Preparing for advanced practice radiation therapy in South Africa: Conceptual and curricular considerations

The higher education landscape in South Africa has recently changed with the new National Qualifications Framework, leading to the introduction of four-year degrees in all four radiography disciplines. Additionally, there have been developments in the extension of roles in radiography, while the need for interdisciplinary practice has also been emphasised. The Professional Board for Radiography and Clinical Technology (PBRCT) of the Health Professions Council of South Africa is currently revising the scope of the profession which will now include extended roles. However, the extended role concept in radiation therapy has not received the attention similar to Diagnostic/Medical Imaging. The aim of this paper is, therefore, to provide concept clarification and key considerations for developing a postgraduate curricular framework for training radiation therapists to practise in the envisaged extended roles. For this narrative review, a Boolean search for advanced practice and role extension in radiation therapy was done on all databases (43) available on EbscoHost to source for peer-reviewed articles published between January 1950 and September 2020. A total of 17 articles met the inclusion criteria and were used to frame the discussion. Advanced practice emerged as the more suitable concept as it goes beyond an extension of tasks to include critical characteristics that are necessary to drive transformation in the local social, professional and educational arenas. It is envisaged that some of the key points discussed in this paper could assist the PBRCT in thinking about the implementation of the proposed extended roles for radiation therapists in South Africa.


Introduction
Radiography education in South Africa (SA) has evolved in the last few years with a focus to have all disciplines of radiography (Diagnostic/Medical Imaging, Nuclear Medicine Technology, Radiation Therapy [RT], and Ultrasound) offered at undergraduate level. Previously, it was mainly medical imaging that was offered at the undergraduate level with the other disciplines available as post-basic qualifications.
Radiation Therapy remains one of the key cancer treatment modalities (Ndlovu 2019) whilst it is estimated that 52% of all cancer patients can benefit from RT (Baskar et al. 2012;Duxbury 2015). However, there is widespread shortage of radiation therapists (RTs) across public cancer treatment centres in SA, and this has a significant bearing on service delivery. This, combined with other factors, has resulted in increased workload for available staff and unacceptable RT waiting times in certain centres (Department of Health 2017). The World Health Organization (WHO) recommends 'task shifting' as one of the strategies to tackle staff shortages in health (Harnett et al. 2019). The core of this strategy is to enable healthcare professionals to work beyond their traditional roles (Eddy 2006). Several stakeholders have reported implementing this strategy in response to increasing cancer burden, RT staff shortages and long waiting times (Acharya et al. 2013;Bolderston 2004;Coleman et al. 2014;Eddy 2006;Harnett et al. 2014Harnett et al. , 2019Monk et al. 2013).
Simultaneously, there have been developments in the scope of practice in radiography which have led to altered roles and responsibilities (The College of Radiographers 2003). These changes seem to be because of role extension (RE) and advances in technology. Hardy (undated) defines RE as a post-qualification acquisition of skills, responsibilities and resultant additional professional accountability. Advanced practice (AP) is another concept associated with RE and The higher education landscape in South Africa has recently changed with the new National Qualifications Framework, leading to the introduction of four-year degrees in all four radiography disciplines. Additionally, there have been developments in the extension of roles in radiography, while the need for interdisciplinary practice has also been emphasised. The Professional Board for Radiography and Clinical Technology (PBRCT) of the Health Professions Council of South Africa is currently revising the scope of the profession which will now include extended roles. However, the extended role concept in radiation therapy has not received the attention similar to Diagnostic/Medical Imaging. The aim of this paper is, therefore, to provide concept clarification and key considerations for developing a postgraduate curricular framework for training radiation therapists to practise in the envisaged extended roles. For this narrative review, a Boolean search for advanced practice and role extension in radiation therapy was done on all databases (43) available on EbscoHost to source for peerreviewed articles published between January 1950 and September 2020. A total of 17 articles met the inclusion criteria and were used to frame the discussion. Advanced practice emerged as the more suitable concept as it goes beyond an extension of tasks to include critical characteristics that are necessary to drive transformation in the local social, professional and educational arenas. It is envisaged that some of the key points discussed in this paper could assist the PBRCT in thinking about the implementation of the proposed extended roles for radiation therapists in South Africa.
Keywords: curriculum; radiation therapy; training; advanced practice; role extension.

