Evolution of the Radiation Therapist Role in a Multidisciplinary Palliative Radiation Oncology Clinic

Evolution of the Radiation Therapist Role in a Multidisciplinary Palliative Radiation Oncology Clinic

Journal of Medical Imaging and Radiation Sciences Journal of Medical Imaging and Radiation Sciences xx (2018) 1-7 Journal de l’imagerie médicale et ...

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Journal of Medical Imaging and Radiation Sciences

Journal of Medical Imaging and Radiation Sciences xx (2018) 1-7

Journal de l’imagerie médicale et des sciences de la radiation

www.elsevier.com/locate/jmir

Evolution of the Radiation Therapist Role in a Multidisciplinary Palliative Radiation Oncology Clinic Bronwen LeGuerrier, BTech, MRT(T), BScN*, Fleur Huang, MD, Winter Spence, BSc, MRT(T), MHSc, Brenda Rose, MRT(T), CMD, Jacqueline Middleton, MRT(T), MEd, Megan Palen, BSc, MRT(T), Kitta Thvone, MRT(T), Shazma Ravji, BSc, MRT(T), Brita Danielson, MD, Diane Severin, MD, Karen P. Chu, MD and Alysa Fairchild, MD Palliative Radiation Oncology, Department of Radiation Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada Received 6 January 2018; revised 23 June 2018; accepted 9 July 2018

ABSTRACT Background: Palliative radiation therapists (PRTs) have been integrated in varying capacities into outpatient palliative radiation therapy (RT) services across Canada for over 2 decades. At our institution, PRTs have developed an essential role over 11 years within a palliative radiation oncology (PRO) clinic that focuses on integrating symptom management with radiation oncology assessment for palliative RT. PRTs have had direct clinical, technical, research, and administrative involvement as the clinic evolved from a pilot in 2007 supporting one half-day per week to the current model of five full clinical days. Methods: Using collaborative reflection, we explored the PRTs’ experience and insight. Twelve PRTs who contributed to the PRO clinic for varying lengths of time from 2007 through to 2016 were invited to participate in the development of a collective expression of the PRT experience. Seven PRTs consented to completing an electronic survey consisting of fifteen open-ended questions regarding individual roles and perspectives relating to our PRO clinic. Survey answers were enhanced by semistructured interviews when needed for clarification. Responses were contextualized within the operational changes to our multidisciplinary clinical model, from pilot to integrated service. Results/Discussion: Five respondents answered all of the questions. From the narratives, PRT roles and responsibilities were outlined and their insights and reflections included to contextualize clinical changes. Four phases of the clinic were identified and elucidated. Beginning in January 2007, three PRTs staffed a multidisciplinary clinical pilot one half-day per week for single-fraction, symptomatic bone metastases. The clinic has now evolved through various iterations to the current model with four PRTs sharing a ‘‘navigator’’ role with two registered nurses five full clinic days per week. The

range of PRT experiences, responsibilities, and challenges encountered reflected specific clinical and operational conditions. Conclusion: As our clinical service model evolved from short-term pilot to fully integrated departmental service, so did the PRT role. PRTs contributing to RT as part of a multidisciplinary model support and advance nontraditional involvement in the holistic care of patients with advanced cancer.

  RESUM E Contexte : Les radiotherapeutes en soins palliatifs (RSP) ont ete integres a differents titres dans les services de radiotherapie palliative pour les patients externes au Canada depuis plus de deux decennies. Dans notre institution, les RSP ont developpe un r^ole essentiel depuis onze ans au sein d’une clinique de radio-oncologie palliative qui met l’accent sur l’integration de la gestion des sympt^omes avec l’evaluation radio-oncologique pour les soins palliatifs de radiotherapie. Les RSP ont participe aux aspects cliniques, techniques, administratifs et de recherche de l’evolution de la clinique depuis le projet pilote mene en 2007 une demi-journee par semaine jusqu’au modele actuel de cinq journees cliniques completes.  l’aide de la reflexion collaborative, nous avons exMethodologie : A plore l’experience et les perceptions des RSP. Douze RSP ayant contribue a la clinique de radio-oncologie palliative pendant des durees variables entre 2007 et 2016 ont ete invites a participer au developpement d’une expression collective de l’experience de RSP. Sept d’entre eux ont accepte de repondre a un sondage electronique comprenant 15 questions ouvertes sur les r^oles et les points de vue individuels a propos de notre clinique. Les reponses ont ete bonifiees dans le cadre d’entrevues semi-structurees pour clarification au besoin. Les reponses ont ete mises en contexte par rapport aux

