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Review article |
Academic Clinical Oncology and Radiobiology Research Network (ACORRN), c/o Christie Hospital NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
Correspondence: ACORRN Research Radiographer Working Party, Christie Hospital NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK. E-mail: acorrn{at}manchester.ac.uk
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Abstract |
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 Top Abstract IntroductionMethods and materialsResultsDiscussionConclusionReferences |
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In conclusion, the ACORRN RR Working Party makes the following recommendations for the future development of the community:
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Introduction |
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TopAbstractIntroductionMethods and materialsResultsDiscussionConclusionReferences |
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The last decade has seen rapid advances in the application of computerized technology in radiotherapy. Developments have included processes and technologies such as conformal radiotherapy (CRT) [2], electronic portal imaging (EPI) [3–5], intensity modulated radiotherapy (IMRT) [6, 7] and image-guided radiotherapy (IGRT) [8, 9]. These advances have benefited cancer healthcare by allowing the possibility of dose escalation and potentially improved tumour control in many tumour sites. Evidence of this has already been demonstrated in the treatment of prostate cancer [10–12]. These developments have opened up additional areas for research and the corresponding need to implement the research and development findings into clinical practice. Implementation of these practices into radiotherapy departments needs to be managed by therapy radiographers with the appropriate knowledge and skills.
The drive to re-establish national research into cancer has resulted in increases in funding, which has allowed greater numbers of national trials to be undertaken. The nature of many of these trials is such that coordination needs be undertaken at a local, as opposed to national, level. Consequently, some therapy radiographers have taken on responsibilities for radiotherapy trial co-ordination within their department. Over the same period, a cultural change in the way radiotherapy is practised has taken place; there has been a concentrated effort to base healthcare on the best available evidence [13]. Local radiotherapy departments have therefore instigated audit and appraisal into the daily cancer care service, much of this undertaken by radiographers.
These four factors have resulted in an increased requirement for radiographers to be involved in the activities of audit, research, technical development, trial coordination and clinical implementation of new technologies [14]. However, radiographers need to have additional knowledge and skills in order to carry out these activities [15]. Ideally, all radiographers should be involved in these areas, but this is not always feasible and so the role of research radiographers (RRs) has evolved [14].
Review of the present roles and responsibilities of those RRs currently in-post would suggest that a diversity of responsibilities exists for these staff. However, while no formal census has been conducted, anecdotal evidence suggests that their numbers are still relatively few across UK radiotherapy departments – in the order of 50 established posts.
The radiographer community has historically had no clearly defined register or dedicated organization to look to for guidance and practical support regarding research. Thus, in 2004 the NCRI established an organization, the Academic Clinical Oncology and Radiobiology Research Network (ACORRN), to provide a mechanism for networking and supporting individuals involved in radiotherapy and radiobiology research in the UK.
In March 2005, ACORRN established a RR Working Party to address the needs of their community and become a central voice. Their first task was to conduct a mapping exercise of colleagues and decipher the extent of varying expertise and responsibilities within the role. The aim of the survey was to create a comprehensive register of UK RRs and would include identifying the role descriptions and training needs. Recommendations could then be made to clarify the role and responsibilities of the therapy RRs and determine the training needs to undertake this role.
The results of this UK-wide survey, with discussion and conclusions, are described in the remainder of this report.
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Methods and materials |
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TopAbstractIntroductionMethods and materialsResultsDiscussionConclusionReferences |
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The questionnaire included eight questions on the following subjects: department and role descriptions, time allocations (set answers), demographics, funding, research responsibility description, barriers to conducting research and how ACORRN could help (open text fields). Two further questions addressed training, both received and required, on a scale of 1 to 4 (1 = low score, 4 = high score).
Departments were encouraged to respond to the survey if only to report that there was no RRs in role at that time.
The results were analysed using SPSS Version 11.5 (SPSS Inc., Chicago, IL) for descriptive statistics as no formal comparisons were being made.
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Results |
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TopAbstractIntroductionMethods and materialsResultsDiscussionConclusionReferences |
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15 returned questionnaires were later excluded from the results analysis: 13 of these had been filled out by radiotherapy managers indicating that their department had no RRs (2 of these cases reported that staff carried out small audit projects; 1 reported that there might be prospective MSc students; and 1 reported that they had 1–4 research radiographers seconded from another area, but were not part of their hospital); and 2 department managers had filled out the survey about their own role instead of passing it on to the RR, so were not considered relevant to the results.
