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Training radiographers to deliver an intervention to promote early presentation of breast cancer
Radiography 18 (2012) 232e237
Contents lists available at SciVerse ScienceDirect
Radiography journal homepage: www.elsevier.com/locate/radi
Training radiographers to deliver an intervention to promote early presentation of breast cancer Caroline Burgess a, *, Emma Teasdale b, Lynne Omar c, Lorraine Tucker d, Amanda-Jane Ramirez d a
Kings College London, UK University of Southampton, UK c South Bank University, UK d Institute of Psychiatry, King’s College London, UK b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 16 February 2012 Received in revised form 9 May 2012 Accepted 24 June 2012 Available online 7 July 2012
Aim: To evaluate the feasibility of training sufficient radiographers to deliver an intervention to promote early presentation of breast cancer to all older women attending for their final routine mammogram within the NHS Breast Screening Programme. If the Promoting Early Presentation (PEP) intervention is demonstrated to be cost-effective, it may be implemented across the NHS requiring at least four radiographers per screening service to deliver the intervention. Methods: A pilot study in a single breast screening service was conducted to assess the feasibility of training sufficient radiographers to meet this objective. Quantitative and qualitative methods were used to evaluate the impact of training on participating radiographers and the screening service. Competency to deliver the intervention was assessed at key points during training according to quality criteria based on delivery of the key messages and style of delivery. Confidence to deliver the intervention was assessed using a self-report measure before and after training. Radiographers’ experiences of training were elicited in face-to-face qualitative interviews. Results: Seven of eight radiographers who were released to undertake the training achieved the required level of competency to deliver the intervention within four months. All improved over time in their confidence to deliver the key messages of the intervention. The qualitative analysis revealed the benefits and challenges of training from the perspective of the radiographers. Conclusion: It was feasible and acceptable to train sufficient radiographers to deliver the PEP Intervention. The training package will be streamlined to improve efficiency for large implementation trials and clinical practice across the NHS. Ó 2012 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Keywords: Breast cancer Promoting early presentation Health promotion Radiographer training
Introduction Women in the United Kingdom have poorer survival from breast cancer than many other Western European countries1 and differences in stage of diagnosis are largely responsible.2 Late stage at diagnosis is almost certainly due to late presentation by some women and delays in onward referral by some general practitioners. Risk factors for delay in presentation of breast cancer include older age, less education and presenting with non-lump symptoms.3 Older women have particularly poor knowledge of non-lump symptoms and of the increase in breast cancer risk with
* Corresponding author. Department of Primary Care & Public Health Sciences, Kings College London, Capital House, Weston Street, London SE1 3QD, UK. Tel.: þ44 (0) 20 7848 8750. E-mail address: [email protected] (C. Burgess).
age.4 About 20% of older women report that they never look at or feel their breasts.5 Older women present with more advanced disease, and have much higher short term mortality rates than younger women.6 An intervention has been developed to equip older women with breast cancer awareness, in other words, the knowledge, confidence, motivation and skills to present promptly to primary care on discovering breast cancer symptoms.7 A randomized controlled trial of this intervention was conducted with women attending for their final routine mammogram at age 67e70 years on the UK National Health Service Breast Screening Programme. At one and two years follow-up, the Promoting Early Presentation (PEP) Intervention increased the proportion of women who were breast cancer aware more than any other intervention of its kind.8e10 If the PEP Intervention proves to be cost-effective it may be implemented across the NHS Breast Screening Programme. The majority (over 70%) of older women (67e70 years of age) attends
1078-8174/$ e see front matter Ó 2012 The College of Radiographers. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.radi.2012.06.003
C. Burgess et al. / Radiography 18 (2012) 232e237
for their final invited mammogram (BSP, 2008). Diagnostic radiographers and assistant practitioners (both groups hereafter referred to as “radiographers”), as the front-line NHS staff conducting breast screening, would be appropriately placed to deliver this intervention. The feasibility in principle of training a small number of radiographers working within the NHS Breast Screening Programme has been demonstrated,11 but there remains the challenge of training sufficient numbers of radiographers to offer the intervention effectively to all older women attending breast screening. There are 80 screening units across the UK each inviting a defined population of eligible women through their general practices. The average breast screening service invites approximately 3000 women per year for their final invited mammogram. In order to deliver the intervention effectively to all women attending for their final invited mammogram in routine clinical practice, at least four radiographers per breast screening service would be required, taking account of attrition and cover for leave. This paper reports the results of a pilot study in one breast screening service to assess the feasibility of training the required number of radiographers to deliver the intervention to all women receiving their final invited mammogram. The impact of the training on both the participating radiographers and the NHS Breast Screening Programme was assessed. If successful, this method could provide a model for training radiographers to deliver the intervention for implementation across the NHS Breast Screening Programme. The study was approved by Lewisham Local Research Ethics Committee 2008 (08/H0810/59). Methods Study design A pilot study was conducted, using mixed methods, to assess the feasibility of training the required number of radiographers in one breast screening service. Assessment was made of the number of radiographers volunteering for training, the number able to be released for training, and the time for radiographers to complete training. The impact of being trained on the competence and confidence of radiographers to deliver the intervention was assessed at key time points during the training process. Radiographers’ perceptions and experiences both of training and delivering the intervention were assessed using qualitative interview methods. Participants Expressions of interest were sought from all radiographers working in one breast screening service (N ¼ 25). All qualified radiographers working in the service were eligible to participate in the study. Signed consent was obtained from participants prior to the start of training. Older women with forthcoming appointments for their final invited mammogram were identified by the breast screening service and sent an invitation letter and information sheet about the study. Signed consent to receive video-recorded practice interventions from the radiographers in training was obtained when women attended for their appointments. Participants were assured that all video-recordings would be deleted upon completion of the study.