* Corresponding author: Bronwen LeGuerrier, BTech, RTT, BScN(c), Cross Cancer Institute, 11560 University Avenue, Edmonton, Alberta T6G1Z2, Canada. E-mail address: [email protected] (B. LeGuerrier). 1939-8654/$ - see front matter Ó 2018 Published by Elsevier Inc. on behalf of Canadian Association of Medical Radiation Technologists. https://doi.org/10.1016/j.jmir.2018.07.005

changements operationnels apportes a notre modele clinique multidisciplinaire, du projet pilote au service integre. Resultats/Discussion : Cinq repondants ont repondu a toutes les  partir des exposes narratifs, les r^oles et les responsabilites questions. A des RSP ont ete delimites et leurs reflexions et commentaires ont ete inclus afin de contextualiser les changements cliniques. Quatre phases  partir de 2007, trois de la clinique ont ete identifiees et elucidees. A RSP ont ete affectes a une clinique multidisciplinaire pilote, une demi-journee par semaine pour les metastases osseuses symptomatiques, en fraction unique. La clinique a evolue au fil de differentes iterations jusqu’au modele actuel, o u quatre RSP partagent un r^ole

de « navigateur » avec deux infirmieres, cinq jours cliniques complets par semaine. La gamme des experiences, des responsabilites et des defis rencontres reflete les conditions cliniques et operationnelles specifiques. Conclusion : L’evolution du r^ole des RSP a suivi celle de notre modele de service clinique, depuis le projet pilote jusqu’au service entierement integre. Les RSP qui contribuent a la radiotherapie dans le cadre d’un modele multidisciplinaire appuient et font progresser un engagement non traditionnel dans les soins holistiques aux patients atteints d’un cancer avance.

Keywords: Autonomy; Collaborative; Continuity of care; Navigator; Quality improvement

Introduction Palliative radiation therapy (RT) assists with the management of a number of symptoms due to advanced cancer. Although the utilization of this treatment modality is not new, the way in which oncology patients are connected to supportive care services and directed through the medical system is changing rapidly, with the help of navigator positions in Canadian cancer care settings [1]. The evolution of the palliative radiation therapist (PRT) role in radiation oncology clinics at larger Canadian cancer centers began in approximately 1996 with the Rapid Response Radiotherapy Program at the Odette Cancer Centre [2] followed by the Palliative Radiation Oncology Program (PROP) at the Princess Margaret Cancer Centre in 1997 [3]. Both utilize one or more radiation therapists (RTTs) as team members and/or central facilitators. Although several other Canadian cancer centers have palliative radiation oncology programs, they do not include a radiation therapist as part of their core staff [4–6]. Beginning in 2007, the [Cross Cancer Institute] piloted an outpatient palliative RT clinic that incorporated the assessment and management of symptoms for patients with bone metastases by a multidisciplinary team (MDT), along with provision of palliative RT when indicated [7]. Initially named the Rapid Access Palliative Radiotherapy Program (RAPRP) but now called the Palliative Radiation Oncology (PRO) clinic; this clinic has existed in various iterations since then, all of which have included RTTs in prominent roles [7–9]. Using collaborative reflection, this article describes how PRTs have contributed to the evolution of the PRO clinic. The achievements of this unique role are illuminated, which include enhancing the way patients with advanced cancer connect to supportive services when RT is being considered for symptom control while optimizing both continuity of care and patient-centeredness. Methods A request for participation was sent via email to all (n ¼ 12) PRTs previously and currently involved with this clinic model at the institute. The purpose of this survey was to gather process and outcome information, along with personal perspectives, to inform the narrative of the clinic’s evolution. 2

Seven PRTs gave consent. Each was emailed fifteen openended questions (Appendix) regarding their experience in, and opinions of, the PRO clinic. A single observer then performed informal conversational interviews to clarify survey responses. Supplemental informal interviews with other professionals associated with the clinic were undertaken to understand the reasons for transitioning to new operational models and implementing staffing changes. The results of these interviews and surveys are combined below with a description of the clinic’s evolution for perspective and context. Ethical considerations were weighed using the [Alberta] Innovates ARECCI Ethics Screening Tool, which concluded that this work would be best categorized under ‘‘quality improvement’’ and ‘‘evaluation project’’ [10]. The ‘‘ARECCI Ethics Guidelines for Quality Improvement and Evaluation Projects’’ were used to guide ethical considerations throughout the development of this project [10]. Initiation: Bone Metastases January 2007–July 2009 Beginning in January 2007, the initial 6-month pilot of the RAPRP served patients with bone metastases suited to same-day single-fraction treatments [7] (Table 1). The PRTs had clinical roles and responsibilities (detailed below) but were also responsible for fluoroscopic simulation, planning, and delivery of treatment (Table 1). In addition to the PRT, the clinical team included other disciplines whose extent of involvement was customized based on patient needs: a registered nurse (RN), nurse practitioner (NP), clinical pharmacist (CP), registered dietician, occupational therapist (OT), social worker, and a radiation oncologist (RO) leading the pilot. By the end of the pilot, in June 2007, the RAPRP had become a weekly standard at our institution, but scheduling was made more flexible, so that bone metastases requiring any fractionation were permitted. PRT Roles and Responsibilities. The PRT role began as a mix of a clinician and clinical navigator who managed the patient’s acute needs within the department, oversaw general clinic functioning, and participated in research. These foundational aspects remain constant to this day. Responsibilities of the PRT/RN

