INTRODUCTION
Breast cancer is the most common female cancer in the United Kingdom (UK).1 In 2005 approximately 46,000 new cases were diagnosed and over 99% of these cases were in women; breast cancer in men remains rare.1 Whilst incidence and prevalenceReference Maddams, Brewster, Gavin, Steward, Elliott, Utley and Møller2 is increasing, overall mortality has decreased over recent yearsReference Ferlay, Autier, Boniol, Heanue, Colombet and Boyle3 not only due to earlier detection and thus more treatable tumours but also from the use of chemotherapy and hormonal therapy.4 Radiotherapy after conservative surgery has been shown to improve local control and overall survival rates.5 Thus the workload in UK oncology centres from breast cancer alone remains high. Indeed, attempting to treat the high numbers of women whilst fulfilling the NHS cancer plan targets6 with limited resources remains problematic for many centres.
Since the Calman-Hine Report in 1995,7 cancer services have undergone a major transformation.6 Indeed the NHS as a whole has been the subject of significant reform. It has moved away from a service provided for patients towards a service led by patients. The NHS Improvement Plan8 and Creating a Patient–Led NHS9 have set the scene for such changes. Patient and public involvement grew from these Government initiatives, giving access to a communication vehicle offering real dialogue between users and providers. However, for the NHS to be truly patient led, all aspects of service provision must be open and receptive towards the views and experiences of its users. Without direct involvement of radiotherapy patients in a discussion, it may be asked how the radiotherapy service can attempt to be patient-centred.
During this time of significant reform, Breast Cancer Care (BCC) conducted qualitative research to discover the views and experiences of women using UK radiotherapy services. ‘What breast cancer patients want from a world class radiotherapy service’ was published in 200510 and was conducted to help inform both the National Radiotherapy Advisory Group and the National Cancer Action Team of users views and opinions. Unfortunately, the results showed that many women’s experiences were unpleasant and unacceptable, a direct contrast to the patient-centred care expected by Government.
The Royal College of Radiologists (RCR) published guidance to oncology centres in a drive to improve the patient experience of radiotherapy.11 ‘Making your radiotherapy service more patient-friendly’ provided examples of good practice and recommended all centres gather information about local patient experiences.
Delivering cancer services tailored to users’ needs is paramount within the twenty-first century. To provide such a service the user’s voice must be heard. This qualitative study aimed to explore the patient’s experience of their care throughout the radiotherapy pathway in one oncology centre, with a view to improving patient-centred services.
Research question
‘Do we meet the information, support and communication needs of women receiving adjuvant radiotherapy for primary breast cancer?’
Aims
To explore the patient’s experience of their care throughout the radiotherapy pathway, with a view to improving patient-centred services.
Objectives
1. Establish the perceptions of patients on service provision,
2. Evaluate the current levels of provision,
3. Determine areas of care patients believe require improvement,
4. Propose strategies for Service Improvement.
Literature Review
NHS reform
The NHS Improvement Plan8 and Creating a Patient-Led NHS9 described how the NHS must transform from being a service-centred organisation to one with patients leading their own care and playing an active role in service provision. National patient surveys12 sought the patient voice on key areas. However this broad information gathering may not have provided much more than an overview. National surveys, albeit useful, could have limited value for informing local services such as the unique experience of radiotherapy.
The Cancer Reform Strategy13 promised ten key pledges to patients, one of which stated that the NHS will provide
‘high quality information and support, tailored to your personal needs’
Higher priority should be placed on ‘improving information for patients, face-to-face communication with health professionals and co-ordination and continuity of care’.13 The strategy gave a clear message about informing, engaging and empowering patients to enable them to obtain their own preferred level of informed decision making about care and treatment. Bespoke ‘Information Prescriptions’ were devised and piloted13 where individuals received personalised prescriptions drawing on local and national knowledge and information, sign-posting people to Websites and support groups.
