Chapter 16: Radiation Therapy

Uncertainty in Radiation Therapy

To identify where uncertainty exists for the radiation therapist and radiation therapy learner, it is necessary to consider the intent of radiation therapy as a treatment for cancer and the role of the radiation therapist within the multidisciplinary team. The main aim of radiation therapy is to deliver doses of radiation to the region of the body where a cancer is located or has been resected (the target) while minimising the radiation dose to healthy body organs and tissues which lie close to this target area. The high-energy x-rays, electrons, and particles used in the different radiation therapy modalities are lethal. As radiation traverses the body, it causes cellular damage to any tissues (both cancerous and non-cancerous) within its path. The degree of cellular damage is influenced by the amount of radiation deposited in the cell over time and the cell’s capacity to repair the damage. If radiation therapy is not planned and delivered with precision – accurately and reproducibly each day – to the exact site of the body where it is required, serious irreversible harm can be caused. For example, excessive radiation damage to normal (i.e., non-cancerous) cells can cause distressing chronic side effects, which may impact physical, cognitive, psychological, and social function and quality of life. Excessive radiation doses may also lead to an increased risk of secondary cancer or even death.

Radiation therapists are members of multidisciplinary radiation oncology teams of healthcare professionals who work collaboratively to ensure people with cancer receive the best possible care. This care is centred around the specific needs and safety of the individual. In addition to radiation therapists, the healthcare team consists of radiation oncologists, radiation oncology medical physicists, radiation oncology nurses, medical engineers, and other allied health practitioners, such as dieticians, physiotherapists, speech pathologists, occupational therapists, and social workers.

Uncertainty in the radiation therapy workplace includes decisional uncertainty and interpersonal uncertainty, which manifest through technical concerns about the safety and accuracy of treatment delivery and the application of ever-evolving technologies and approaches to cancer care, challenges relating to how to best individualise treatment delivery and supportive care needs, and the changing role of the radiation therapist within the multidisciplinary team. It is important for educators to explore experiences of uncertainty with their radiation therapy learners so they are better prepared for clinical practice.

Uncertainty in the radiation therapy workplace has not been overtly explored in the literature. Therefore, the following discussion primarily draws on the authors’ clinical and education experiences, observations, and reflections.

Accuracy and Reproducibility of Treatment

The role of the radiation therapist is to locate the tumour using medical imaging modalities, to create individualised treatment plans (i.e., maps which predict where the radiation dose will be deposited within the body), and to deliver the daily prescription of radiation with millimetre-level accuracy, which often involves immobilising the patient (Duffton et al., 2020). A key part of the radiation therapist’s role is to support the patient during these unfamiliar procedures, which often provoke anxiety. In addition, the radiation therapist needs to recognise physical and psychological signs, symptoms, and side effects which the patient may experience and to make referrals to the appropriate member of the multidisciplinary team for support and management when necessary (Larsen et al., 2015).

The individual characteristics of the person being treated, the tumour location relative to body organs, and the natural motion from physiological functions (such as peristalsis, bladder and rectal filling, and breathing) can make the goals of accuracy and reproducibility challenging to meet. As a result, the degree of accuracy and reproducibility and what is acceptable and safe may require tailoring to each individual. This may foster feelings of uncertainty in radiation therapists (and learners) about how to ‘best fit’ the goals of treatment to each individual while still achieving a safe and effective therapeutic outcome. For a closer look at the roles of accuracy and reproducibility in radiation therapy, see Cancer Research UK (2018) (opens in new tab).

Reliance on Protocols

Radiation therapists routinely use protocols to inform their clinical decisions. The challenge for the profession and in educating learners is to overcome the perception that using protocols means practitioners should not be creative in their problem-solving and ‘think outside the box’ when a protocol will not achieve the best possible outcome for the patient. This perception may limit the capability of radiation therapists and learners to make clinical decisions in the face of uncertainty, extending beyond the parameters of their roles, which have traditionally been very clearly defined and ‘fixed’ (Matthews et al., 2021). Therefore, radiation therapists may fear the consequences of not adhering to protocols, of not being ‘exact’ in delivering the radiation, and may feel uncertain about the impact of this on the patient.