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Table 1 Evolution of a Dedicated Outpatient Palliative RT Clinic Date Range

Jan 2007–Jul 2009

Aug 2009–Oct 2012

Nov 2012–Dec 2014

Jan 2015–Present

Phase

Bone metastases integrated clinic pilot* RAPRP 1

Service expansion to brain metastases piloty

Navigation pilot and process improvement exercisez PRO Three ROs/postgraduate RO trainees until May 2013, then rotation of 11 ROs RN redeployed elsewhere; NP redeployed elsewhere as of July 2014

Scaled-up model

Clinic name Radiation Oncologists

1–Bone clinic 1–Brain clinic

Multidisciplinary team

Routine involvement: CP, NP, RN, PRT Available by referral: OT, SW, RD, other

Schedule

One half-day per week, max four patients per day

Eligibility criteria

Bone metastases; single fraction RT

Roles/responsibilities of PRT Assessment, referrals, clinic logistics, ensuring relevant imaging available, wayfinding, simulation, calculation, treatment delivery, phone follow-up

* y z x

One half-day per week per clinic, max four patients per day Brain and bone metastases booked to separate clinicsx

Same as previous þ MMSE for brain metastases

All 23 ROs in department

RN reassigned as co-navigator 3 days per week (PRT full time); CP support 1 day per week in collaborative clinic Three half-days per week, max Five days per week, max six four patients per day patients per day Brain and bone metastases seen Bone and brain metastases and within the same clinicsx palliative chest RT; other sites when supportive care MDT assessment requiredx PRO clinic navigator role Continuation of navigator piloted to receive referrals for role: assessment before consult, referral to supportive care triage eligibility; expanded assessment role, loss of services before/at consult, treatment planning and facilitation of logistics of clinic delivery role; CT simulation day, phone follow-up now standard of practice

CP, clinical pharmacist; MDT, multidisciplinary team; MMSE, Mini–Mental Status Examination; PRT, palliative radiation therapist; NP, nurse practitioner; OT, occupational therapy; PRO, Palliative Radiation Oncology; RAPRP, Rapid Access Palliative Radiotherapy Program; RD, registered dietician; RN, registered nurse; RO, radiation oncologist; RT, radiation therapy; SW, social worker. Bone metastases–only clinic continued from July 2007 to August 2009. Bone and brain metastases clinics continued from January 2010 to November 2012. Initial iteration of PRO clinic continued until January 2015 program change. No restrictions on dose-fractionation schedule.

during the clinic included symptom screening, assessment, and education about the clinic and what to expect that day. During this phase in the evolution of our services, a maximum of four patients could be seen on clinic days. Screening tools used in the clinic included an in-house MDT assessment form and the Edmonton Symptom Assessment System [11]. Once the core providers (PRT/RN/CP) had completed their respective screening and assessments, a team meeting would occur with the RO to propose recommendations for supportive care MDT referrals [12] before the RO consult. Based on the compilation of all evaluations, performance status and prognostication scales were completed, which included the Karnofsky Performance Status [13], the Palliative Performance Scale [14], and the Edmonton Classification Scale for Cancer Pain [15]. If the patient consented to RT, the treatment was simulated, calculated, and delivered by the RAPRP PRTs under the clinical direction of the RO. The patient was then discharged from clinic. Phone follow-up was booked for 1 and 4 weeks after RT, to be completed by the PRT [16], RN, or CP. PRT Insight and Reflections. PRTs involved in the original phase of the clinic commented on their ‘‘start-to-finish’’ role from initial assessment to treatment, ensuring continuity of care for patients receiving same-day single-fraction RT

(Table 1). This was especially advantageous if patients were bedbound and/or in significant pain. The clinic team was aware of transfer, positioning, and medication details, which did not then have to then be re-verbalized to different teams of staff in the simulator, other clinic areas, and at the linear accelerator. This was viewed as a strategy to decrease the chance of miscommunication or error. This approach was initially possible with three PRTs rostered to one half-day clinic each week. Appointment times were designated for RAPRP patients on a given treatment unit. However, for a variety of reasons, treatment plans were often not ready on time, which meant these patients were added on to fully booked treatment unit schedules. Initially this required the RAPRP PRTs to treat clinic patients during the unit’s scheduled break times. One PRT remarked: ‘‘Eventually the unit was a little more understanding of our workload on those days and treated the clinic patients as we had them ready.’’

