Advanced practice radiation therapists: an Australian context

Abstract The purpose of this scoping review is to examine the literature regarding the development, implementation, scope and extent of Advanced Practice Radiation Therapist (APRT) roles in Australia in peer reviewed journals, government reports, conference proceedings and reports. A search was undertaken of PubMed, Web of Science and CINAHL, the ASMIRT website and, and Google Scholar to identify relevant documents. Combinations of keywords with Boolean operators ((advanced practice) OR (advanced practitioner) OR (specialist)) AND ((radiation therapist) OR (radiation therapy)) were used. Online and physical searches were conducted between July 16 and 23 2017. Results were not date limited. The searches retrieved 352 after duplicates were removed with 46 remaining after filtering for eligibility criteria. Items consisted of journal articles, conference abstracts, presentation slides, online presentations, State government and ASMIRT reports. A number of potential and existing APRT roles were found in the identified articles, including image review, stereotactic, treatment review, breast localisation, palliative radiotherapy, brachytherapy, radiation engineering and urology. Despite reports indicating that radiation therapists in Australia have been concerned with professional directions since 2001, there is little evidence of formal progress towards defined APRT roles. Several centres have implemented roles in a number of practice areas. The success of APRT roles lies in the ability to demonstrate that implementation goals have been achieved and that patient care has improved. The literature suggests that this is occurring, however, the presented evidence is not compelling.


Introduction
The incidence of cancer in Australia is increasing with new diagnoses rising from 124,465 in 2013 to an estimated 134,174. 1 Coupled with this, a growing number of people survive their initial cancer diagnosis, but "live with recurrent cancer, requiring ongoing monitoring, treatment, care and support". 2 This growing demand will put increased pressure on the health system, and in particular on cancer services. Radiation therapy is a safe, highly effective treatment for many types of cancer for both cure and palliation. 3 Traditionally, planning, delivery and quality assurance of radiation therapy in the radiation oncology department has been compartmentalised, where tasks are apportioned to radiation oncologists (RO), radiation therapists (RT) and radiation oncology medical physicists (ROMP), based on their specific areas of expertise. This could lead to gaps or delays in service meaning that patients may not receive care as efficiently as possible.
One approach to improve continuity of services delivered to patients is to minimise the divide between professional groups through skills transfer. Smith et al. 4 note that "skills transfer. . .has been proposed as a means of meeting growing demand" and suggests delegation of tasks traditionally completed by one professional group to another. In the context of the medical radiation science professions, Smith further argues that this delegation requires the development of advanced practice roles. Advanced practice (AP) is "assumed to indicate working beyond one's traditional scope of practice underpinned by expert evidence based knowledge". 5 Advanced Practice Radiation Therapist (APRT) positions have been in place for more than a decade in the United Kingdom 6 and the province of Ontario 7 in Canada. These roles were developed in response to drivers such as increased demands for service and emerging technologies and are underpinned by increased autonomy in RT practice. 6 The key goal for the implementation of APRT roles is to improve service delivery for patients receiving radiation therapy treatment, including improved access, timeliness and treatment quality. 8 There is evidence that APRT roles have been developed and implemented in Australia, however, little has been published regarding these roles. There is now a pathway for individual recognition by the professional body, the Australian Society of Medical Imaging and Radiation Therapy (ASMIRT, formerly known as the Australian Institute of Radiography, AIR) and there are currently four professionally recognised APRT in Australia: two in breast, one in urogenital and one in palliation.
The purpose of this scoping review is to examine the development, implementation, scope and extent of APRT roles in Australia in peer reviewed journals, government and professional body reports and conference proceedings. An understanding of the current state of these roles will assist in answering the question of whether APRT roles can play a part in addressing the increasing demands on radiotherapy services and improve patient outcomes.

Method
A search was undertaken of the databases PubMed, Web of Science and CINAHL to identify literature relating to APRT roles in Australia. The "view related/similar article/ cited by" features of each of the databases were also used. A search of the ASMIRT website, ASMIRT conference handbooks and Google Scholar was also conducted to identify other relevant documents or reports published from other sources. Combinations of keywords with Boolean operators (advanced practice) OR (advanced practitioner) OR (specialist) AND (radiation therapist) OR (radiation therapy) were used. Searches and physical searches were conducted between July 16 and 23, 2017. Results were not date limited and included the date of the search. To increase the likelihood of identifying relevant literature, citations and references within the documents retrieved in the initial search were also reviewed. The search was restricted to literature published in English.
