Codes Sub themes Theme
Integral in service delivery
Reduces waiting times Reduces pressure of the service
Increases throughput of the number of patients that can be seen Aids the clinicians workload
Enhances service
Service targets
Impact Patients seen earlier and
quickly
Improves the patient pathway
Continuity of patients care
Improves the patients journey
Point of contact for patients
Help shape the patient pathway
To look after patients and make them happier
Perceived patient experience Motivate staff Influence change Permits valuable partnership working Harmonious working Potential career progression for radiographers Informs practice Collaboration Professional outcomes
Part of the team Integral part of team Central to team Established in team Element of competition Strained relationship Close relationship
Support from oncologists Support from Surgeons Pivotal
Working Relationships
Autonomy in decisions Assist/helps the patient Assesses patients Makes own medical judgement
Consenting patients Coordinating patient care Expert clinical practice Service delivery Independent practice Reviews own patients Discusses treatment options Follow up patients Role aspects Identity Huge respect
Very well respected Have a presence Wealth of expertise Leads from the front Pushing boundaries Appreciation Acceptance Confidence Flawed concept Reservations Any added value
Presence Wrong perception to patients Wrong impression Warranted title Appropriate title Reflects the role
Separates the role from others Provides a difference Recognition Status Gap in service Service need Needs for patients Evolving service Cancer services changing globally Implementation of 4-tier structure Adopts a multidisciplinary team approach to service
Development Purpose
Lack of medical knowledge Medico-legal Indemnity Funding Financial pressures Blurring of boundaries Encroachment Concern Challenges Medical prescribing Dose prescribing Site expansion More consultant radiographers Recommendations Future Accountability Hierarchy Control Maintain Preserve Uphold Battles
Medical Dominance Power
Table 6.1 Thematic framework for case study site 1a 6.4.3 Presentation of key themes
Theme 1: Impact
This was a dominant theme that was apparent throughout the interviews at this case study site. The overall views of the participants during the interviews perceived that the consultant therapeutic radiographer had made considerable impact within the department. Four areas of perceived impact were identified and grouped as service
targets, perceived patient experience, professional outcomes and working relationships.
Service targets as perceived by the participants related to examples of how the
CTR influenced the service provisions for instance:
“(CTR) was integral in terms of delivering the treatments…the actual
(speciality site).” (SpR1a)
In addition,
“The oncologists don’t have time to look at where the gaps are but (CTR) has
really evolved the service.” (Adv.Prac1a)
Although the patient’s viewpoints were not directly captured, the interview participants at this case study site all perceived that the role of the CTR played a very important part towards the patient’s journey. The participant’s offered a range of examples pertaining to the perceived patient experience; for instance:
“So the impact for the patient is huge and hugely beneficial as it means they have a point of contact with an expert and specialist knowledge.”
(Adv.Prac1a) Moreover,
“(CTR) gives some kind of continuity of care, it’s nice for them in some ways as they are more contactable than the Oncologist and if they have a problem they will get back to them quite quickly, so they probably get a better care
from sort of personable perspective.” (SpR1a)
To reinforce this, feedback from patients on their behalf were also afforded by the participants, for example:
“The patient’s views about (CTR) are always positive” (SpR1a)
In addition,
“Always positive feedback only from the patient, and they feel (CTR) spends
time with them.” (SpR1a)
The participants highlighted that the role does have a reasonable bearing on the
professional outcomes in terms on how influential the CTR can be. Participants
perceived that the CTR had made an impact at a local level (within the department):
“(CTR) has the ability to motivate research, the staff and influence the decision making process within the department” (Adv.Prac1a) Also on the wider radiotherapy agenda:
“You’re looking at uhm having a good career progression; it attracts people into the profession if they know there is a route to go.” (CTR1a) Discussion on the working relationships with the CTR was also a prevalent topic as conveyed by the participants. Participants expressed mixed views on their working relationship with the CTR. Some of the participants acknowledged the positive relationship they felt they had:
“We work very closely with (CTR) an integral part of the team, so yeah; (CTR)
is a central part of the team.” (SpR1a)
In addition,
“Huge amounts of support from the oncologist and the surgeons – the doctors are very keen for someone to come aboard and look after the patient.”
(CTR1a) Conversely, there were some discouraging comments for instance
“(CTR) was a very good advanced practitioner but in some ways (CTR) lost their integral role in the team when they became a consultant therapeutic
radiographer.” (Clin.Onc1a)
Moreover,
“There was some competition, we had to just get our heads around it…..I think it was hard…but we learned to kind of work with one another.”
(Adv.Prac1a) The extracts acknowledge that impact was a central theme within this case study site. The participants overall perceived there were indeed examples of impact as demonstrated by the CTR.
Theme 2: Identity
The notion of identity as a theme throughout this case study site brought about varied views from the participants. The initial viewpoints were very much surrounding the CTRs presence within the case study site, for example:
“(CTR) is very respected by the surgeons and the team.” (Adv.Prac1a) “(CTR) is fairly well known in our hospital and with the department” and we have every confidence in them and is perfectly capable of doing this role.”
