British Journal of Radiology (2004) 77, 493-498
© 2004 British Institute of Radiology
doi: 10.1259/bjr/82394256
Clinical implementation of dynamic intensity-modulated radiotherapy: radiographers' perspectives
H A McNair, MSc, BSc, DCR(T)
1
G Francis, MSc, BSc, TDCR
2 and
J Balyckyi, HDCR(T), MBA
1
1 Radiotherapy Department, Royal Marsden NHS Trust, Sutton, Surrey SM2 5PT and 2 Kingston University & St George's Hospital Medical School, London, UK
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Abstract
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The ability of intensity-modulated radiotherapy (IMRT) to sculpt the dose distribution closely around the tumour volume has the potential to have a major impact on radiotherapy clinical practice. However, dynamic IMRT treatment delivery differs from that of conventional treatment because of the constantly moving multileaf collimators (MLCs) and higher monitor units (MUs) required. The implementation of new technology can be affected by the users response. Radiographers' attitudes regarding technology and their perceptions of the clinical implementation of IMRT were explored using a qualitative study based on semi-structured interviews. 16 radiographers were interviewed and data was analysed using a framework analysis to identify themes and categories. The majority of radiographers (12/16) demonstrated positive attitudes regarding technology. The introduction of IMRT was seen to be stimulating and motivating. Negative aspects were associated with increased stress from learning new skills and the additional pressure of the increased workload. Although there were contradictory views regarding the effect of the increased use of technology on the patient–radiographer relationship, technological skills and patient care were not found to be mutually exclusive. Radiographers' perceptions regarding the clinical implementation of IMRT appeared to be influenced by their mainly positive attitudes regarding technology. With the current problems of recruitment and retention of radiographers, full exploitation of modern technology could be used to improve job satisfaction. However, careful integration is required to balance training needs with service demands.
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Introduction
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The introduction of intensity-modulated radiotherapy (IMRT) into clinical practice has the potential to improve the treatment of tumours that surround sensitive anatomical structures, for instance surrounding the spinal cord in head and neck cancers or the rectum in pelvic cancers [1]. Planning studies have quantified the potential benefit of IMRT plans compared with 3D conformal and 2D conventional treatment planning [2, 3]. Consequently, clinical trials are underway to assess the effect on tumour control and treatment outcome [4].
In the past, the introduction of new technology into the radiotherapy department has changed working practice and increased efficiency, for example, the introduction of electronic portal imaging (EPI) and multileaf collimators (MLCs) [5]. The clinical introduction of IMRT has not only resulted in further changes in the treatment verification and checking procedures performed by radiographers but also, thus far, in increased treatment times [6]. Dynamic IMRT involves continual movement of the MLC, generally in the form of a "window" sliding from one side of the field to the other. Varying the speeds of the leading and trailing leaves then modulates the intensity of the beam. This differs from conformal radiotherapy (CRT) delivery where the MLC shapes remain fixed for each beam delivery. The monitor units (MUs) necessary to deliver the required dose are also in the order of 3–6 times greater than that for CRT. Although the effectiveness of the introduction of a new technology can be influenced by user response [7], to date the use of IMRT has not been explored from the radiographers' perspective.
A Phase 1 dose escalation study of the use of IMRT to treat the prostate and pelvic nodes in patients with prostate cancer was implemented at this centre in August 2000. The treatment technique used NOMOS Corvus planning system (NOMOS, PA, USA) and Elekta Sli linacs (Elekta, Crawley, UK) to deliver dynamic IMRT. The linacs were operated in "service" mode and the department was among the first in the UK to use this technique. This paper explores radiographers' perceptions of the impact of dynamic IMRT in this centre, 4 months after implementation.