Eligibility criteria included information regarding the development, implementation, scope and extent of APRT roles in Australia with source as a secondary criteria to determine inclusion. Articles must have been published in peer reviewed journals providing data regarding APRT roles in Australia. Reports must have been released under the auspices of state or federal governments or professional bodies representing RTs. Studies discussing role expansion for RTs were included as evidence of progress towards implementation. Abstracts of conference presentations, conference e-posters, editorials and commentary were included where it was judged to have relevance to the purpose of the review.
Titles and abstracts of journal articles and report summaries were reviewed to determine eligibility for inclusion. If it was unclear that an article, report, editorial or commentary met eligibility criteria, it was retrieved and viewed in full prior to inclusion. Editorials and commentaries were viewed in full. Conference presentations were included where complete abstracts were published or presentations were available to view. The abstracts of e-posters were reviewed and if eligible were retrieved. Whilst these latter sources were judged to be of less weight when compared to those higher in the evidence hierarchy such as peer reviewed journal articles, they were included to provide context in light of the scarcity of literature.
A flowchart was constructed to document the search strategy and record the items found, reasons for exclusion and subsequent number of items that met the inclusion criteria (Fig. 1). These items were documented in a summary table (Table 1). After the initial search all subsequently identified items were checked against the summary table to exclude duplicates. The table was updated throughout the search process, resulting in a summary of all relevant items for the review.

Results
Initial searches of databases retrieved 55 items. Searching other sources including Google Scholar, conference handbooks and cited references yielded 269 additional items. After duplicates were removed, 287 items remained. Titles and abstracts of journal articles were viewed before retrieving 13 in full. Of these, two were review articles, one a conceptual paper, eight discussed elements of APRT roles and two were not relevant. Reports regarding implementation of AP and expanded practice roles were  in full. Conference abstracts were retrieved from printed and online conference handbooks. In two cases, presentation slides were available for retrieval. In three cases, presentations were retrieved for online viewing. A total of 46 items were included in the review.
Acharya et al. 9 published a systematic review on the state of role expansion internationally to understand the opportunities for such roles in Australia. This review identified six potential roles and noted that none were present in Australia at the time of publication. A survey of national practice 10 notes that some advanced practice roles did exist but that they were locally driven and without formal structure. Another review reported that little development had been made towards advanced practice roles in Australia but elements of extended practice were being undertaken, including CT planning, verification, patient weekly reviews, and planning and delivery of brachytherapy treatment. 4 A number of existing and proposed APRT roles were identified. These included roles such as image review, 11-15 treatment review, [15][16][17][18][19][20][21][22][23][24][25][26] breast localisation, 14,27,28 palliative 29-33 and urology. 34 Two conference abstracts note APRT roles at the Peter MacCallum Cancer Centre (PMCC), including imaging, breast, brachytherapy and radiation engineering. 14,28 All of these roles are closely allied with an article 5 on curriculum design and a conference presentation 35 to support AP roles. A conference presentation in 2016 indicates that research into  the barriers to implementation of AP roles is currently being undertaken. 36 A multidisciplinary group editorial 37 proposed an APRT role in paediatric radiotherapy treatment, advocating for specialist RTs in the care of children undergoing radiation therapy. A practice guideline authored by a multidisciplinary group advocating for an APRT role in stereotactic ablative body radiation therapy to "be responsible for management of RT responsibilities within the SABR program" 38 also met the inclusion criteria.
ASMIRT produced a number of reports relating to AP for radiographers and RTs. 39-42 These culminated in Advanced Practice Pathway documents in 2014 43,44 with a revision in 2017. 45 The paper by Smith et al. 46 underpins this model. Australian Capital Territory (ACT) Health developed 3 documents relating to extended practice for RTs, including a systematic review of the literature, a report into current practice and a phase 1 document identifying potential areas of role extension. [47][48][49] No reports relating to subsequent phases were identified. In 2013, the Department of Health and Human Services, Victoria, produced a project report on APRT. 26 In 2014, the Department of Health and Human Services (Tasmania) prepared a governance framework for implementation of expanded scope of practice for allied health professions in the Tasmanian Health System including the radiation therapy profession. 50

Discussion
A motion passed at the Annual General Meeting of the AIR in 2001 resulted in the formation of a steering committee to investigate "what we are going to be doing in 10 years time. . .the model they would expect and that the direction for the implementation of the model is put into place by the year 2012". 39 The timing coincided with the roll-out of the four tier practitioner model in the UK. The Professional Advancement Working Party (PAWP) was charged with evaluating role extension and role expansion, identifying the feasibility of role expansion and the education required; essentially the precursors to the development of an advanced practice model. The 2006 PAWP report delineates the difference between role extension and role expansion, noting that the former is "the acquisition of additional knowledge and skills as a direct result of the increasing demands made upon the professions" 39 whilst the latter refers to "formally and explicitly recognising enlargement of existing scope of practice into new tiers of practice accompanied by additional education, theory and practice". 39 The AP model was built upon the latter definition. A report by the Advanced Practice Working Group (APWG) in 2009 39 elaborated on a model and outlined the scope for several diagnostic imaging and radiation therapy AP roles. This report also gives a clear recommendation for engagement with stakeholders, including other professional bodies, state and federal government, tertiary institutions, medical colleges and private providers, as necessary to moving forward with AP roles.