Toward the end of this time period, staffing was reduced to one PRT. Thus, the role transitioned toward the present situation where the PRT functions as more of a liaison for the patient as they move through the treatment planning process. One PRT stated she enjoyed the breadth of care from assessment to treatment because she felt she was using everything she

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had learned in her training. The experience of these PRTs from the early RAPRP period is unique as many RTTs will work in one specific role, seeing one part of the patient’s journey through the department. The RAPRP clinic role demanded that the PRTs understand and be able to navigate a patient through each part of the process, depending on the patient’s needs and treatment plan. Describing this continuity a PRT stated: ‘‘I liked having more responsibilities and being fully involved in the patient’s entire treatment pathway.’’

Although most of the PRTs involved in this period mentioned their technical roles, one highlighted the underlying goal of engaging in supportive care and symptom management from a radiation oncology perspective. However, misunderstandings about each provider’s workload and role occurred early on due to the lack of clarity about who (‘‘floor’’ therapists or the RAPRP PRTs) was ultimately responsible for delivering RT to RAPRP patients. Several PRTs discussed their frustration with this ambiguity: ‘‘The . unit staff felt the RAPRP staff should sim, calc, and treat all their ‘own’ patients and it had nothing to do with the unit schedule/staff. From my perspective this was extremely frustrating since I mentioned we went down to one PRT in the clinic. I found myself constantly reinforcing the importance of team work and patient-centered care.’’

For some PRTs, this difficulty was experienced throughout the duration of their work in the clinic. Others found it lessened over time as colleagues and other professionals grew to understand and value the work being done. In response to the survey question asking PRTs about the transition of PRT focus from treatment delivery into more of a liaison role, two PRTs made the following observations: ‘‘I liked seeing the patient from start to finish. Being able to treat them at the end and connect with them, especially, because they are palliative, and normally we don’t get that much time with them on the unit.’’

Initiation: Brain Metastases August 2009–October 2012 A similar clinical pilot [9] on one half-day per week catering to patients with brain metastases launched in August 2009 and was adopted as a regularly scheduled program in January 2010 (Table 1). In addition, department-level changes saw planning processes transition from the conventional simulator to the CT-simulator in February 2010. In moving to CTsimulation for all patients, the technical aspects of the PRT role were altered yet again. PRT Roles and Responsibilities. Roles and responsibilities during this phase were similar to what was described previously with the exception of the learning curve associated with caring for patients with brain metastases. Part of the PRT’s responsibilities during this phase of the clinic was the application of several new assessment tools in addition to our routine in-house MDT

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assessment form. These new tools included the Mini–Mental Status Examination [17], which allowed clinic staff to objectively quantify neurocognitive function, the Princess Margaret Hospital Brain Metastases Symptom Checklist [18] to evaluate symptoms, and the EuroQol EQ-5D [19] to evaluate quality of life. Several physician-reported measures were also recorded with PRT assistance: Karnofsky Performance Status [13], Palliative Performance Scale [14], the Radiation Therapy Oncology Group neurologic function classification [20], and the Radiation Therapy Oncology Group recursive partitioning analysis class for prognostication [21]. PRT Insight and Reflections. Working in the clinic provided the PRTs with opportunities that were not available to the RTT working on the treatment floor. The professional autonomy and MDT interactions were gratifying experiences for all PRTs. These topics were consistently mentioned when the PRTs were asked what they most enjoyed about their role in the clinic. ‘‘Having access to a variety of health professionals to bounce ideas off of as well as the learning opportunities available because of the connection to these colleagues has been so instrumental in learning how to ask better questions.’’

During 2010–2011, one of the PRTs attempted to reintegrate the treatment preparation and calculation aspects into the clinic role. As the main champion for this approach, it was not pursued further once she left the clinic to engage in other opportunities. Remembering this period, she explained: ‘‘I was adamant that the PRT be involved in simulation and treatment planning. We have the knowledge and training to prepare this aspect of the patient’s care for review by the RO.’’

