the concept of caring: perceptions of radiation therapists

Radiography (2010) 16, 198e208

ava i lab le a t www.sc iencedi rec t .com

journa l homepage : www.e lsev ier . com/ loca te / rad i

The concept of caring: Perceptions ofradiation therapists

Amanda Bolderston a,*, Donna Lewis b, Martin J. Chai c

aRadiation Medicine Program, Princess Margaret Hospital, University Health Network, Toronto, Ontario M5G 2M9, CanadabRadiation Therapy, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, CanadacRadiation Therapy, Medical Radiation Sciences, The Michener Institute for Applied Health Sciences, Toronto, Ontario,Canada

Received 29 October 2009; revised 15 March 2010; accepted 31 March 2010

KEYWORDSRadiation therapist;Caring;Patient care;Phenomenology

* Corresponding author.E-mail address: amanda.bol

(A. Bolderston).

1078-8174/$ - see front matter ª 201doi:10.1016/j.radi.2010.03.006

Abstract Aims: This study explores radiation therapists’ understanding and interpretationsof the concept of caring within their profession.Background: Health professions’ concepts of care have been explored in disciplines such asnursing and medicine. However, there has been little previous attempt to describe what caringmeans to radiation therapists.Methods: A qualitative phenomenological approach was used and 27 radiation therapists wereinterviewed in four focus groups. Discussions were transcribed and analysis was performed toidentify themes from the data.Results: Threeoverarching themesemergedfromthedata:humanconnectionestablishedbetweenradiation therapists and patients, technical care as the use of technology and procedures in treat-ment planning and delivery, and the therapist’s unique identity as compared to other professions.Conclusions: Theconcept of carewas seenby radiation therapists primarily as a supportive relation-ship with the patient but they were unable to agree if the technical aspects and procedures wereconsidered a part of caring. Further research is needed to further examine the connection betweentechnology and care.ª 2010 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.

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0 The College of Radiographers.

Background

Introduction

“The secret of the care of the patient is in caring for thepatient”.1

For health professionals, including radiation therapists,caring for patients is understood to be an essential part of

Published by Elsevier Ltd. All rights reserved.

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The concept of caring 199

their practice. However, there has been little attempt toascertain the perceptions of radiation therapistssurrounding the concept of caring. A qualitative approachwas taken using focus groups with therapists of differingexperiences and backgrounds to examine this issue.

Definitions and theories of caring

Caring is definedas to feel interest or concern2 and tobecaredfor is a basic human need.3 To actively and unselfishly care foranother person, relates to the notion of altruism. Altruism isalso one of the fundamental expectations of a profession4 andto care, or to help others, is a commonly stated reason whypeople enter medical, nursing and allied health professions.5

In the health care field, the concept of caring is preva-lent in the logos, visions, and mission statements of manyinstitutions, health authorities, professional bodies andorganizations (see Fig. 1). However, despite the ubiquitoususe of the term, caring in health care is “a complex, elusiveconcept to define6” (p. 24). Caring has been alternativelydescribed as the affective or humanistic aspect of health-care, in contrast to the technologic side. Often in thehealth care literature these two elements are seen as beingin opposition, leading to a potential technology-humanismdualism7 and the concern that perhaps technologic sophis-tication8 rather than caring or humanism is becoming thefocus of medicine and healthcare.

Patients who feel cared for by health care professionalsoften have higher levels of satisfaction,9 psychologicaladjustment10 and compliance with treatment-relatedrecommendations.11 In addition, today’s patient-centeredenvironment, with its emphasis on consumer choice andquality improvement is driving the need to enhancefeatures of the healthcare experience that patientsvalue.12 These features include emotional support, comfortand communication, all of which have been identified asimportant elements of caring.13

Figure 1 The concept o

In nursing, theories and models of caring have beenevolving since the days of Florence Nightingale.14 Nursecaring has been studied “philosophically, theoretically,ethically, ethnographically and in numerous clinical situa-tions15” (p. 284). Common to many of these perspectives isthat caring is the “essence and central, unifying anddominant domain that distinguishes nursing from otherhealth disciplines11” (p. 285). Morse et al.,16 identified fivethemes of nurse caring found in the literature, namely asa human trait, a moral imperative, an affect, an interper-sonal interaction and a therapeutic intervention. A usefulgeneral distinction made by Widmark-Petersson et al.,17

divides caring into two main elements. These are:

1. Expressive: focusing on the affective dimension anddefined as caring about a patient.

2. Instrumental: focusing on comfort and defined as caringfor a patient, or physical care and treatment.

Caring is not exclusive to nursing e it has also beendefined as the heart of other health professions such associal work.18 Definitions and descriptions of caring maydiffer due to differences in the development of theprofessions, rather than more fundamental differences.19

For example, in medicine caring has been alternativelydescribed as compassion, empathy, respect and humanisme as well as the art, rather than the science, of medicine.8

Kern et al.,10 described doctors who practiced humanisticcare as addressing patients’ “values, concerns, andemotional, social, cultural and spiritual needs” (p. 8). Theauthors claim that such care serves to improve accuratediagnoses, increase patient and physician satisfaction,improve clinical outcomes and decrease litigation.

In the medical radiation sciences, the importance ofcaring and patient care has been discussed for over 40years.20 It is recognised that imaging and treatment envi-ronments can be isolating and depersonalising. The patient

f caring in logos, etc.