Information needs
Several studiesReference Jenkins, Fallowfield and Saul14,Reference Meredith, Symonds, Webster, Lamont, Pyper, Gillis and Fallowfield15,Reference Cox, Jenkins, Catt, Langridge and Fallowfield16 have shown that patients want a high level of information regarding their disease and treatment. Some researchers have used an individualised concept to develop information needs scales, recognising a variation in needs amongst individuals and at differing stages of the patient journey. Reference Arraras, Wright, Greimel, Holzner, Kuljanic-Vlasic, Velikova, Eisemann and Visser17,Reference Mesters, van den Borne, De Boer and Pruyn18 These mainly quantitative studies concentrated upon the patient experience from diagnosis, prognosis and treatment choice rather than information needs concerning radiotherapy. Very little literature has been published specifically concerned with radiotherapy and the experiences of women with breast cancer receiving radiotherapy. Halkett and Kristjanson however did publish work in 2007Reference Halkett and Kristjanson19 relating solely to breast cancer patient’s concerns and information needs related to radiotherapy. They argued that without a reliable and valid tool it is difficult to determine information needs during radiotherapy
The public is generally poorly educated about radiotherapy, which heightens anxiety and fear prior to a course of radiation.Reference Halkett, Arbon, Scutter and Borg20 Although much work has been done to improve information provision for the cancer patient,Reference Cox, Jenkins, Catt, Langridge and Fallowfield16,21 for many their needs vary over time and remain unmet.Reference Halkett and Kristjanson22,Reference Rees and Bath23 This identifies that information provision for radiotherapy as a standard for all patients at a single interval of time would be insufficient.
Support needs
Much literature concerns the support and unmet needs of patients and in particular women with breast cancer. Sanson-FisherReference Sanson-Fisher, Girgis, Boyes, Bonevski, Burton and Cook24 investigated the support needs of nearly 900 cancer patients by means of a Supportive Care Needs Survey. The study involved a cross-section of patients at varying stages of the cancer pathway, from diagnosis through to post-treatment. Results showed high levels of unmet needs, particularly in the psychological and information domains.
Communication needs
Communication has a key role in relationships with patients particularly when attempting to provide information and support.Reference Booth25 Indeed communication is considered essential in healthcare and forms a core dimension in the NHS Key Skills Framework (KSF).26 The ability to address patient’s needs must be dependent upon the healthcare professional’s ability to communicate appropriately with the individual patient.
BoothReference Booth25 investigated the radiographer– patient relationship by means of a transactional analysis approach. Although this research concerned diagnostic radiographers, some similarities with therapeutic radiographer relationships could be inferred. Communication attitudes varied depending upon the characteristics of the individual radiographer, the patient’s characteristics, the need to perform a task and the need to keep the department running. Although education and training may promote the use of more patient-centred communication, Booth suggested that the personal characteristics of the radiographer may provide the biggest barrier to effective communication with patients. Booth also suggested that selection of student radiographers should include consideration of personality and communication. As some of the radiographer’s role is psychosocial, this theory may prove to be correct. Creating a Patient-Led NHS9 advocated treating patients as equals, open communication and information targeted to the patient’s own capacity to understand.
Discussions of such empowerment and shared decision making have been found elsewhere within the literature. Cartmell and ColesReference Cartmell and Coles27 identified that patients often felt disempowered and suggested healthcare professionals such as radiographers were ideally placed to help restore empowerment to patients. However empowerment can only come when patients actively participate in decisions about their cancerReference Fallowfield28 and when healthcare professionals communicate effectively with the patient.
Patient-centred care
Little literature exists regarding patient-centred care for breast cancer patients. A recent studyReference Mallinger, Griggs and Shields29 identified an increase in patient satisfaction when doctors demonstrated patient-centred care. However little specific literature for the breast cancer patient undergoing radiotherapy could be found.
