Introduction

AD: Good morning Denyse, firstly thank you for agreeing to be interviewed today to talk about your contribution to the world of radiotherapy, your career and your views on current and future practice. I know you have contributed significantly to the education and training in radiotherapy and oncology for a number of years and I look forward to exploring these contributions with you today.

In the UK, you are especially well known for your input and specialist interest in the engagement of patients and carers, otherwise termed as ‘service users’ in the practice and in the education and training of practitioners, when did this specialist interest develop?

DH: My interest in service user involvement in contributing to the enhancement of practice developed right at the outset of my career. From the moment I first visited a radiotherapy department I just knew that I was in the right place and that working with patients was what I was meant to do. I remember in the first few months of my training, I would read patients notes and find things out about them so that I felt that I could talk to them and get to know them with confidence. Even though I really liked the technical side of the job, I felt that communicating with patients was what I really was interested in and enjoyed.

I can still clearly remember those early days in practice and one patient in particular stood out. I had treated her initially for breast cancer, she returned a couple of months later and was very poorly and was laid on a trolley. At that time, I felt that we had failed her and I didn’t know what I should say to her. I plucked up courage and went over to talk to her and addressed her by her name and asked her what had happened to her since her initial treatment. She told me that she had spinal metastases and needed further treatment. Even though she was in pain, I could see that she was really pleased that I had approached and remembered her and that I had taken the time to go over and speak with her. At that time, I reflected that remembering patients and their names, made such a difference to both our experiences and I guess that was the start of it for me of ‘putting patients first’.

Even though I have always welcomed new and complex technical developments, I was conscious that when practitioners are preparing for treatment during set up they are concentrating on that task. So it is all too easy to forget that there is a person right in front of you on the treatment couch and it is important to always remember that.

AD: During your career you have undertaken some interesting and varied different roles, can you outline some of the roles you have undertaken?

DH: I worked as a junior and a senior therapy radiographer for a number of years at the James Cook Cancer Centre in Middlesbrough. After having my children, I became employed part time, in those days you had to relinquish your seniority. At this time I also became interested in education, so I completed a teaching course and became more involved in the education and training of students, which I really enjoyed. Then in 1998 an interesting opportunity arose to work for the Regional Cancer Network, through a secondment opportunity. This was post the Calman-Hine ReportReference Calman and Hine ¹ and the Department of Health was heavily investing money to improve cancer services and patient outcomes. Specialist Cancer Centres were identified and received investment to employ specialist educators, so I applied and was appointed to the role of an Education Facilitator across the Cancer and Palliative Care Network for Teesside, UK, named the Cancer Care Alliance. This Network covered a wide geographical area and was there to support the restructuring of Cancer Centres and charged with improving patient experience.

In my new and varied role, I was involved in the development and delivery of education for practitioners from varied backgrounds. To ensure that the education delivered would have a positive impact on patient experience I developed links with patient forums and liaised with a range of patients, who had undergone different forms of treatment.

I took responsibility for organising and delivering conferences, with the purpose of bringing together a wide range of specialists and patients. I think that hearing the ‘message’ directly from the patient is much more powerful and more likely to influence how practitioners and students practice. I can still remember some of these powerful messages. One in particular, was the wife of patient who was very critical of their experiences. My initial thought was this was useful and constructive feedback because it meant we could look at what we could do to improve the service in the future. It was interesting that some practitioners took this feedback as a personal criticism and they didn’t feel comfortable hearing it. I feel that we have to ensure that practitioners are trained to be able to take feedback and use it to make a positive impact on future practice; the patient experience is so important. We have to take every opportunity to reflect and use people’s experiences to improve what we do.

AD: I attended some of one of these Conferences which you also chaired, I was impressed with how successful it was and how it brought together, not only health providers and service uses, but also manufactures of new products, research posters demonstrating quality improvements and innovation. In addition, I noted the attendance of voluntary agencies involved in supporting cancer patients from the different Charities.