The total number of RR questionnaires returned by RRs included in the results was 70, spanning 38 UK departments.
Department description
Of the 38 departments surveyed, 24 (63%) declared the number of RRs in their department (Table 1
). The most common number of RRs reported per department was one (14 departments) with the highest being five (one department).
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The most frequent RR grade was Superintendent III (26%), followed by Senior I (17%). See Table 2 for the full list of grading. 25 participants described their academic achievements in addition to training grade. 10 RRs were found to be educated to MSc level, one to MPhil level and one to PhD level.
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depicts role description results. A large proportion of RRs (43%) described themselves as having a solely developmental/specialist role. 26% of RRs had a role that spanned two or more of the descriptions. Six RRs (9%) reported undertaking all three roles and were all from teaching hospitals. One RR held an academic post (university lecturer).
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with the activity time allocations.
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illustrates the funding streams of respondents. 40% of RRs were fully funded by their NHS Trust. Other sources of funding included national or local cancer networks, charitable funds or the pharmaceutical sector.
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Table 4
indicates that time allocations for each activity varied extensively between departments. The survey determined just 5 RRs (out of 70) in the UK with a 100% research role. These individuals were located in teaching hospitals or universities and funded by local appeals, cancer networks or charities – except one, who was funded by the NHS. The majority of RRs' time was spent horizon scanning (73% of RRs conducted this activity at some point). The range of time dedicated to this activity was between 5% and 60%. A number of RRs (62.5%) spent time coordinating national trials, with time allocations ranging between 2% and 100% of the working week. This was the only activity that was allocated more than 60% of the time available; 30% of RRs fell into the 50–100% time bracket for this task and just 5% of all RRs were fully dedicated to trial coordination. Implementing new technologies/techniques was undertaken by 62% of RRs, with time allocations ranging between 5% and 50%.
Interestingly, 26% of participants were asked to cover routine service instead of carrying out their own duties. This occurred around 1–10% of the time although it was reported to be as much as 50% in some cases. The funding streams for these cases came from all sources.
Dedicated academic time, for example, to perform literature searches or writing up research projects, was the activity most frequently not included in the RR role; over half of the participants did not have time allocated to this activity. Those that did have dedicated academic time had mostly between 1% and 10%, although some had up to 35%.
Most RRs (90%) spent some time on other research-related activities, e.g. teaching, facilitating the research of others, lecturing students and providing trial updates for staff. Time allocated ranged from 2% to 40%, with the majority falling in the 1–10% time bracket.
Structured timetable
It was found that most responding RRs (32 out of 40; 80%) did not have a structured timetable in which to allocate time to cover their research responsibilities. Of this group, just 7 out of 32 RRs (22%) declared they had no structured timetable but always got everything done; stating that it was their duty to ensure they took on only as much work as they had time. The remaining portion of RRs without a timetable (25 out of 32; 78%) reported that all their responsibilities were not fulfilled owing to excessive workload, which was partially due to their clinical commitments. Some RRs reported that they completed their research activities in their own time.
20% of RRs did have a structured timetable. Within this group, one RR reported that the timetable was not correctly apportioned to achieve the responsibilities of the role and that data management suffered as a result.
Training
Figure 2 shows the extents of training that each of the RRs currently in-post has received in order to carry out the responsibilities of the role. Results indicated that "little or no training" had been received in: the Human Tissue Bill; research funding/grant application writing; the Clinical Trials Directive; statistical analysis; and scientific report writing. Figures showed that 30–60% of RRs had "no training" in these subjects. A "fair amount of training" had been received in research methodology and in critical evaluation of the literature. In comparison, "a lot of training" had been received in good clinical practice (approximately 40% of RRs).
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). Further training in the following subjects was shown to be highly desirable: scientific report writing/presenting; statistical analysis; ethics approval; good clinical practice; and research funding/grant application writing. Training in the Human Tissue Bill scored highly for "not desirable" as well as "desirable". Informed consent was thought to be highly desirable, but only as practice changes.
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Discussion |
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TopAbstractIntroductionMethods and materialsResultsDiscussionConclusionReferences |
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A response rate of 76% from UK departments was a very positive result.