Dignity
The culture of the NHS must change to provide care with the patient as the main focus and with that, roles and responsibilities of frontline clinical staff must also change. To empower patients, the staff delivering services must have a degree of empowerment and autonomy.9 GallagherReference Gallagher30 described this ‘two pronged approach’ to dignity and respect and argued that professionals cannot deliver a service tailored to patient need if staff are not treated similarly by their employers. Although the work by Gallagher primarily concerned nursing practice, the concept translates into radiotherapy. Within the Code of Conduct,31 radiographers must ‘demonstrate respect for individual dignity, belief, culture and autonomy’ in relationships and must ‘listen and respect service user’s views, communicate clearly, openly and effectively and be conscious of their ability to make decisions for themselves’. Such a code implies total patient-centred care.
Breast Cancer Care (BCC) interviewed 22 women by telephone and an additional 26 participated in three focus groups held in London and Sheffield. It focussed upon patient’s needs during radiotherapy in contrast to the main body of research concerning the whole patient pathway. However the women selected were from the BCC advocacy network, campaigns panel and those who contacted the organisation with concerns for service provision, which may have introduced bias into the study. As a professional within radiotherapy, this document was very unpleasant to read. Patients were mostly dissatisfied with the radiotherapy service itself but moreover the overall care by the radiographers. One particularly alarming quote demonstrated a situation in complete contrast to that of a patient-led, patient-centred NHS;
‘I felt like a piece of meat on a slab when I wanted and needed to be seen as a person’
Thus a study to investigate local breast cancer patient’s needs was developed.
METHOD
The data for this study were collected as part of a wider project using both a questionnaire and focus group to gather patient’s views. The questionnaire allowed initial broad data gathering providing themes for further exploration within the focus group. This paper will concentrate upon the findings revealed by the focus group only.
The study achieved local regional ethics committee and trust research and development approval prior to commencement. It complied with all recommended processes to maintain and promote informed consent and participant confidentiality.32,33
Women with primary breast cancer, referred to the oncology centre for adjuvant radiotherapy were approached opportunistically at pre-treatment. An information sheet was given and the study explained. The researcher met women again during the first week of treatment to seek consent and administer the questionnaire. Women expressing an interest in the focus group were provided with additional information and contacted by letter after completing treatment. The sample size for the questionnaire study was 40 which equated to 10% of the annual number of referrals to the centre. Eight women were invited to participate in the focus group; consent was obtained at the start.
Focus group design
Focus groups may provide an ideal method of gathering qualitative data.Reference Freeman34 They allow exploration of the detailed attitudes and experiences of the participants; similarities and differences can be discovered as experiences and opinions are shared.Reference Freeman34 Moreover, participant interaction could provide informative interesting themes and would be a truly patient-centred method of informing service provision.Reference Pope, Ziebland and Mays35 Careful facilitation of the group by the researcher ensured the discussions remained focussed but with an element of free interaction.
The questionnaire responses and detail from the BCC Report10 were used to provide quotes, which acted as discussion points during the session.Reference Krueger and Casey36 These may be found in Table 1.
Table 1. Quotes used as focus group discussion points
Data analysis
A manual thematic analysis was performed to analyse data from the focus group transcript (transcribed verbatim by the researcher). Responses that were covered by more than one code/category were allocated multiple codes to allow for cross-referencing. A frequency count was made to allow data to be ranked as most commonly occurring themes. Individual quotes were recorded to demonstrate participant’s views.
FINDINGS AND DISCUSSION
Eight women were invited to participate in the focus group. One became ineligible due to possible metastatic disease; two other women were unable to attend due to holidays. Thus five women attended the focus group which ran for 2 hours and was facilitated by the researcher. All women had either Stage 1 or 2 disease; their mean age was 53.6 years (range 32 to 69 years).
Categories and themes from the analysis of the focus group transcript may be found in Tables 2 and 3.
Table 2. Categories from focus group transcript
Table 3. Overarching themes
Theme 1: Information provision
Information provision was the joint highest ranked theme in this study.
Individualised information
The women felt their information needs were mostly met, which would agree with the findings of Halkett and KristjansonReference Halkett and Kristjanson19 who suggest a universal package of information will not meet all women’s needs. The use of bespoke information packs13 and an information needs assessment tool may address these unmet needs. Women’s information needs and their views on the level of information provision varied quite considerably between participants. Individual women will want to know varying details and levels of information regarding their treatment.