Having a PRT fulfill the treatment preparation and calculation role facilitated continuity of care and ease of communication with the RO because the planning could be done in the clinic itself. However, with a team of radiation therapy planners already in place in the department, this aspect of the PRT role was phased out because the resources and time needed to maintain RT planning skills outweighed the benefits. Toward the end of this time period, it was identified that it took up to, and sometimes greater than, 30 minutes of triage time for the RO to determine if a patient was an appropriate candidate for a palliative radiation consult. Triage often included but was not limited to confirming pathology, arranging or interpreting imaging, calling the patient or referring provider, and liaising with other clinicians as needed. The question was therefore raised as to whether some of these tasks could be completed by the PRT and NP, working in collaboration with ROs. With support from the [Alberta] Cancer Foundation’s Dr. Solomon Levin Memorial Award [22], the PRT and NP undertook site visits to the PRO clinics at the Princess Margaret Cancer Centre [3] and the Odette Cancer Centre [2] to investigate this approach. Their observations formed the basis of the new ‘‘navigator’’ position shared by the PRT and NP, starting in November 2012.

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Evolution: Co-Navigation for All Indications November 2012–December 2014 During this time period, RO staffing increased from three ROs (along with several RO postgraduate trainees) to eleven ROs on a rotating basis, each of whom had different tumor site subspecializations. This increased capacity for patient consults from 4 to 12 each week. This added capacity was needed because more than 1000 patients per year were receiving palliative radiation therapy at our institute, but only a small proportion were benefiting from the enhanced services offered through PRO [23]. Quality improvement (QI) statistics from the end of this clinic phase show the total number of patients seen in PRO from January 1 to December 31, 2014, to be 270. After the increase in physician staffing and to address department-level resource demands, the RAPRP NP was redeployed to another clinical area in July 2014. An RN was then engaged to share the navigator role with the PRT in August 2014. The name of the clinic was changed during this time from RAPRP to PRO to better distinguish the team and service changes. PRT Roles and Responsibilities. The introduction of the shared navigator role between the PRT and NP marked an important milestone. Referrals made to the institution’s intake office for consideration of palliative RT, or those made directly to the PRO clinic, were funneled to the PRO navigator (PRT or NP) who would then use pre-established eligibility criteria, often in discussion with the RO on triage duty, to book patient consultations and arrange pre-visit investigations, if required. Some referrals made directly to the ROs did not go through this pathway, but the PRO navigator was often informed and sometimes assisted with booking after RO triage. Although the practice differences between ROs was a learning curve for the PRTs, the experience of seeing a larger number of patients cared for by a wider array of physicians was exciting and challenging. This resulted in significant professional growth and learning for the involved PRTs, NPs, and RNs at the time. PRT Insight and Reflections. At the end of this time period, the PRO clinic team began an externally facilitated process improvement project to problem-solve department-wide and clinic-specific issues in the face of limited staff and infrastructure resources. This work also contributed to establishing an environment within the PRO clinic dedicated to continuous QI, which has been maintained to the present day [8]. Department-wide issues noted at the start of this project included utilization of multiple clinical pathways for patients receiving palliative RT, which resulted in inconsistent symptom screening and patient education [23]. MDT services, meant to be triggered by patient need, were not always accessed in a predictable way when patients presented with unexpected same-day needs, leading to workflow issues for the clinic as well as MDT members. Other issues addressed in this improvement initiative included the following: continuity of care felt disrupted if returning patients were seen by a different RO each time, suboptimal clinic flow often leading

to late RO assessment and CT simulation arrivals, and nursing support limited by the PRO RN’s schedule each week [23]. When asked what they enjoyed about their role during this time period, a PRT remarked: ‘‘I liked having an autonomous role where I could decide how to manage my time. I also liked getting to interact with a large number of multidisciplinary professionals in order to find a way to help each patient with unexpected needs. An example of this was when a patient needed a bath chair but the OT was unavailable in a department in-service. The OT left the inservice briefly to teach me how to explain the correct use of the bath chair, which I then relayed to the patient. This interprofessional collaboration allowed me to meet the patient’s immediate needs, so that they would be safe at home when showering that evening. It was a great example of backup behavior within our team.’’