Despite interest shown in an AP model, a review published in 2009 identified a lack of data in Australia identifying or evaluating APRT roles 9 with a further study 16 noting little progress had been made towards formal APRT roles. Further to this, in 2009, Dempsey and Burr noted that radiation therapists were "reluctant to progress the issue of responsibility for higher level plans and treatment. . ...without the appointment at a senior or advanced practitioner level". 51 Current literature suggests that development, implementation and the establishment of APRT roles has occurred since that time. The success of any APRT role lies in the ability to demonstrate that the APRT has the requisite knowledge and skill to perform the duties of the role and that the desired goals which led to the creation of the role have been met. There is some limited evidence of the effectiveness of the roles in addressing both of these measures in the Australian literature, for example concordance measures of field placement between APRTs and ROs 30 and decreased patient wait times. 31 Drivers such as the growing demand for services, the expansion of radiotherapy services in regional areas and the rapidly changing technology in the professional field have provided impetus for the development of APRT roles. The APWG report notes that the focus of these roles should be primarily directed towards the needs of the patient: improving service delivery and patient care, by addressing service gaps and delays, and reducing wait times. 39 Acharya argues that APRT role development can be seen as a means of "embracing innovative ways of service provision to maximise patient benefits and promoting flexible career pathways to retain highly skilled health practitioners". 9 There is, however, no published literature to support the latter in Australia.
In a survey designed to define current RT practice in 2008, Sale et al. 10 found that "some advanced roles were currently practiced in Australia by some RTs; however, there was no evidence of structure to support these roles in the current system and they were based on local need". Two survey respondents identified that they fulfilled advanced practice roles; one in a review clinic position and one in a physics/engineering position. Matthews wrote that "RT advanced practitioner implementation to date has been "ad-hoc" and determined by the clinical need for such a role in individual clinical centres, hence role definition, training and scope of practice has been broadly interpreted". 5 However, APRT roles are intended to address identified and agreed gaps in service delivery which will differ between departments. This means that there may be "differing role descriptors and different expectations of the RTs within the roles". 25 The Peter MacCallum Cancer Centre (PMCC) was proactive in developing APRT roles, introducing breast , and subsequently roles in imaging, brachytherapy and radiation engineering. These were driven by departmental needs and underpinned by distance education academic work and mentorship. PMCC at that time consisted of six sites and not all roles were present at each site. A paper presented by Matthews in 2012 evaluating the impact of the roles on stakeholders noted that the roles had had varying success across the organisation. 14 Six of a total of 17 breast AP graduates and 14 of 24 imaging graduates were still practising in their AP role in 2016. 28 Despite these numbers of APRTs in PMCC, there is no peer reviewed literature on the impact on service of these roles. Matthews has highlighted difficulties faced in sustaining these roles, including high attrition due to inhibition of training ability, the lack of availability of suitable academic course material, and management restructure. 28 The abstract by Toikka in 2013 reports a positive response to the introduction of a breast APRT in her centre, supporting "gains in efficiency, continuity and flexibility". 27 This study evaluated the efficiencies gained in the planning process when the APRT assumed the duties of the RO in attending simulation sessions, localising breast tissue and assessing anatomical field placement on the planning CT dataset, and included measures around total simulation and planning time, resources, availability and accuracy.
The APRT roles at PMCC and other centres were supported by short course programs, developed and delivered by Monash University. Clinical mentorship from local ROs was provided to support APRT roles in breast, treatment review and advanced imaging. Approximately 50 RTs in centres across Australia had completed one of these courses in 2014. 5 These short courses are no longer available. In 2012 a consortium of five universities was awarded funding through the Better Access to Radiation Oncology program to develop a national curriculum for APRT. 35 This project has resulted in the development and ongoing delivery of online professional practice modules, such as advanced anatomy, psychosocial care, imaging and patient assessment and toxicity management. There is no peer reviewed evidence of their evaluation and effectiveness nor any evidence demonstrating that these modules have been used to contribute to the establishment of new APRT roles.
