Patient Involvement

Patients (more recently known as ‘service users’) have formed an integral component of successful clinical training since the early days of medicine. Historically, contact with patients was confined to clinical practice, but now many health professions have responded to a call for greater patient involvementReference Francis³ across all aspects of pre-clinical training. A key benefit of engaging patients in the academic environment is that it changes the dynamic and constraints of the professional–patient relationship and allows students to ask questions that they perhaps would not feel comfortable asking in clinical departments.Reference Henriksen and Ringsted⁴ Published benefits of involving patients in the medical education classroom are considerable and include value to both students and patients; a recent discussion paperReference Hill, Thompson, Willis and Hodgson⁵ eloquently summarised the rationale and current status of patient involvement. Published impact of this includes increased empathy,Reference Gidman⁶ improved engagementReference Henriksen and Ringsted^4, Reference Stickley, Stacey, Pollock, Smith, Betinis and Fairbank⁷ and reduced use of jargon.Reference Thomson and Hilton⁸ From an educational perspective, the involvement of patients is frequently reported as helping to bridge the theory–practice gap in nursing,Reference Carpenter^9, Reference Turnbull and Weeley¹⁰ radiographyReference Bleiker, Knapp and Frampton¹¹ and mental health.Reference Perry, Watkins, Gilbert and Rawlinson¹²

Patients can be involved in student medical education via a variety of different mechanisms. Towle’s comprehensive reviewReference Towle, Bainbridge and Godolphin¹³ outlined a detailed taxonomy for classifying these different levels of patient engagement with medical education programmes. These levels range from ‘Level 1’ where patient details are used as the focus of teaching activities to ‘Level 6’ where patients are involved in policy and curriculum planning at institution level. Recent research into patient involvement in radiotherapy education has been limited with a recent discussion paperReference Hill, Thompson, Willis and Hodgson⁵ only locating four published papers. Unsurprisingly, within this limited evidence base, current publications mostly evidence Levels 3 and Level 4 where patients share experiencesReference Williamson, White, Pope and Mundy¹⁴ or help with teaching or evaluating students.Reference Bridge, Pirihi and Carmichael¹⁵ Outcomes from research in this field predominantly relate to the impact of the interventions on the quality of student experience. It is clear that more in-depth evaluation and publication relating to patient involvement is sorely needed. In particular, it would be interesting to see extension of the evidence base across the full range of Towle’s taxonomy along with some evidence quantifying its specific value for student professional practice and the long-term impact on the patient experience.

Personal Skills

The modern curriculum embeds a range of activities and teaching that aims to nurture development of reflective practice, emotional intelligence (EI) skills and resilience. Reflection was first postulated as a valuable professional development tool in the late 1980sReference Schon¹⁶ and slowly gained in popularity, featuring as the focus of debate in one of the first JRP editions in 1999.Reference Newnham¹⁷ It dramatically increased in prevalence and importance to radiotherapy in the 2000s when mandatory recording of CPD activities became a common professional body requirement.¹⁸ The modern practitioner is required to maintain a reflective portfolio and evidence reflection on their practice. Formal integration of reflective learning and portfolio development outcomes into educational curricula has therefore been widely introduced to help prepare students for future reflective practice. Reflection brings an additional academic skill to the traditional blend of explanation, evaluation and literature skills.

Teaching and assessmentReference Brackenridge¹⁹ of reflective practice rationale, theory and models is now only one component of personal skills development. ResearchReference Smith²⁰ links reflective practice to self-awareness elements of EI. EI abilities are evidently deemed as valuable to health professionals with a recent publication suggesting that they should be core competenciesReference Codier and Codier²¹ and proposing a link with success and resilience.Reference Libbrecht, Lievens, Carette and Côté²² Increasing interest in possible development of EI is evident from recent longitudinal tracking results.Reference Carmichael, Bridge and Harriman²³ A variety of techniques have been reported as beneficial for developing personal skills throughout the student learning journey including narrative journaling,Reference Smith²⁰ EI trainingReference Fletcher, Leadbetter, Curran and O’Sullivan²⁴ and interprofessional workshops.Reference Flowers, Thomas-Squance, Brainin-Rodriguez and Yancey²⁵ Although evidence supports the value of EI for health professionals, the topic is fraught with controversy. The multifactorial nature of professional development presents a challenge in identifying the exact role of EI. Furthermore, debate continues concerning its classification as a trait or ability and the extent to which its elements can be measured and improved. Reflection on the other hand suffers from a lack of evidence supporting its value to clinical practice, but is easier to measure with some useful developed reflective marking models.Reference Findlay, Dempsey and Warren-Forward²⁶ It is commonly accepted that reflection, EI, empathy and resilience are increasingly vital skills for today’s radiotherapy graduates. There is a real need for stronger evidence concerning the value and roles of these potentially valuable educational outcomes as well as pedagogical theories to support their effective development within the modern curriculum.