The therapy radiographer is ideally placed to assess the information needs of individual patients and then address any unmet information needs; this should be an integral part of their role.Reference Halkett and Kristjanson37 Women linked much of the information giving to the breast care nurses, who provided each woman with a large information pack at the time of diagnosis. Whilst women welcomed this, all found the sheer volume of information at such a crucial time to be overwhelming: ‘I felt relieved I didn’t have to read it’ (Participant B). All women felt the information provided them with a resource to refer to during the treatment. It may be argued that information provision around radiotherapy should be in the domain of expert practitioners, radiographers. It should be tailored to the exact radiotherapy prescription and treatment volume for the individual rather than a generic pack offered at diagnosis. As identified by Rees and Bath,Reference Rees and Bath23 women’s information needs vary over time; well-timed information relevant to the specific area of the patient’s treatment trajectory offers the most appropriate provision.
Information giving prior to the first treatment was through a ‘quiet room’ appointment with a member of staff. All women were appreciative of this provision: ‘I’m impressed they programmed in this quiet room slot it was really helpful . . . . .. it would have alleviated a bit of the anxiety knowing that the quiet room is there and you have an opportunity to ask questions I just thought quiet room what’s that okay I’ll just go and see’ (Participant D). However, it was not fully explained prior to the appointment and actually caused heightened anxiety: ‘that’s another thing you don’t want that stress from do you?’ (Participant A).
The pre-treatment appointment is the first contact women have with staff responsible for their radiotherapy and as such is crucial in setting the scene for the whole course of treatment. It is imperative that staff instantly build trust and rapport helping women to be well-informed. This could help provide not only a positive technical outcome but also a positive experience for women. As Halkett et al.Reference Halkett, Arbon, Scutter and Borg20 describe, the public is generally poorly educated about radiotherapy, heightening their fear and anxiety that is reflected in these study results. Participant A explains: ‘when you go in there the machine is quite intimidating, . . . . if you were quite nervous or shy you would look at that and think what the hell is that going to do to me?’. Present information provision did not allay all participants’ fears indicating that improvements should be made: ‘I think it would have been better to have seen it (machine) before hand’ (Participant C).
End of treatment provision
Information provision at the end of treatment (EOT) was highlighted as a particular area for improvement. The women described different experiences regarding the level of provision at this time. Disparity between individuals reflects the findings of both ArrarasReference Arraras, Wright, Greimel, Holzner, Kuljanic-Vlasic, Velikova, Eisemann and Visser17 and MestersReference Mesters, van den Borne, De Boer and Pruyn18 but in addition to the differences in expectation some women described a variation in the process: ‘I wasn’t given a huge amount of information . . . and told to go away and read (leaflets)’ (Participant B) and ‘I heard by chance that the treatment carries on after . . . but that information wasn’t written down and if you don’t ask the questions you won’t get the information’ (Participant D). Although individual needs may vary, radiographers must offer a consistent level of information at the EOT.
When offered, information was provided on the very last day of treatment around or in the treatment room. As Participant D highlighted, ‘it’s interesting that they don’t have a comparable end of treatment quiet room appointment’. This could formalise the information process at this crucial time, allow quality discussion and would potentially reduce the number of women ‘slipping through’ and receiving no information at all.