DH: One of the main achievements of the Network was that we gained interest and enhanced collaboration from all allied health professions, nurses and social workers, volunteers and Charities. The most important ethos in cancer care is that you have a collaborative team working together and to respect and recognise the importance of how each contributes to the patient experience.

I really valued and enjoyed working in a lead role in oncology. At that time as an AHP, many of these roles were not open to AHP’s, only to nurses as the recognition of therapeutic radiographers’ knowledge and experience were not well know. When the secondment came to an end, one of my key measures of success was that I believe I had made a difference to bring a multi-disciplinary group of people together to enhance the patient experience.

AD: I would like to acknowledge one of your major achievements, in the project you undertook to a training needs analysis of whole of the workforce and mapped required knowledge, skills, competencies. This was one of the first documents that included the whole of the workforce and the beginning of recognising the patient pathway during their cancer journey.

DH: That was in 2000 and was developed for multi professions called the Competency Framework in Cancer and Palliative Care. This framework was used by service to develop the workforce across patient pathways.Reference Husband, Banks Howe, Boal and Hodgson ² At the time it was innovative and now it is seen as accepted practice.

AD: Moving on in your career you took on the challenge of becoming one of the first professional development facilitators (PDF) at Sheffield Hallam University (SHU). This new role was part of an initiative to ensure that the future training of the therapy radiographer workforce was met and to deliver the College of Radiographers aspirations of the introduction of new and different types of practitioners.Reference Beardmore, Colyer and Duxbury ³ Can you explain the background to how and why this new and innovative post had been developed and funded and specifically what did the role involve?

DH: In 2000, the College of Radiographers launched the ‘A strategy for the education and professional development of therapeutic radiographers’. Their proposed new framework was to enable flexible career pathways for practitioners and facilitate wider access for pre and post registration education. This strategy had been developed in response to the growing imperatives which require this group of professionals to function effectively within the inter-professional team at all points along the cancer patients’ pathway, promoting the cancer care ideal of a seamless and equitable service.

The PDF role was developed to support learning at all 4 levels of the workforce for: assistant practitioner, practitioner, advanced practitioner and consultant practitioner; so termed the 4 tier structure.Reference Beardmore, Colyer and Duxbury ³ An important point at this time was that SHU had been awarded a new contract for the education and training of both pre and post registration for therapy radiography. This afforded an ideal opportunity to design an educational framework that would fit the requirements of the future workforce. The PDF was an important role to support the educational aspirations of the Cancer Centres and SHU team involved in training and education. The new role was funded by the commissioners and PDF’s were recruited to all 9 Cancer Centres working in partnership with SHU.

The PDF role was to support the escalation of skills required in the radiotherapy workforce. I had gained a masters degree and I could support practitioners at different levels, from assistant practitioners up to master’s level. My manager at the James Cook Cancer Centre had heard about the proposed new role and she spoke to me about it and thought it was an ideal role for me. At this time, my secondment to the Cancer Network was coming to an end and even though my heart was and still is in the treating patients, I had really enjoyed the educational aspects of the secondment and learned about education in different settings. I had also developed new knowledge and skills and I felt that this PDF role would provide me with the opportunity to make a contribution to the education and development of others, so it just came up at the right time and it’s probably been the highlight of my career.

This was a dream role and I was fortunate to be able to have been appointed and I supported many individuals in different ways to ensure we have a continuing workforce in RT. The role involved working at the Cancer Centre with some academic work based at Sheffield Hallam University. I have enjoyed working with students in much the same way as I had with patients. Encouraging students and seeing them put my feedback into practice, has been very rewarding.

AD: Tell me about the programmes that you have been involved in from inception through to delivery developed whilst at SHU?

DH: When I was first appointed to the PDF role I was afforded the opportunity to work collaboratively with Teesside University. I worked with a multi-professional team to develop a Foundation Degree Programme for assistant practitioners. We devised a programme that had routes for all AHP’s professional areas and nurses; this programme was one of the first in the UK.