mammogram. The script covers the symptoms of breast cancer, the increased risk of developing breast cancer with increasing age, rehearsal of the skills required to check for breast changes and what women should do if they discover a breast change. Training to deliver the intervention Training methods were based on evidence of effective training techniques for health professionals to deliver psychological interventions. 12e16 The training package was refined from an earlier study of the feasibility of training radiographers to deliver the intervention.11 Training was delivered locally in the breast screening service and comprised two formal training days, separated by 4 weeks to learn the intervention “script” and for rehearsal of skills. Practice interventions were undertaken, initially with colleagues, and then “in vivo” with women attending breast screening clinics. An intervention manual was developed, which included instructions for intervention delivery and a scripted schedule to support accurate delivery of the health messages within the 10-min time-frame. Evidence suggests that having a detailed manual or protocol supports training and improves adherence.16 Active participatory methods were used in training, including skills rehearsal and constructive feedback. The two formal training days included interactive teaching sessions with video demonstration, group exercises in information and communication skills, constructive feedback on video-recorded role-play and practice interventions with women attending screening. In addition to the formal training days conducted by trained communication skills facilitators, regular one-to-one performance feedback was provided in the breast screening clinics throughout the training period by two “coaches” who were research radiographers already trained and experienced in delivering the intervention. Coaches provided immediate performance feedback on the practice interventions in clinics so that radiographers could build on their skills after each intervention. Radiographers were trained to video-record their practice interventions to enable assessment of quality and performance feedback. Competence to deliver the intervention was examined according to a quality checklist for content of the key health messages of the intervention (see Box 1). The checklist also
Box 1. Domains of content and style of delivery assessed by quality checklist Content of the intervention 1. 2. 3. 4. 5. 6.
Introduces and explains purpose of intervention Explains risk of developing breast cancer Describes 11 breast cancer symptoms Discusses breast awareness Delivers key message to see GP with any breast chances Promotes disclosure of breast change to close friend or relative 7. Encourages participant to make action plan 8. Summarises main points of intervention 9. Delivers debrief and invites queries Style of delivery of the intervention
The PEP intervention The PEP Intervention is a scripted 10-min one-to-one interaction between a radiographer and the woman, supported by a booklet, delivered after the woman has received her
233
10. Clear 11. Collaborative 12. Motivating.
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assessed the extent to which the intervention was delivered in a style that was clear, collaborative and motivating. Descriptors were developed for rating delivery style in order to promote reliability between those rating the quality of intervention. Outcomes (i) Acceptability of training to the breast screening service The number of radiographers who expressed an interest in being trained was assessed as well as the number that could be released from their regular NHS work to attend training. Measurement was made of the amount of time required for each radiographer to achieve the required level of competency in order to assess the impact of training on the breast screening service. Feedback was obtained from senior staff regarding the logistics of accommodating the training into the normal running of the service.
Results Acceptability to the breast screening service The majority of radiographers (88%, n ¼ 22/25) employed in the breast screening service expressed an interest in being trained to deliver the intervention. The service was able to release eight radiographers from their regular NHS work to take up the training. One radiographer later withdrew from training for personal reasons. It was feasible for those undertaking training to be covered for their regular NHS work. Staff cover was required for the two formal training days and 8 h of coaching time per radiographer (on average) to rehearse the intervention with colleagues and women attending breast screening clinics. Senior staff managing the screening service reported that the logistics of organizing sufficient time for training was feasible and acceptable for this number of radiographers. Routine clinical practice was not disrupted during the training period.
(ii) Competence to deliver the intervention The main outcome was the number of radiographers achieving the required level of competence to deliver the intervention within two months of the start of training. The aim was to achieve the outcome within a two-month time-frame in order to minimise disruption to the normal running of the breast screening service during the training period. Two months was judged to be a realistic time-frame based on earlier experience of training radiographers to deliver the intervention, allowing the service to allocate sufficient time for skills rehearsal outside normal clinic hours.11 Competence to deliver the intervention was assessed according to a 12-item quality checklist covering 9 content domains and 3 style domains. Adherence of 100% was expected to four key health messages and 75% for each style item (clear, collaborative, motivating). In the current study, competence to deliver the intervention was assessed at 1, 2, 3 and 4 months after the start of training. At each monthly assessment, randomly selected video-recorded interventions for each participant were assessed for competency by one of the training facilitators. (iii) Confidence to deliver the key messages of the intervention Confidence to deliver the key health promoting messages of the intervention was assessed on the first formal training day and at two months using a self-report questionnaire. Confidence items were scored from very confident (10) to not at all (1) and included confidence to: inform older women about the symptoms of breast cancer, explain absolute and relative risk of developing breast cancer, advise women how to be breast aware, encourage women to present immediately when they discover a breast change, discuss the advantages of early treatment for breast cancer, deliver health-promoting messages in a positive and motivating way and respond to signs of distress in women receiving information about breast cancer. (iv) Participant perceptions of training and delivering the intervention Radiographers’ experiences and views of training were elicited using semi-structured interviews 4 months after the start of training. An interview schedule was developed to elicit the radiographers’ experiences of the training days and coaching process, and the impact of being trained in terms of benefits and challenges. Interviews were conducted by a member of the research team who was not involved in the training, audio-recorded, with the participant’s permission, and fully transcribed. A simple thematic analysis of the responses was conducted.
Competence to deliver the intervention The mean number of interventions conducted with women attending screening for each radiographer during training was 8.57 (range 5e14). Assessments of competence to deliver the intervention to women attending screening were conducted at months 1, 2, 3 and 4 during training (Fig. 1). Baseline competence for delivering the content of the intervention was higher than that for style of delivery. It was more challenging during training for radiographers to achieve the minimum cut-off (75%) for delivery style than it was to achieve 100% for adherence to the content of key messages. All seven radiographers achieved competency to deliver the intervention as defined by our quality criteria for content and style of delivery. Four of these achieved competence within two months; the remaining three were assessed as competent to deliver the intervention within four months of the start of training. Reasons for variation in time to achieve competence included gaps in training due to radiographers having annual leave, absence due to illness and other work and training commitments. Confidence to deliver the key messages of the intervention Changes in confidence to deliver the key messages of the intervention over time are illustrated in Fig. 2. All radiographers who completed the training increased their confidence to deliver the health-promoting messages. Prior to training, radiographers were fairly confident about advising older women to present to the GP immediately with a breast change (mean ¼ 7.3, SD1.0) although less confident about delivering more complex health messages such as older women’s risk of developing breast cancer (mean ¼ 5.3, SD1.2). Responding to emotionally challenging situations such as women becoming distressed about breast cancer elicited the least confidence at baseline (mean ¼ 4.6, SD1.1). After two months of training, radiographers remained most confident about promoting early presentation of breast cancer (mean ¼ 9.9, SD0.4) and confidence to deliver the other key messages improved considerably. Confidence to respond to signs of emotional distress in women also improved slightly but remained the area where radiographers felt least confident (mean ¼ 7.4, SD1.9). Participant perceptions of training and delivering the intervention Interviews were conducted with all seven radiographers who completed training. Their responses are summarised under three subheadings: experiences of being trained to deliver the
C. Burgess et al. / Radiography 18 (2012) 232e237
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Competency threshold for content
100
75
50 Month 1
Month 2
Month 3
Month 4
100
90
80
Competency threshold for style
70
60
50 Month 1
Month 2
Month 3
Month 4
Figure 1. Progress by individual radiographers in achieving competency in content and style to deliver the intervention over time. Percentage competency scores for content of the intervention over time for individual radiographers. Percentage competency scores for style of delivery of the intervention over time for individual radiographers.