The last day is an emotional occasion for many women and it may be argued that the opportunity to rationally discuss and retain information is reduced. Moreover the support of staff and returning to the ‘safe’ hospital environment for a number of weeks may be perceived as no longer there at the last fraction. Such a hiatus in care has been described within the literature.Reference Nazareth, Jones, Irving, Aslett, Ramsay, Richardson, Tookman, Mason and King38 Women may require reassurance about the journey that lies ahead, although they admit a desire to return to ‘normality’: ‘… you just want to get back to living again, back to work, back to normal things . . .’ (Participant B). After ‘active’ treatment has been completed, women may feel isolated: ‘you feel out on a limb’ (Participant E), the gradual steps back to normality could be charged with fear and anxiety: ‘I didn’t take time off (during treatment) as I wanted to be as normal as possible’ (Participant D). The impact of cancer may never leave an individual, each day the surgical scar is visible albeit fading, and the reactions from treatment still obvious. At this stage, support should be paramount and women may need a dedicated appointment to discuss the next part of the pathway. Many would suggest it was just beginning, becoming a cancer survivor.
Theme 2: Communication and support
Communication and support was the second highest-ranked theme.
Communication variation
Communication has a key role in relationships with patientsReference Booth25 and is a core dimension in KSF.26 It is essential that radiographers can and do communicate effectively with patients during their radiotherapy.
Women within the focus group felt that levels of communication varied between staff. Three women suggested staff had excellent communication skills whilst two felt that staff failed to communicate effectively. Participant A explained one experience for her, ‘people were always waiting an hour and there was no apology for being an hour late, nobody came out to talk to you or see how long you had been waiting’. Conversely Participant B explained ‘staff . . . would still remember things you were going to do a few days earlier and would ask oh how did that go?’ which agreed with the experience of Participant D, ‘they always were speaking or communicating with me at the appropriate times’.
BoothReference Booth25 described the main methods of communication staff use with patients and suggested that individual staff characteristics would influence the radiographer–patient relationship. This was described by women in the focus group indicating a disparity in service provision or indeed a variation in women’s individual expected or perceived levels of care.
Women valued receiving care from the same members of staff each day indicating the importance of building the patient–radiographer relationship,Reference Halkett, Short and Kristjanson39 as Participant C explains, ‘it’s wonderful to me to see the same faces time after time. Not who are you? Little things they remembered I was so impressed . . .’. This facilitates a level of empowerment to patients, which radiographers are in a perfect position to fulfil as described by Cartmell and Coles.Reference Cartmell and Coles27
Communication barriers
Barriers to communication were revealed in the data, Participant A described problems she encountered at her ‘quiet room’ appointment for information giving; ‘I didn’t understand a word…I feel that maybe you need to address that–that 15 minutes was important to me…I mean I didn’t know anything about radiotherapy and you need to be able to understand what they are saying’. Radiographer’s ability to convey information and be understood by patients must be paramount. As discussed earlier, communication is a variable individualised skill which is essential for good patient care.Reference Booth25,Reference Fallowfield, Jenkins, Farewell, Saul, Duffy and Eves40 Strong accents, staff with English as a second language or indeed any issue affecting communication skills must be considered by service providers and the regulating professional body alike. Participant B also reiterated such barriers to communication, ‘you don’t want to come across as being racist in any way which you’re not but it is quite difficult particularly if they’re from an Indian sub continent area or something but it could be they’re Geordie . . . .’.
BoothReference Booth25 suggests the selection of prospective radiography students should involve consideration of personality and communication skills, which must surely be transcribed into selection of qualified staff. Further exploration of the barriers to communication is beyond the scope of this paper but as a local issue affecting communication, it is a barrier experienced by some women.
Listening skills
Listening skills are equally important. The women reported that many staff had good listening skills; however, women were acutely aware of the time pressures on staff as Participant A explained ‘they probably haven’t got the time to spend long with you’. Clearly if women need to talk, staff must be available and mechanisms need to be developed to overcome such problems. Treatment rooms may be inappropriate for these discussions as staff must maintain adequate throughput of patients to offer a timely, quality service. Thus departments should provide additional space nearby to treatment units to enable the practicalities of patient communication to be met more readily.
Theme 3: Support needs
The emotional support needs of all the women were not met during their radiotherapy. Some women indicated support was fulfilled by their family and friends, whilst those for whom family support was unavailable or inappropriate reported varying levels of unmet needs.