Evolution: Scaled-Up Services January 2015–Present Ultimately, the process improvement project was a catalyst for significant change in the PRO clinic’s model of care. Instead of a rotation of 11 ROs with assigned clinic days, the model changed to allow ROs to book patients in according to their schedule, and each RO would see their own patients. Focus was put on streamlining process, access, and efficiency with a re-emphasis on the central goal of providing palliative RT supported by symptom management and supportive care services [8]. The final model was implemented in January 2015 and continues at present. To provide perspective on the growth of service since implementing this new model, the number of patient consults seen in the PRO clinic from January 1 to December 31, 2017, was approximately 750. PRT Roles and Responsibilities. Since January 2015, the role of the PRT is a hybrid of navigator and clinic facilitator with the ongoing responsibilities of patient assessment by phone before and after the clinical encounter and in person on the day of the consult. Although the PRT is no longer participating in treatment planning or delivery, their expertise in how the radiation oncology department functions and how other services within and outside of the cancer center connect to the clinic is vital to a patient’s smooth transition from community, to the department for treatment, and then back home again. Working with an RN in a shared role has created a natural opportunity to cross-train with a unique combination of educational and experiential backgrounds. These interprofessional skills interface for optimum execution of key team processes, such as mutual performance monitoring and back-up behavior [24]. Navigation begins when the patient is referred. Ideally, there is time to call the patient at home, or to fax a screening form to an inpatient ward if the patient is admitted, to screen for symptom burden and functional concerns ahead of the PRO visit. Planning based on patient needs and priorities before consult usually means that the patient gets connected to services that may improve their quality of life as soon as

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possible, in addition to being provided a contact number to call if something changes before their appointment. This initial contact also serves to alleviate any practical concerns that new patients may have about their first visit in this clinic. The [Alberta]-wide patient-reported outcomes screening form (now titled ‘‘Putting Patients First’’) includes the Edmonton Symptom Assessment System–r symptom rating scale [11], a short quality-of-life scale (EuroQol EQ-5D) [19], and Canadian Problem Checklist, which asks patients to describe their main areas of current concern [25]. Using this document, the PRT creates a picture of the patient’s overall state of health together with recent imaging, referral information, and chart notes from any previous visits. Tentative recommendations for supportive care services can then be made. For example, some patients will be set up with home care, so that a home safety assessment may be completed, or urgent medication management initiated before their consult; others may require an OT evaluation in conjunction with their consult to avoid a second trip into the city from their rural home. Understanding the patient’s needs before consult allows for MDT members to schedule patients in instead of seeing them ad hoc, which, anecdotally, has allowed for improved workflow. PRT Insight and Reflections. The PRT role has always relied on self-managed tasks and self-initiated undertakings to improve care, solve problems, and answer clinical questions. This autonomous setup could not be more true of the current state, with the PRT working 5 days per week within a clinic that offers palliative RT, often on an urgent basis. On days where consultation booking capacity is not reached, administrative tasks can be attended to, such as telephone assessments and follow-up contacts. Administrative and QI tasks were discussed by one PRT who stated: ‘‘I have been the go-to person for pilots of electronic documentation and questionnaires within the institute and as well as on a provincial level. This has included problem solving with regards to how we get that data out on the back end (from a data warehouse).’’

Research and collaboration with other professionals on a multitude of connected projects keeps the role interesting and engaging, connecting MDT members on shared academic projects in addition to fostering clinical partnerships. Examples of MDT research involvement include academic studies initiated by PRTs [16,26], case reports [27], involvement in MDT survival prediction [28], and an international initiative aimed at understanding MDT behavior [24]. As well, PRTs have been instrumental in identifying and analyzing metrics that have contributed to the continuous QI of the program. One PRT described her 8 years of experience in the clinic this way: ‘‘The role has changed so much during my time in it .. What has stayed the same is the overall goal, which is to provide an RO consult for consideration of palliative radiation therapy while using a multidisciplinary approach to manage symptoms, address concerns, and provide support.’’ 6

Discussion Throughout the existence of the program, each PRT has helped evolve the model of clinical care and MDT collaboration espoused by the PRO clinic vision. Every PRT expanded a position that grew out of a need for specialized expertise in RT, so that a particular group of patients could be navigated fluidly through a potentially chaotic pathway of medical encounters. Since 1996, this role has taken on many forms across different Canadian cancer centers, each one tailored to the local clinical culture. In January 2015, the Dr. H. Bliss Murphy Cancer Centre established a PRO clinic [29] with a PRT as part of the core care team. This new clinic was based on our institute’s model after the PRT from Newfoundland visited our clinic to observe clinical and operational processes. The PRO clinic’s current model relies heavily on the shared PRT/RN navigator position. Although the need for such a position may seem obvious, disconnectedness in the medical system, even within freestanding institutes providing dedicated cancer care, may result in misunderstandings between providers [1,30]. The PRT co-navigator position exists to identify and address those gaps while advocating for marginalized patients. This anchors patient-centered care delivery and helps the MDT weather changing clinical or operational conditions by ensuring continued focus on the patient. Through these informal interviews with previous and current PRO clinic PRTs, many positive statements were made regarding career satisfaction and opportunities for enhanced learning. Frustration when the program began may have contributed to resistance to further change in the department due to a lack of understanding of the overarching goals of the program. Although that frustration appears to have lessened over time, new and different challenges were encountered. Regardless, learning from those who came before has educated the current PRO MDT members and increased their understanding of the medical system with all of its moving parts. Each successive PRT who took on the role engaged in ongoing professional learning, collaborated with others while providing education, and ultimately entrenched the position within the institute. The role would not be what it is today were it not for the contributions of each PRT who helped grow the service.

