BACKGROUND
Introduction
The development and introduction of the four-tier career progression professional structure for radiographers 1 has led to a wider acknowledgement of the existence of radiographer expert practice as well as support for the development of expertise in other areas of radiographer practice.2 Many radiographers now have broader responsibilities than previously held and work beyond traditional boundaries. It has been recognised that extending and adapting staff roles gives greater flexibility to service provision and to the professionals themselves, enabling both personal and career developments, all leading to improvements in service and patient care.3 This article looks at the levels of satisfaction with the care they received, expressed by patients who took part in an in-house survey of on-treatment review clinics led by the advanced practitioner urology radiographer. The scope of practice of the advanced practice urology radiographer covers the care of prostate and bladder cancer patients requiring radiotherapy. The purpose was to determine the efficacy of advanced practitioner radiographer-led review clinics.
Development and accreditation of advanced practice working
Prostate cancer is the most commonly diagnosed cancer among men in the UK, with almost 35,000 cases diagnosed in 2004.4 As part of the department's ongoing commitment to patient care, the role of the specialist urology radiographer was created at the oncology unit in the Addenbrooke's Hospital in April 2003 to fulfil a service need for specialised radiotherapy support for patients with urological cancers. It was deemed necessary that the service needed expert knowledge and skill base in urological cancers and related treatment and patient review techniques. An individual working within this role was developed to the advanced practitioner level by the creation of a personalised educational plan. This was developed from consultation between the post holder, lead consultant oncologist for urology, head of radiotherapy and workforce development superintendent, so that the appropriate knowledge and skills could be gained in accordance with the framework set out by the SCoR.1 Postgraduate training undertaken included, among others, Masters-level on-treatment review.
On-treatment review process
A part of the original remit of the role was to establish a protocol-driven, radiographer-led, on-treatment radiotherapy review clinic in which patients had to visit at 2-week interval during the period of treatment, or more frequently according to patient need. The final review is normally conducted by a consultant oncologist, but in their absence, patients would be seen by either a medical registrar or the advanced practitioner radiographer. Although clinicians prefer to see patients during their final week of treatment, during holiday times or absence due to illness or study, they have expressed satisfaction when the final review is conducted by the radiographer. In this circumstance, it is the radiographer who writes to the patient's GP to keep him or her informed of patient progress, including details of medication (if any) prescribed during treatment, and need for continuation or cessation of treatment such as androgen deprivation.
Because of the large number of patients having radiotherapy at any given time, it is impossible for every patient to be seen fortnightly in the radiographer-led clinic. Instead, when this clinic is fully booked, patients revert to being booked into their consultant's on-treatment review clinic. To maintain consistent recording of treatment-related toxicity between individual staff members, a review form was developed. This is used along with treatment record sheets in which a brief summary of each review is documented.
Rationale and aim of survey
In line with normal departmental practice, a prospective survey was carried out in association with the Trust's audit department to assess patient satisfaction with the service provided in the urology radiographer-led clinic. The urology on-treatment review service had not been assessed previously for patient satisfaction, and therefore no direct comparisons could be made with an oncologist-led service. The survey of the radiographer-led on-treatment review service would be used to assess general levels of patient satisfaction and to highlight any problems or issues within the service. The results could also be used as a baseline against which further changes in on-treatment review service could be compared by future audits.
Method
Between November 2006 and January 2007, 50 patients undergoing external beam radical radiotherapy for prostate cancer or bladder cancer were each given a questionnaire (Appendix 1) by their team of treatment delivery radiographers during the final week of radiotherapy treatment. The patients were requested to complete the questionnaire without the involvement of the staff. The patients who participated in this study were not selected based on any criteria: all the patients treated for prostate or bladder tumours during the study period were approached until 50 questionnaires had been given out.
Patient anonymity was maintained, and patients returned the completed questionnaires to the Clinical Audit department either by post (enclosed in the pre-paid envelope provided) or handed it to the radiotherapy reception staff. All the patients were assured that the radiographers had no access to the completed questionnaires and that anonymity was guaranteed. No patient demographics were collected. Non-NHS patients were excluded because the protocol requires that wherever possible they will be seen by their consultant oncologist.