Clinical Technology Advances

Radiotherapy clinical practice has undergone rapid technological development over the last decade with advances including multimodality imaging,Reference Guden, Ceylan and Berberoglu²⁷ a range of image-guided radiation therapy (IGRT) technology,Reference Qi, Wu, Newman, Li and Hu²⁸ volumetric arc therapy (VMAT)Reference Maungwe and Chamunyonga²⁹ and proton therapy.Reference Bridge³⁰ Not only have these developments outpaced those in many other professions, but the different uptake rates have created a uniquely diverse range of clinical environments. This presents a challenge not only to clinical staff but also to educators who must ensure that students are well equipped to engage with new technology and embrace a rapidly evolving environment. In order to respond to these changes, radiotherapy education has had to ensure that students are both prepared to use new equipment and equipped with the necessary skills to adapt to future change.

The first of these requirements is supported by the 10-year vision document,² which clearly states the importance of aligning curricula with changes in practice. This necessitates horizon scanning,³¹ understanding of current practiceReference Bridge, Dempsey and Giles³² and active engagement with manufacturers, research teams and professional bodies. In terms of skills development, the evidence base clearly shows that technological innovation such as IGRT increasingly demands much greater clinical decisionmaking from therapy radiographers.Reference Waldon, Plank and Middleton³³ Although sound decisionmaking must be informed by clinical experience, it is important that students develop core understanding of the process and requirements as well as an enquiring and critical mind. An additional challenge arises when judging the extent to which students should be immersed in emerging specialised technology that they may not encounter for years after qualification. Linked with this are the inevitable situations that may occur when students gain experience in technology such as VMAT planning that their clinical mentors may not have. Students have the luxury of devoted time to study and engagement with the emerging evidence base; hectic clinical schedules restrict this opportunity for most practitioners. It is, therefore, essential that education continues to not only provide for students but also help identify and assist with addressing skills gaps in the workforce arising from technique and technology development.Reference Hoskin and Bhattacharya³⁴

The second element of radiotherapy education relating to technological advances is change management. With such a dynamic environment and the constant need for training in techniquesReference Sale and Batson³⁵ and equipment,Reference Amols³⁶ it is vital that students gain transferable skills and aptitudes. These include cognitive tools to evaluate new technologies and evidence, decision-making skills, the emotional capacity to reflect on their own development needs and a thirst for continuous learning. It is also important to ensure that introduction of teaching into new developments is not at the expense of interpersonal skills training and that core understanding from more basic technology is still retained.

The vision for radiotherapy² document reiterates the value of collaboration with regards to research and innovation. Although current research is clearly focussed on implementation of new technology, greater understanding of human factors and response to change is equally important and further research into how best to future-proof radiotherapy graduates is urgently required. Collaborative quantitative research into technological development should be partnered with qualitative research into how best to equip radiotherapy educators, students and the wider workforce for knowledge transfer and adaptability. In particular, it would be interesting to determine the optimal level of decision-making skills required by graduates and how best to ease the transition to clinical decisionmaking. It would also be useful to quantify the extent to which pre-registration understanding and skill development with complex technology or techniques is retained post-qualification.

Technology-Enhanced Learning

It is not only clinical equipment that has been subject to rapid development, technology has revolutionised our everyday communication and knowledge transfer processes. Mobile technology and the rapid explosion of Internet resources have enabled instantaneous communication and access to an overwhelming range of facts, images and ideas. The learner of today has grown up with digital technology and generally has unparalleled access to information; in 2009, 82% of UK learners had home access to the Internet.Reference Eynon³⁷ Different terms for the modern cohort have been proposed including Generation Y,Reference Horowitz³⁸ the Net GenerationReference Tapscott³⁹ or Millennial students.Reference Howe and Strauss⁴⁰ These students typically have high levels of Internet and social media use. It is important to acknowledge that modern radiotherapy cohorts embrace a particularly diverse range of learners from school age to mature students; a broad-brush adoption of a single-learning style should be avoided. It is also important to distinguish between e-communication and e-learning; a 2012 studyReference Robinson and Stubberud⁴¹ indicated that face-to-face communication was still preferred by students in the United States and Norwegian Universities, whereas a studyReference Jones and Healing⁴² into Year 1 English students’ engagement with technology highlighted the distracting nature of social media. Despite this, technology impacts positively on student learningReference Tamim, Mohammed, Bernard, Borokhovski, Abrami and Schmid⁴³ and can facilitate a range of pedagogical strategies; chiefly that of ‘blended’ learning with its mixture of traditional and electronic learning tools. A recent meta-analysisReference Bernard, Borokhovski and Schmid⁴⁴ neatly summarised the challenges of unravelling the multiple factors impacting on student learning and identified a need for more rigorous primary research into blended learning benefits.