Preparing for advanced practice radiation therapy in South Africa: Conceptual and curricular considerations
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In SA, the Professional Board for Radiography and Clinical Technology (PBRCT) of the Health Professions Council of South Africa (HPCSA) (Department of Health 2020) has drafted a new scope of the profession of radiography, including RT. The recommended scope will allow appropriately trained RTs to undertake roles that were traditionally not performed by them. Whilst processes to approve this scope continue, it is beneficial to discuss how these roles will be developed and implemented. Most radiography-related task-shifting discussions in SA have been in medical imaging, with the concept of RE dominating these discussions (Gqweta 2015;Koch et al. 2017;Munro et al. 2012;Williams 2006;. Internationally, there is paucity of literature on task shifting or RE in RT, a situation not dissimilar to SA. The aim of this article as a way to contribute to the narrative of RE in RT, especially in the SA context, is twofold: (1) concept clarification, by comparing the concepts of RE and AP, as conceived in RT literature.
(2) key considerations for developing a postgraduate curricular framework for training RTs to practise in the envisaged roles.

Methods
Although the authors borrowed some of the processes of a systematic review (SR), this article is fundamentally a narrative review (NR). Systematic reviews are different from NRs in that they are based on evidence from systematic and comprehensive literature searches in all available resources and minimise selection bias (Pae 2015).
Nonetheless, the quality of NRs can be improved by using effective search strategies and some of the processes of a SR aimed at reducing selection bias (Ferrari 2015), as was the case in this project.
A Boolean search was done on all databases (43) available on EbscoHost. The terms 'advanced practice radiation therapy (APRT)' OR 'AP radiotherapy' OR 'RT RE' OR 'radiotherapy RE' were used to source for peer-reviewed full-text articles available online and published between January 1950 and September 2020. The expanders were set to 'apply related words', 'apply equivalent subjects' and 'also search within the full text of the articles'. The search resulted in 37 articles that were included for potential review.
A second search for the same terms was done on Google Scholar. The search was set to find articles 'with all of the words' in the title, published between 1950 and 2020, including patents and citations. The search yielded 51 articles included for potential review, resulting in a total of 88 articles for potential review. Title and abstract scanning and full-text skimming were done using inclusion criteria, and duplicates were removed. After this, a total of 9 articles were included for review. The inclusion criteria were that articles must be full-text, peer-reviewed, available online, published in English, and should discuss some form of 'task shifting' in RT.
To actively find work done locally, individual journal searches were done on the South African Radiographer, African Journal of Health Professions Education and Health SA Gesondheid, using the terms 'AP' OR 'RE' OR 'radiotherapy' OR 'RT', separately. The searches yielded 132 articles but only 1 was included for review after applying the inclusion criteria and removing duplicates, resulting in a total of 10 articles for review.
A manual search was done on the reference lists of the 10 articles, this process resulted in 5 additional articles, and was repeated until no new articles were found on reference lists of all articles. Lastly, 2 handpicked articles were added to the pool and a final total of 17 articles were included in the review.

Ethical considerations
This article followed all ethical standards for research without direct contact with human or animal subjects.

Results
Articles reviewed were published from 2004 to 2020. Advanced practice appears to be the most popular term with 12 articles (70.6%) discussing AP, either alone or with other concepts, whilst RE was discussed in only 2 articles (16.7%). The search focused on AP and RE, but concepts of role development (RD) (2 articles) and role expansion (REx) (2 articles) were noted as they emerged in the literature reviewed. Although the United Kingdom (UK) is generally known to have taken a lead in AP and RE work (Monk et al. 2013), most articles (7) were from Australia, followed by Canada (4). Despite additional efforts to find literature published locally, only 1 article was from Africa and none from SA. A summary of these results is presented in Table 1.

Discussion
The authors aim to present a discussion by exploring the concepts of RE and AP in RT, and related curricular issues, with an emphasis on the SA context.