Department description
The survey identified that 40% of responding radiotherapy departments in the UK had between 0 (19%) and 1 (21%) RR. Such disparate numbers of RRs across the UK is not conducive to a sustainable research workforce. The larger departments, which included teaching hospitals and universities, did not have proportionately higher numbers of RRs than the smaller departments.
The most frequent grade of participants was Superintendent III (26%) followed by Senior I (17%). This was expected since a RR needs this level of expertise and experience. Grade of role did not correlate with the academic grading (e.g. BSc, MSc, etc.) achieved. The survey identified that only 12 out of 70 RRs were educated to at least MSc level. This figure is in agreement with Castle et al [17], who reported that most participants in a Continuing Professional Development survey of radiographers did not have post-registration qualifications. In 2001, it was reported that just eight radiographers (diagnostic plus therapeutic) had a PhD [18]. The Society and College of Radiographers' (SCoR) research strategy [15] outlined that the number of post-doctoral researchers should significantly increase with 3% of the profession research active by 2010. In 2003, there were 11 687 diagnostic radiographers in the NHS and 1657 therapeutic radiographers [19]. This ratio is 7:1 (diagnostic:therapeutic) and, based on the 2003 figures, this would translate to at least 350 diagnostic and 50 therapeutic researchers by 2010. Currently, this target seems unrealistic. It should be noted, however, that the SCoR priorities are set in order to improve the professional profile and standing of radiographers. ACORRN aims to re-invigorate research to improve patient treatment, which would not necessitate post-doctoral input. ACORRN aims to encourage and support research by radiographers. Small departments that have hitherto been research inactive or poorly supported will be encouraged to participate in radiographer-developed and-led multicentre trials. Research priorities will be identified and dialogue within the radiography community will enable achievable endpoints. This process has already generated interest among radiographers with topics for research being highlighted. This should promote research within departments with the potential for radiographers with particular interests to be involved.
It is anticipated that, with the support of ACORRN, radiographers will disseminate their research findings to the oncology community through publication and presentations. This process is being facilitated in part by the development of research forums on the ACORRN website and technology groups linked to national clinical trials.
Role and research activity description
Essentially, the survey identified two main RR roles: developmental/specialist (43%) and trial coordinator (16%) with overlap into other areas. No participants indicated that they worked purely as research assistants, although 17% had the activity incorporated in their role. Several participants indicated that they had difficulty categorizing their role due to continuous variation of duties with time.
The description of research tasks performed within the role similarly fell into two categories: trial coordination and technique development and implementation. Trial coordination encompassed local, national and international radiotherapy or related clinical trials incorporating trial promotion, protocol management, informed consent, data gathering and/or statistical analysis, follow-up, networking and recruitment, and providing support for students and staff. Technical/technique development and implementation was predominantly in areas such as IMRT, immobilization/organ motion, imaging and IGRT. The mix of activities documented indicated that each individual took on differing tasks throughout different departments.
The diversity of the RR role may in part be influenced by the type of department that employs them; whether the departments are large or small; what the department and hospital priorities are; and the funding source, be it NHS or local appeals. In the larger departments the role included more responsibilities incorporating development/specialism, trial coordination and research assistant work. The source of funding may have a strong influence on the role; as only 40% of posts were funded by the NHS there may be pressure for the RR to be involved in trial recruitment to provide additional sources of funding.
The type of research conducted by the RR will, in part, also be defined by the needs of the hospital based on the existing equipment in the radiotherapy department and the time allocated for research compared with time required to implement new technologies.
The six participants who specified that they were responsible for all three main roles identified in this survey were all from large teaching hospitals. This suggests that there are not enough research radiographers in the UK, even in larger departments where one might expect to find additional staff.
A high proportion of RRs (93%) reported they were involved in multidisciplinary team work and had a research support mechanism. It is recommended that all RRs should have access to a multidisciplinary team
Funding
Just 40% of RRs were fully funded by their NHS Trust. In some cases, RRs funded by other soft monies/non-renewable resources conveyed feelings of job instability and reported that, additionally, this made it difficult to start long-term projects. It is possible that other RRs under short-term contracts felt equally unstable, which is identified as a barrier to research in the SCoR strategy [15]. The survey identified 7% of RRs as purely 100% research in role. These individuals were all located in large departments and funded by local appeals, cancer networks or cancer charities, except one who was funded by the NHS. This highlights one of the issues associated with the research role within the clinical setting; it may be that, unless the funding is research specific, the researcher may be liable to be seconded onto clinical duties.
