teaching sessions, the use of a multimedia tool can be investigated in the future.

12-hour Shifts for Radiation Therapists.

BACKGROUND: In Canada, Radiation Therapy program hours have ranged between 8 and 10 hours a day. Some centres have an option of a 4-day, 10-hour-day workweek. In 2012, Cancer Care Ontario released their Radiation Treatment Capital Investment Strategy. In this, they mandated that in order to maximize the use of current infrastructure, cancer centres will need to be operational for 12 hours in the future. This strategy was supported by a cost-benefit analysis. OBJECTIVE: Currently, Ontario Radiation Therapy managers are developing a 12-hour staffing model. The objective of this study was to determine radiation therapists' (RTs) perceptions on 12-hour shifts. METHODS: A survey, both quantitative and qualitative, was developed based on a comprehensive review of the current literature. The survey was distributed to 126 RTs at the Juravinski Cancer Centre and the Walker Family Cancer Centre. There were 48 respondents to the survey. Data were analyzed using the Sign Test and Kruskal-Wallis test to determine the difference from the null hypothesis (neutral). RESULTS: The results revealed that RTs have a neutral interest in working 12-hour shifts and that there is a greater number of recognized disadvantages and concerns associated with 12-hour shifts than benefits. Although the extra days off are desired, burnout, scheduling, poor quality of life outside of work, and the challenges with operating such a system with multiple departments seem to have a greater impact on the opinions of RTs. CONCLUSION: In conclusion, further research on staffing models, the incorporation of other departments, and an arrangement of sufficient breaks to prevent fatigue are needed to make 12-hour shifts a more attractive and feasible option to RTs.

Management of patients with implantable cardioverter-defibrillators and pacemakers who require radiation therapy.

BACKGROUND: Radiation therapy (RT) may pose acute and long-term risks for patients with cardiac implantable electronic devices (CIEDs), including pacemakers (PMs) and implantable cardioverter-defibrillators (ICDs). However, the frequency of these problems has not been accurately defined. OBJECTIVE: The purpose of this study was to determine the prevalence of CIEDs among patients requiring RT and report the common CIED-related problems when patients are managed according to a standard clinical care path. METHODS: In a single tertiary-care center, we prospectively screened all patients requiring RT and identified patients with ICDs or PMs. We collected clinical data about their cancer, RT treatment plan, and CIED. Radiation dose to the device was estimated in all patients, and any device malfunction during RT was documented. RESULTS: Of the 34,706 consecutive patients receiving RT, 261 patients (0.8%, mean age 77.9 ± 9.4 years) had an implantable cardiac device: 54 (20.7%) ICDs and 207 (79.3%) PMs. The site of RT was head and neck (27.4%), chest (30.0%), and abdomen/pelvis (32.6%). Using our care path, 63.2% of patients required continuous cardiac monitoring, 14.6% required device reprogramming, 18.8% required magnet application during RT, and 3.4% required device repositioning to the contralateral side before RT. Four patients (1.5%) had inappropriate device function during RT: 3 experienced hemodynamically tolerated ventricular pacing at the maximum sensor rate, and 1 experienced a device power-on-reset. No patient died or suffered permanent device failure. CONCLUSION: Nearly 1% of patients receiving RT in this series has a PM or ICD. However, with a systematic policy of risk assessment and patient management, significant device-related complications are rare.

Staffing Model for Radiation Therapists in Ontario.

PURPOSE: The Cancer Care Ontario's (CCO) Radiation Program Leadership tasked the Radiation Therapy Professional Advisory Committee (RTPAC) to develop a radiation therapist (RT) staffing model to support current radiation therapy practice. BACKGROUND: A 1999 RT staffing model was outdated. Limitations included: (1) the inability to keep pace with advanced treatment planning and/or delivery techniques, (2) the exclusion of staffing for brachytherapy and orthovoltage, and (3) the omission of vital patient safety activities that are required to support clinical practices. METHODS: The RTPAC used a comprehensive scientific methodology to develop the new staffing model. A thorough literature review was completed, and an evidence-based model was developed. A unique creativity tool, the simplex process, was used to identify all the RTs' domains of practice that are integral for professional practice. All domains identified were included in the recommended staffing model. RESULTS: The staffing model recommends basing the number of RTs on equipment and associated clinical activities. The following staffing numbers are recommended: (1) linear accelerators: 4 full-time equivalent (FTEs) RTs per 10-hour day, (2) brachytherapy: 3 FTEs/8-hour day, (3) orthovoltage: 3 FTEs/8-hour day, (4) CT simulator: 3 FTEs/8-hour day and 4 FTEs/10-hour day, (5) dosimetry: 1 FTE/325 courses per year, (6) radiation oncology systems support and technology development implementation: 1 FTE/4 linear accelerator, (7) administration and education: 1 manager, 1 FTE supervisor/30 staff, 1 FTE professional practice leader/8 linear accelerators, 1 FTE staff educator/8 linear accelerators, 1 FTE undergraduate educator/8-10 students, and (8) additional 20% FTEs of the total for vacation, sick time, maternity leaves, and other leaves. CONCLUSIONS: The recommended staffing model is now more suitable for today's radiation therapy profession by addressing the domains of practice and clinical activities. Further research includes monitoring performance indicators annually to ensure that the staffing model is current. These indicators include wait times, access to care, radiation incidents, technological advances, and the quality of work-life of RTs.