Concept clarification and role definition: Is there still a need?
In SA, the task-shifting discourse is unfolding in the form of RE discussions. Although the need for RE for RTs in SA has been recognised (Lawrence et al. 2011), most discussions are taking place in the medical imaging space (Gqweta 2015;Koch et al. 2017;Munro et al. 2012;Williams 2006;. Moreover, there seems to be no deliberate intentions to define or clarify the concepts of AP and RE in these discussions. A possible reason for this is that unlike internationally where multiple terms are used and potentially cause confusion (Smith et al. 2015), the term RE dominates the task-shifting discourse in SA radiography.
Despite earlier attempts to offer some clarity on the concepts of RE and AP (Hardy & Snaith 2006) unclarity (Matthews et al. 2014) and confusion (Harnett et al. 2014). It is, therefore, important to attempt to clarify and contextualise these two concepts, that is, RE and AP.  Eddy (2006) defines RE in RT as the inclusion of a skill or practice area which was previously not part of a typical RTs role. Notably, the included skill or practice area may have been, traditionally, within the role of another profession (Eddy 2006;Martino & Odle 2007;White et al. 2005). This is congruent with the conception of RE by Kyei and Engel-Hills (2011), who studied the possibility of extending the role of RTs in Ghana to include pain assessment, a function typically performed by radiation oncologists (ROs). This also appears to be the way RE is conceived in medical imaging in SA (Gqweta 2015;Koch et al. 2017;Munro et al. 2012;Williams 2006;, and can possibly be interpreted to be the same for RTs in SA, because of the proximity of the disciplines and especially considering that the four new RT extended roles in the PBRCT proposed scope of the profession are traditionally within the scope of ROs and to some degree, the scope of Oncology Nurses (ONs). These roles are: (1) control and administration of contrast media, (2) approval of portal verification images, (3) counselling of patients and their families and (4) on treatment patients review.

Advanced practice
It is argued that RE as currently conceived happens in a 'very practical and skills-based way' (Harnett et al. 2019), and it is mostly based on delegated tasks (from one profession to the other), which are executed following well-defined protocols (Eddy 2006

Curricular considerations
Education and training significantly impact AP roles as AP revolves around roles that involve new skills (D'Alimonte et al. 2017;Hilder et al. 2013). In the SA context, the PBRCT has set the tone by proposing that extended roles must be preceded by an approved postgraduate qualification whilst noting that there is no prescription of the National Qualifications Framework (NQF) level at which such a qualification must be pitched. Below, the authors discuss some of the fundamental considerations in designing such curricula for SA.

The foundation: Philosophies and values
As discussed, and like RE, APRT responds to professional, political and societal needs (Bolderston 2004), but goes further to incorporate critical and high-level characteristics such as leadership, innovation and transformation. Consequently, APRT seems to be better positioned to respond to the need for and aid efforts towards transformation at the multiple local arenas than RE.

Programme level
Internationally, all AP articles reviewed (12) agree that some formal education is necessary to prepare RTs for AP. In SA, the PBRCT recommends that this training should be at a postgraduate level. However, the question remains, what type of qualification would this be? An international trend is that a master's degree is appropriate for preparing RTs for AP (Bolderston 2004;Coleman et al. 2014;Eddy 2006;Martino & Odle 2007;Matthews et al. 2014;Smith et al. 2015). Matthews et al. (2014) particularly recommend a coursework master's degree. In SA, a master's degree programme at NQF level 9 appears to be an appropriate vertical articulation as the current minimum undergraduate RT training's exit level is NQF 8. However, the PBRCT is considering having training for the extended roles offered below a master's degree level to avoid exclusion of professionals who may only be in possession of the old NQF level 6/7 qualifications.
Horizontal articulation by means of a postgraduate diploma (NQF 8) might seem to be another option. However, according to the national Department of Higher Education and Training (DHET), the postgraduate diploma's primary purpose is to prepare graduates for highly skilled work by enabling them to 'undertake advanced reflection and development by means of a systematic survey of current thinking, practice and research methods in an area of specialisation' (DHET 2013). Based on this description, the https://www.hsag.co.za Open Access postgraduate diploma might be suitable for preparing graduates for RE but not for AP because it does not aim to develop key characteristics of the innovative and transformative leader, which form the foundation of APRT as conceived internationally and contextualised nationally. A master's degree seems to be a better option as it aims to develop self-directed, original and autonomous graduates who can deal with complex issues in a systematic and creative way (DHET 2013). Nonetheless, stakeholders need to think of ways to ensure that graduates holding the old qualifications have access to the programmes that will be developed. A possible consideration could be to pitch such a programme at level 9 and accommodate those with old NQF levels 6/7 through the recognition of prior learning route or a bridging course.