intervention, perceived benefits of being trained, and the challenges experienced during training and delivering the intervention. Experiences of being trained The formal training days and one-to-one coaching were received very positively by the radiographers: “I think the training days were excellent. I think the trainers were excellent. They were very professional, got to know us all individually.” (Participant 1) “It gave a great overview of what was expected from us. It was a lot of information but it was all documented and we had our little files” (Participant 2) “I really enjoyed the whole way it was set up. I could see from the background how they’d gone down the path they had gone down” (Participant 7) Video-recording their own practice interventions was reported as feasible and acceptable by the radiographers. The experience of receiving constructive performance feedback from the two trained and experienced radiographers was described as encouraging, balanced (i.e. highlighted both what was going well and not so well) and helpful in improving their skills to deliver the intervention. “Everytime you see a (video-recorded) intervention you learn something more about your own delivery, your own way of communicating.” (Participant 5)
“They were very enthusiastic, very encouraging. Even if you hadn’t done so well, they were encouraging” (Participant 6) Benefits of being trained Radiographers reported an increase in their own breast cancer awareness as a result of undertaking the training. This increased their confidence to impart the health messages not only to women targeted to receive the intervention but also to other women attending breast screening who did not receive the intervention. Specifically, radiographers reported that since being trained they tended to convey more detailed information about breast cancer risk, symptoms and importance of early presentation to women attending for their final invited mammogram. They also felt more able and confident to answer common queries raised by women attending screening: “Sometimes you get the opportunity to feed in some of the information from the intervention to women (attending screening) and that can be helpful.” (Participant 3) “It has changed, to a certain extent, my interaction with ladies, especially on the mobile units. Although I don’t get a lot of time I am quite aware of trying to tell older ladies, more so now, that yes, this is what you can do and this is your risk and you should continue with screening.” (Participant 6) They also reported that their learning had been passed on to the other radiographers within the breast screening service:
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C. Burgess et al. / Radiography 18 (2012) 232e237
Very 10
9
Mean Confidence Score
8 7 6 5 4
Pre-training Post-training
3 2 1
Not at all
0
s sk ms ice GP ent tyle tres g ri pto adv gs the atm dis n inin e s i ym o h r t a s t t t s l g wi ne tiva on rly Exp ibin are ing tati mo f ea scr eal sen t aw so na D t i s e i De f r a n e p en bre ntio ng gb ing agi rve our ssin lain inte c u p g n c x E E rin Dis live De
Confidence to deliver key messages Figure 2. Mean scores for confidence to deliver key messages of the intervention before and after the two formal training days.
“I think the knock on-effect is that staff within the department are also more aware about breast cancer and older ladies. When you talk to your colleagues the general knowledge raises a little bit.” (Participant 5) Challenges of training Although many benefits and positive aspects of training were reported, a recurrent theme of the interviews was the challenge posed by having to learn and adhere to the scripted schedule for the intervention. Some radiographers had not anticipated the amount of time required in learning and developing their skills to deliver the intervention. “If your memory is not that good, that was quite hard going. I wouldn’t say I ever got it 100% actually.” (participant 2) “Having to learn the intervention because it was fairly prescriptive; knowing that we had to get across all these points” (participant 6) Obtaining time for learning and rehearsing the script was difficult for some radiographers because of competing demands both at work and home. Some reported that pressure on radiographer capacity in the screening service impacted on their opportunities to conduct pilot interventions with women in clinics resulting in lack of continuity in training. “Thinking back to the beginning the problem we had was that the interval between learning and doing it for the first time and then practicing it on ladies subsequently, the gaps could have been two weeks or more. That was an issue because you thought you’d got the hang of it and then two weeks later you thought, I can’t remember what I supposed to be doing.” (Participant 7) Discussion The pilot study demonstrated the feasibility of training sufficient numbers of NHS radiographers to deliver an intervention to
promote early presentation of breast cancer to all older women attending breast screening. It was possible to train four radiographers to achieve the required standard within a time-frame of two months. Provision of on-site coaching by trained and experienced radiographers was a novel approach to training which enabled tailoring to the individual needs of the radiographers. The one-toone performance feedback ensured a speedier transfer of skills to the clinical setting than was achieved in an earlier study.11 All seven radiographers in the current study who received the training were assessed as competent to deliver the intervention within four months. All improved in their confidence to deliver the key messages of the intervention in the required style as a result of training. Being trained and delivering the intervention in clinics was a broadly positive experience according to analysis of the individual interviews with the radiographers. Radiographers reported enjoying having their role extended to include health promotion. They also felt that the benefits of the training had generalised to their routine clinical work and had improved their communication skills and confidence to respond to women of all ages attending breast screening. The findings highlighted some challenges to delivering training effectively and scope for improving efficiency. For the intervention to be delivered effectively in routine clinical practice, it will be important to convey to those interested in undertaking the training the level of commitment required to develop the skills to deliver the intervention. Robust selection procedures are needed to ensure that only those with the motivation and time to undertake the training are recruited. Those who have arranged extended periods of annual leave or with competing work and training commitments are likely to struggle to complete training in a reasonable timeframe. Evaluation of the training with larger numbers of staff might usefully assess whether different levels of staff achieve competency at varying rates in order to inform the content and length of training. It was apparent that breast screening services require clearer guidelines to provide radiographers with sufficient clinic