One participant felt well supported, Participant B explained ‘. . . (one) had an arm around me when I walked in. Then there was this one young girl who was absolutely fabulous and she used to chatter away to me . . ., whilst another suggested no support was available: ‘. . . I missed out on a lot of the support, . . . . support would have been great for me as sometimes I’ve needed to talk to someone and I’ve thought who the hell can I talk too?’ (Participant A). All participants believed insufficient time and opportunity existed for staff to offer support, Participant C suggested it may be beneficial to have ‘a friendly face . . . . sometimes someone to chat to’.
The study by Halkett and KristjansonReference Halkett and Kristjanson37 also demonstrated the importance of radiographers communicating and forming a relationship with patients during radiotherapy. They suggested this enables patients to feel more supported during radiotherapy, enhancing their treatment experience. Considering the findings of these authors, it may be that in this study not all staff could have built such relationships with patients. Those suffering a perceived lack of emotional and psychological support would no doubt have a sub-optimal treatment experience.
Theme 4: Dignity and individualised care
Individualised care
The women believed the level of patient-centred care during their radiotherapy was very good although perceptions of patient-centred care varied with the individual. Participant B reported high levels of satisfaction with patient-centred care: ‘my whole experience from day one . . . . can’t really fault anything at all’, although others raised concerns over the time constraints which reduced the ability of the service to be individualised: ‘maybe more time to chat but I understand how busy they are and can’t keep patients waiting unnecessarily’ (Participant C). Pressures to deliver radiotherapy in accordance with waiting targets6 requires careful balance; quality of care does not solely lie in the domain of timely treatment.
Dignity
The BCC report10 identified severe issues with dignity and respect during radiotherapy. Conversely, all participants in this study felt strongly that they were almost universally treated with great dignity and respect: ‘they are never too busy to smile and respected (my) dignity’ (Participant D). Staff considered women’s dignity; covering the breast whenever possible, avoiding a feeling of being vulnerable and exposed on the treatment couch. For any individual, being undressed, even within the hospital environment may be an awkward situation causing stress and anxiety. This is likely to be compounded when the area exposed is of a particularly intimate nature. Moreover, previous surgery can leave women with issues of body image. The psychosexual impact of breast cancer is beyond the scope of this paper but staff must be aware of such issues to both support women and offer a holistic patient-centred service.
Although the women felt treated with dignity in many ways during treatment, they did suggest certain areas needed improvement, particularly relating to the gowns used for treatment and waiting in these gowns in mixed waiting areas.
‘you do feel like you’re waiting in a corridor in the gown, but . . . . the other machines with special changing rooms, you go into to change and come out straight into the room. On the other side you’ve got the cleaners going in their cupboard, . . . you’ve got people walking past . . . . and the gowns only come in 2 sizes–very small and very large so you sit with one side of the gown out more than the other and . . . you felt frightened to bend over’. (Participant B)
Service accessibility
Study participants universally believed the environment of the oncology centre to be clean, welcoming and pleasant. Some comments were made concerning appointment availability and variation but this was not problematic for all women.
Women were aware that delays were almost inevitable at some stage during their course of treatment and were grateful when staff communicated any delays to patients in a timely manner. In particular, the focus group participants praised the reception staff, as Participant A describes: ‘the reception ladies were lovely . . . not like doctors receptionists, friendly right from the second you got to them and if you get that right from the beginning it’s important’. This clearly indicates the important role of support staff providing care and an appropriate level of support for all patients.
Theme 5: Staff relationships
Halkett and KristjansonReference Halkett and Kristjanson37 described how patients placed high importance on the emotional support from radiographers during treatment. Within this study women found the staff to be professional and caring in general.
Professionalism
‘They were very friendly and very professional’ (Participant B) and ‘staff always have to put on this air that gave you confidence, and if they did have problems certainly nothing ever showed at all. They just did what I would expect of a professional person’ (Participant C). Such examples indicate the value of a good relationship with patients. However the professional behaviour of staff does not imply that a relationship has been formed to the benefit of the patient. Indeed it is the rapport and type of relationship that patients have with healthcare professionals that has most influence upon the emotional and psychological support experienced by patients. Reference Lee, Kristjanson and Williams41Great care must be taken to ensure the ‘power’ balance is correct; offering emotional and psychological support in an appropriate manner. As with communication, the individual skills of particular radiographers would have a profound effect upon the level of care and satisfaction experienced by the patient.
