[Survey by SFRO, SNRO and AFPPE about the evolution of the radiation therapist profession in France]

PURPOSE

As part of the multidisciplinary team, radiation therapists are in charge of elements of treatment preparation and delivery of radiotherapy to cancer patients. Helping scientific and technological improvements, more and more patients with cancer were treated with radiotherapy including hypofractionnated radiotherapy, that explain the increase of demands on services. The professional impacted by this increase of demands are radiation oncologists and medical physicists. The opportunity to push forward the radiation therapist's competencies appears with the possibility to shift them some tasks. In this context, a first work was performed with objectives to have an overview of the tasks shifted to radiation therapists in France, the tasks that they could perform but also to evaluate some criteria of job satisfaction.

MATERIAL AND METHODS

The committee of "new status and value of status" including six radiation oncologists (the French society of radiation oncology [SFRO] et national union of radiation oncologists [SNRO]) and six radiation therapists committee members of the French association of radiation therapists (AFPPE), built a questionnaire including three parts: demographic characteristics, tasks shifted and job satisfaction criteria. In total, the questionnaire included 19 questions and 24 items assessed with a four point-Likert scale (ranging from "completely disagree" to "completely agree"). This survey, formatting with google form, was tested by the committee members and the final version was sent to the SFRO, AFPPE and SNRO members, before being disseminated on the social networks.

RESULTS

From November 18th 2022 to December 31st 2022, 492 responses were received (response rate=18.3%): 55 % of the respondents had at least 11 years of experience in radiotherapy. The respondents worked in different type of health facilities (36 % in specialized cancer centres, 19.5 % in private centers, 17.5% in university and general hospital, 10.2% in general hospital). More than ¼ of the respondents had a teaching lecturer activity, 20% had a management team activity and a research activity for 18%. Less than 10% of the respondents had another degree than that of radiation therapist: university degree (n=27), degree in dosimetry (n=11) and master (n=3). More than 76% would like to be trained and to have access to the advanced practice, more than 50% would like expend competencies with a university degree, 30% with a master and 67% would like to participate in research. Forty-two percent of the respondents were involved in a task shifting (excluding decree relating to acts and activities carried out by radiation therapists) and among the radiation therapists non-involved, 63% would be interested in being. Regarding job satisfaction, 53% of the respondents were satisfied with their job and their salary and 68% believed that their job occupation is in line with their professional aspirations. More than 2/3 of the respondents described a significant workload and mental load, 53% thought to have time for their patient care and 70% felt some organisational difficulties.

CONCLUSION

This survey shows: (i) A significant involvement of radiation therapists in the task shifting; (ii) A very strong demand for career development, in particular with existing degrees or to be created degree such as advanced practice; and (iii) The need to reinforce a job satisfaction for almost the half of the respondents, linked to a workload, a mental load and some organisational difficulties.

[Radiation therapists shortage in France: Organizational consequences and difficulties in deploying new missions and/or tasks delegation]

PURPOSE

Radiation therapists shortage has been evaluated at national level in France, specifically in oncology radiotherapy, in terms of: (i) organizational adaptations, (ii) impact on patients care, and (iii) difficulties in deploying new missions and/or tasks delegation.

MATERIALS AND METHODS

French professional organisations representing radiation therapists - SFRO, SNRO and AFPPE - sent their members a national survey (ten questions on 32 items).

RESULTS

From 18 November 2022 to 31 December 2022, 55 responses were received (response rate: 31%) from radiotherapy managers or department heads; 51% had a structure comprising three to five treatment rooms (receiving 500 to 1000 patients per year [36%], or 1500 to 2000 patients per year [33%]). Activities performed were intensity-modulated radiotherapy (100%), stereotaxic radiotherapy (85%), brachytherapy (40%), adaptive radiotherapy (34%). These structures described consequences in closing machine time for 25% of them (reduction of the hourly volume greater than 10% in 57%) with the following consequences in the last 6 months: (i) an extension of the period of medical care (78%), a closing of one or more accelerators (50%) and the development of moderate hypofractionation scheme or extreme hypofractionation (50%). In current functioning, linear accelerators can deliver treatments with a team of two radiation therapists per room for a short day (43%) or two to four radiation therapists per room teams for a long day (40%). During the last 6 months, there has been a 10% increase in linear accelerators operating with a single team. (ii) regarding treatment planning: 16.4% reported a decrease in the opening amplitude (less than 20% in 44% of cases, from 20 to 50% in 33 % of cases). The initial scheduling of appointments for radiotherapy sessions was carried out by radiation therapists in 84% of the departments in current functioning (0.1 to 1 FTE dedicated to this activity in 62% of the departments). Over the last 6 months, there has been a clear reduction in the number of dedicated FTEs: [FTE=0.1 to 1]=-8%; [FTE=0]=+7%. (ii) Regarding tasks delegation (excluding the decree on acts and activities carried out by the radiation therapist): organ at risk delineation is partially performed by radiation therapist in 26% of the centres; caregiver support time in 78% (56% totally or 22% partially). This activity has been reduced by 42%. Seventy-five percent of departments want to develop new techniques, patient-centered approaches (44%), implement task delegation (organ at risk delineation: 58%; weekly consultations: 67%; positioning imaging validation: 71%), and 78% of departments are interested in developing advanced radiotherapy practice. However, the number of radiation therapists is considered insufficient in their implementation in 76% of cases (one to two FTE missing for 72% of structures).

CONCLUSION

This survey shows a significant impact of radiation therapist shortage in radiotherapy oncology care (treatment delays, access to caregiver support time, workload on treatment teams), and represents a major obstacle to the development of radiotherapy structures.