The stage and grade of the cancer, individual comorbidities, and physical and psychosocial issues which impact on how the treatment is planned and delivered may be sources of uncertainty. For example, if a patient receiving radiation therapy finds it difficult to remain in the treatment position for the required length of time, such as when a person is in pain, they may move during treatment delivery. This may compromise their safety and lead to a geographical miss, when the radiation does not ‘hit’ the correct target area. Faced with this situation, the radiation therapist will need to decide whether the treatment should be delayed for the patient to receive pain control, or if the patient should be reviewed by their doctor before treatment, or if the treatment position could be adjusted to provide more comfort without compromising accuracy. In this scenario, the radiation therapist may need to overcome the uncertainty of deviating from the protocol and choose the solution to the problem that will achieve the best outcome for the individual.

Experience

Like other healthcare professionals, radiation therapists may develop a specialisation when they work for a long period in a single area, such as alignment to a particular type of cancer or body system, or to treatment or planning sections of the workplace. Their subsequent transition into a different working environment with a different team and work tasks may be a source of uncertainty (Matthews et al., 2021). With this type of transition, there are often variables associated with tumour type protocols, equipment, workflows, and working relationships, which may lead to ambiguity until a sense of familiarity is reached.

Advances in Technology

The practice of radiation therapy has continually changed in response to technological advances. In recent years, these advances have been characterised by the rapid evolution of computing and artificial intelligence technologies. Radiation therapist uncertainty may be caused by changes in equipment, protocols, or workflows aligned with new technologies (Wong et al., 2021). Transition to new or updated versions of equipment may be a source of uncertainty for radiation therapists, particularly when they are expected to teach learners about the equipment. Radiation therapists may wonder whether artificial intelligence will take over many of the tasks they currently perform (Huynh et al., 2020; O’Shaughnessey & Collins, 2023). They may have uncertainty about the reliability and accuracy of tasks performed by computers, or conversely, the use of artificial intelligence may, in the longer term, make radiation therapists more complacent about practice or more reliant on protocols.

Changing Oncology Practice

Cancer care and oncology are rapidly evolving (Debela et al., 2021), and changes in management strategies for cancer may reveal gaps in the evidence base and, consequently, radiation therapy knowledge. Examples include not knowing the impact of new equipment and treatment techniques (Tsang & Routsis, 2021), how different cancer management strategies interact, and considerations for clinical outcomes. Lack of knowledge may lead to uncertainty among radiation therapists. Potentially compounding perceptions of uncertainty, radiation therapists and learners may not always feel comfortable asking their colleagues questions: they may fear they do not know the ‘right’ questions to ask or may be fearful of the response to a perceived ‘silly’ question.

Communication

Communication by radiation therapists with patients, including how, what, and when information is communicated and who is involved in the communication interaction, may be a source of uncertainty. People receiving radiation therapy are often unfamiliar with the equipment and the environment, which can look quite intimidating when first encountered. Radiation therapists need to allay any fears and support the patient to feel comfortable at a difficult time in their life, particularly as they may have only recently received a cancer diagnosis (Elsner et al., 2017). Radiation therapists may feel uncertain about how to best approach person-centred communication during such an anxious period for the individual. This entails considering how the person may react to the unfamiliar situation, what information and support needs the person and their loved ones may have, and which member of the multidisciplinary team is best suited to meet these (Larsen et al., 2015).

Radiation therapists may also experience uncertainty in communicating a person’s associated care needs or treatment delivery concerns to other members of the multidisciplinary team. This may be especially true of novice radiation therapists, who may feel less confident than their more experienced colleagues.

Role in the Multidisciplinary Team

Role definition, role boundaries, and professional identity are areas of uncertainty for entry-level practitioners and for more experienced practitioners transitioning into new or advanced roles (Matthews et al., 2021). Within the multidisciplinary team, uncertainty may be present regarding the expectations of colleagues and the radiation therapist’s role definition, identity, and scope of practice. As with many professions, communication within the team may also be a source of uncertainty (Goh & Di Prospero, 2017). How to overcome the perception of being ‘the technologist’ who carries out the instructions of the radiation oncologist rather than a decision-maker in their own right may be a source of uncertainty for the radiation therapist. The blurring of roles may result in uncertainty about who should communicate what, when, and how to the patient. This may be compounded by systems and organisational changes related to workforce redesign and defining work tasks in new ways.