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Methodology
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A qualitative approach was used to enable the broader implications of the introduction of IMRT to be explored. All 30 qualified radiographers at the Royal Marsden NHS Trust, Sutton were invited for interview, providing a systematic, non-probabilistic sample [8]. Data collection was by semi-structured interview. The questions were developed from the findings of a focus group consisting of two physicists and two radiographers with the most experience of IMRT and supplemented from the literature (see Table 1
). Biographical data were also collected about the group to provide information that may affect attitudes to technology [9]. Two pilot interviews were undertaken to test both the schedule and the equipment. The main study interviews were carried out between March 2001 and April 2001. The interviews were taped and lasted 20–30 min.
The local Research Ethics Committee approved the research. Anonymity and confidentiality were protected. The lead researcher was known to the radiographers and although expectations were bracketed this may have introduced bias.
The data were analysed using a framework for deductive analysis [10]. This involved:
- Familiarization — whilst the tapes were not transcribed by the researcher they were listened to and checked by the researcher. The transcriptions were read again to gain an overall sense and meaning of the text.
- Identifying a thematic framework — the key issues, concepts and themes were identified.
- Indexing — the framework was applied to all the data. Sentences were highlighted which were related to the themes. When new themes emerged, previous transcripts were re-read.
- Charting — the data were rearranged according to the appropriate part of the thematic framework to which they related.
- Mapping and interpretation — the charts were examined to find associations.
Insufficient attention to rigour has perhaps led to criticisms of qualitative research. Accepting that all research is selective [8], the perspective was taken that validity was assured through the shared language of the lead researcher and the radiographers [11]. By maintaining meticulous records and by audio taping, the re-test reliability of the data was safeguarded.
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Results
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Of the 30 radiographers who were invited for interview 17 agreed. One could not be interviewed due to sickness. The demography of the sample is shown in Table 2. Within the broad categories of questions certain themes emerged from the analysis. These are presented under the original categories. Quotes from the radiographers are included to illustrate the themes, the number in brackets representing the radiographer interviewed.
Attitudes to technology
Most of the radiographers interviewed expressed positive attitudes towards technology (Figure 1). These attitudes were illustrated in terms of the use of technology being stimulating and efficient.- "It makes it easier and it makes it more interesting, I think it is probably what has kept me in radiotherapy because of the many new things that have come" (6).
Older radiographers appreciated that it may take longer to learn new skills, but it was still expressed as a positive aspect.- "Perhaps it takes longer to learn it when you are older, but it makes it interesting and it means that even if you have not gone out of your way to learn new things, new things are coming to you all the time so that keeps it interesting" (5).
Those who accepted that technology was part of their job, but preferred the patient contact illustrated neutral attitudes towards technology.
- "I like the interaction with patients, I do like the sort of mechanical aspects of the machinery. It's all quite rewarding at the end of the day, but I like the interactions with the patients and staff" (4).
Impact of technology on clinical practice
Within this category themes emerged regarding the impact of technology on the patient–radiographer relationship. Though radiographers identified themselves as more patient or technology orientated, there were no clear trends in the relationship between their attitudes to technology and their inclination towards patient care or technology.
Radiographers displaying positive attitudes to technology did not all prefer the technological aspects of the job, with some describing themselves as more patient orientated (Figure 2). Radiographers who did prefer the technological aspects of the job, felt their priorities had changed from patient-orientated to technological-orientated.
- "It's funny, if you had asked me this 5 years ago I would have said no, I am a patient orientated person. But I'm not now. I shouldn't say less patient orientated... but people do tend to be one or the other. I think I prefer the technology now" (13).
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Figure 2. Attitude towards technology in relation to preference for technological skills or patient care.
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There were contradictory views on whether the patient–radiographer relationship changed with the increased use of technology and these were not consistent with the radiographers' descriptions of themselves. Those who felt that technology took the focus away from the patient described themselves as either being technically minded or preferring patient contact although liking the technology aspects, or mainly patient focused.- "I think there is a danger of losing that [the patient–radiographer relationship] to a certain extent because you get so wrapped up in the technological side of the treatment, sometimes you forget you have a patient on the bed" (14).