C. Burgess et al. / Radiography 18 (2012) 232e237
time for training and rehearsal of skills. Now that the average number of “in vivo” practice interventions required to achieve competency (i.e. eight) has been determined, clearer information can be provided to superintendent radiographers and programme managers. It is important to maintain the momentum of training in order for radiographers to build and consolidate their skills and knowledge by providing regular ongoing performance feedback. Skills and confidence of those delivering complex interventions may diminish over time without supervision.12,17 Although our intervention is relatively brief compared with some psychological interventions, it is nonetheless complex comprising multiple components, rendering it liable to variable delivery between radiographers and even within the same radiographer. Such variation in the clinical setting can jeopardise the effectiveness of an otherwise effective intervention.16 A method of quality assurance for the intervention has been developed that includes the manual for effective intervention delivery, the training package, and ongoing performance feedback based on regular assessments of videorecorded interventions using our quality checklist. Overall, the results of this small pilot study were very encouraging, suggesting enthusiasm from staff to be trained to promote early presentation of breast cancer in older women. The potential was demonstrated for flexibility within the system for training to be delivered in the busy setting of the NHS Breast Screening Programme. Some challenges to effective delivery of the training need to be addressed, particularly in relation to the amount of time required for radiographers to learn and rehearse the script. Ways of further streamlining the training package will be explored and tested so that it can be implemented with more efficiency and minimal disruption to the NHS in large research trials and clinical practice. If the intervention is incorporated into clinical practice there would be a case for submitting the training for accreditation by the College of Radiographers so that it could be delivered to the entire workforce. This would place radiographers in a key position to promote early presentation of breast cancer among older women and potentially increase the likelihood of timely diagnosis and treatment of the disease.
Ethical approval The study was approved by Lewisham Local Research Ethics Committee 2008 (Ref number: 08/H0810/59).
Competing interests None declared.
237
Acknowledgements We are grateful to all the staff of the Surrey Breast Screening Service including Dr Julie Cooke (Clinical Director), Jean Jupp (Superintendent Radiographer), and all the radiographers and assistant practitioners who took part in the study. We are also grateful to the women attending for breast screening who agreed to participate. This study was supported by Cancer Research UK. References 1. Berrino F, De Angelis R, Sant M, Rosso S, Lasota MB, Coebergh JW, et al. Survival for eight major cancers and all cancers combined for European adults diagnosed in 1995e1999: results of the EUROCARE-4 study. Lancet Oncol 2007;8:773e83. 2. Sant M, Allemani C, Capocaccia R, Hakulinen T, Aareleid T, Coebergh JQ, et al. Stage at diagnosis is a key explanation of differences in breast cancer survival across Europe. Int J Cancer 2003;106:416e22. 3. Ramirez AJ, Westcombe AM, Burgess CC, Sutton S, Littlejohns P, Richards MA. Factors predicting delayed presentation of symptomatic breast cancer: a systematic review. Lancet 1999;353:1127e31. 4. Grunfeld EA, Ramirez AJ, Hunter MS, Richards MA. Women’s knowledge and beliefs regarding breast cancer. Brit J Cancer 2002;86:1373e8. 5. Linsell L, Burgess CC, Ramirez AJ. Breast cancer awareness among older women. Brit J Cancer 2008;99:1221e5. 6. Moller H, Sandin F, Bray F, Klint A, Linklater KM, Purushotham A, et al. Bolmberg breast cancer survival in England, Norway and Sweden: a populationbased comparison. Int J Cancer 2010;127:2630e8. 7. Burgess CC, Bish AM, Hunter HS, Salkovskis P, Michell M, Whelehan P, et al. Promoting early presentation of breast cancer: development of a psychoeducational intervention. Chron Illness 2008;4:13e27. 8. Linsell L, Forbes LJL, Burgess C, Kapari M, Omar L, Tucker L, et al. A randomised controlled trial of an intervention to promote early presentation of breast cancer in older women: effect on breast cancer awareness. Brit J Cancer 2009;101:S40e8. 9. Forbes LJL, Linsell L, Atkins L, Burgess CC, Tucker L, Omar L, et al. A promoting early presentation intervention increases breast cancer in older women after 2 years: a randomised controlled trial. Brit J Cancer 2011;105(1):18e21. 10. Austoker J, Bankhead C, Forbes LJL, Atkins L, Martin F, Robb KA, et al. Interventions to promote cancer awareness and early presentation: systematic review. Br J Cancer 2009;101:s31e9. 11. Omar L, Burgess CC, Tucker LD, Whelehan P, Ramirez AJ. Can radiographers be trained to deliver an intervention to raise breast cancer awareness in older women? Radiography 2010;16:101e7. 12. Mannix KA, Blackburn IM, Garland A, Gracie J, Moorey S, Reid B, et al. Effectiveness of brief training in cognitive behaviour therapy techniques for palliative care practitioners. Palliat Med 2006;20:579e84. 13. Fallowfield L, Jenkins V, Farewell V, Saul J, Duffy A, Eves R. Efficacy of a cancer research UK communication skills training model for oncologists: a randomised controlled trial. The Lancet 2002;359:650e6. 14. Moorey S, Cort E, Kapari M, Monroe B, Hansford P, Mannix K, et al. A cluster randomized controlled trial of cognitive behaviour therapy for common mental disorders in patients with advanced cancer. Psychol Med 2009;39:713e23. 15. Kinmonth AL, Wareham NJ, Hardeman W, Sutton S, Prevost AT, Fanshawe T, et al. Efficacy of a theory-based behavioural intervention to increase physical activity in an at-risk group in primary care (ProActive UK): a randomised trial. Lancet 2008;371:41e8. 16. Hardeman W, Michie S. Training and quality assurance of self-management interventions. In: Newman S, editor. Chronic physical illness: self-management and behavioural interventions. Open University Press; 2009. p. 98e119. 17. Heaven C, Clegg J, Maguire P. Transfer of communication skills training from workshop to workplace: the impact of clinical supervision. Pat Ed Couns 2006;60:313e25.