Despite the limited evidence base, it is fair to say that educational institutions have eagerly embraced the efficiency gainsReference Bridge and Appleyard⁴⁵ and pedagogical power of digital communication technology. Modern radiotherapy students enjoy access to rich virtual learning environments providing them with immediate access to resources, assessment and feedback mechanisms, mobile learning facilitation and a raft of communication options. Today’s classroom is significantly different from that of 10 years ago with recent developments increasing student access to and control of resources.

Figure 1 comprises four scenes illustrating how technology has impacted on the learning environment and shifted the ‘focus of learning’ from the lecturer towards the student cohort. Scenes 1 and 2 show how technology has expanded the focus from the lecturer alone to a combination of the lecturer and online learning resources. Scene 3 illustrates the recent trend of shifting from a tutor-centred learning environment towards a ‘flipped classroom’.Reference Phillips and Trainor⁴⁶ The flipped classroom model draws on the rich availability of knowledge by providing students with resources via remote access before attendance at student-led seminars. This changes the focus of teaching time from knowledge provision to facilitating clinical application of knowledge and development of high-level academic skills. Scene 4 represents the current growth of mobile learning, with increasing use of independent learning and online resources facilitating individual learning. The focus of learning here is diffuse with each student experiencing their own blend of learning. Although the academic here is depicted in the office gazing wistfully at the students, it is unlikely that personal interaction will disappear from the radiotherapy academic environment. The emerging role of the tutor coordinating and facilitating remotely will need supplementing with personal contact to ensure development of interpersonal skills.

Figure 1 The evolution of the radiotherapy classroom.

The nurturing of independent learning skills, however, should particularly benefit the future radiotherapy graduates and equip them for evidence-based practice and lifelong professional development. Further independent learning is facilitated by e-learning technology to support placement-based distance learning with both pre-registration students and post-graduate clinical staffReference Probst, Eddy and Doughty⁴⁷ reporting high levels of satisfaction. E-learning has developed a unique role in the support of clinical learning with students able to access reflective portfolio and learning resources while in the clinical environment; this enables rapid capturing of reflection-in-action as well as optimising placement time.

The fusion of technology and traditional teaching methods can clearly help to cater for increasingly diverse cohortsReference Bernard, Borokhovski and Schmid⁴⁴ while nurturing enquiry-based independent learning. The increased potential for facilitation of independent learning and provision of flexible resources to suit a range of learning styles is of particular interest to radiotherapy education. In particular, e-learning is transforming traditional teaching into more personalised education with different resources and formats available for individual learners. This tailored approach mirrors the clinical drive towards personalised radiotherapyReference Ree and Redalen⁴⁸ and further research into how best to manage and optimise this would be useful.

An interesting offshoot of technology-enhanced learning has been the use of Open Access education, including Massive Open Online Courses, social network learning and online journal clubs. The future role of these is controversial and they bring a new series of challenges and opportunities to radiotherapy education. Although Open Access education has been seen as a temporary whim or even a threat to traditional educational models in some quarters, it does have great potential for collaborative learning, generating debate and sharing ideas; an essential aspect of helping to drive change.

Current educational research suggests that the increasing dependence on mobile technology will lead to drastically different pedagogical approachesReference Vazquez-Cano⁴⁹ as seen in Figure 1 (Scene 4) and it will be interesting to see how this impacts on students’ collaborative learning development. It is clear that the increasingly collaborative nature of the upcoming ‘iGeneration’ or ‘Generation Z’Reference Horowitz³⁸ is going to radically change the face of radiotherapy education. It is important that academic and clinical educators prepare to embrace and support this new generation in academia and also that we prepare our clinical departments for forthcoming patients from Generation X.

Simulation

In health profession training, ‘simulation’ implies use of technology or techniques to replicate aspects of clinical practice and allow students to develop valuable skills in a safe environment. This allows for training in potentially complex procedures that were previously limited to ‘in at the deep end’ experiences on patients who desperately need the procedure to be performed correctly. Simulation is not a new educational tool in radiotherapy. Students have long been prepared for clinical practice through activities and equipment in academia; this ranges from simple communication role playing to use of non-clinical treatment planning systems. Simulation in radiotherapy has recently undergone a transformation, thanks to the introduction of virtual reality (VR) simulation.