Some radiographers felt that the care of the patient had not changed with increased use of technology.
- "I think I deal with the patients in the same way with a machine that is not technical, so I can't really see how it would alter" (4).
Two radiographers considered that with the increase in technology, patients' expectations were higher because they demanded more information.
- "I think we certainly do give them a lot more technology based information than we ever used to. It was always very patient care orientated before, whereas now not only do we need to tell the patients more....but the patients are a lot more aware of what is happening as well" (9).
Organizational impact
The impact IMRT has on the organization focused on the radiotherapy department rather than the Trust and the themes were divided into two groups; factors increasing stress and factors increasing job satisfaction (Figure 3).
Factors increasing stress
Factors that increased stress were mentioned in relation to the workload of the department. All radiographers mentioned that the time taken to treat was an issue when considering the impact on the department.- "It is a lengthy procedure so it is not something that we can just slip in 5 minutes in between other patients" (15).
Pressure was seen to result from the high workload and the time necessary to learn new skills. Stressful factors specific to IMRT were identified as problems of delivery verification and concern regarding unusually high MUs: these factors were also related to a feeling of loss of control.
Factors increasing job satisfaction
In contrast 10 radiographers mentioned that background knowledge, provided by informal lectures, helped with the implementation. It made them aware of the implementation in the early stages. The radiographers who had been involved in the initial implementation mentioned the benefit of participating in testing the procedure.
- "I did like the way it was implemented, the way we did the phantom patient. It was excellent" (1).
When the issues regarding treatment verification and trust in machines were discussed the result of working in a multidisciplinary team was reflected back to trust in the physicists.
- "We put an awful faith in them anyway .....so this is just another progression which is there to enhance the technology" (2).
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Discussion
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Attitudes to technology
The positive attitudes demonstrated towards technology, have been related to previous direct experience of technology [9]. Radiographers' experience of technology has increased during the last 20 years and may have had a pre-conditioning effect, particularly since recent innovations, for example, MLC and portal imaging have made aspects of the job more efficient. The positive and neutral attitudes demonstrated by the radiographers reinforce the notion that radiotherapy is a technology-dominated environment. In such an environment new technology can be adopted with an automatic assumption of the benefit [12, 13]. This has been previously illustrated in the area of diagnostic imaging where the positive aspects of CT scanning encouraged widespread use without appropriate consideration [14]. In the case of IMRT however, there is a growing recognition of the need to assess the benefits or detriments before its universal adoption [6, 15–17].
An increased sense of job satisfaction with a high degree of responsibility and variety has been attributed to positive attitudes towards technology. The high esteem of nurses, held by society and patients, when using technology in intensive care reinforced positive attitudes in the nurses [9]. If positive attitudes can be linked to retention of radiographers this will have implications in radiotherapy departments.
However, when considering the demography of the sample size, the positive attitudes to technology could also have been affected by age. The majority (75%) of radiographers interviewed were in the age band 20–34 years. This was slightly lower than the ages of the radiographers who declined to be interviewed where 36% were below 35 years, 64% ranged between 35 and 52 years. Older radiographers might take longer to learn and adapt to new technology but the data do not suggest that this would result in a negative attitude to technology and a consequent unwillingness to be interviewed. The age bias is more likely to be attributed to domestic reasons: most of those interviewed were full time. The older, mainly part-time radiographers, might have declined due to insufficient spare time.
The fact that the lead researcher was known to the interviewees might have made it difficult for them to express negative views. However there may have been advantages, the importance of building a relationship between the interviewer and interviewee and developing a shared language has been identified [18]. The relationship might have encouraged the radiographers to talk more freely.
