Introduction
The radiation therapy (RT) profession has collectively evolved in the past decade. Technological and treatment advances paralleled with the push for higher educational training have shaped RT practice to develop specialised clinical roles to promote research, education and academic productivity.Reference Harnett, Palmer, Bolderston, Wenz and Catton1, Reference Bolderston, Harnett, Palmer, Wenz and Catton2 In Ontario, Canada, the advanced practice radiation therapist role emerged as a result of the profession's readiness both clinically and academically to meet the increasing needs of cancer care in the health system. The development of the clinical specialist radiation therapist (CSRT), a radiation therapist with advanced clinical competencies, was a key component of the HealthForceOntario human resource strategy.3 Established in May 2006, the innovative CSRT role was designed to increase staffing flexibility, enhance system efficiencies and improve the overall access of cancer care.4
One of the five original CSRT roles funded by the provincial government was the Patient Assessment and Symptom Management (Breast-Site) CSRT. The role was developed within the breast-site group of the Radiation Medicine Program at the Princess Margaret Cancer Centre to enhance timely access and delivery of high-quality care for breast cancer patients receiving RT. Through collaboration of the Radiation Oncology and Radiation Therapy disciplines, advanced clinical education and technical training was provided to the CSRT. Following site-specific education, supervised clinical practice, and simulated learning, the CSRT attained various advanced clinical and planning competencies outside of the traditional RT scope of practice. With the successful integration, demonstration and validation of these expanded clinical competencies, the CSRT undertakes ‘on treatment’ reviews,Reference Lee, Harnett, Zychla and Dinniwell5 new patient clinics, and seroma target volume delineation.Reference Lee, Fyles and Cho6 Extending beyond these clinical duties, the breast CSRT is actively involved in research and education activities. The CSRT actively participates in patient education and the education of students in the RT and radiation oncology disciplines. The CSRT may be a suitable lecturer to provide teaching of clinical knowledge and skills beneficial to RT student learners.
The notion of incorporating an expert clinical RT practitioner to engage in teaching is not new. In the United Kingdom, a similar role to the CSRT is the consultant radiographer, an allied practitioner working in the core domains of: (1) expert clinical practice; (2) leadership and consultancy; (3) education and training; and (4) service development and research.Reference Forsyth and Maehle7 The role of education varies between individual practitioners and may involve teaching locally within their institution and/or externally at a university. The educational involvement of the consultant radiographer may include organising in-house teaching materials, lecturing in university tutorial sessions, teaching within undergraduate and/or post-graduate level RT programs, and teaching at medical and nursing programs.Reference Forsyth and Maehle7, Reference Ford8
Although undergraduate RT level teaching is the most common education activity of expert RT practitioners,Reference Forsyth and Maehle7, Reference Ford8 currently, little is known about how students perceive these individuals and their teaching. The objective of our study is to assess the RT student's perception of the CSRT's contribution to their learning within the scope of a case-based learning workshop tailored for breast cancer. The CSRT may be an ideal candidate to bridge and transfer theoretical and clinical knowledge by engaging RT students to develop their practical knowledge and skills required for the clinical environment.
Materials and methods
Design
A breast-site workshop was designed by the CSRT. The aim of the workshop was to broaden the student's knowledge of breast RT treatment. Students were provided with background pre-lecture readings pertinent to breast cancer. To facilitate student learning, the workshop was divided into two parts. The first part included a case-based scenario for the students to discuss within a small group setting. The students were pre-assigned into groups of four to five people. All the groups were given the same background patient information, but the context of the problems was based on the clinical process of a patient's RT treatment pathway (consultation, CT simulation, treatment planning, treatment delivery). Each group contributed to one aspect of the typical treatment process. Following the case study, the CSRT facilitated an open class interactive discussion, tailoring the lecture contents to the aims of the session. For each treatment process, the CSRT highlighted the main concepts and clinical knowledge, why they are important, and how they contribute to the overall RT process. The students were encouraged to participate in the open discussion to ensure their learning needs were met.