Letter in response to 'The role of research for advanced practitioners'.

This letter to the Editor is in response to the paper 'Conceptualisation of the characteristics advanced practitioners in the medical radiation professions' by Smith et al. and the subsequent letter from Jenny Sim. The writers agree that research should be explicitly listed in the conceptual model of advanced practice, and provide some evidence and viewpoints from over a decade of advanced practice work in Canada.

A Qualitative Comparison to Understand the Differences between Perceptions and Reality of Errors in Radiation Therapy: An Understanding Based on Principles of Perception Psychology.

PURPOSE: The purpose of this study was to qualitatively, compare, and understand why perceptions of errors in radiation therapy differ from actual reported errors. METHODS: The qualitative study consisted of one-on-one semi-structured interviews that were conducted with three radiation therapists and two medical physicists. Eight interview questions were based on the discrepancies that existed between perceptions and actual error reports from a survey administered in 2010. Interviews were voice recorded and transcribed followed by three independent thematic analyses. Saturated themes were those that were shared across all respondents. Interpretation of these results was based on the literature of perception psychology in an attempt to understand why such perceptions existed or differed from actual reports. RESULTS: The thematic analyses revealed that workload, documentation, motives, continuing education, and expectations were recurring themes. The effects of workload were attributed to the psychology of attention and an overburdened filtration process. It is common to find irrelevant distracters or stressors functioning as noise, which make it more difficult to identify and attend to important information. Many forms of stress such as workload, personal, or environmental can function as noise hindering the filtration process, which has been positively associated with therapist burnout. Respondents shared views on redundancy and consistency of documentation. In the literature, adaptation has been shown to play a major role in the formation and alteration of perceptions. Habituation is a form of adaptation that refers to a lessened degree of sensitivity to any one continuous stimulus. Adapting to an environment with a persistent stimulus can result in a passive frame of mind effectively dismissing the redundant stimulus. It is apparent that with redundant documentation, staff members may find themselves habituated with the process of continually transcribing from one document to the next and therefore, making documentation more prone to error. Motives were found as a common theme when respondents were asked to explain why treatment delivery was the area perceived to be where most errors occur, when in reality this was not true. Respondents expressed the onus of responsibility on therapists at the treatment delivery level. The driving force for this perception is the psychological effect of an individual's motives and the physical consequences of errors at the treatment delivery level. Bolus was perceived to be a greater error than it actually is. From the perspective of the "self-fulfilling prophecy" theory by Robert K. Merton, it would state that radiation therapy staff perceived bolus to be a common error because they expected it to be a common error. Expectations of bolus indicated were its subjectivity of placement, the uncertainty of its error, and its lack of an active interlock system. CONCLUSIONS: Emergent themes from this study have shown the implications and value of a qualitative approach in providing detail rich information and insight for further research of radiation therapy error analysis. Specifically, referencing the literature of perception psychology, we were able to theorize why therapists perceive certain errors to be more common than others and what factors may influence these perceptions. Future large scale studies in radiation therapy of this nature would benefit the field in helping to create reflective policies and procedures to ultimately minimize human errors and broaden our approach to error analysis.

A Comparison of Perceptual and Reported Errors in Radiation Therapy.

PURPOSE: The aims of this study are to investigate error perceptions in radiation therapy (RT), to analyze 13 years of reported errors by type and location, and to identify the similarities and differences between perceptual and reported errors. METHOD: Close-ended surveys were distributed to radiation therapists, RT students, medical physicists, and medical physicist residents at a large cancer centre. Two areas of relevance were: (1) to select the five most common categories of errors in radiation therapy and (2) to rank the many different stages where errors can be made in radiation therapy. The purpose of the survey was to investigate error perceptions based on type of error and location. The survey findings were compared to reported errors tabulated over 13 years (1998-2010) as collected by the Radiation Therapy Quality Assurance Committee on site. Frequency of survey responses and actual error occurrences were ranked and compared. Survey responses were analyzed by demographics based on gender, profession, and levels of experience. Statistical tests were also performed. RESULTS: The total response rate for the survey was 45% (58 of 130 respondents). There is a consensus that documentation errors and treatment delivery errors occur most frequently. However, errors relating to bolus, geographic miss, and positioning device were outstanding in the perception of errors. Categories with high error frequencies for reported errors included field size, shielding, and monitor units calculation. There were no significant differences in survey responses based on demographics. CONCLUSION: The incongruence in certain types of errors between those perceived and those reported is alarming. When there is lack of awareness, the errors can be even more prone to occur. Patient safety culture starts from the individual; hence, understanding staff perception is critical in managing a quality assurance program. As technological advancements decrease certain errors, they may also have the potential to introduce new types of errors. Therefore, the last line of defense in any system remains qualified and attentive staff members.

Measuring quality of work-life: a participatory approach in a Canadian cancer center.

BACKGROUND: Quality of work-life (QWL) has been gaining increasing attention in health care settings. To our knowledge, no QWL data for cancer centers have been published. METHODS: A participatory approach was used to develop a QWL survey that was administered to staff in Year 1 (Y1) and Year 2 (Y2) in a Canadian ambulatory cancer center. RESULTS: Overall staff QWL scores were moderate in Y1 and Y2; however, there was considerable variation among four main employee groups (physicians, nurses, physicists, radiation therapists). CONCLUSIONS: The survey data provide a benchmark against which other cancer centers can be compared.