Priorities to Prepare Learners for Uncertainty in Radiation Therapy

Learners who are preparing for a career in radiation therapy need guidance throughout the stages of transition, from beginner to competent (i.e. entry-level) practitioners and beyond. These transitions provide learners with opportunities to develop the confidence, capability, and strategies needed to manage their uncertainty related to radiation therapy practice. Radiation therapy courses typically include clinical placement, where it is the joint responsibility of the education team at the university and the clinical supervisory team in the practice site to support the learner in developing uncertainty tolerance. When a new graduate enters the profession, structures should be implemented by employers (and the profession) to support their developing practices (Harvey-Lloyd et al., 2019). Similarly, as radiation therapists become more experienced and take on new roles, employers, universities, and the profession can all play a part in supporting and guiding them to recognise the different sources of uncertainty and to manage new areas of uncertainty (Matthews & Duchesne, 2023). Of importance is the message for both learners and practitioners that it is okay to feel uncertain about aspects of practice.

Activities which allow radiation therapy learners to practise strategies to manage uncertainty, through university and clinical placement learning experiences, are essential (Stephens et al., 2022). To enhance radiation therapy service delivery and provide safe, person-centred care, opportunities to practise managing uncertainty should be scaffolded through learner transition from beginner to entry-level graduate practitioner and beyond.

Fostering Uncertainty Tolerance in Radiation Therapy Learners

Prioritised learning activities to foster uncertainty tolerance in radiation therapy learners could include, firstly, delivery of foundational knowledge in a way that emphasises the variability in how it is applied in different clinical services. Sources of variability to consider for inclusion are available equipment and technologies, workplace structures, referral patterns, and the clinical preferences of the prescribing radiation oncologist. Learners need preparation to reconcile how the ‘facts’ presented within coursework may differ from those observed in clinical practice and to understand that there may be multiple acceptable ways to achieve similar clinical outcomes.

Another learning activity to foster uncertainty tolerance could be exposure to how published or organisational clinical protocols often need to be modified to deliver the best possible therapeutic outcome for the patient, depending on the personal or anatomical characteristics of the individual and/or their cancer. Additionally, learners need skills to recognise that there can be multiple options when deciding the ideal approach for radiation therapy delivery and that choosing between different technical features and resultant dose outcomes to the tumour or normal body tissues is commonplace. Activities that expose learners to a range of individual tumour and anatomical presentations and the associated nuanced technical and clinical decisions that may align with them are important, both in simulated education environments and on clinical placement.

Thirdly, uncertainty tolerance can be fostered through activities that develop learners’ critical thinking, self-awareness, and reflective practice capabilities enabling them to evaluate and problem-solve when practice observations and tasks may not align with their academic readings or experiences or when faced with an entirely new and unfamiliar experience.

Finally, uncertainty tolerance can be built through communication skill development activities using simulated learning and clinical placement to equip learners to engage in interprofessional and intraprofessional interactions. Learners need to be able to professionally question when practice observations don’t align with their past experiences, to ask for guidance when feeling uncertain about practice activities, to actively listen to others in the team when different options for care are presented, and to effectively explain their clinical decisions and problem-solving when performing clinical tasks.

The following section describes a learning activity designed for novice to advanced radiation therapy learners. Radiation therapy planning (RTP) using simulated cases and online peer-led discussion enables learners to foster uncertainty tolerance while developing their technical and practical capabilities through using a reflective approach to plan development, ‘outside of protocol’ problem-solving and clinical decision-making, and peer-to-peer communication.

Exemplar Activity: Simulated Cases with Online Peer-Led Discussion

Activity Origin

This activity was developed and implemented within the Department of Medical Imaging and Radiation Sciences at Monash University, Melbourne, Australia. Prior to the implementation of the activity, RTP learning was achieved asynchronously as part of descriptive learning packages. We had observed that students often felt lost in completing the packages, as these did not perfectly align with what they were observing on clinical placement. Uncertainty often arises within radiation therapy clinical practice when the intention for a patient’s radiation therapy delivery does not align strictly with protocols and/or the evidence-based literature. Variations across a presenting cohort of cases can occur due to differences in tumour size or location relative to adjacent anatomy; organ motion from breathing or peristalsis; anatomical disruption as a result of cancer, comorbidities, or surgery; or other factors. This presents a challenge for radiation therapy learners, as they may anticipate the application of ‘facts’ learned during the course, within a protocol, or from a clinical placement to be a ready-made solution for all clinical problems and decisions (moderator: objective worldview). However, there is not a ‘one size fits all’ approach for addressing such clinical problems. This challenge is compounded by the risk associated with radiation delivery: learners are often hesitant to deviate from the ‘facts’ when faced with uncertainty, through fear of compromising safety (moderator: low subject proficiency).