Conclusion The PRT navigator role continues to progress in step with the evolution of the clinical culture within which it operates. PRTs consider the MDT approach to be essential to optimally support the complex and often daunting task of caring for palliative oncology patients with a variety of different symptoms and concerns. Other providers benefit from the chance to ask questions about RT when working in the clinic, while in turn sharing their professional insights. Professionally, the PRT navigator role provides an opportunity for growth and learning, as well as contributions to research and collaborative projects. Although an RN is the most common professional to work within a navigator role in [Alberta],

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in a specific setting such as PRO, the PRT’s educational background and knowledge of radiation department processes have been invaluable to bridging gaps and maximizing communication efficiency. It is this unique perspective that allows the PRT to smoothly navigate patients through this part of their disease trajectory. Footnotes Contributors: All authors contributed to the conception or design of the work, the acquisition, analysis, or interpretation of the data. All authors were involved in drafting and commenting on the paper and have approved the final version. Funding: This study did not receive any specific grant from funding agencies in the public, commercial, or notfor- profit sectors. Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/ coi_disclosure.pdf and declare: no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work. Ethical approval: Ethical considerations were weighed using the Innovates ARECCI Ethics Screening Tool, which concluded that this work would be best categorized under ‘‘quality improvement’’ and ‘‘evaluation project’’ [10]. The ‘‘ARECCI Ethics Guidelines for Quality Improvement and Evaluation Projects’’ were used to guide ethical considerations throughout the development of this project. References [1] Dennis, K., Linden, K., Balboni, T., & Chow, E. (2015). Rapid access palliative radiation therapy programs: an efficient model of care. Future Oncol 11(17), 2417–2426. [2] Nguyen, J., Giovanni, J. D., & Zhang, L., et al. (2012). Projected referral to other healthcare services in an outpatient palliative radiotherapy clinic. Expert Rev Pharmacoecon Outcomes Res 12(2), 237–243. [3] Kirkbride, P., & Barton, R. (1999). Palliative radiation therapy. J Palliat Med 2(1), 87–97. [4] Wu, J. S., Kerba, M., Wong, R. K., Mckimmon, E., Eigl, B., & Hagen, N. A. (2010). Patterns of practice in palliative radiotherapy for painful bone metastases: impact of a regional rapid access clinic on access to care. Int J Radiat Oncol Biol Phys 78(2), 533–538. [5] Lefresne, S., Berthelet, E., & Cashman, R., et al. (2015). The Vancouver rapid access clinic for palliative lung radiation, providing more than just rapid access. Support Care Cancer 23(1), 125–132. [6] Fitzgibbon, E. J., Samant, R., Meng, J., & Graham, I. D. (2006). Awareness and use of the rapid palliative radiotherapy program by family physicians in Eastern Ontario: a survey. Curr Oncol 13(1), 27–32. [7] Fairchild, A., Pituskin, E., & Rose, B., et al. (2009). The rapid access palliative radiotherapy program: blueprint for initiation of a one-stop multidisciplinary bone metastases clinic. Support Care Cancer 17(2), 163–170. [8] Huang, F., LeGuerrier, B., & Severin, D., et al. (2015). Beyond the pilot: navigating through 8 years of palliative radiotherapy integrated symptom management (PRISM). J Clin Oncol 33(29_suppl), 156. [9] Danielson, B., & Fairchild, A. (2012). Beyond palliative radiotherapy: a pilot multidisciplinary brain metastases clinic. Support Care Cancer 20(4), 773–781.