It was clear from the outset, with radiotherapy being a small profession; there wasn’t the critical mass of students from radiotherapy to make the route viable. The commissioners agreed to financially support the development of an assistant practitioner’s programme at SHU that would be delivered through work based learning (WBL). I was given the lead for developing this programme with the intention that we would be able to have progression for these students/assistant practitioners into the radiotherapy degree programme.

The education team at SHU worked in collaboration with clinical colleagues to develop the Higher Diploma in Radiotherapy and Oncology to support the training of assistant practitioners in Radiotherapy in 2005 with the opportunity to continue studying onto the BSc Hons Radiotherapy and Oncology that confers registration with the Health and Care Professions Council (HCPC) ⁴ as a therapy radiographer. The Diploma programme is delivered entirely through WBL so that student assistant practitioners can study in their workplace and are supported by the PDF, this model also assured that we had a large enough group of students to provide a student community and peer group support, for their studies. These students attended study days at SHU delivered by the team of PDF’s .This programme has stood the test of time and we have accepted students from all over the UK to register onto the programme. Additionally, a number of them have progressed to complete the BSc programme, which has been a positive addition to the workforce.

The next development that I took a lead for was to support the expansion of the master’s degree framework of modules to introduce more multi-disciplinary modules to include practitioners involved the wider cancer patient pathway. I think because of my previous experience and ethos the new modules needed to be appropriate for different professionals, I am a great believer that individuals learn from each other. We developed two modules. Advanced Communication Skills and the Psychology of Cancer Care. These were delivered at SHU on a weekend and included many different practitioners from different cancer and palliative care settings, from nurses to clergy. Practitioners were able to meet up from all different services from all over the UK and contribute to the content of the modules.

Another development was a third master’s programme: the MSc in Supportive and Palliative Care. This was developed in collaboration with staff at St Luke’s Hospice in Sheffield.

AD: Whilst you were working on the MSc Supportive and Palliative Care, with staff at the Hospice, you were seconded to the Hospice for a year, what other work did you do?

DH: I worked with another SHU member of staff and developed a training needs analysis for all staff and volunteers at the Hospice. I also supported their education lead who was already delivering a collaborative degree approved by SHU, mainly for nurses, but some AHP’s were enrolled. The education lead at the hospice, who was a nurse, worked with the team at SHU to develop and deliver the MSc in Supportive and Palliative Care. This programme has a multi and inter-professional ethos; modules reflect this and are all about working together and communication. With the advent of the availability of new technology based platforms, SHU’s other masters modules were moving from taught methods to distance learning (DL) delivery, through a virtual learning platform. Transferring from taught delivery to DL was a real challenge for these modules due to the topics. We had to work hard to bring some individuals along with the concept of using DL for subjects such as Counselling. We have successfully achieved this and the MSc and specialist modules are available to all health care practitioners, making them more accessible with delivery continuing to grow all around the world.

AD: Whist being at SHU, you have continued to have an interest in service user involvement in education, I know you have developed patient involvement in all aspects of SHU education programmes, can you tell us how you involve service users in the programmes at SHU?

DH: Service users are involved in all aspects of course development and delivery. They are involved in the planning stages of all reapproved courses, admissions processes and interviewing for pre-registration programmes. They have been involved in specialist projects such as producing videos where patients explain their experiences. We use a ‘talking heads’ approach, these are objects that contribute to the learning for the DL modules and for other programmes. We have also used the ‘talking heads’ for the admissions process. Prospective students watch the video and then we use ‘trigger questions’ to see how they are able to articulate the patient’s experience and how they would contribute to improving it. For radiotherapy, this has been a good deciding factor on whether we offer a place to prospective students; we are seeking those who can demonstrate empathy and understanding of the patient perspective. We also have service users on the interview panel; they are able to offer their views on the candidate’s performance.