Impact of technology on clinical practice
The questions on the impact of technology on clinical practice led to discussions regarding the relationship between the radiographers, the patient and technology. The distinction between technological skills and patient care was not clearly identified. Some radiographers stated that although the patient contact was the most enjoyable part of their job, they acknowledged they still liked working with technology. The difficulty in separating the two areas of care has also been highlighted in studies of nurses attitudes to technology. Though the time spent with technology and away from the patient was found to be a major source of stress in nurses, 79% of nurses agreed that the technical and caring aspects of the job could not be separated [9]. Indeed one might ask whether time dealing with technology is away from the patient. Other studies have also found contradictory statements regarding the use technology and time spent with the patients [19].
To avoid the risk of technology diverting or diluting patient care it is important that the two areas of care are not seen as mutually exclusive. Models that have been developed with respect to nursing practice may be useful in radiotherapy departments to maintain the combination of technological care and patient care [20, 21].
It was interesting that two radiographers, qualified for 7 and 10 years, respectively, felt they had changed from being patient-focused to technically-focused. This may have been due to the increased use of technology during their working time. The need for improved technological skills would have been emphasised, making the development of their patient care skills less apparent.
Organizational impact
Radiographers expressed concerns about the effect on the department from their perspective. The "system" of IMRT was acceptable but was marred by the time taken for the treatment delivery and training needs. The treatment time will become less of an issue when the developing IMRT technology reduces the treatment delivery times.
There was a conflict between the pressure of learning new skills and the stimulation of implementing new technology. Training needs have been recognized as necessary in the introduction of new technology [9, 22]. The value of training was shown here in that radiographers who initially treated the patient and had participated in "practice runs" felt more confident about the implementation. If the perceptions of these key radiographers were other than positive it might have affected the implementation. However, considering the already high workload, allocating time for training created additional pressure and logistical problems.
The IMRT delivery during this study was complicated by the fact that the linacs were operated in a non-clinical mode. Compared with using a purpose built system, the delivery would have appeared more complex and may have influenced the radiographers perceptions.
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Conclusions
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Although this is a preliminary study and claims cannot be overstated, it provides insight from the radiographers' perspective into the impact of the introduction of new technology into the radiotherapy department. The small sample may limit the application of results to other departments but many of the findings here were reinforced by the literature, which suggests a degree of generalizability [23]. There is debate regarding the "quality" of qualitative research, ranging from the relativist view that all research is unique and equally valid to the realist view that there is truth independent of the researcher [11]. In addition, qualitative analysis of texts always involves reduction of data [11]. Although no alternative or supplementary methods of analysis were undertaken here, the framework of analysis was included to increase transparency of process.
Radiographers were positive regarding the use of new technology and found it stimulating. Technological skills and patient care were not found to be mutually exclusive. The acknowledgment of training needs encouraged the positive response but was hindered by the stress involved from learning new skills within the context of already high workloads. These points should be considered when seeking to improve job satisfaction and encourage recruitment and retention in radiographers.
Initially the use of technology is driven by innovators and technology enthusiasts [24]. There is a temptation to disregard the opinion of the user of technology once technology has ceased to become a novelty and becomes less interesting [22]. To ensure the use of technology continues and quality is maintained, it is important that there is careful preparation and support of the user during the implementation process.
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Acknowledgments
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The authors would like to acknowledge the radiographers for their willingness to be interviewed. Also Dr Christina Victor and Ms Caroline Dacy, MSc Office St George's Medical School for their advice throughout. We are also extremely grateful to Dr Christopher Nutting for help with the manuscript.
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Footnotes
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This work was supported by Cancer Research UK and Royal Marsden NHS Trust. 
Received for publication July 9, 2003.
Revision received October 8, 2003.
Accepted for publication November 25, 2003.