As educators, we cannot describe within the curriculum all possible variations that learners may observe in clinical practice. Instead, we need to encourage learners to appreciate that variations faced in real clinical practice often require active problem-solving and adaptation of the protocol to achieve a ‘best fit’ therapeutic outcome (moderator: orientation). Integration of RTP software and simulated clinical cases (consisting of a brief clinical history and medical imaging dataset) within radiation therapy curricula is a common strategy to assist learners in developing their technical planning skills. We have developed and scaffolded RTP simulated cases across our course (stimulus: grey cases) to represent the breadth and complexity learners may encounter in day-to-day clinical practice (moderator: uncertainty dress rehearsal). Cases of specific tumour types are aligned for delivery with concurrent learning content. Additionally, over time, cases increase in complexity regarding clinical or anatomical presentation and increase in difficulty regarding applied technical skills and problem-solving (moderator: scaffolding uncertainty). An online peer-led discussion is integrated within each simulated case to provide a safe space for peer support, mutual problem-solving, and sharing of different approaches that may be applied to achieve a desired clinical outcome (moderators: pastoral care, diverse teamwork). The procedure for each RTP simulated case and online peer-led discussion is shown in Table 16.1.

Table 16.1 Radiation Therapy Planning Simulated Cases With Online Peer-Led Discussion Procedure

Step	Procedure
Simulated case (stimulus)	This includes a brief clinical narrative, radiation therapy prescription dose, and any medical imaging datasets.
Simulated practice, Week 1	Learners use RTP software to design a radiation therapy plan that meets, or is working towards meeting, the clinical objectives for the case. Learners are required to problem-solve and make decisions to create a clinically effective solution. Actions may be informed by previous experiences, evidence-based protocols, and academic knowledge.
Online peer-led discussion, 1 hour (moderator)	The discussion is learner led, with facilitation by the educator. Learners share the progress of their case plans via a synchronous video discussion, with an emphasis on areas of difficulty and problem-solving attempts. Peers offer strategies to assist with managing presented challenges drawn from their own experiences with the case and clinical practice.
Simulated practice, Week 2	Learners continue to develop a clinically effective radiation therapy plan for the simulated case, informed by the strategies shared by others during the online peer-led discussion.
Submission and feedback	Final plans and documented critical self-reflection of the outcome are submitted to the educator for feedback. As an assessment-for-learning strategy, individual feedback is focussed on assisting future problem-solving and learner skill development. A group feedback and demonstration session may also be facilitated for less experienced learners.

Sources of Uncertainty

The sources of uncertainty that may arise from a RTP simulated case are listed below:

• Learners are guided to use a specific technical approach to develop their plan, but there are multiple variables and decisions to be made in relation to this which will impact on the overall radiation dose distribution, as well as how long the patient will be required to maintain the treatment position. Learners need to balance the technical aspects to achieve an effective clinical outcome with the timeliness of treatment delivery.
• Anatomically, there are often overlapping targets and organs at risk within the treatment region, each with competing dose requirements. Learners will need to compromise on achieving maximum dose effectiveness to the targets while maintaining minimum dose to the organs at risk.
• Similarly, influenced by patient age and disease presentation, learners will face uncertainty trying to balance tumour control (and better prognosis) with minimal toxicity (and better quality of life).
• Learners may also grapple with the broader impacts of a patient’s cultural background, personal circumstances, and psychosocial needs on their treatment experience.

Facilitator Guide

Before implementing the RTP simulated case and online peer-led discussion, it is important to consider how the concept of uncertainty is integrated more broadly into the course. How uncertainty and the associated discomfort may be experienced within the radiation therapy workplace can be demonstrated by the educator team through case-based tutorials, clinical placement debrief discussions (moderators: intellectual candour, reflective learning), and integration of alternative practices from the peer-reviewed literature into learning materials (moderator: scaffolding uncertainty). This encourages learners to expect uncertainty as a ‘normal’ feature of practice (moderator: career value).

There are several key considerations for an educator seeking to introduce an RTP simulated case and online peer-led discussion at both the preparatory and the delivery stages of the activity. Preparatory considerations include:

Infrastructure Learners require access to RTP software, either on campus or online. Activity design and delivery may be influenced by access location and any concurrent use limitations related to the number of learners in the cohort. Online access to the RTP software is ideal for learners to share their plans during the peer-led discussion (moderator: reflective learning).