We have also been involved in an inter university project, commissioned by the East Midland Health Science Network. As part of this project we have developed a web based resource for service user involvement. In addition we have received monies to use the materials developed for this project to produce some art work and a logo to represent the Faculty’s commitment to partnership working with service users.

AD: Given your work on service user involvement, you now take a wider Faculty lead role to embed best practice across the Faculty for AHP’s and nurses and midwife programmes. Can you us about some of the work you are currently involved in?

DH: There are a number of issues when working with service users, they need to be carefully selected and supported. One problem that all education providers have is that of providing remuneration and reward for their input, so we have been working on development of policies to achieve a consistent approach across the Faculty. In some cases, service users are receiving benefits and to remunerate them for their work with us, could impact on eligibility. We have been developing a strategy to support other ways in which we can reward these individuals. For example, if someone has just stepped down from the role, we now have funds available to buy and send a small university gift and card, to thank them and value their input. We have had an excellent response from them, they report that this gesture has meant so much to them. There is national guidance available to guide policy and we have tailored this to the needs of our service user community.

AD: All of this work and development on service user involvement has come to fruition through the work you have undertaken for your thesis to complete your Doctorate in Education. Can you outline your findings and emerging themes from your research?

DH: The whole point of my doctoral work was to examine the pedagogy of service user involvement and to explore the impact of not just having service users in the classroom with students, but to examine the impact this has on student learning. In addition, I was interested in identifying the factors involved that were beneficial to both students and service users, gained from being in the learning environment together.

One key theme that came from interviews with students was that I had underestimated the emotion that the students expressed in response to learning activities involving service users. I had made the assumption that feeling emotional is part of the territory of being a therapeutic radiographer. However students revealed that involving service users in education helped them to develop strategies to manage their emotions. It also was beneficial to service users in coming to terms with their experiences.

We have now embedded the findings of the study into the curricula.Reference Hodgson ⁵ We have built opportunities into the pre registration programme for clinical debrief sessions and discuss strategies on how to manage difficult situations and emotions. In the past, practitioners just ‘got on with’ managing their emotions and these emotions were not formally and openly acknowledged or discussed. In addition, we have begun to harness the notion of emotional intelligence in the programme. Emotional intelligence is related to how students develop and have the potential to adopt strategies to understand others and enhance their practice. Some evidence suggests that you can develop emotional intelligence.Reference Salovey and Mayer ^{6 –} Reference Freshwater and Stickley ⁸ I believe that some individuals already have a natural ability and that this trait can be further developed through reflection on experiences. Currently, we are using and developing techniques for students to enhance their emotional intelligence, for example self-assessment and reflective activities. There are a number of tools for measuring emotional intelligence. I hold a strong view that some measuring tools don’t necessarily work; we can all answer questions based on what we think is the right thing to do in emotional situations with patients, but the important thing is how we continue to display these behaviours in practice.

AD: What are your views on how we talk about cancer survivorship?

DH: I think it’s an interesting term ‘cancer survivorship’ and we are using this terminology much more in public. ⁹ However, it must be recognised that some people identify with this term and others do not. Therefore, I believe that you have to be respectful and sensitive to how people feel when using a label that is associated with them. A good guide is to see if the individual uses this term themselves, but be cautious that others may not want to have this terminology applied to them. This recognises the individuality of people and collective terms are not helpful.

We must acknowledge that across the world, there are millions of people who have survived cancer and lead normal lives. However, post diagnosis and treatment; some individuals don’t lead a normal life either through physical or mental after-effects of treatment. It is very difficult to define what we mean by ‘survivorship’, but central to this concept is each experience is different. There is a growing number of people who need some method of ongoing support to improve their lives. Currently, the emphasis is on ‘self-management’ and there are many groups available that offer support and on-line platforms have become popular. It is about the management of long term survival and educating people with the facts, the resources available are designed to help them and to emphasise that they do not have to deal with this alone.