Study sample and setting
The study sample included 16 RT students, who had commenced their final year, 30-week clinical practicum at a large urban cancer center located in Toronto, Canada. All of the students were enrolled in a 3-year RT degree/advanced diploma program. Their theory-based education was jointly provided at a university and a health institute while their clinical placements were at the hospital.
Data collection and analysis
The study was approved by the institution's Research Ethics Board. An information letter detailing the purpose of the study was given to the students following the breast site workshop. The link to the online survey together with an electronic copy of the information letter was emailed directly to the students and a remainder email was sent 1 week prior to the closure of the study. The students were aware that their anonymous responses to the online survey constituted implied consent to the study and that they may withdraw from the study at any time.
The self-administered, online survey contained a series of statements that examined themes about the student's previous didactic and clinical exposures, their knowledge (previous and current) of the breast-site CSRT and their perception of the breast-site CSRT in contribution to their learning. The students rated their response on a 4-point Likert scale according to their level of agreement to the statements. The 4-point Likert scale was chosen to avoid neutral responses. The anonymous responses were collated and analysed using descriptive statistics.
Results
A total of 15 (94%) out of the potential 16 students participated in the study. Their previous breast-site didactic and clinical exposures are listed in Figure 1. The percentage of students who rated their previous didactic experience as ‘some’ or ‘a lot’ in treatment planning, patient care, treatment unit and CT simulation were 100%, 92%, 77% and 46%, respectively. In contrast, the students felt their clinical experiences in these settings were substantially less; those who rated their experience as ‘some’ or ‘a lot’ only accounted for 25% (treatment planning), 39% (patient care), 46% (treatment unit), and 15% (CT simulation). Aside from two partial respondents who omitted the remainder of the survey, 13 (81%) students completed the survey in its entirety.
Figure 1 Previous didactic and clinical experiences of radiation therapy students. This figure illustrates how the students rate their previous didactic and clinical experience in the breast-site.
Prior to the workshop, only two (15%) students were aware of the breast-site CSRT position. However, after the workshop most of the students (85%) had an understanding of the clinical, technical and patient care roles of the CSRT. The responses to the survey questions are listed in Table 1. All students unanimously agreed that the CSRT enhanced their understanding of the material with 12 students (92%) agreeing and 1 student (8%) somewhat agreeing that the CSRT was a useful resource for their training and education. There was agreement (46%-agree and 54%-somewhat agree) that the CSRT had influenced the student's future career as a radiation therapist. In contribution to their learning, the students felt more engaged in the workshop being facilitated by the CSRT (54%-agree and 46%-somewhat agree). Two students provided additional comments in their surveys and both suggested developing similar workshops for other disease sites.
Table 1 Summary of radiation therapy students’ perceptions of the breast-site CSRT
Abbreviation: CSRT, clinical specialist radiation therapist.
Discussion
CSRT and student learning
This is a study to examine the RT student's perception of the CSRT's teaching in contribution to the student's learning relevant to the breast-site module within their curriculum. Our study revealed that the students perceived the CSRT to not only enhance their understanding of the lecture content but also viewed the CSRT as a useful learning resource to further their training and education (Table 1). One student noted: ‘(the) CSRT was excellent and really consolidated the information. I wish we would have a lecture from a CSRT for each super team/disease site’. The sharing of clinical experience and consolidation of knowledge is important for third-year RT students. Being equipped with didactic knowledge from the classroom setting, they are now focused on how to apply their knowledge and skills in a live clinical environment. In a study exploring role model qualities perceived by final-year diagnostic radiography students, their perceptions of role model attributes correlated with their learning needs throughout the course of their program. While students at the beginning of their program focused on radiographers with technical skills as role models, final-year students working in the clinical setting attributed more importance to higher order skills, such as communication, patient care, content knowledge and sharing of experience to enhance and consolidate their learning.Reference Conway, Lewis and Robinson9 The teacher's ability to share practical knowledge and experience beyond the textbook was perceived by the radiography students as attributes of a role model with practical and tangible traits. Hence, the majority of students role-modeled after clinically practicing radiographers as opposed to their university lecturers.Reference Conway, Lewis and Robinson9 The training curriculum of medical radiation sciences students in the RT stream is akin to those in the diagnostic radiography. The perceptions of RT students for favourable teaching traits would then be expected to be similar to their diagnostic radiography colleagues. Likewise, RT students evidently valued the sharing of practical knowledge in a clinical environment by the CSRT; all of the students expressed positive views that the CSRT enhanced their understanding of the material presented and perceived the CSRT as a useful resource in their breast-site learning module. These findings suggest that the CSRT may be viewed by the students as a clinical role model with the ability to link didactic knowledge to practical and tangible clinical knowledge.