Contents lists available at SciVerse ScienceDirect
Radiography journal homepage: www.elsevier.com/locate/radi
Training radiographers to deliver an intervention to promote early presentation of breast cancer Caroline Burgess a, *, Emma Teasdale b, Lynne Omar c, Lorraine Tucker d, Amanda-Jane Ramirez d a
Kings College London, UK University of Southampton, UK c South Bank University, UK d Institute of Psychiatry, King’s College London, UK b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 16 February 2012 Received in revised form 9 May 2012 Accepted 24 June 2012 Available online 7 July 2012
Aim: To evaluate the feasibility of training sufficient radiographers to deliver an intervention to promote early presentation of breast cancer to all older women attending for their final routine mammogram within the NHS Breast Screening Programme. If the Promoting Early Presentation (PEP) intervention is demonstrated to be cost-effective, it may be implemented across the NHS requiring at least four radiographers per screening service to deliver the intervention. Methods: A pilot study in a single breast screening service was conducted to assess the feasibility of training sufficient radiographers to meet this objective. Quantitative and qualitative methods were used to evaluate the impact of training on participating radiographers and the screening service. Competency to deliver the intervention was assessed at key points during training according to quality criteria based on delivery of the key messages and style of delivery. Confidence to deliver the intervention was assessed using a self-report measure before and after training. Radiographers’ experiences of training were elicited in face-to-face qualitative interviews. Results: Seven of eight radiographers who were released to undertake the training achieved the required level of competency to deliver the intervention within four months. All improved over time in their confidence to deliver the key messages of the intervention. The qualitative analysis revealed the benefits and challenges of training from the perspective of the radiographers. Conclusion: It was feasible and acceptable to train sufficient radiographers to deliver the PEP Intervention. The training package will be streamlined to improve efficiency for large implementation trials and clinical practice across the NHS. Ó 2012 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Keywords: Breast cancer Promoting early presentation Health promotion Radiographer training
Introduction Women in the United Kingdom have poorer survival from breast cancer than many other Western European countries1 and differences in stage of diagnosis are largely responsible.2 Late stage at diagnosis is almost certainly due to late presentation by some women and delays in onward referral by some general practitioners. Risk factors for delay in presentation of breast cancer include older age, less education and presenting with non-lump symptoms.3 Older women have particularly poor knowledge of non-lump symptoms and of the increase in breast cancer risk with
* Corresponding author. Department of Primary Care & Public Health Sciences, Kings College London, Capital House, Weston Street, London SE1 3QD, UK. Tel.: þ44 (0) 20 7848 8750. E-mail address: [email protected] (C. Burgess).
age.4 About 20% of older women report that they never look at or feel their breasts.5 Older women present with more advanced disease, and have much higher short term mortality rates than younger women.6 An intervention has been developed to equip older women with breast cancer awareness, in other words, the knowledge, confidence, motivation and skills to present promptly to primary care on discovering breast cancer symptoms.7 A randomized controlled trial of this intervention was conducted with women attending for their final routine mammogram at age 67e70 years on the UK National Health Service Breast Screening Programme. At one and two years follow-up, the Promoting Early Presentation (PEP) Intervention increased the proportion of women who were breast cancer aware more than any other intervention of its kind.8e10 If the PEP Intervention proves to be cost-effective it may be implemented across the NHS Breast Screening Programme. The majority (over 70%) of older women (67e70 years of age) attends
1078-8174/$ e see front matter Ó 2012 The College of Radiographers. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.radi.2012.06.003
C. Burgess et al. / Radiography 18 (2012) 232e237
for their final invited mammogram (BSP, 2008). Diagnostic radiographers and assistant practitioners (both groups hereafter referred to as “radiographers”), as the front-line NHS staff conducting breast screening, would be appropriately placed to deliver this intervention. The feasibility in principle of training a small number of radiographers working within the NHS Breast Screening Programme has been demonstrated,11 but there remains the challenge of training sufficient numbers of radiographers to offer the intervention effectively to all older women attending breast screening. There are 80 screening units across the UK each inviting a defined population of eligible women through their general practices. The average breast screening service invites approximately 3000 women per year for their final invited mammogram. In order to deliver the intervention effectively to all women attending for their final invited mammogram in routine clinical practice, at least four radiographers per breast screening service would be required, taking account of attrition and cover for leave. This paper reports the results of a pilot study in one breast screening service to assess the feasibility of training the required number of radiographers to deliver the intervention to all women receiving their final invited mammogram. The impact of the training on both the participating radiographers and the NHS Breast Screening Programme was assessed. If successful, this method could provide a model for training radiographers to deliver the intervention for implementation across the NHS Breast Screening Programme. The study was approved by Lewisham Local Research Ethics Committee 2008 (08/H0810/59). Methods Study design A pilot study was conducted, using mixed methods, to assess the feasibility of training the required number of radiographers in one breast screening service. Assessment was made of the number of radiographers volunteering for training, the number able to be released for training, and the time for radiographers to complete training. The impact of being trained on the competence and confidence of radiographers to deliver the intervention was assessed at key time points during the training process. Radiographers’ perceptions and experiences both of training and delivering the intervention were assessed using qualitative interview methods. Participants Expressions of interest were sought from all radiographers working in one breast screening service (N ¼ 25). All qualified radiographers working in the service were eligible to participate in the study. Signed consent was obtained from participants prior to the start of training. Older women with forthcoming appointments for their final invited mammogram were identified by the breast screening service and sent an invitation letter and information sheet about the study. Signed consent to receive video-recorded practice interventions from the radiographers in training was obtained when women attended for their appointments. Participants were assured that all video-recordings would be deleted upon completion of the study.