I have just supervised a research student who is a specialist nurse and she identified the factors that can help the patient during and after treatment. The study recruited prostate cancer patients, who participated in a 6 week recovery programme post-treatment to identify the most important things that supported them. The key source of support was that from peers and they valued the ability to involve their partners in the programme. The issue of self-management was central to the study aims; however it emerged that they needed ongoing support directly from professionals to build confidence.

AD: What do you consider needs to be taken forward in the future to further enhance patient care or support?

DH: It’s all about ensuring key messages are understood by practitioners and these have to be signalled through undergraduate education. Educators need to gradually instil the belief in our future professionals that understanding patients’ need is central to care and that it varies from person to person. Professionals need to ask some very simple questions of patients to elicit their concerns. It is about developing practitioners’ skills that are transferable to any setting and having the ability to communicate in a compassionate and effective way. We must develop practitioners with the right skills and values in order to deliver high quality care. ¹⁰ We all need to demonstrate empathy and only by ‘putting yourself in another’s shoes’ can we consider what their needs may be. And only by asking, can we find out the best way to help. Patient satisfaction is closely related to the therapeutic relationship or the connection they have with the professionals they encounter. This is what the patient values and remembers, the personal contact that was good and made them comfortable, safe and a human being.Reference Thorne, Kuo, Armstrong, McPherson, Harris and Hislop ^{11 ,} Reference Turnbull and Weeley ¹²

AD: How important do you think having a high degree of altruism as a key attribute in health care practitioners?

DH: I think this is very important; altruism is one aspect of being a professional and is stated in the Standards of Proficiency for Radiographers, published by the HCPC. ⁴ The standards of proficiency (SOPs) are the threshold standards for safe and effective practice that all registrants must meet. To have a professional title requires a demonstration of specialist knowledge, a commitment to research and education, but above all, the desire to help others through your work. I would question that if you didn’t want to help others and get something rewarding out of that, then really should you be in healthcare? History has demonstrated that important attributes have evolved for the health professions, for example the issue of compassion. Particularly in the nursing profession, the literature shows that 15 years ago, compassion was not viewed as professional and a level of detachment was needed. However, in the aftermath of the Francis report,Reference Francis ¹³ the importance of demonstrating compassion has become a vital attribute for all health practitioners.

AD: How important do you think ‘culture’ is in how we deliver care?

DH: I think a good caring culture is crucial. When I worked for the Cancer Network and visited nursing homes, I remember visiting care homes that were in old buildings and required decoration, but you could feel the good atmosphere and the care and compassion received by the residents. In contrast, in some purposely built new nursing homes, the environment was very clinical with some staff not appearing to understand how to care for people. I think that a compassionate culture is something that has to develop in an organisation and is a result of good leadership and good role models.

AD: Given that technology in radiotherapy is becoming much more automated and the whole procedure more streamlined and efficient, how will education need to develop in the future?

DH: The relationship between the therapy radiographer and the patient during treatment is centred on how we can enhance their overall experience. At the outset of my career, we developed a ‘quality circle’ to enhance patient experience. One initiative was to allocate a named radiographer to a group of patients, the radiographer checked on them daily and we had our ‘primary care’ meeting each day to communicate any actions. This initiative was very successful and patients would say, ‘I have spoken to my radiographer today and she/he is going to do this for me’. This fostered a really good environment in the department and the patients felt supported. I think it also helped reduce their anxiety about the technology. It has to be recognised that the nature of the technology and what is required of the patient to undergo during treatment, should not be underestimated. Treatment has become more complex requiring longer set up and treatment times.

In terms of education I believe that both technical and caring attributes should be developed in students. Reflecting on different situations will inevitably help students improve and good role models who are both technically competent and caring can be so important for students. We need to be encouraging students to strive to improve their performance and to ask patients for feedback. ‘Do you think I have offered you enough support during your treatment and could I have done anything else’? Students who receive positive affirmations that they have made a difference to a patient’s experience will never forget that learning.

AD: Thank you very much Denyse, for your time today and for sharing an invaluable insight into your contributions to oncology and cancer education and training.