VR simulation in radiotherapy demands replication of a ‘whole-room’ and the ‘Virtual Environment for Radiotherapy Training’ (VERT) softwareReference Bridge, Appleyard, Ward, Philips and Beavis⁵⁰ continues to support pre-clinical radiotherapy training.Reference Flinton⁵¹ In the clinical environment, use of simulation in busy clinical departments has allowed some students to make good use of machine down time or practice for specific patient encounters without impacting on workflow. It is clear, however, that VERT’s real strength lies in acquisition of technical and dosimetry evaluation skills as opposed to direct knowledge transfer. Carter et al.Reference Carter, Birak, Magias, Hulse and Willis⁵² failed to determine benefit for anatomy teaching, although this could possibly have been attributed to pedagogical technique. One of the criticisms of VERT-based simulation in radiotherapy has been the failure to deliver the promised expansion of clinical training capacity. VERT is certainly a valuable addition to clinical placement learning but users still lack the evidence base to support its use as a ‘placement’.

It should also be noted that simulation encompasses a broad range of learning tools. In addition to technical skills development, simulation activities and equipment offer students opportunities to hone other essential radiotherapy skills. Research into a range of simulation systems is vibrant and extensive, covering a range of relevant skill acquisition opportunities. Studies have demonstrated the relative value of VR and simulation training over traditional methods for acquisition of interpersonal communication skills,Reference James, Sim, McDonald and Ryan⁵³ practical infection control skillsReference Luctkar-Flude, Pulling and Medves⁵⁴ and nursing clinical skills.Reference Mosalanejad, Shahsavari and Sobhanian⁵⁵ Simulation is an ideal addition to and preparation for clinical practice, but given the wide range of potential factors, identifying the specific impact of this on student skills and patient outcomes is challenging. Much of the research relating to simulation reports qualitative outcomes based on student satisfaction and engagement; typically based on small cohorts. Published data is also largely restricted to conference presentations, with relatively few formal peer-reviewed articles contributing to the evidence base. More widespread high-quality evidence is urgently needed to establish the wider impact of simulation on student learning and, ultimately, patient experience.

VR simulation technology, in particular, is rapidly evolving, being heavily influenced by the lucrative gaming industry. There is great current interest in VR headsets to increase sense of embodiment and thus effect behaviour change.Reference Kim, Prestopnik and Biocca⁵⁶ Simulations such as Ball’s dementia simulatorReference Ball, Bluteau, Clouder, Adefila and Graham⁵⁷ highlight the potential value of vastly increased immersion in more realistic virtual clinical environments. Indeed one authorReference Waters⁵⁸ has heralded VR headsets as ‘redeeming’ VR in higher education. Fundamental work establishing best practice in pedagogical guidelines and a move towards a more standardised approach to evaluation of VR-based resources should yield valuable data and help prepare the academic community for future developments in this space.

Limitations of the Evidence Base

One of the most commonly voiced maxims in radiotherapy concerns how small a world it is. The relatively small number of practitioners compared with other professions can be a challenge when seeking research funding or establishing a strong publication profile. The effect is also felt in academia with radiotherapy class sizes frequently dwarfed by those of other health science professions. Much of the evidence base concerning education in radiotherapy is therefore characterised and somewhat thwarted by small cohort sizes. The review of evidence revealed a mean cohort size of 42 (minimum=1, maximum=227) and a median of 24. Most (58%) of the cohort sizes were <40 with 25% being 40–80 and only two papers with cohorts over 100. This contrasts starkly to papers relating to education in nursing where cohorts numbering over 100 are commonplaceReference Harris, Pittiglio, Newton and Moore^59–Reference Rush, Firth, Burke and Marks-Maran⁶¹ with correspondingly high statistical power.

Radiotherapy and academia both have a long tradition of independent development based around single institutions. The faces of both these environments are changing, however, with a growing enthusiasm for collaborative working and resource sharing, including the national radiotherapy dataset,Reference Hoskin, Forbes, Ball, Riley and Cooper⁶² standardisation of practiceReference Haviland, Owen and Dewar⁶³ and audit of practice.Reference Bridge, Dempsey and Giles³² The true strength of collaboration in radiotherapy educational practice and research, however, lies in collaboration between multiple academic institutions and clinical departments as encapsulated by the UK Academic Health Science Networks.² There are certainly challenges to HEI collaboration,Reference Siska, van Swet, Pather and Rose⁶⁴ including knowledge sharing and intellectual property issues, and it is clear that widespread adoption of collaborative practice will require a culture shift from resource guarding to resource sharing and an institutional-level commitment to collaboration in educational development. The benefits, however, include enriched skill mix, increased reliability of findings, higher quality published output, and a louder voice and stronger presence in the professional environment. More widespread endorsement of collaborative publication and projects at both editorial and institutional level is to be encouraged.

It should also be noted that much of the current evidence base in radiotherapy education consists of conference presentations and posters with few of these being written up as peer review articles. Although these formats are useful, when compared with other professions there is a real need for high-quality primary evidence that can be used to inform practice and drive change. The rapid rate of change in radiotherapy education means that expanding this evidence base should be a key priority.