mammogram. The script covers the symptoms of breast cancer, the increased risk of developing breast cancer with increasing age, rehearsal of the skills required to check for breast changes and what women should do if they discover a breast change. Training to deliver the intervention Training methods were based on evidence of effective training techniques for health professionals to deliver psychological interventions. 12e16 The training package was refined from an earlier study of the feasibility of training radiographers to deliver the intervention.11 Training was delivered locally in the breast screening service and comprised two formal training days, separated by 4 weeks to learn the intervention “script” and for rehearsal of skills. Practice interventions were undertaken, initially with colleagues, and then “in vivo” with women attending breast screening clinics. An intervention manual was developed, which included instructions for intervention delivery and a scripted schedule to support accurate delivery of the health messages within the 10-min time-frame. Evidence suggests that having a detailed manual or protocol supports training and improves adherence.16 Active participatory methods were used in training, including skills rehearsal and constructive feedback. The two formal training days included interactive teaching sessions with video demonstration, group exercises in information and communication skills, constructive feedback on video-recorded role-play and practice interventions with women attending screening. In addition to the formal training days conducted by trained communication skills facilitators, regular one-to-one performance feedback was provided in the breast screening clinics throughout the training period by two “coaches” who were research radiographers already trained and experienced in delivering the intervention. Coaches provided immediate performance feedback on the practice interventions in clinics so that radiographers could build on their skills after each intervention. Radiographers were trained to video-record their practice interventions to enable assessment of quality and performance feedback. Competence to deliver the intervention was examined according to a quality checklist for content of the key health messages of the intervention (see Box 1). The checklist also
Box 1. Domains of content and style of delivery assessed by quality checklist Content of the intervention 1. 2. 3. 4. 5. 6.
Introduces and explains purpose of intervention Explains risk of developing breast cancer Describes 11 breast cancer symptoms Discusses breast awareness Delivers key message to see GP with any breast chances Promotes disclosure of breast change to close friend or relative 7. Encourages participant to make action plan 8. Summarises main points of intervention 9. Delivers debrief and invites queries Style of delivery of the intervention
The PEP intervention The PEP Intervention is a scripted 10-min one-to-one interaction between a radiographer and the woman, supported by a booklet, delivered after the woman has received her
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10. Clear 11. Collaborative 12. Motivating.
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assessed the extent to which the intervention was delivered in a style that was clear, collaborative and motivating. Descriptors were developed for rating delivery style in order to promote reliability between those rating the quality of intervention. Outcomes (i) Acceptability of training to the breast screening service The number of radiographers who expressed an interest in being trained was assessed as well as the number that could be released from their regular NHS work to attend training. Measurement was made of the amount of time required for each radiographer to achieve the required level of competency in order to assess the impact of training on the breast screening service. Feedback was obtained from senior staff regarding the logistics of accommodating the training into the normal running of the service.
Results Acceptability to the breast screening service The majority of radiographers (88%, n ¼ 22/25) employed in the breast screening service expressed an interest in being trained to deliver the intervention. The service was able to release eight radiographers from their regular NHS work to take up the training. One radiographer later withdrew from training for personal reasons. It was feasible for those undertaking training to be covered for their regular NHS work. Staff cover was required for the two formal training days and 8 h of coaching time per radiographer (on average) to rehearse the intervention with colleagues and women attending breast screening clinics. Senior staff managing the screening service reported that the logistics of organizing sufficient time for training was feasible and acceptable for this number of radiographers. Routine clinical practice was not disrupted during the training period.
(ii) Competence to deliver the intervention The main outcome was the number of radiographers achieving the required level of competence to deliver the intervention within two months of the start of training. The aim was to achieve the outcome within a two-month time-frame in order to minimise disruption to the normal running of the breast screening service during the training period. Two months was judged to be a realistic time-frame based on earlier experience of training radiographers to deliver the intervention, allowing the service to allocate sufficient time for skills rehearsal outside normal clinic hours.11 Competence to deliver the intervention was assessed according to a 12-item quality checklist covering 9 content domains and 3 style domains. Adherence of 100% was expected to four key health messages and 75% for each style item (clear, collaborative, motivating). In the current study, competence to deliver the intervention was assessed at 1, 2, 3 and 4 months after the start of training. At each monthly assessment, randomly selected video-recorded interventions for each participant were assessed for competency by one of the training facilitators. (iii) Confidence to deliver the key messages of the intervention Confidence to deliver the key health promoting messages of the intervention was assessed on the first formal training day and at two months using a self-report questionnaire. Confidence items were scored from very confident (10) to not at all (1) and included confidence to: inform older women about the symptoms of breast cancer, explain absolute and relative risk of developing breast cancer, advise women how to be breast aware, encourage women to present immediately when they discover a breast change, discuss the advantages of early treatment for breast cancer, deliver health-promoting messages in a positive and motivating way and respond to signs of distress in women receiving information about breast cancer. (iv) Participant perceptions of training and delivering the intervention Radiographers’ experiences and views of training were elicited using semi-structured interviews 4 months after the start of training. An interview schedule was developed to elicit the radiographers’ experiences of the training days and coaching process, and the impact of being trained in terms of benefits and challenges. Interviews were conducted by a member of the research team who was not involved in the training, audio-recorded, with the participant’s permission, and fully transcribed. A simple thematic analysis of the responses was conducted.
Competence to deliver the intervention The mean number of interventions conducted with women attending screening for each radiographer during training was 8.57 (range 5e14). Assessments of competence to deliver the intervention to women attending screening were conducted at months 1, 2, 3 and 4 during training (Fig. 1). Baseline competence for delivering the content of the intervention was higher than that for style of delivery. It was more challenging during training for radiographers to achieve the minimum cut-off (75%) for delivery style than it was to achieve 100% for adherence to the content of key messages. All seven radiographers achieved competency to deliver the intervention as defined by our quality criteria for content and style of delivery. Four of these achieved competence within two months; the remaining three were assessed as competent to deliver the intervention within four months of the start of training. Reasons for variation in time to achieve competence included gaps in training due to radiographers having annual leave, absence due to illness and other work and training commitments. Confidence to deliver the key messages of the intervention Changes in confidence to deliver the key messages of the intervention over time are illustrated in Fig. 2. All radiographers who completed the training increased their confidence to deliver the health-promoting messages. Prior to training, radiographers were fairly confident about advising older women to present to the GP immediately with a breast change (mean ¼ 7.3, SD1.0) although less confident about delivering more complex health messages such as older women’s risk of developing breast cancer (mean ¼ 5.3, SD1.2). Responding to emotionally challenging situations such as women becoming distressed about breast cancer elicited the least confidence at baseline (mean ¼ 4.6, SD1.1). After two months of training, radiographers remained most confident about promoting early presentation of breast cancer (mean ¼ 9.9, SD0.4) and confidence to deliver the other key messages improved considerably. Confidence to respond to signs of emotional distress in women also improved slightly but remained the area where radiographers felt least confident (mean ¼ 7.4, SD1.9). Participant perceptions of training and delivering the intervention Interviews were conducted with all seven radiographers who completed training. Their responses are summarised under three subheadings: experiences of being trained to deliver the
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Competency threshold for content
100
75
50 Month 1
Month 2
Month 3
Month 4
100
90
80
Competency threshold for style
70
60
50 Month 1
Month 2
Month 3
Month 4
Figure 1. Progress by individual radiographers in achieving competency in content and style to deliver the intervention over time. Percentage competency scores for content of the intervention over time for individual radiographers. Percentage competency scores for style of delivery of the intervention over time for individual radiographers.