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References
|
|---|
- Nutting C, Dearnaley DP. Intensity modulated radiation therapy: a clinical review. Br J Radiol 2000;73:459–69.[Abstract]
- De Meerleer GO, Vakaet LAML, De Gersem WRT, De Wagter C, De Naeyer B, De Neve W. Radiotherapy of prostate cancer with or without intensity modulated beams: a planning comparison. Int J Radiat Oncol Biol Phys 2000;47:639–48.[CrossRef][Medline]
- Pirzkall A, Carol M, Lohr F, Hoss A, Wannenmacher M, Debus J. Comparison of intensity-modulated radiotherapy with conventional conformal radiotherapy for complex-shaped tumours. Int J Radiat Oncol Biol Phys 2000;48:171–80.
- Zelefsky MJ, Fuks Z, Hunt M, et al. High dose intensity modulated radiation therapy for prostate cancer; early toxicity and biochemical outcome in 772 patients. Int J Radiat Oncol Biol Phys 2002;53:1111–6.[CrossRef][Medline]
- Helyer SJ, Heisig S. Multileaf collimation versus conventional shielding blocks: time and motion study of beam shaping in radiotherapy. Radiother Oncol 1995;37:61–4.[CrossRef][Medline]
- IMRT Collaborative Working Group. Intensity-modulated radiotherapy: current status and issues of interest. Int J Radiat Oncol Biol Phys 2001;51:880–914.[CrossRef][Medline]
- Blacker F, Brown C. Evaluation and the impact of information technologies on people in organizations. Human Relations 1985;38:213–31.[Abstract]
- Mays N, Pope C. Qualitative research: rigour and qualitative research. Br Med J 1995;311:109–12.[Free Full Text]
- Fitter M. The impact on new technology on nurses and patients. In: Payne R, Firth-Cozens J, editors. Stress in health professionals. Chichester: John Wiley & Sons Ltd, 1987:211–29.
- Pope C, Ziebland S, Mays N. Analysing qualitative data. Br Med J 2000;320:114–6.[Free Full Text]
- Burnard P. Interpreting text: alternative to some current forms of textual analysis in qualitative research. Soc Sci Health 1995;1:236–45.
- Ashworth P. Technology and machines – bad masters but good servants. Intensive Care Nurs 1987;3:1–2.[CrossRef][Medline]
- Carnevali DL. Nursing perspectives in health care technology. Nurs Admin Quart 1985;9:10–8.
- Jennett B. Diagnosis-the technology of tests. In: Jennett B. High technology medicine: benefit or burden? Oxford: Oxford University Press, 1986:53–74.
- Glastein E. Intensity modulated radiation therapy: the inverse, the converse, and the perverse. Semin Radiat Oncol 2002;12:272–81.[CrossRef][Medline]
- Schultz R, Kagan R. On the role of intensity-modulated radiation therapy in radiation oncology. Med Phys 2002;29:1473–81.[CrossRef][Medline]
- Zhen W, Thompson RB, Enke CA. Intensity-modulated radiation therapy (IMRT): the radiation oncologist's perspective. Med Dosim 2002;27:155–9.[CrossRef][Medline]
- Rubin H, Rubin I. Listening, hearing and sharing social experiences In: Rubin H, Rubin I. Qualitative interviewing. The art of hearing. London: Sage 1995:1–16.
- Wichowski HC. Professional uncertainty: nurses in the technologically intense arena. J Adv Nurs 1994;19:1162–7.[CrossRef][Medline]
- Locsin R. Machine technologies and caring in nursing. Image J Nurs Sch 1995;27:201–3.[Medline]
- McConnell E. The impact of machines on the work of the critical care nurse. Crit Care Nurs Quart 1990;12:45–52.
- Rinard R. Technology, deskilling, and nurses: the impact of the technologically changing environment. Adv Nurs Sci 1996;18:60–9.[Medline]
- Silverman D. Theory in qualitative research. In: Silverman D. Doing qualitative research. A practical handbook. London: Sage, 2000:75–87.
- Rogers EM. Innovativeness and adopter categories. In: Rogers EM. Diffusion of innovations. New York: The Free Press, 1995:252–80.
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Abstract
Introduction