Environment
The environment within which the curriculum unfolds is inextricably linked to the curriculum and is as complex as the curriculum is. This environment includes institutional culture and traditions, people, values, curricular elements and how all these interplay, amongst other things (Genn 2001). Some of the characteristics of a desirable environment include non-hierarchal and non-patriarchal structures and relationships, non-discriminatory policies and processes, interprofessionalism, social justice, gender equity, empowerment, student-centredness, patientcentredness, ethics and enhancement of well-being (Barnes 2007;Genn 2001;Lehmann et al. 2018;McKimm 2007). These must be both taught and lived (Lehmann et al. 2018). It is, therefore, important that stakeholders consider the environment when planning the curriculum, to ensure constructive alignment and minimise the hidden curriculum (unwritten, unofficial and often unintended lessons) (Marsh 2009). Matthews et al.'s (2014) successful pilot of the APRT curriculum employed stakeholder groups throughout development and implementation. The need for an open dialogue between stakeholders when developing APRT roles and curriculum has also been highlighted by others (Coleman et al. 2014;D'Alimonte et al. 2017;Eddy 2006;Hilder et al. 2013). This is especially important considering that the proposed roles currently fall within the scope of other professions. However, it must also be noted that stakeholders are more than just members of the multidisciplinary team, and other stakeholders, including patients (Harnett et al. 2014), should be consulted using appropriate methods, for the relevant stages of curriculum development. This approach resonates with the primary healthcare (PHC) principles of participation of all, multidisciplinarity and involvement of all service providers (Alperstein 2009). It is also aligned with Beane's (2001) (as cited by Marsh 2009) conception of a curriculum, which involves many groups and decision-making at various levels, amongst other things. However, a fundamental question remains, who are the stakeholders in the SA context?

Stakeholder engagement
In considering the stakeholders, the challenges experienced in developing AP and RE in other countries should be considered, and these include medical dominance (Bolderston 2004;White et al. 2005 (Hilder et al. 2013) and management and service restructuring (Hilder et al. 2013;Kyei & Engel-Hills 2011). Considering these challenges, it would seem justifiable to have the multidisciplinary team (RTs, ROs, medical physicists and ONs), health authorities (Department of Health) and regulators (PBRCT), other policymakers (DHET, Department of Employment and Labour), hospital and academic managers, professional bodies and patients as part of the essential stakeholders. This kind of multidisciplinary and multisectoral engagement might assist in navigating some of these challenges.

Teaching, learning and assessment
Traditionally, RTs' training has a strong focus on skills development, aligning with the skills-based nature of the profession. However, there is currently a paradigm shift to training that develops life-long learners. In the SA context, this has been seen with the move to the four-year degree which allows the students to do courses that are beyond the development of clinical skills and now includes courses like research (methodology and project), health education, imaging informatics and management as part of their undergraduate training. This move harmonises well with the principles of APRT.
Advanced practice radiation therapy aims to develop highly skilled professionals who function with more autonomy (Bolderston 2004;Eddy 2006;Harnett et al. 2019;Martino & Odle 2007;Matthews et al. 2014), responsibility and accountability (Acharya et al. 2009;Eddy 2006), more decision-making power and independence (Martino & Odle 2007), who will collaborate with the inter-professional team (D'Alimonte et al. 2017) with professional confidence (Bolderston 2004). It will take more than just a fine selection of content to develop such attributes and characteristics, it will require appropriate pedagogies. It is, therefore, important that when designing the APRT curricula pedagogies are carefully selected, influenced by appropriate learning theories (McKimm 2007). One such learning theory is social constructivism which considers students to be co-constructors of knowledge, where both teachers and students constantly switch positions to facilitate learning (Roth & Radford, as cited in Barker et al. 2015). This type of relationship appears to be conducive to boosting the confidence and collaboration skills of RT students. DasGupta et al. (2006) further argue that non-hierarchical teacher-learner relationships can be translated to professional-patient relationships.
In line with trends in health professions education, more student-centred and active learning methods should be considered for these curricula (McKimm 2007). Such methods' emphasis on students taking responsibility for their own learning can assist with training more responsible professionals (Harden et al. 1984), a necessary characteristic for APRT. Furthermore, such methods must consider assessment as an important element of the curriculum that is sometimes argued to drive learning (Hift 2014;O'Sullivan et al. 2012). Curricula planners need to carefully choose appropriate methods for assessing the intended competencies for APRT (Epstein 2007;Hift 2014;Schuwirth & Van der Vleuten 2018).
Although the selection of assessment tasks will depend on a clearer and agreed upon role definition and associated competencies, the use of a high stake and all-summative assessment programme should be avoided. However, considering that the qualification will lead to some form of licensure and therefore high stakes assessment tasks cannot be totally avoided, the authors propose a balance of high, medium and low stakes assessments, with both summative and formative tasks and high-quality feedback. This can assist with balancing between educational impact and community or employer confidence.