One of the complexities of this issue is that, over time, tasks initially seen as role expansion have become part of normal scope of practice. This is the case for the role suggested by Rybovic et al. in 2007 11 andBurow et al in 2009. 12 By 2011, image review had become part of normal scope of practice for RTs 13 . Matthews notes that at the PMCC there have been 24 graduates of an Advanced Imaging program with 14 still practising. The scope of these roles is much broader than image review and includes technique development, implementation, support and analysis. 28 No evidence on the impact of service delivery, satisfaction of patients or staff with respect to these roles has been published.
The treatment review APRT role was discussed by several authors. This role has been established in a number of Trusts in the UK for many years. Alfieri found evidence to support "very positive outcomes for patients including improved communication, decreased patient waiting times and a more consistent approach to the monitoring and management of the patient through the increased continuity of care". 16 This is supported in peer reviewed literature from the UK and the role was found to be beneficial for RTs, improving job satisfaction and confidence through increased involvement in patient care and increased autonomy. [52][53][54] The evidence for this was gained through self-report and survey. Rivett"s 19 abstract describes the process used to develop an AP role in posttreatment head and neck patient review in a regional area, utilising telehealth for patients with lower acuity. The abstract by Karzon 22 outlined the role of the AP treatment review RT at the St George Cancer Centre. Other authors investigated RT capability with respect to breast treatment review in two centres, 18,23,24 including concordance between RTs and ROs in assessing skin toxicity, and patient experiences, supporting the ability of RTs to conduct treatment review in this site. Whilst providing some evidence, the study sizes are small, making it difficult to draw definite conclusions.
In 2013, Monk et al published a feasibility study of RT led treatment review in a regional radiotherapy department. 17 This study used two measures of feasibility; a medical intervention (MI) rate of less than 35% (based on previous studies) and levels of agreement between ROs and RTs on RT capabilities to conduct treatment reviews approaching 100%. Neither measure was met, with a higher overall MI rate of 59% and agreement not approaching 100%. Furthermore, none of the five ROs were willing to delegate the review clinics to RTs. This study prompted correspondence from several writers. The first of these pointed out differences between this and other studies and presenting additional studies which support treatment review APRT roles. 15 The second, from a chief radiation therapist in a centre which has implemented several specialist RT and one APRT role stresses the importance of inter-professional communication, and consultation, particularly with ROs, in developing APRT roles. 25 Research on the palliative APRT role at the Mater Radiation Oncology Centre has provided data on capability and service improvement. A retrospective blinded comparison of field placement between the APRT and RO, 30 was followed by a prospective study where the APRT delineated the fields on DRR blinded to the RO field placement. These studies demonstrated a high level of concordance between the APRT and the RO, with 89% of fields deemed acceptable in the second study. Management by the APRT as opposed to the standard pathway has been shown to demonstrate improved mean time for the complete planning process, 29 and reduced wait times for palliative patients. 31,55 In 2014, the AIR established a pathway for recognition as an Advanced Practitioner. This requires the submission of a practice portfolio for independent assessment by experts. The portfolio must demonstrate that the candidate meets the seven characteristics of AP and provide evidence of their advanced capability in each: expert communication; internal and external collaboration, high degree of professionalism, advanced clinical expertise, high level of scholarship and teaching, professional judgement based on evaluation of evidence and clinical situation and clinical leadership. 45 The underpinning principles are similar to those for APRTs in the UK and for CSRTs in Ontario. In 2015, the AIR awarded the status of Advanced Practitioner to the first APRT. Since that time, a further three RTs have been awarded this status by the professional body. Whilst recognition by the professional body represents progress in advancing the overall recognition of APRT roles, there is no registration category for Advanced Practitioners with the regulatory body, the Medical Radiation Practitioners Board of Australia.

Conclusion
The success of APRT roles in Australia lies in the ability to demonstrate that the goals of implementation have been achieved: that the gaps in service have been addressed, that service delivery, and patient care has been improved. The literature provides limited evidence that this is occurring, however, the majority is provided through conference presentations rather than papers in peer reviewed journals. Matthews noted that implementation in Australia had been "irregular and uninformed by evidence". 35 This lack of breadth and depth of evidence may in part be due to the emerging nature of the roles. It is important that those centres who have established APRT roles provide information about the creation and implementation of the roles, and evidence of outcome measures which support their ongoing presence. To truly harness the potential benefits of these roles, more evidence regarding timeliness of care, improvement in patient care, improved access and reduced wait times is needed to support their realisation on a national scale.