Time allocations
The response rate was slightly lower for this section of the survey (approximately 40% not specified). The reason for this was that the initial paper results were disregarded after participants reported misinterpreting the questions. In addition, participants reported difficulty in answering these questions due to the varied nature of their role. The online survey "timing" questions were thus adapted to aid clarification.
Time and culture are critical factors for a RR as service demands are prioritized over research time. This survey identified that 26% of RRs were asked to cover routine service delivery; clearly a huge barrier to operating smoothly in the designated post. Academic work was pushed to one side to backfill discrepancies in service provision; the shortage of radiotherapy staffing has been previously identified in the literature [20]. "Time" was also identified as the most important barrier in conducting research. The demand for the RR to cover service delivery ranged from a voluntary basis to structured service time incorporated into the RR contract.
The survey identified that much of the role of the RR was spent investigating new technologies, coordinating trials and implementing new technologies/techniques into the department, demonstrating the impact of advancing technologies and the resultant activities of the NCRI in bringing radiotherapy research to the fore. This may also be the case for other healthcare professions such as research nurses who, for example, may have taken on trial-related duties.
Over half of the participants did not have time for academic work. Time for literature searches and writing up research projects should be fundamental to the role of the RR. In particular, almost all respondents were expected to teach and support staff and students, as well as present or update new relevant information; this may have been time consuming where the RR had not had adequate academic time to read-up.
Structured timetable
The survey illustrated that most RRs either did not use or have a structured timetable. Of those who did, just one RR felt that the time was not apportioned correctly to enable all duties to be achieved. This demonstrated that, where put into place, the structured timetable worked. It is possible that RRs need to improve their skills in time management to enable them to cope with the changeable workload. Nonetheless, the result is in agreement with the fact that time was regarded as extremely limited and was probably confounded by covering routine service on an ad hoc basis.
The repeatedly strong message was that RRs were viewed as a back-up to clinical service, which may cause others to perceive research as of secondary importance rather than a necessity. This suggests that there is a culture that accepts that research receives less resource than routine services and is therefore less important. Furthermore, a lack of research equipment coupled with a paucity of research staff only serves to reinforce this culture. This confirms earlier literature which voiced concerns about research being viewed as a "token gesture" [14]. This issue needs to be addressed firstly to enable good quality research to be done from the outset and secondly to promote the rapid dissemination of research findings into the clinic. Without progress, there is stagnation. Research needs to be viewed as an integral part of service delivery.
Training
The mixed responses to these questions supported the concept that RRs had varied roles and responsibilities throughout the UK.
The survey by Castle et al [17] indicated that 40% of therapeutic and diagnostic radiographers had received no training for either changing roles or developing new competencies. Many radiographers progress into research roles without being supported to undertake the additional training required. Similarly, although 40% of RRs indicated that they had received "a lot" of training in good clinical practice, this is less than 50% of the RR community, for what should be considered a core subject.
Training received and required were considered in conjunction and revealed that more training was urgently required in: scientific report writing/presenting; statistical analysis; and research funding/grant application writing. Further training in the Human Tissue Bill scored highly for "not desirable" as well as "desirable", indicating that respondents were unsure whether this was relevant to their profession. Similarly, RRs felt that they required more training in ethics approval, but the extent of training already received was mixed, suggesting it was not urgently required.
It was interesting that the majority of RRs stated that they had a research support mechanism but needed more training in research writing and statistics, and additionally felt support was a key barrier to research. Where support is not sufficient, hospital trusts could link with educational institutions; for example, the SCoR strategy aims to promote the value of staff secondment, to encourage more members to be research-active and improve career opportunities in other research or related settings [21].
The urgent need for more training is evident because the survey found that no more than 40% of RRs were trained in any one topic. This highlights the need for continuous professional development (CPD) which should be tailored to the type of role that the RR is undertaking, as previously identified by Castle et al [17]. Movement towards online courses could also improve uptake of CPD.
A lack of training was indicated as a key barrier to conducting research. It is suggested that one confounding factor is the lack of time and funding available to attend courses. In addition, it is felt that participants have not been given the appropriate direction as to which courses were available and useful to them. The ACORRN website aims to hold such information and ask the community to feed in this type of information for proper dissemination.