Simulated cases The RTP simulated cases provide authentic clinical scenarios for which there is no fixed solution. This enables learners to experience the ‘real world’ of practice (moderator: uncertainty dress rehearsal), in which expected protocols are often starting points to be modified to suit the individual patient’s needs. Each case should include brief case notes, a management plan, and any imaging datasets required for the task. Pre-marked contours may or may not be included with the imaging dataset, depending on the focus of the activity. A clinical protocol is intentionally not provided (moderator: open pedagogy), in order to centre the uncertainty of having many possible solutions.

Alignment with unit learning outcomes and content The RTP simulated cases are scaffolded across the course, enabling learners to experience increasing uncertainty with increasing clinical complexity (and fewer options for a ‘right’ answer) as they develop their knowledge and applied skills (moderator: scaffolding uncertainty). The type of case (with respect to cancer and complexity) should align with concurrent delivery of related academic learning content to maximise learning opportunities. Similarly, the objectives of the RTP simulated case activity should align with the overall unit or course learning outcomes.

Learner needs The type of case should reflect the needs of the learners at the point in time of delivery (moderator: subject proficiency). This includes where they are positioned on the beginner-to-competent continuum of learning (Benner, 1984) and any prior experiences of RTP they may have had within the course and on clinical placement. The complexity of the case should reflect the current or expected capabilities of the learners at the point in time of delivery. Also, the duration required for activity completion could be extended or reduced depending on learner confidence and competence. Additional educator-led support sessions may be considered for less experienced learners to help guide their use of RTP software (moderator: subject proficiency).

Delivery considerations include:

Setting expectations The activity’s success relies on the formative aspect of assessment and the psychological safety of the peer-led discussion. It is essential to frame the expectations of the activity as safe for learning before commencing (moderator: setting clear expectations).

Online peer-led discussion This promotes normalisation of making ‘mistakes’ during problem-solving and communicates that it is okay to feel uncertain (moderator: psychological safety). The nature of the peer-led discussion fosters psychological safety towards being uncertain by allowing all learners to be vulnerable in presenting their works in progress and to choose when to share their cases (moderators: responsible for knowledge, diverse teamwork). Additionally, learners are exposed to various clinical options and experiences through peer discussion, demonstrating that practice is not black and white (moderator: reflective learning). The effectiveness of the synchronous peer-led discussion session is maximised when there is enough space and time for learning and when it is a safe space for learning (i.e., clear expectations of respectful discourse moderated by an educator) (moderator: pastoral care). For larger cohorts (more than 30), scheduling more than one session may be necessary.

Facilitator role The role of the educator as the facilitator during the peer-led discussion is closely associated with learner needs: less experienced learners may require more guidance around their role and the expectations of peer-led discussion (moderator: low subject proficiency), as well as encouragement to share their plans in progress (moderator: pastoral care). Regardless of learner needs, facilitators have an active role in normalising uncertainty and variations in practice (moderator: intellectual candour), encouraging problem-solving attempts, sharing clinical experiences when requested (although the emphasis should remain on learner sharing), and maintaining a safe space for learners to posit contrasting thoughts and experiences without fear (moderators: pastoral care, expert guidance).

Effective feedback The RTP simulated cases are ungraded, allowing learners a safe opportunity to submit a ‘best fit’ outcome for educator feedback (moderator: flexible assessments). As an assessment-for-learning strategy, thorough individualised feedback on submitted plans is essential to encourage future development (moderator: expert guidance). Reflection on feedback enables learning and application to future clinical practice (moderator: reflective learning). A group feedback session may also be useful, particularly for less experienced learners, whose learning may be assisted by an ‘expert’ plan demonstration and discussion.

Activity: RTP Simulated Case

This RTP simulated case (stimulus: grey cases) is intended for more advanced (entry-level) learners in the final period of their course (moderator: high subject proficiency). Case notes are provided to learners with a brief history and management plan (see Table 16.2). Learners also have access to a complete digital computed tomography (CT) planning dataset within the RTP software system for the case. The CT dataset includes relevant contours, such as gross, clinical, and planning target volumes (PTV) and normal organs sensitive to radiation (organs at risk).