In our study, the students were receptive to learning in a workshop format. The majority of RT students perceived the workshop from the CSRT as value added to their learning of the breast-site material (Table 1). One student commented: ‘An extremely useful workshop! We need these for each site’. The student's interest in the workshop was not only driven by their positive perception of the CSRT, but also influenced by their learning environment and the teaching methods used. Both of these factors closely relate to the intrinsic and extrinsic motivators that affect the way students learn.
Extrinsic learning environment
The provision of an ideal learning environment can act as a positive extrinsic motivator to enhance student learning.Reference Hutchinson10 The CSRT-led learning workshop was conducted in the RT student classroom, an open and comfortable environment that is well known to the students. The case-study was done within a small group setting and each group was arranged into a circular format. The aim of this arrangement was to maximise shared learning by fostering a safe atmosphere. In each group, the students were not only able to freely participate and openly share their knowledge with their class mates, but also identify their own learning needs.Reference Hutchinson10 Following the group discussion, the group elected one student to contribute in the open discussion facilitated by the CSRT. Prior to engaging in small group sessions, the composition of the groups was determined to afford a mix of different learning styles and a balance of introverted and extroverted learners. Introverted students could safely learn within the environment without the threat of forced participation and the fear of being questioned ‘on the spot’. The small groups balanced by the different personalities and learning styles of the students helped to support the individual strengths of all participants. According to Maslow's hierarchy of needs for motivating learning, the safety of the learner's environment directly impacts on their ability to learn.Reference Hutchinson10, Reference Green11 If the safety needs of the students are not met, they may be less likely to develop the confidence and self-esteem necessary to achieve higher order learning. Hence, the balanced small group discussion allowed the students to safely and openly explore their understanding of the material and creatively problem solve within the group.
Intrinsic motivator
Students can be influenced by their perception of the clinical relevance of the material, which acts as an intrinsic motivator. The CSRT-led open discussion was a means to understand the students’ existing knowledge and allowed the CSRT to adapt the lecture content to meet the aim of the session and the students’ learning needs. For each process of the patient's RT treatment pathway, the CSRT highlighted the most relevant information and concepts required for the students to succeed in their breast clinical rotations. The relevance of the material to the students’ immediate and future clinical need is a vital intrinsic motivator for learning.Reference Hutchinson10 In a study that observed the teaching method preferred by nursing students of the Generation X and Generation Y, all the students of both age groups highlighted the importance of wanting to know ‘why’ they are learning the material.Reference Walker, Martin and White12 This finding is in agreement with the learning styles described for each generation learners, who are pragmaticReference Clausing, Kurtz, Prendeville and Walt13 and need to see the immediate effect on how their learning impacts upon their clinical environment.Reference Johnson and Romanello14 Both of these groups are reward (grades) seeking and prefer to have clear expectations and outcomesReference Clausing, Kurtz, Prendeville and Walt13 as they often do not wish to spend time on learning things that do not impact their end-results.Reference Walker, Martin and White12, Reference Johnson and Romanello14 Similarly, these observations in learning styles may be applicable to our current RT students who have similar demographic details. The RT students are situated at the beginning of their clinical practicum and may feel uncertain about the expectations of their clinical skills. Hence, the identification of clinically relevant information acts as a strong intrinsic motivator, contributing to their overall positive experience in the workshop.