Barriers to conducting research
The major obstruction to conducting high-quality research, highlighted throughout this paper, is "time", which has been previously identified in the literature [1, 13, 15, 16, 22, 23]. The lack of time could be related either to a fundamental lack of time or to limited access to clinical equipment. Often research activities are conducted out of hours to enable access to equipment, which could create a negative opinion of the value of research [22].
A reluctance to prioritize research may also have contributed to the lack of research vision found in this study. This report supports the need for protected research time for all research-active staff [1]; academic time is extremely important to maintain competency to practise and conduct good quality research. The situation has the potential to change as the Department of Health (DH) has recently published a research and development strategy, "Best Research for Best Health" [24]. This report is very exciting as it shows the importance the DH is placing on prioritizing research and closing the gap between research and clinical practice. In addition, the timely development of the SCoR research strategy and five-year plan aims to make research a fundamental component of professional practice [15]. To make these changes, individual departments and radiographers must take responsibility to develop research. For example, an objective included in the SCoR research strategy was that the CPD portfolio should incorporate research examples to encourage members to evaluate the effectiveness of research on practice [21]. However, the survey by Castle et al [15] identified that most radiographers in the South and West Regional Health Authority did not have any post-registration qualifications and just over half were involved with activities associated with changing roles and developing new competencies [17]. It is possible that if this study were repeated today the results would be more positive, but that must not be assumed.
In order to achieve increased participation in research there needs to be a boost of research morale to promote research as an exciting and stimulating subject. If research activities are viewed merely as an undergraduate course requirement and the findings are neither widely disseminated nor put into practice, then it is unlikely that the profession will advance or be research led [22]. Research work must be valued by staff and not just a "token gesture" in the department [14]. A cultural shift in the service environment to encompass more research "thinking" would thus facilitate the transfer of new research into the clinic.
Other factors identified as a barrier to research were a lack of funding, support and training, which has also been found in previous studies [16, 23]. In addition it was shown that RRs were unable to keep in regular contact with one another. This increased the possibility of the duplication of research effort, which is uneconomical. Streamlined research activity would allow the community to progress faster. Disparate responsibilities and functions throughout the different departments in the UK could contribute to a low morale and intensify the isolation noted by many participants.
How can ACORRN help the research radiographer community?
The RR community felt that ACORRN could provide the most assistance by facilitating knowledge sharing and discussions throughout the community. The lack of support and ability to communicate across UK departments is currently being addressed by the radiotherapy and radiobiology community via the ACORRN website, which allows 640 members (accrual as of September 2006) to communicate and collaborate in an instant. In particular, the ACORRN discussion forums have been pioneered and embraced by the RR community, with questions being answered within one day of posting (see www.acorrn.org). This successful model could be applied to other Allied Health Professionals who are classically disparate throughout the UK, and ACORRN encourages all radiotherapy and radiobiology disciplines to use the available resources.
RRs felt that ACORRN could provide training or workshops on subjects such as statistics or LENT SOMA (the Late Effects on Normal Tissues (LENT) – Subjective, Objective, Management and Analytic (SOMA) scales), which could be aimed specifically at RRs. Aside from this, there is adequate availability of courses at present and ACORRN aims to gather this information and disseminate it to the community via the website. Similarly ACORRN will disseminate information on funding opportunities, projects, trials and job vacancies. ACORRN can also help to put people in touch, arrange collaborative meetings and pay travel monies, as well as provide support on writing grant applications.
RRs also reported that ACORRN could help identify areas for RR research participation and raise awareness. The ACORRN Research Radiographer Working Party aims to be a central voice for RRs and to lobby authoritative bodies with the needs of RRs (see www.acorrn.org for more details). A formal process such as this should bring greater understanding of the RR profession and improve communication. This can then help bring the RR needs into consideration when training and professional developments are being put into place.
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Conclusion |
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TopAbstractIntroductionMethods and materialsResultsDiscussionConclusionReferences |
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As a result of this survey the ACORRN RR Working Party makes the following recommendations for the future development of the RR:
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Acknowledgments |
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Received for publication January 11, 2007. Revision received March 28, 2007. Accepted for publication April 25, 2007.
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References |
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  BJR review of the year -- 2007 Br. J. Radiol., April 1, 2008; 81(964): 265 - 269. [Full Text] [PDF]
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