[10] Alberta Innovates [Internet] (2010). ARECCI ethics screening tool. Available from: www.aihealthsolutions.ca/arecci/screening/. Accessed April 21, 2018. [11] Watanabe, S. M., Nekolaichuk, C. L., & Beaumont, C. (2012). The Edmonton symptom assessment system, a proposed tool for distress screening in cancer patients: development and refinement. Psychooncology 21(9), 977–985. [12] Pituskin, E., Fairchild, A., & Dutka, J., et al. (2010). Multidisciplinary team contributions within a dedicated outpatient palliative radiotherapy clinic: a prospective descriptive study. Int J Radiat Oncol Biol Phys 78(2), 527–532. [13] Schag, C. C., Heinrich, R. L., & Ganz, P. A. (1984). Karnofsky performance status revisited: reliability, validity, and guidelines. J Clin Oncol 2(3), 187–193. [14] Anderson, F., Downing, G. M., Hill, J., Casorso, L., & Lerch, N. (1996). Palliative performance scale (PPS): a new tool. J Palliat Care 12(1), 5–11. [15] Nekolaichuk, C. L., Fainsinger, R. L., & Lawlor, P. G. (2005). A validation study of a pain classification system for advanced cancer patients using content experts: the Edmonton classification system for cancer pain. Palliat Med 19(6), 466–476. [16] Dixon, W., Danielson, B., Pituskin, E., Fairchild, A., & Ghosh, S. (2010). The feasibility of telephone follow-up led by a radiation therapist: experience in a multidisciplinary bone metastases clinic. J Med Radiat Sci 41(4), 175–179. [17] Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). ‘‘Minimental state’’ a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 12, 189–198. [18] Banihashemi, B., Zurawel-Balaura, L., & Garraway, C., et al. (2008). Construction and testing of a symptom checklist for patients with brain metastases. Radiother Oncol 88(Suppl 1), S1–S63. [19] Park, S. M., Park, M. H., & Won, J. H., et al. (2006). EuroQol and survival prediction in terminal cancer patients: a multicenter prospective study in hospice-palliative care units. Support Care Cancer 14(4), 329–333. [20] Borgelt, B., Gelber, R., & Kramer, S., et al. (1980). The palliation of brain metastases: final results of the first two studies by the radiation therapy oncology group. Int J Radit Oncol Biol Phys 6, 1–9. [21] Gaspar, L., Scott, C., & Rotman, M., et al. (1997). Recursive partitioning analysis (RPA) of prognostic factors in three radiation therapy oncology group (RTOG) brain metastases trials. Int J Radit Oncol Biol Phys 37(4), 745–751. [22] Alberta Cancer Foundation [Internet] (2013). Alberta: Alberta cancer foundation. Building Excellence Awards; [about 13 screens]. Available at: https://albertacancer.ca/investing-in-progress/building-excellenceaward#solomon. Accessed 25 April 2018. [23] Severin, D., Huang, F., & Chu, K., et al. (2015). Palliative radiation oncology clinic improvement. Edmonton (AB): Alberta Health Services. [24] Huang, F., Driga, A., & LeGuerrier, B. E., et al. (2016). Supporting patients with incurable cancer: backup behavior in multidisciplinary crossfunctional teams. J Oncol Pract 12(11), 1123–1134. [25] Bultz, B. D., Groff, S. L., Fitch, M., Blais, M. C., Howes, J., & Levy, K., et al. (2011). Implementing screening for distress, the 6th vital sign: A Canadian strategy for changing practice. Psychooncology 20(5), 463–469. [26] Yeo, R., Campbell, T., & Fairchild, A. (2012). Is weekend radiation therapy always justified? J Med Radiat Sci 43(1), 38–42. [27] Daoud, A. M., Hudson, M., & Magnus, K. G., et al. (2016). Avascular necrosis of the femoral head after palliative radiotherapy in metastatic prostate cancer: absence of a dose threshold? Cureus 8(3), e521. [28] Fairchild, A., Debenham, B., Danielson, B., Huang, F., & Ghosh, S. (2014). Comparative multidisciplinary prediction of survival in patients with advanced cancer. Support Care Cancer 22(3), 611–617. [29] Kelly, M. (2017). Thanks and update! [Internet]. Message to: Bronwen LeGuerrier. [cited 2018 Apr 25]. [8 paragraphs]. [30] Barnes, E. A., Chow, E., & Andersson, L., et al. (2004). Communication with referring physicians in a palliative radiotherapy clinic. Support Care Cancer 12, 669–673.

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Appendix. Survey instrument: fifteen open-ended questions sent to PRTs. 1. Over what time period did you work in the clinic? 2. How much time per day/week were you working in the clinic? 3. What did the clinic look like at that time? How did it function? 4. What other professionals did you work with directly in the clinic? 5. Can you tell me about three of your main responsibilities in the clinic? 6. What demographics of patient were you caring for? Histology and symptoms.

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7. What studies were you involved in during your time in the clinic? How are they important? 8. What aspects of your role stayed the same/changed over time? 9. What were your significant time points/role changes? 10. What obstacles did you overcome to move the role to a new time point or level of responsibility? 11. In what ways was your role functioning in an ‘‘advanced practice’’ setting for radiation therapy at the time? 12. What advances did you champion for the PRT role within the clinic? 13. What did you enjoy and not enjoy about the role? 14. Why did you leave this role? 15. What else is important about this role that I haven’t asked about?

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