Table 16.2 Example of Radiation Therapy Planning Simulated Case Notes Provided to Learners

Item	Description
Name	Alistair
Age	53
Gender	Male
Cancer primary	Stage: T2N2M0 Histopathology: squamous cell carcinoma of the oropharynx
Disease history	53-year-old male presented with bilateral neck lymphadenopathy six weeks ago, with no associated pain Fine needle aspiration of lymph nodes in the neck revealed malignant cells Imaging: CT scan revealed a mass at the base of tongue on the left side; positron emission tomography scan revealed no metastatic disease, but adjacent lymph node uptake Immunohistochemistry reported p16+ tumour cells (human papilloma virus positive) Diagnosed as human papilloma virus positive T2N2M0 squamous cell carcinoma of the oropharynx (base of tongue) Referred for definitive chemo-radiation therapy
Past medical history	Managing high cholesterol with atorvastatin Nil other medical issues
Social history	Married with one daughter (23 years old) Self-employed software designer Social drinker, non-smoker
Family history	Mother diagnosed with breast cancer 10 years ago No other family history of cancer
Medications	Atorvastatin
Allergies	Nil reported
Clinical examination	On examination, lymphadenopathy is palpable in the bilateral supraclavicular region and neck; however, no visible appearance of thickening or asymmetry Reports feeling quite well, maintaining normal levels of activity
Management plan	Radical intent concurrent chemo-radiation: Chemotherapy: Cisplatin at Weeks 1, 4, and 7 Radiation therapy: modulated approach with simultaneous integrated boost, five fractions (i.e., treatments) per week over seven weeks Gross disease: PTV70Gy* High-risk lymphatics: PTV63Gy Low-risk lymphatics: PTV56Gy Maintain organs at risk (i.e., submandibular glands and parotid glands) below tolerance doses

Note*: PTV planning target volume (i.e., tumour plus margin); Gy Gray (i.e., unit of radiation dose)

Several moderators of uncertainty are typically relevant when implementing this activity. The initial stage involves independent planning, which may challenge learners (moderator: responsible for knowledge). This is balanced with the online peer-led discussion phase (moderators: diverse teamwork, reflective learning), in which learners can work together to discuss different approaches to the case. Learners may also choose to pre-emptively engage in peer discussion via course forums. Learners’ previous experiences with simulated cases or clinical placement typically influence their experiences of uncertainty in this activity. Learners may choose to draw on course materials and recommended evidence-based clinical resource, such as EviQ (2024)(opens in new tab).

Online Peer-Led Discussion

The online peer-led discussion (moderator: diverse teamwork) is facilitated one week after the release of the case. Learners volunteer to share their cases in progress, and peers then offer guidance drawing from their experiences (moderator: capacity for reflection). The role of the facilitator for more advanced learners is to ensure a safe space for exposing uncertainty and learning and to offer clinical experience input when requested (moderators: pastoral care, expert guidance).

Video 16.1 (read the transcript) demonstrates an online peer-led discussion activity. The video was created and shared with the permission of the learner participants; however, case information has been intentionally blurred. The activity opens with the facilitator welcoming learners and asking who would like to share their plan in progress and then shows a learner sharing their plan.

Video 16.1  Initial Online Peer-Led Discussion © The Authors & Monash University is licensed under a Creative Commons Attribution-NonCommercial 4.0 license

There are some key aspects in the video. Firstly, the learner could describe to their peers the radiation dose coverage on their pre-prepared plan by screen-sharing the images and verbally explaining decisions they made. This simulates the types of conversations which would occur regularly in the clinical environment with members of the multidisciplinary team (radiation therapists, radiation oncology medical physicists, and radiation oncologists).

Secondly, the learner explained what could be seen from the plan images and analysed why they thought the dose distribution was not ideal and the plan not clinically acceptable. In this case, the main area of uncertainty for the learner was containing the high-dose region outside the target areas. A safe space was created in the discussion which allowed the learner to show their vulnerability in not knowing how to address clinical challenges. Being uncertain about not creating the ‘perfect plan’ is something which occurs in daily practice when radiation therapists need to adapt protocols to align with individual anatomical presentations.

In addition, the learner verbally articulated uncertainty about not knowing how to modify the dose distribution further. They had reached a point of uncertainty and did not know what to do next. The activity allowed them to experience clinically authentic uncertainty in planning, because all patient cases are unique. Most importantly, the learner experienced that it is okay to ask for help when uncertain.

Finally, the learner also verbally articulated successful attempts to problem-solve challenges within the plan. They practised and demonstrated self-awareness and reflection, not only on the perceived negative aspects but on aspects of the task they were proud of.

Video 16.2 (read the transcript) shows the peer discussion that followed the learner demonstration and explanation of their plan.

Video 16.2  Subsequent Online Peer-Led Discussion © The Authors & Monash University is licensed under a Creative Commons Attribution-NonCommercial 4.0 license

There are some key aspects in the video. Firstly, learners in this peer learning environment clarified areas of uncertainty that the learner highlighted during their presentation and explored suggestions for improvement. Peers demonstrated their ability to interpret and paraphrase information. Paraphrasing can be used during activities as a strategy for having learners demonstrate their understanding of or uncertainty around what a peer has previously described.