At the time of the survey, the clinical urologic oncology medical team within the department comprised five consultant oncologists and their registrars: all were informed that the survey was to be undertaken and that their patients would be involved. The Clinical Audit department had obtained approval from the local ethics committee for the content and use of the questionnaire.
RESULTS
None of the patients who responded reported that they were unable to read or to understand the questionnaire.
Review frequency
Of the 50 questionnaires distributed, 34 (68%) were returned, and of these all patients (100%) stated that they were seen by the urology radiographer at least once during their treatment: most (46%) of the patients were seen three times (the frequency planned for their treatment), 18% were seen twice, 21% were seen once and 15% were seen more than three times during their treatment course (Table 1).
All patients responded to the question ‘how many times did you see a doctor at the review clinic?’. 3% (one patient) who were seen more the standard three times, 15% who were seen three times, 18% who were seen twice, 2% who were seen once, and 3% who did not see an oncologist during their treatment course (Table 2).
The patient who stated not seeing the doctor at any time during the course of radiotherapy treatment did not report this as being a hindrance to the treatment because the patient wrote ‘everything was perfect’.
Initial point of contact
To the question, ‘when did you first meet your Urology Radiographer?’, 33 of the 34 patients were able to identify when initial contact with the urology radiographer was made. Fourteen of the thirty-three reported that initial contact with their urology radiographer was made at the ‘new patient’ clinic in oncology during the visit in which they first met their oncologist. Ten (30%) reported to have first met the urology radiographer at the on-treatment review clinic and 9 (27%) when they came to the department for the radiotherapy planning scan. All the patients (100%) had met their urology radiographer and were familiar with their role before the need arose to discuss any medical problems (Table 3).
Approaching patients
On being asked whether the urology radiographer introduced himself/herself?, 33 of 34 patients responded. Thirty-two (97%) patients responded with a ‘yes’ and 1 patient with a ‘no’. The one patient also stated that the role of the urology radiographer in the treatment was not clear. The patients did not mind seeing a urology radiographer instead of a doctor and felt that the urology radiographer was able to answer any of the questions they had. This patient answered most of the other questions with a ‘yes’, but they said ‘no’ when asked whether seeing the doctor ‘three times’ at their review clinic was sufficient; the patients failed to state a reason for this (Table 4).
Understanding the role of the urology radiographer
The role of the urology radiographer was understood by almost all the patients. When asked ‘Did you understand their role in your care?’, 33 of the 34 patients answered. Of the 33, 31 (94%) patients responded that they understood the role of the urology radiographer in their care, whereas two patients reported that they did not; one of these two patients stated that there were no unanswered questions when the review(s) was over (Table 5).
Patient satisfaction with level of support provided
Patients were generally happy with the level of support they received from the urology radiographer. Of the 34 patients, 32 answered the question ‘In your experience of having radiotherapy treatment, do you feel the Urology Radiographer gave you enough support?’ Thirty (94%) responded with ‘yes all of the time’ and two (6%) reported ‘yes some of the time’. None of the patients said that they did not receive enough support (Table 6).
All the 33 patients who answered the question ‘If you had a problem on a day you were receiving radiotherapy but were not due to see the urology radiographer at a review clinic, did you feel you could ask for their help?’ replied with a ‘yes’ (Table 7).
All the patients (33) who answered the question ‘Did you feel you had enough time in your review(s) with the Urology Radiographer?’ responded that they did feel that they had enough time (Table 8).
Patient satisfaction with radiographer review
Overall, the patients expressed a high level of satisfaction with radiographer-led clinics. The 33 patients (of the 34) who responded to the question ‘Did you mind that in some review clinics you saw a Urology Radiographer and not a Doctor?’ said that they did not mind that in some of their review clinics they saw a urology radiographer and not a doctor (Table 9).
Information provided by the radiographer
The information requested by the patients could normally be provided by the urology radiographer. Of the 33 patients who answered the question ‘Did you find that the Urology Radiographer could answer any questions you had?’, 31 (94%) answered with a ‘yes’ and 2 (6%) answered ‘sometimes’; none of the patients answered in the negative (Table 10).
Few patients felt that they had unresolved issues at the end of the review. Of the 33 patients who provided a response to the question ‘Did you feel you had any unanswered questions when you had finished your review(s) with the Urology Radiographer?’, 29 (88%) responded with a ‘no’ and 4 (12%) reported ‘sometimes’; none of the patients responded with a ‘yes’ (Table 11).
