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; 2009), 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.

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). Conversely, AP is characterised by functioning at a more autonomous, independent and complex level (Acharya et al. 2009; Bolderston 2004; Harnett et al. 2019; Martino & Odle 2007), with advanced education and training (Martino & Odle 2007; Monk et al. 2013). This is in addition to working beyond traditional boundaries, which may include tasks traditionally performed by ROs (D’Alimonte et al. 2017; Harnett et al. 2014). Such practitioners are expected to be leaders, transformers and innovators (Harnett et al. 2019), both within and outside their particular roles (Coleman et al. 2014).

It is noted that other authors use AP synonymously with REx (Eddy 2006; Harnett et al. 2014), whilst others suggest that AP can have either REx or RE (Martino & Odle 2007) and others argue that it is a synthesis of both (Smith et al. 2015). This confusion appears to lie in the different definitions of REx. Demystifying this is not within the scope of this article. Moreover, REx is a seldom used term in SA radiography, compared to the more popular RE term. Nevertheless, what is clear about AP is that it incorporates the elements of RT RE as it is conceived internationally, in Africa, and most likely in SA, with high level and complex skills and characteristics. The authors recommend further debate with the aim of refining, contextualising and adopting the concept of AP, to develop APRTs who will not only alleviate ROs’ workload by taking additional tasks but will catalyse transformation within and outside their profession through innovation, and new ways of thinking and doing (Harnett et al. 2019).

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.

If the goal is to train APRTs to be transformers, a transformed and transformative curriculum is needed (Duncan et al. 2006; Frenk et al. 2010) to train transformed transformers, training them to ‘be’ and not just to ‘do’, moving beyond competency alone to form an integrated identity (Jarvis-Selinger et al. 2012). A transformed and transformative curriculum is built on the foundation of rigorously debated values, philosophies and principles (Duncan et al. 2006; Frenk et al. 2010).

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 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.

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, patient-centredness, 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?

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), professional boundaries (D’Alimonte et al. 2017; Harnett et al. 2014), territorialism (Harnett et al. 2014), ethico-legal issues (Acharya et al. 2009; Eddy 2006; Monk et al. 2013), resources and remuneration (Coleman et al. 2014; Kyei & Engel-Hills 2011), lack of training capacity (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.

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 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 work-integrated learning (WIL) programme, with an inter-professional 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). In Canada (D’Alimonte et al. 2017) and Australia (Acharya et al. 2009; Matthews et al. 2014), ROs mentored and successfully provided supervision, advanced technical and clinical training to trainees. Matthews et al. (2014) describe how the university taught the theory, whilst ROs mentored and assessed at clinical training sites. This shared curriculum was further supported by clinical facilitators who liaised with the different stakeholders, and an online system where all participants could engage. Locally, WIL is not new as current RT undergraduate programmes employ this approach, and the use of clinical facilitators is common.

Potential gains are that this offering would be in line with the global shift towards inter-professional education (IPE) (McKimm 2007) and can assist in developing inter-professional collaboration and communication, an important characteristic of an APRT and a PHC philosophy principle. Moreover, IPE has been a catalyst for change in modern healthcare (Academy of Science of South Africa 2018). However, this offering will have to be explored with local practicalities in mind. Such practicalities include the fact that in SA, most RT and RO academic training takes place at different types of institutions, for example, out of four institutions that offer RTs training, only one of them also offers ROs training. Moreover, there is a shortage of ROs, who are already responsible for training RO registrars and might not be able to accommodate additional training responsibilities.

The shift to the use of IPE could also consider training collaboration with the nursing profession that already has the AP in the form of ONs. Oncology Nurses curricula include training outcomes that could benefit training of RTs for advanced roles. For example, ON curricula offered within SA include learning outcomes associated with managerial strategies and technologies in an oncology healthcare environment, principles of research in oncology, counselling, etc. Currently, there are at least four universities in SA that offer ON training (Nursing 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).

Lastly, both the curricula (Marsh 2009) and APRT (Eddy 2006; Matthews et al. 2014) are constantly changing and 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.