(SpR1a) Furthermore the views were also based around how the positioning and the presence of such a role was a favoured example of being a leader and progressing onwards and upwards, for instance:
“(CTR) has a wealth of knowledge and lead from the front and has pushed the boundaries every time and at every point.” (Adv.Prac1a) Conversely, some thoughts on the value of the role whether in fact it added any benefit was raised, such as:
“so the question is how much extra benefit there is….it is nice to have but it’s difficult to know what the benefit is within the department…it’s probably a big
benefit to them.” (Clin.Onc1a)
This was an interesting response as the views were very much alluding to the fact that there was no benefit or presence within the actual department, but more so the role was seen as a benefit to the person assuming the identity and the profession.
Equally, the issue of the title Consultant provided a mixed response in terms of its appropriateness. Some of the views were very much supportive of the title as it reflected the role for instance:
“I think the title is warranted, I think that actually it is a huge responsibility and (CTR) is an expert in their field, it’s definitely very respected the title.”
(Adv.Prac1a) In addition, acknowledging the recognition of the role:
“It separates their role from the other radiographers in that (CTR) can see patients on their own and sort of make medical decisions.” (SpR1a)
On the other hand, views were also made in terms of how the title could potentially confuse the patients for example:
“Will the patients understand it is a radiographer as opposed to a doctor?” (Clin.Onc1a) In addition,
“I think there is a bit of confusion at times the patients assume that they are seeing a consultant doctor – but actually it wasn’t, so it just implies different
things.” (SpR1a)
Overall the participants felt that regardless of the title the patient care should not be impacted on:
“It’s fine as long as the patients’ treatment isn’t compromised.” (SpR1a)
Using an alternative title was considered but not offered:
“It’s difficult to know whether that’s the best way of labelling them or whether there’s something else that they should use, don’t know what though.”
(Clin.Onc1a) Interestingly reference to a nurse role was also cited as a comparison to the CTR role, yet to a Clinical Nurse Specialist (CNS) rather than a Nurse Consultant which is more comparable to the CTR:
“(CTR) is good as any CNS and it takes the role of the CNS in a lot of ways, so it is being able to be the radiographer and also be the CNS at the same
time.” (SpR1a)
This comparison does potentially imply that perhaps the SpR may not see the postholder as having a level of consultant skill.
There was also much discussion throughout all the interviews regarding the role of the CTR. Participants were able to demonstrate an awareness of what they perceived the aspects of the role entailed. The perceptions from the participants focused their understanding on two specific areas, which were the practice component of the role and qualities of the role. The practice component of the role
was in reference to the duties that CTR performed. Running a clinic and seeing / reviewing patients were the popular examples of the role, with participants citing:
“(CTR) has a clinic um….that (CTR) runs with their own patients”
(Clin.Onc1a) In addition,
“(CTR) will see patients in the new clinic and assess their appropriateness for
treatments.” (Clin.Onc1a)
Moreover, the physical act of providing the radiotherapy treatment was also an aspect of the role that the participants cited on numerous occasions, for instance:
“(CTR) will also carry out the treatments and review the patient during
treatment.” (Adv.Prac1a)
“The role involves delivering treatment….. (CTR) also has a follow up clinic,
undertaking examination.” (Clin.Onc1a)
Furthermore,
“(CTR) is one that presses the buttons in terms of switching all the machines.”
(SpR1a) In terms of the qualities of the role, this aspect focussed on the abilities the CTR would need to demonstrate. The responses made reference to some of the four domains/pillars of consultant practice. For instance the domain of expert practice was highlighted as being a key attribute:
“I perceive the consultant radiographer to be an expert practitioner within a specialised area, developing an expert clinical practice.” (Adv.Prac1a) Moreover,
“Has expert knowledge within whichever area they are practising in and also have advanced communications skills.” (Clin.Onc1a) The domain of leadership was also highlighted with reference to autonomy and independent working for example:
“Someone who has a degree of autonomy in their decisions.” (CTR1a) “(CTR) can see patients on their own accord and make their own medical
judgments,” (SpR1a)
In addition,
“Somebody who is authorised to have independent practice, that’s what I
think.” (SpR1a)
The extracts illustrate that the participants within this case study site had awareness and some familiarity with the CTR role in terms of the attributes and were able to provide an overview of the role from their own perspectives.