intervention, perceived benefits of being trained, and the challenges experienced during training and delivering the intervention. Experiences of being trained The formal training days and one-to-one coaching were received very positively by the radiographers: “I think the training days were excellent. I think the trainers were excellent. They were very professional, got to know us all individually.” (Participant 1) “It gave a great overview of what was expected from us. It was a lot of information but it was all documented and we had our little files” (Participant 2) “I really enjoyed the whole way it was set up. I could see from the background how they’d gone down the path they had gone down” (Participant 7) Video-recording their own practice interventions was reported as feasible and acceptable by the radiographers. The experience of receiving constructive performance feedback from the two trained and experienced radiographers was described as encouraging, balanced (i.e. highlighted both what was going well and not so well) and helpful in improving their skills to deliver the intervention. “Everytime you see a (video-recorded) intervention you learn something more about your own delivery, your own way of communicating.” (Participant 5)
“They were very enthusiastic, very encouraging. Even if you hadn’t done so well, they were encouraging” (Participant 6) Benefits of being trained Radiographers reported an increase in their own breast cancer awareness as a result of undertaking the training. This increased their confidence to impart the health messages not only to women targeted to receive the intervention but also to other women attending breast screening who did not receive the intervention. Specifically, radiographers reported that since being trained they tended to convey more detailed information about breast cancer risk, symptoms and importance of early presentation to women attending for their final invited mammogram. They also felt more able and confident to answer common queries raised by women attending screening: “Sometimes you get the opportunity to feed in some of the information from the intervention to women (attending screening) and that can be helpful.” (Participant 3) “It has changed, to a certain extent, my interaction with ladies, especially on the mobile units. Although I don’t get a lot of time I am quite aware of trying to tell older ladies, more so now, that yes, this is what you can do and this is your risk and you should continue with screening.” (Participant 6) They also reported that their learning had been passed on to the other radiographers within the breast screening service:
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Very 10
9
Mean Confidence Score
8 7 6 5 4
Pre-training Post-training
3 2 1
Not at all
0
s sk ms ice GP ent tyle tres g ri pto adv gs the atm dis n inin e s i ym o h r t a s t t t s l g wi ne tiva on rly Exp ibin are ing tati mo f ea scr eal sen t aw so na D t i s e i De f r a n e p en bre ntio ng gb ing agi rve our ssin lain inte c u p g n c x E E rin Dis live De
Confidence to deliver key messages Figure 2. Mean scores for confidence to deliver key messages of the intervention before and after the two formal training days.
“I think the knock on-effect is that staff within the department are also more aware about breast cancer and older ladies. When you talk to your colleagues the general knowledge raises a little bit.” (Participant 5) Challenges of training Although many benefits and positive aspects of training were reported, a recurrent theme of the interviews was the challenge posed by having to learn and adhere to the scripted schedule for the intervention. Some radiographers had not anticipated the amount of time required in learning and developing their skills to deliver the intervention. “If your memory is not that good, that was quite hard going. I wouldn’t say I ever got it 100% actually.” (participant 2) “Having to learn the intervention because it was fairly prescriptive; knowing that we had to get across all these points” (participant 6) Obtaining time for learning and rehearsing the script was difficult for some radiographers because of competing demands both at work and home. Some reported that pressure on radiographer capacity in the screening service impacted on their opportunities to conduct pilot interventions with women in clinics resulting in lack of continuity in training. “Thinking back to the beginning the problem we had was that the interval between learning and doing it for the first time and then practicing it on ladies subsequently, the gaps could have been two weeks or more. That was an issue because you thought you’d got the hang of it and then two weeks later you thought, I can’t remember what I supposed to be doing.” (Participant 7) Discussion The pilot study demonstrated the feasibility of training sufficient numbers of NHS radiographers to deliver an intervention to
promote early presentation of breast cancer to all older women attending breast screening. It was possible to train four radiographers to achieve the required standard within a time-frame of two months. Provision of on-site coaching by trained and experienced radiographers was a novel approach to training which enabled tailoring to the individual needs of the radiographers. The one-toone performance feedback ensured a speedier transfer of skills to the clinical setting than was achieved in an earlier study.11 All seven radiographers in the current study who received the training were assessed as competent to deliver the intervention within four months. All improved in their confidence to deliver the key messages of the intervention in the required style as a result of training. Being trained and delivering the intervention in clinics was a broadly positive experience according to analysis of the individual interviews with the radiographers. Radiographers reported enjoying having their role extended to include health promotion. They also felt that the benefits of the training had generalised to their routine clinical work and had improved their communication skills and confidence to respond to women of all ages attending breast screening. The findings highlighted some challenges to delivering training effectively and scope for improving efficiency. For the intervention to be delivered effectively in routine clinical practice, it will be important to convey to those interested in undertaking the training the level of commitment required to develop the skills to deliver the intervention. Robust selection procedures are needed to ensure that only those with the motivation and time to undertake the training are recruited. Those who have arranged extended periods of annual leave or with competing work and training commitments are likely to struggle to complete training in a reasonable timeframe. Evaluation of the training with larger numbers of staff might usefully assess whether different levels of staff achieve competency at varying rates in order to inform the content and length of training. It was apparent that breast screening services require clearer guidelines to provide radiographers with sufficient clinic
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time for training and rehearsal of skills. Now that the average number of “in vivo” practice interventions required to achieve competency (i.e. eight) has been determined, clearer information can be provided to superintendent radiographers and programme managers. It is important to maintain the momentum of training in order for radiographers to build and consolidate their skills and knowledge by providing regular ongoing performance feedback. Skills and confidence of those delivering complex interventions may diminish over time without supervision.12,17 Although our intervention is relatively brief compared with some psychological interventions, it is nonetheless complex comprising multiple components, rendering it liable to variable delivery between radiographers and even within the same radiographer. Such variation in the clinical setting can jeopardise the effectiveness of an otherwise effective intervention.16 A method of quality assurance for the intervention has been developed that includes the manual for effective intervention delivery, the training package, and ongoing performance feedback based on regular assessments of videorecorded interventions using our quality checklist. Overall, the results of this small pilot study were very encouraging, suggesting enthusiasm from staff to be trained to promote early presentation of breast cancer in older women. The potential was demonstrated for flexibility within the system for training to be delivered in the busy setting of the NHS Breast Screening Programme. Some challenges to effective delivery of the training need to be addressed, particularly in relation to the amount of time required for radiographers to learn and rehearse the script. Ways of further streamlining the training package will be explored and tested so that it can be implemented with more efficiency and minimal disruption to the NHS in large research trials and clinical practice. If the intervention is incorporated into clinical practice there would be a case for submitting the training for accreditation by the College of Radiographers so that it could be delivered to the entire workforce. This would place radiographers in a key position to promote early presentation of breast cancer among older women and potentially increase the likelihood of timely diagnosis and treatment of the disease.