Resources
Resources are an important curricular element; they shape how curricula are planned and enacted (Matthews et al. 2014). Coleman et al. (2014 further report that resources were one of the barriers to implementing APRT roles. Although there are many, one resource factor to consider is expertise, in the form of staff. The question of who will train APRTs, a seemingly controversial debate (Eddy 2006), is particularly significant because some of the tasks that will form part of the envisaged roles belong to other professions.
Based on (1) international trends, (2) SA's existing undergraduate RTs, ROs and ONs specialist training programmes and (3) alignment with the identified philosophical underpinnings, the authors propose a workintegrated learning (WIL) programme, with an interprofessional approach, facilitated by ROs, ONs and expert RTs (for some AP areas, expert RTs may not be initially available). These three factors are briefly discussed below.
An international trend is the use of a WIL approach (Matthews et al. 2014 24 2020). Oncology Nurses clinical facilitators and educators can, therefore, play a crucial role in IPE for shared competencies, especially in allying for the competencies aligned to the extended roles that the PBRCT is considering for implementation. Another consideration to overcome the physical space and resources challenge would be the use of blended learning, which will also increase access by accommodating working professionals who reside far from academic institutions. A number of blended learning programmes have been successfully implemented in SA.
The clinical training component can be led by the respective clinical sites, with ROs providing supervision, RT and ON clinical facilitators providing necessary support. This model has seen success in six Australian centres (Matthews et al. 2014). Moreover, some elements of clinical training can be incorporated into the existing clinical training of RO registrars, to avoid ROs doubling up on work, also considering that tasks (skills) that form part of the proposed extended scope of RTs fall within the remit of ROs and form part of RO registrar training. According to Abratt (2018), there is a relative shortage of ROs in SA and 79.5% (147) of all the country's ROs are in the private sector. For the proposed model of involving the ROs in RTs training, it would be beneficial to expand the training to include the ROs who are in the private sector. Moreover, there seems to be willingness for such a discussion amongst ROs in SA (Abratt 2018).

Programme monitoring and evaluation
Lastly, both the curricula (Marsh 2009) and APRT (Eddy 2006;Matthews et al. 2014) are constantly changing and https://www.hsag.co.za Open Access developing. Therefore, a postgraduate curriculum that is designed to train RTs in AP will need robust monitoring and evaluation mechanisms, to ensure that it remains effective and relevant. Such a review and revision should be based on stakeholder engagements. However, the list of stakeholders needed at this level is not as extended as the one for the initial role development and curriculum design. At this level, essential stakeholders can include students, teachers, academic managers, authorities, service managers and health regulators (McKimm 2007), aligned to the Council on Higher Education (CHE) processes.
Based on the above discussion and recommendations, four broad questions (Figure 1) are put forward to facilitate the debate on the design and development of the needed curricula.

Conclusion
This article has explored the concepts of RE and AP as they relate to RT. Advanced practice appears to be the more suitable concept as it goes beyond an extension of tasks, to include critical characteristics that are necessary to drive transformation in the local social, professional and educational arenas. Some fundamental questions that should be considered in designing postgraduate curricula to train SA RTs in AP were also explored. The key points discussed in this article could be instrumental in assisting the PBRCT in strategising and implementing the envisaged RE or AP for RTs in SA.

Limitations
Although the applied NR approach intentionally aimed to avoid bias that can be associated with NR, this review was not a SR.