Also, peer learners reflected on their experiences in completing the same planning activity and their different approaches to solving the problem. Conversation between the learner and peer learners allowed them to reflect on their experiences and collaborate in problem-solving when facing uncertainty.

Finally, the facilitator made positive and supportive comments and asked if there were any other areas or uncertain aspects requiring clarification. The learner could summarise learning points and clearly define the next steps. The activity continued with other learners sharing their plans and ongoing discussion of potential challenges and solutions. The facilitator provided guidance and prompted learning and reflection as necessary to further explore areas of uncertainty and contrasting clinical experiences.

Final Stages

As shown in Table 16.1, following the online peer-led discussion, learners continue developing their plans and submit these with reflections on the outcomes and their learning for educator review and feedback (moderator: reflective learning). For less experienced learners, the facilitator may also host a group session to demonstrate an ‘expert’ plan (moderator: expert guidance). The group session may include a demonstration of plan variations that the facilitator used in their own problem-solving when creating a clinically appropriate plan (moderator: intellectual candour).

Impact

The initial stage of this activity was evaluated formally and experientially. In the authors’ context, completion of RTP simulated plans scaffolded across the course has been a part of the curriculum for some time. A qualitative evaluation of student experiences showed that the RTP curriculum was able to support student learning and preparedness for clinical practice (Osborne et al., 2022). However, the online peer-led discussion activity is a more recent addition and was not a component of this evaluation. Therefore, what follows are the reflections of the authors in relation to the observed impact of the activity.

The concept was introduced with our more experienced learners concurrently with full-time clinical placement. At that time, the key motivation was to simulate the multidisciplinary team meeting (chart round) focusing on learning peer-to-peer clinical communication skills. We soon realised, however, that the main gains were in enabling learners to explore variations in clinical practice experiences and observations in the context of the RTP simulated case and in providing a safe space in which learners could express their uncertainties relating to the case and collaboratively problem-solve. We observed that learner reflections during the online peer-led discussions and in the subsequent submissions to the educator were more in-depth and demonstrated greater degrees of self-awareness than previously seen. It also became apparent over time that learners appeared more confident to embrace areas of uncertainty and openly disclose when they were struggling with an unknown. These are all vital skills for the developing healthcare professional. As a result, the online peer-led discussion activity was introduced to less experienced learners and continued to be a feature integrated across each semester of the course.

Adaptations and Summary

A structured approach was taken to this learning activity by providing learners with the case history and the CT anatomical dataset to test their knowledge and practise their skills in planning and problem-solving. An alternative method, facilitating learner self-directedness and presenting uncertainty for the observers in the group, would be to allow each learner to choose their own clinical case to present. This would more closely represent the real-world clinical setting, where the radiation therapist can be presented with unfamiliar clinical cases and a restricted timeframe within which to make clinical decisions. This type of approach may be appropriate for experienced learners who are preparing to graduate, but it is not advised for beginner learners, as they may not have the foundation knowledge needed to be able to select a case of the appropriate complexity for their stage of learning.

A further adaptation could be to make the activity more person centred through the educator as facilitator prompting questions and discussion relating to the information in the case history. This would encourage learners to consider uncertainty associated with the physiological and psychosocial factors that impact planning and delivering radiation therapy and person-focussed care. The activity could also be easily incorporated into a summative case-based assessment for learning (individual or group) in which learners are presented with the case, develop a radiation therapy plan, discuss their plan with peers, and reflect on this process. As an online activity, there is also clear potential to explore collaborative peer learning across local and international borders.

In implementing this activity, we have learned that it is possible to incrementally add areas of uncertainty into learning tasks and to support learners to address and manage this uncertainty, thereby better preparing them for practice, through focussed peer-led discussion.

Conclusion

Uncertainty is a common feature in the radiation therapy workplace and in decision-making by radiation therapists. It is important to prepare radiation therapy learners for uncertainty so they are better able to navigate the experience. The activity described in this chapter gives learners an opportunity to experience uncertainty in a safe and collaborative environment. Additionally, when faced with uncertainty, safe practice relies upon learners engaging in critical thinking, reflection, and communicating, all of which are integrated into the activity.

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References

Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Addison-Wesley.