Ethical approval The study was approved by Lewisham Local Research Ethics Committee 2008 (Ref number: 08/H0810/59).
Competing interests None declared.
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Acknowledgements We are grateful to all the staff of the Surrey Breast Screening Service including Dr Julie Cooke (Clinical Director), Jean Jupp (Superintendent Radiographer), and all the radiographers and assistant practitioners who took part in the study. We are also grateful to the women attending for breast screening who agreed to participate. This study was supported by Cancer Research UK. References 1. Berrino F, De Angelis R, Sant M, Rosso S, Lasota MB, Coebergh JW, et al. Survival for eight major cancers and all cancers combined for European adults diagnosed in 1995e1999: results of the EUROCARE-4 study. Lancet Oncol 2007;8:773e83. 2. Sant M, Allemani C, Capocaccia R, Hakulinen T, Aareleid T, Coebergh JQ, et al. Stage at diagnosis is a key explanation of differences in breast cancer survival across Europe. Int J Cancer 2003;106:416e22. 3. Ramirez AJ, Westcombe AM, Burgess CC, Sutton S, Littlejohns P, Richards MA. Factors predicting delayed presentation of symptomatic breast cancer: a systematic review. Lancet 1999;353:1127e31. 4. Grunfeld EA, Ramirez AJ, Hunter MS, Richards MA. Women’s knowledge and beliefs regarding breast cancer. Brit J Cancer 2002;86:1373e8. 5. Linsell L, Burgess CC, Ramirez AJ. Breast cancer awareness among older women. Brit J Cancer 2008;99:1221e5. 6. Moller H, Sandin F, Bray F, Klint A, Linklater KM, Purushotham A, et al. Bolmberg breast cancer survival in England, Norway and Sweden: a populationbased comparison. Int J Cancer 2010;127:2630e8. 7. Burgess CC, Bish AM, Hunter HS, Salkovskis P, Michell M, Whelehan P, et al. Promoting early presentation of breast cancer: development of a psychoeducational intervention. Chron Illness 2008;4:13e27. 8. Linsell L, Forbes LJL, Burgess C, Kapari M, Omar L, Tucker L, et al. A randomised controlled trial of an intervention to promote early presentation of breast cancer in older women: effect on breast cancer awareness. Brit J Cancer 2009;101:S40e8. 9. Forbes LJL, Linsell L, Atkins L, Burgess CC, Tucker L, Omar L, et al. A promoting early presentation intervention increases breast cancer in older women after 2 years: a randomised controlled trial. Brit J Cancer 2011;105(1):18e21. 10. Austoker J, Bankhead C, Forbes LJL, Atkins L, Martin F, Robb KA, et al. Interventions to promote cancer awareness and early presentation: systematic review. Br J Cancer 2009;101:s31e9. 11. Omar L, Burgess CC, Tucker LD, Whelehan P, Ramirez AJ. Can radiographers be trained to deliver an intervention to raise breast cancer awareness in older women? Radiography 2010;16:101e7. 12. Mannix KA, Blackburn IM, Garland A, Gracie J, Moorey S, Reid B, et al. Effectiveness of brief training in cognitive behaviour therapy techniques for palliative care practitioners. Palliat Med 2006;20:579e84. 13. Fallowfield L, Jenkins V, Farewell V, Saul J, Duffy A, Eves R. Efficacy of a cancer research UK communication skills training model for oncologists: a randomised controlled trial. The Lancet 2002;359:650e6. 14. Moorey S, Cort E, Kapari M, Monroe B, Hansford P, Mannix K, et al. A cluster randomized controlled trial of cognitive behaviour therapy for common mental disorders in patients with advanced cancer. Psychol Med 2009;39:713e23. 15. Kinmonth AL, Wareham NJ, Hardeman W, Sutton S, Prevost AT, Fanshawe T, et al. Efficacy of a theory-based behavioural intervention to increase physical activity in an at-risk group in primary care (ProActive UK): a randomised trial. Lancet 2008;371:41e8. 16. Hardeman W, Michie S. Training and quality assurance of self-management interventions. In: Newman S, editor. Chronic physical illness: self-management and behavioural interventions. Open University Press; 2009. p. 98e119. 17. Heaven C, Clegg J, Maguire P. Transfer of communication skills training from workshop to workplace: the impact of clinical supervision. Pat Ed Couns 2006;60:313e25.