[Ethical competence of the radiation therapist in the management of a crisis]

Many situations can be considered as a crisis in radiotherapy (failure of equipment, absenteeism, excessive workload, errors, urgent care, pandemic, etc.). Such events are defined as difficult situations in the course of daily activity, they can at any time escape the vigilance of the concerned actors when they are not prepared for it. The crisis can induce a disruption of balance between the normal course of the radiation therapy and the obligation for the manipulators to reconcile the consequences of the ongoing crisis with the objective of taking charge of all patients scheduled for the program. The crisis and its management will inexorably cause stress, fatigue and, as a consequence, impact patient safety. Management has an essential role to play in maintaining team dynamics when a crisis occurs, the work environment may no longer be the same. The aim of this article is to describe these situations in order to highlight the needs of the teams and more specifically the needs of the radiation therapist. It highlights the organization of patient care in the event of crisis management (Covid-19), during palliative radiotherapy with an opportunity to develop advanced practice. The reflection on the ethical concern of the radiation therapist in the prioritization of patients leads us to analyze the knowledge of medical ethics provided during initial training. When they perform their duties, manipulators seem to be confronted with situations that give rise to ethical dilemmas. It is then a question of understanding how they reflect on their practice in order to make it evolve. Is the radiation therapist confronted with ethical issues in the course of his practice? What solutions can be implemented to deal with these issues?

[Ethical stakes in palliative care in radiation oncology]

In 2021, the Ethics Commission of the SFRO has chosen the issue of the practice of palliative care in radiotherapy oncology. Radiation oncology plays a central role in the care of patients with cancer in palliative phase. But behind the broad name of palliative radiotherapy, we actually find a large variety of situations involving diverse ethical issues. Radiation oncologists have the delicate task to take into account multiple factors throughout a complex decision-making process. While the question of the therapeutic indication and the technical choice allowing it to be implemented remains central, reflection cannot be limited to these decision-making and technical aspects alone. It is also a question of being able to create the conditions for a singularity focused care and to build an authentic care relationship, beyond technicity. It is through this daily ethical work, in close collaboration with patients, and under essential conditions of multidisciplinarity and multiprofessionalism, that our fundamental role as caregiver can be deployed.

[Cooperation protocol and advanced practice, an evolutionary perspective for the French radiation therapist]

For several years, the profession of radiographer has been unattractive and is in search of professional recognition. Increasingly complex therapeutic and diagnostic evolutions forces professionals to develop their skills to ensure quality and safe care for all patients. The primary role of the radiographer is to support patients and to accompany them during their examination or treatment, combining caregiver and technician's roles. Transversal missions and delegation of tasks are inherent to the profession but are not widely recognized. Cooperation between radiotherapy professionals is a response to offer the therapeutic radiographer/radiation therapist (RTT) opportunities in terms of attractiveness, career prospects, and increased skills. In radiotherapy, advanced practice activities already exist in some departments but require regulatory adjustments, in particular regarding the redistribution of the roles of RTT but also the status of these professionals. The formalization of these practices can be largely inspired by the many feedbacks around the world. This article aims to reflect the evolution's perspectives in the career of an RTT and on the valorisation of this profession in the current context.

[Health democracy: Patient partnership]

In 2019, the scientific committee of the French society of radiation oncology (SFRO) created an ethics committee. Its mission is to provide our professional community with food for thought on ethical issues, and to identify its specificities within the radiation oncology departments. For the 2020 annual conference, the commission looked into the evolution of the patient-carer relationship, and more particularly to the strong idea of patient partnership. Indeed, the writing of the White Book of Cancer gave voice to sick people and stressed the need for new devices, such as the Caregiving Time. Patients can no longer be considered as objects of care but as people whose dignity and autonomy must be imperatively respected. The acquisition of knowledge allows a bilateral exchange, prerequisite of a dynamic collaboration. Patients can be partners in their own care, partners in training and research (expert patient), but also partners in health institutions and policies. It is this notion of partnership and involvement of the person in their path of care in radiation oncology that we will analyse here. It will be about defining it, by developing the concept of autonomy, and bringing out its complexity and ambivalence through two examples from our clinical practice: the shared decision-making process for patients with localized prostate cancer and the patient's involvement in the success of his radiotherapy.

[Risk analysis of a complex sociotechnical system: Case of radiotherapy]

The increasing complexity of radiotherapy work situations (technological developments, dynamics of change, increased constraints, evolution of collective actions, of professions, of interfaces between people, of human-machine interfaces, etc.) and the limits of traditional FMEA method (Failure Mode and Effects Analysis) for analysing the risks incurred by radiotherapy patients generate difficulties in identifying how the work situations of a healthcare team can generate risky situations for patients. This observation has led us to develop a new method of risk analysis: the Work Complexity Sharing and Exploration Spaces (EPECT in French). The objective of this article is to better secure a care process (making practices more reliable, updating prescribed work, defining preventive and corrective measures, continuing reflections) based on an understanding of the complexity of radiotherapy work situations and a change in our way of thinking about risks.

A finite-element model of tracheal collapse

The trachea has been approximated by an appropriate finite-element model. The three-dimensional equilibrium problems set by the tracheal deformation under various stresses have been solved using a convenient augmented Lagrangian functional. The dimensions were obtained from human tracheae. Mechanical constants for the anatomic components were calculated from the stress-strain relationships. The compressive narrowing is essentially due to the invagination of the posterior membrane in the tracheal lumen for transmural pressures down to -7 kPa. A surface of contact between the membranous wall and the lateral walls appears when the transmural pressure equals -6 kPa. The transmural pressure-area relationship is sigmoidal with a compliance equal to 0.08 kPa-1 for a transmural pressure of -2 kPa. The tracheal collapse is greater when the material constants of the membranous wall decrease or when the tracheal segment is subjected to a longitudinal tension. A slight flexion of the trachea induces an asymmetric deformation.