Patients also reported that they were comfortable having their questions answered by a radiographer rather than a doctor. The patients were asked ‘Whilst being seen by the urology radiographer at your review clinic(s) did you have any questions you felt you would rather have answered by a Doctor?’, to which 33 patients answered.
Thirty-one (94%) answered with a ‘no’, 1 (3%) answered with a ‘yes’ and 1 (3%) answered with a ‘sometimes’ (Table 12).
The patient who answered ‘yes’ to this question stated that seeing a urology radiographer rather than a doctor was not a problem and that seeing a doctor ‘twice’ was sufficient. The patient also made the following comment: ‘Dr. and treatment team have provided excellent care. We are very grateful.’ The patient who stated ‘sometimes’ did not mind seeing a urology radiographer instead of a doctor and made the comment: ‘I was very satisfied with the radiotherapy review clinics. All the staff I met were very pleasant and helpful. This also applies to the radiographers who did my image-guided radiotherapy treatment.’
Patient comments
The final question was whether patients had any comments to make concerning their radiotherapy treatment. Sixteen patients responded; the only negative comment made was regarding facilities such as access and car parking rather than criticism on the service provided by the radiographers. Ten of the sixteen (63%) were positive comments such as ‘very happy with the treatment and found everyone very helpful and friendly’, ‘couldn't ask or expect for more’, ‘can't praise them enough’, ‘very impressed by the service throughout’ and ‘they are a good team and they make you feel at ease. Keep up the good work’.
DISCUSSION
The point in the radiotherapy process where the urology radiographer made the first contact with the patient varied: this was in part due to the wide geographical area in which patients live. Those who live in the catchment area of the radiotherapy department may meet up in the ‘new patient’ clinic in oncology during the first consultation with an oncologist. Those who travelled for treatment having initially seen an oncologist in one of the four peripheral clinics held in their local hospital did not have this opportunity.
Overall, patient satisfaction was good, although it is understood that the patients had no other experience or expectations against which they could compare. A better method of measuring effectiveness of this service change could have been to alternate on-treatment review of patients between oncologist and radiographer, with an additional question of ‘did the patient feel there was a difference in the level of care received?’, but there was no capacity in the department in which this option could be explored.
An important component of this survey was to evaluate the care levels provided by a specialist radiographer trained to advanced practice levels. The aim at this stage was to ensure that the training and knowledge base was of a sufficiently high standard to ensure that patent queries and concerns could be resolved without use of expensive medical practitioner time. In the vast majority of cases, this survey demonstrated that the care and support levels were reached, showing that the training programme in this area was adequate for the service needs.
Future surveys will evaluate the effectiveness of the training programme in providing the skills for assessment of treatment toxicity.
Conclusion and recommendations
The level of response was encouraging and felt to offer a reasonable reflection on overall level of patient satisfaction. Patients are generally happy with the service provided by the advanced practitioner radiographer specialising in the care of urology patients, demonstrating that radiographers can be effective in supplying the service needs in this area.
An audit is scheduled to take place in 2009 to ensure that patients continue to be satisfied with radiographer-led review clinics. In the meantime, nothing was highlighted in the survey where the practice was deficient and so no changes to practice have been recommended.
APPENDIX 1
Dear Patient
In Cancer Services we are always striving to improve the service we offer to our patients. Please could we ask you to complete this questionnaire which will help us identify present level of patient satisfaction, and help us to identify areas for improvement? The questionnaire asks about the radiotherapy review clinic(s) when you saw either a doctor or the urology radiographer to discuss how your radiotherapy treatment is progressing.
The information you give will be kept secure in Cancer Services and Clinical Governance & Audit, and will be seen only by staff working in these areas. By completing the questionnaire you are consenting for the information you give to be used in this audit project only. Although details of the audit may be published elsewhere, no-one will be able to link you personally with this audit. Your answers will be treated in the strictest of confidence and completely anonymised and will therefore have no bearing on your personal care. Completed questionnaires will be destroyed after a final report has been written. Thank you for helping us.
Throughout the questionnaire please tick the relevant box