Cancer Research UK. (2018, August 1). What is radiotherapy and how does it work? [Video]. YouTube. https://www.youtube.com/watch?v=V2VGHUjN17w

Debela, D. T., Muzazu, S. G., Heraro, K. D., Ndalama, M. T., Mesele, B. W., Haile, D. C., Kitui, S. K., & Manyazewal, T. (2021). New approaches and procedures for cancer treatment: Current perspectives. SAGE Open Medicine, 9. https://doi.org/10.1177/20503121211034366

Duffton, A., Li, W., & Forde, E. (2020). The pivotal role of the therapeutic radiographer/radiation therapist in image-guided radiotherapy research and development. Clinical Oncology, 32(12), 852–860. https://doi.org/10.1016/j.clon.2020.09.009

Elsner, K., Naehrig, D., Halkett, G. K., & Dhillon, H. M. (2017). Reduced patient anxiety as a result of radiation therapist-led psychosocial support: A systematic review. Journal of Medical Radiation Sciences, 64(3), 220–231. https://doi.org/10.1002/jmrs.208

EviQ. (2024). Head and neck. https://www.eviq.org.au/radiation-oncology/head-and-neck

Goh, P., & Di Prospero, L. (2017). The grey area: An exploration of the scope of practice for nurses and radiation therapists within the radiation oncology program focusing on interprofessional collaborative competencies of role clarity, communication, and team function. Journal of Medical Imaging and Radiation Sciences, 48(1):11–15. https://doi.org/10.1016/j.jmir.2017.02.001

Harvey-Lloyd, J. M., Morris, J., & Stew, G. (2019). Being a newly qualified diagnostic radiographer: Learning to fly in the face of reality. Radiography, 25(3), e63–e67. https://doi.org/10.1016/j.radi.2019.01.007

Huynh, E., Hosny, A., Guthier, C., Bitterman, D. S., Petit, S. F., Haas-Kogan, D. A., Kann, B., Aerts, H. J., & Mak, R. H. (2020). Artificial intelligence in radiation oncology. Nature Reviews Clinical Oncology, 17, 771–781. https://doi.org/10.1038/s41571-020-0417-8

Larsen, T., Fineberg, H., Rinaldo, A., Menon, T., & Jones, G. (2015). Perceptions of radiation therapists about providing psychosocial and supportive care to patients at Peel Regional Cancer Center. Journal of Medical Imaging and Radiation Sciences, 46(1), 37–44. https://doi.org/10.1016/j.jmir.2014.04.007

Matthews, K., & Duchesne, G. (2023). Overcoming uncertainty: A framework to guide the implementation of Australian radiation therapy advanced practitioners. Journal of Medical Radiation Sciences, 70(4), 406–416. https://doi.org/10.1002/jmrs.710

Matthews, K., Duchesne, G., & Baird, M. (2021). Navigating uncertainty: The implementation of Australian radiation therapy advanced practitioners. Technical Innovations & Patient Support in Radiation Oncology, 17, 82–88. https://doi.org/10.1016/j.tipsro.2020.12.002

Osborne, C., Merchant, S., Knight, K., Sim, J., & Wright, C. (2022). A phenomenological study investigating experiences of student learning using an online radiation therapy planning curriculum. Technical Innovations & Patient Support in Radiation Oncology, 24, 6–12. https://doi.org/10.1016/j.tipsro.2022.08.009

O’Shaughnessey, J., & Collins, M. L. (2023). Radiation therapist perceptions on how artificial intelligence may affect their role and practice. Journal of Medical Radiation Sciences, 70(S2), 6–14. https://doi.org/10.1002/jmrs.638

Stephens, G. C., Sarkar, M., & Lazarus, M. D. (2022). ‘A whole lot of uncertainty’: A qualitative study exploring clinical medical students’ experiences of uncertainty stimuli. Medical Education, 56(7), 736–746. https://doi.org/10.1111/medu.14743

Tsang, Y. M., & Routsis, D. S. (2021). Adapting for adaptive radiotherapy (ART): The need to evolve our roles as therapeutic radiographers. Radiography, 27(S1), S39–S42. https://doi.org/10.1016/j.radi.2021.08.004

Wong, K., Gallant, F., & Szumacher, E. (2021). Perceptions of Canadian radiation oncologists, radiation physicists, radiation therapists and radiation trainees about the impact of artificial intelligence in radiation oncology: National survey. Journal of Medical Imaging and Radiation Sciences, 52(1), 44–48. https://doi.org/10.1016/j.jmir.2020.11.013