Theme 3: Purpose
The participants were very confident in being able to identify why the role was created. The majority of the discussions were focussed on the service requirements and how such a role was specifically created to support the service, for instance:
“(CTR) identified a gap in the service and therefore service developed to
address this.” (Adv. Prac1a)
In addition,
“The role really grew from a service need and so we identified that there were gaps in the service and there were quite a few.” (CTR1a) Moreover, the wider perspective of cancer services was also considered particularly in terms of where the participants felt it was moving towards, for instance:
“Cancer service delivery was changing globally and we were at that point of
evolving and growing the service.” (CTR1a)
Patient needs were also another factor in the development, with participants citing:
“It fitted well for the service as a whole, providing patients with information and
support.” (Adv.Prac1a)
“I think the patients need this if we are going to have a patient centred care
with a multi-disciplinary approach.” (SpR1a)
Aside from service, developing the radiotherapy profession and providing opportunities for staff was also acknowledged as a contributory factor with participants stating:
“There was recognition of the four tier structure by the college…it’s multifaceted, you’re looking at having a good career progression and it
attracts people into the profession.” (CTR1a)
Overall the participants’ were very convinced as to why the role had been developed.
Theme 4: Challenges
A number of issues were raised by the participants that they felt the role could be deemed as a challenging aspect of the role itself. The lack of medical knowledge was seen as area of concern, for instance:
“The consultant radiographer can probably say whether the patient has had a stroke or not but whether they would be able to pick up all other things that
are not directly related.” (Clin.Onc1a)
In addition, a reference to non-medical training and knowledge was also provided for example:
“Doctors train for seven to 10 years…but does (CTR) you know see evidence of other medical conditions that are not related.” (Clin.Onc1a) Similarly, medico-legal / indemnity were also a discussion point by some of the participants stating it could be an issue, for example:
“It’s about the license issue….so it’s having to get the license to be able to prescribe (speciality) it’s the issue around that, I think”. (SpR1a) Financial constraints / funding to support the role were a primary source of concern expressed by all participants at this case study site, for instance:
“With the current financial climate there may not be any more consultant
posts.” (CTR1a)
In addition,
“Budgets are in a poor way and to fund someone at a consultant level is a big
hit on the budget you know.” (CTR1a)
The views allude to the possible challenges of sustaining the role and its future.
Potential for role impingement was also raised with a suggestion that:
“They encroach a bit on what the doctors do” (Clin.Onc1a)
In addition, the considerations for ensuring boundaries were not obscured for instance:
“If the boundaries are blurred, then I think there could be a huge concern with
the role.” (SpR1a)
However, the participants agreed that this could be avoided through:
“Understanding the boundaries and making the boundaries very clear, then
there shouldn’t be any concerns” (Adv.Prac1a)
Theme 5: Future
The participants were all very positive in terms of how the role could progress further. Prescribing rights for the CTR was very much a popular topic of discussion; this was pertaining to medical prescribing and radiotherapy treatment dose prescribing, for instance:
“I want to look at actually prescribing the radiotherapy, the patients never see the oncologist anymore to discuss radiotherapy and so take that step out and
to actually prescribe it.” (CTR1a)
In addition,
“(CTR) has been trying to do it getting on the prescription course; I think it will give them a little bit more autonomy in some ways.” (Adv.Prac1a)
Increasing the number of posts and expanding to other sites were also voiced:
“It’s been identified that we would benefit from a consultant radiographer in lung; people would be very keen to have more consultant practitioners very
definitely” (SpR1a)
In addition,
“They are talking about appointing consultant radiographers in high volume sites such as breast and prostate.” (Clin.Onc1a) Interestingly though, any progress in these ideas had been impacted by financial pressures as mentioned in the previous theme, for example:
“Can’t imagine at this time the Trust would agree in paying someone at this level, but we are hoping eventually.” (Adv.Prac1a)
Theme 6: Power
The final theme at this case study site was surrounding examples of potential power issues that existed. The views were very much divided amongst the participants. One view shared was regarding the control of radiotherapy treatment dose prescribing should still remain with the clinician, for instance:
“I think in terms of prescribing the radiotherapy it should still be doctor-
prescribed.” (SpR1a)
When asked to provide a reason this was based on:
“It’s really the accountability issues.” (SpR1a)
Similarly, control in terms of:
“We need to keep hold of this” (Clin.Onc1a)
Indicating protectionism, which the doctor is still responsible for the patient, yet the reason was seen as providing a “safety net” for the CTR.
Another view that was shared was based on hierarchal relationships between the doctor and the CTR citing:
“You might be better than a doctor, you might be cleverer than a doctor but in the end there is a hierarchy and the doctor is the leader of the team and so
you cannot buck the hierarchy.” (Clin.Onc1a)
A further view that was also shared acknowledged both the hierarchy and the shortcomings of the actual role:
“You need to work around the system and if you really want to be the top hierarchy then you better train as a doctor, that’s life you know, the concept is
flawed.” (Clin.Onc1a)
This comment was of particular interest, as the role of the CTR is not to replace the doctor but to work in a synergistic partnership, this can be demonstrated by one participant citing that:
“(CTR) is actually undertaking tasks that were traditionally undertaken by the
medical consultant.” (Adv.Prac1a)
Another view offered regarding the power relations observed, likened it to a tireless battle, which suggests that there is a potential power asymmetry within this case study site, for instance:
“I stood back and on reflection and thought you know this is not a battle worth
fighting,” (CTR1a)