Staff gender
The issue of staff gender was raised by all women in this study. Links between respect and being asked if it was acceptable to be treated by male staff were made. Women felt quite strongly that every time they were treated by male staff they should be verbally asked if it was acceptable, particularly if both radiographers were male: ‘I think it would be a common courtesy to be asked . . . . verbally’ (Participant E) and ‘if you’re there with your top off stuck under the machine and only 2 men in the room it could feel intimidating . . .’ (Participant A). It is interesting to note that the gender of staff was not raised within the BCC report concerning dignity or staff relationships; however, it must be recognised as a local issue within oncology centres affecting the patient’s level of care.
CONCLUSIONS
Perceptions of the radiotherapy service and current levels of provision were good overall particularly around the areas of dignity and individualised care. However women were aware of the time constraints upon staff and believed such issues reduced the opportunity to provide a patient-centred approach. The areas of information and support were perceived as inadequate. Women were grateful to receive their treatment within the NHS and perceived the service to be generally well run in a timely manner. The environment of the centre was well received and much appreciated by the women.
This study has highlighted local areas women feel could be improved. Table 4 identifies recommendations from this research which should be used for service improvement.
Table 4. Study recommendations
Although this study generated areas for service improvement, it is not without limitations. Emergent themes indicated areas of need not fully considered prior to conducting the study. The hiatus in care at the end of radiotherapy and its impact on the women was not fully recognised. The lack of support at this time and possible service improvement should be more fully explored and may be an area for future research.
Radiographer’s communication skills emerged as a further area requiring additional research and exploration, particularly around barriers to communication through staff language. These have been beyond the scope of this study but are local issues affecting communication for women and as such should be explored further within the oncology centre.
PRACTICE IMPLICATIONS
Although this study concentrated upon local services within a single trust and as such may not directly translate to all oncology centres, many issues raised within the themes should be considered by all practitioners and service managers.
Within this study and with previous research it has been seen that patient’s needs vary both between individuals and over time. Traditionally, radiotherapy patient information is given at pre-treatment, on day one and on the last day of treatment; it may be time for this to be reconsidered. As practitioners, radiographers can determine individual information and support needs with the patient and their family (if appropriate) prior to pre-treatment, enabling a bespoke information prescription to be developed. In discussion with patients, information can be delivered at intervals throughout the radiotherapy pathway allowing appointments for dialogue during and after treatment. This could help to minimise the impact of the ‘hiatus in care’ some women experience when active treatment ceases.
Communication skills and potential barriers from English as an additional language must be considered during recruitment and employment. Moreover, centres should invest in the assessment of communication skills for all staff, running training for those in whom such skills could be refined. As a core dimension of the KSF26 this is imperative for all departments.
Women’s perceived lack of time with staff may be difficult to overcome in practice. Lack of staff, delivering government targets and other pressures upon tight NHS resources may make facilitation of ‘more time’ most difficult to achieve. Careful use of skill mix, including assistant practitioners may allow radiographers to have ‘more time’; in addition, providing areas to talk with patients close to each treatment unit may enable communication more readily in an appropriate environment.
All departments must be urged to discover their user’s views. Focus groups enable the patient voice to be heard whilst providing empowerment and dignity to those involved. All patients deserve a world class radiotherapy service driven by patient-led service improvements, as radiographers we can help to facilitate this in the future NHS.
Acknowledgements
I would like to express my gratitude to all the women who participated in this study, without them nothing would have been possible. Also my thanks to the staff in oncology who supported me with this research and to Geraldine, my Research Supervisor. I truly hope this study will be used to provide future breast cancer patients with a better experience during their radiotherapy.