Case-study format
The main purpose of using a case-study scenario was to incorporate some of the general principles of problem-based learning into the student's learning. The third-year RT students are didactically prepared with theoretical knowledge; the majority of students described themselves as having ‘some’ or ‘a lot’ of didactic experience (Figure 1). The small group discussion allows each student to activate their prior didactic knowledge of breast cancer RT from previous readings and class room learning. The case-study questions challenged the students to apply their prior knowledge in critically solving the problems and achieve new learning. This type of creative learning enables the students to better retain new information that can be applied to future clinical scenarios and problems.Reference Morrison15, Reference Wood16 These students have less exposure to the clinical environment; most students indicated having only ‘a little’ experience on the treatment unit and in the provision of patient care, and no experience in treatment planning (Figure 1). Therefore, as the students proceed through their final year in the clinical setting, they would like the teacher directing their learning needs to develop the necessary skills required for the students to develop the necessary professional competencies to succeed in the clinical practicum. Allowing the students to engage with the course material then facilitating and clarifying the difficult concepts will greatly benefit their understanding, learning and retention of the areas of clinical importance.Reference Johnson and Romanello14 Both the discussion session and the ability of the breast-site CSRT to highlight clinically relevant material and key concepts for each RT treatment process were highly valued by the students. This was evident in our findings; while the majority of students were not aware of the breast-site CSRT's role prior to the workshop, following the lecture and discussion, all the students affirmatively agreed that the CSRT enhanced their understanding of the material (Table 1).
Limitations and future directions
This study was conducted in a small sample of RT students and its applicability to the general RT student population may be limited. As the perception of individuals can change over time, the course of training and vary with their exposure to other educational settings, the students’ perception can only reflect their views on the CSRT at that particular point in time. As third-year RT students are more equipped with didactic knowledge than clinical experience, this may influence their receptiveness to the clinical knowledge, skills and attitudes provided and demonstrated by the CSRT. Although the study found an overall positive perception to the CSRT in contributing and enhancing the student's learning, it remains unclear whether the case-study format impacted on the students’ perceptions of the facilitation and teaching by the CSRT. Nonetheless, the study draws attention to the multiple factors that can positively influence and enhance student learning. Teachers and facilitators should strive to motivate and engage their students to maximise their learning experience. Future studies with larger RT student sample sizes to examine their learning experiences and preferences to different teaching methods are needed.
Conclusions
Third-year RT students beginning in their clinical practicum possess more didactic knowledge than clinical experience. These final year students are focused on the acquisition of knowledge within the clinical setting, which may influence their interest and receptiveness to the practical skills provided by the CSRT. The students perceived the CSRT as a useful resource in their breast-site education and identified an enhanced learning experience from the CSRT-led workshop. Educators, facilitators and teachers alike must continually seek effective ways to enhance student learning. By expanding the learning environment and teaching methods to better tailor the material to the student's learning needs, students may be motivated and their learning habits fostered for lifelong learning.
Acknowledgements
The authors are grateful to Lisa Di Prospero and Ruth Barker for their insights in the area of education. They thank all the radiation therapy students who took part in this study.
Financial Support
Salary support was provided by the Ministry of Health and Long Term Care for the Clinical Special Radiation Therapists as part of the CSRT Demonstration Project at Cancer Care Ontario.
Conflicts of Interest
None
Ethical Standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the Tri-Council Policy Statement: Guidelines on research involving human and with the Helsinki Declaration of 1975, as revised in 2008, and has been approved by the University Health Network (UHN) Research Ethics Board.