200 A. Bolderston et al.

may feel alone in an unfamiliar and potentially frighteningenvironment.21,22 It follows, then, that the role of theradiographer should include reducing the objectification ofthe patient/person and ensuring a sense of emotional andphysical comfort while in their care. It has even beenclaimed that “caring is the very essence of .radiologictechnology23” (p. 240). The previously discussed tech-nology-humanism dualism was acknowledged by McKenna-Adler24 who claimed that radiographers (or medical radia-tion technologists) carry out two potentially contradictoryroles, both technologist and carer. Students entering theprofession commonly want to care for or help people,25

which then provides a significant source of professionalsatisfaction.26 Steves cites Goldin’s27 definition of caring inreference to diagnostic radiographers as:

“Providing emotional support, explaining the procedurein a manner the patient can understand, permitting thepatient to express emotion, actively listening toa patient’s concerns and responding in an empatheticmanner and recognising the patient as a unique indi-vidual rather than just another case.” (p. 119)

For radiation therapy specifically, Sandberg28 states thatcaring involves developing a relationship with patientsthrough common interests and meaningful conversation.She also advocates attention to the patient’s physicalcomfort as a way of demonstrating care, including touch toencourage relaxation and minimise the patient’s sense ofisolation. Faithfull and Wells22 have used the termsupportive care to describe aspects of the radiation ther-apists’ role concerned with the physical, psychosocial andspiritual issues faced by the patient. However, in practicesupportive care often refers to information giving, such aspatient education dealing with side effects management,or appropriate referrals to other members of the treatmentteam such as social work or nutrition. Radiation therapyprofessional bodies embody caring professional behavioursin guidelines or standards or practice. For example, theCanadian Association of Medical Radiation Technologists(CAMRT) states that radiation therapists are expected tocomfort patients, explain procedures, answer questionsand provide education and emotional support.29

In terms of the provision of radiation therapy, Colyer30 hasalso commented on the contradictory role of carer and tech-nologist. She has warned that although the profession hasdeveloped a high degree of technical specialism and isincreasingly valued for the central role radiation therapistsplay in the treatment pathway, the profession is in danger ofrelying on this technology to sustain its role in favour of otheraffective skills such as emotional and informational support.

It is evident that caring has been well established asa fundamental element of health care and an overtexpectation of radiation therapy practice. Definitions vary,however, so this research is a preliminary attempt to clarifywhat radiation therapists’ perceptions are of the conceptof caring in their professional practice.

Methodology

A qualitative interpretive phenomenological approach wasutilized with focus group methodology to gain insights from

clinical radiation therapists. Interpretive phenomenology isused to understand and describe the lived experiences ofindividuals, in this case, radiation therapists in theirprofessional role.31 A focus group is a type of group inter-view used to capture data.32 Focus groups are common inphenomenological research,33 although the use of thismethod has been debated because of concerns that indi-vidual voices may be lost in the overall discussion andinteraction.34, 35 However, with careful facilitation, indi-vidual experiences can be preserved in the group setting.34

In addition, focus groups allow the possibility of richer dataas participants hear each other’s stories and add their ownperspectives to the unfolding narrative.36

Within an interpretive phenomenological framework it isrecognized that both the interviewer and interviewee mayaffect the data gathering process and that this is an integralpart of the process.36 In this case, the researchers/authors(AB, DL and MC) are radiation therapists, with botha personal and professional interest in the idea of caringwhich will shape the final results and conclusions.

Purposeful sampling was used to target individuals withinformation and experiences pertinent to the researchtopic at a single large urban cancer centre. Participantswere approached who had a variety of experiences/back-ground. Radiation therapists currently in roles with minimalpatient contact were not excluded from the study, as thesewere usually individuals with many years of previous clin-ical experience. Ethics approval was gained from theappropriate Research Ethics Board prior to data collection.

The total number of participantswas 27with themajority ofthe participants being female (about 93%). Experience in theprofession ranged from just under one year to more than 30years. Participants were provided with a consent form high-lighting the purpose of the study, the risks and benefits, andconfidentiality issues. Four focus groups were conducted intotal, varying in length from50to70 min.Participantsattendedone focus group each, and numbers per group varied from fiveto nine. The same facilitator (AB) conducted all of the sessionsin an attempt to maintain consistency in approach. The facili-tator had knowledge of the radiation therapy clinical environ-ment, but did not work with any of the therapists in the study.Care was taken to deal with the discussions so that all partici-pants had the opportunity to tell their stories. This includedmanaging the dominant talkers as well as encouraging thequieter participants.37 Each participant was also given time atthe beginning of the session to provide their own unique defi-nition of caring and the shared descriptions were used for“discussion, interaction and debate to illuminate further thephenomenonunder study34” (p. 669). A second researcher (MC)was also present to make field notes, monitor the audioequipment and keep track of time. Four key questions guidedthe discussions within the focus groups:

� What is your definition of caring?� Do you think that therapists have a specific way ofcaring?

� Is caring a personality trait?� Has your definition of caring changed since yougraduated?

Participants’ comments are used throughout to demon-strate the themes and concepts drawn from the data.


Analysis

Discussions were audio recorded and transcribed verbatimwith the participants anonymized and comments addedfrom the field notes if necessary. The subsequent analysiswas inductive (not carried out with any presupposedframework or hypotheses) and concurrent with the datagathering. The process was iterative and the emergentconcepts informed the subsequent focus group(s) and theirdirection. All three researchers initially analyzed the dataindependently then the results were discussed anddebated in a number of meetings, emails and telephonecalls. The focus group transcripts were read and re-readseveral times so the researchers became very familiar withthem. Coding consisted of analyzing phrases andcomments in the transcripts to flag those with similarmeaning and tabulating them in a word processing programto provide a coding scheme. Categories were assignedafter the consensus of all researchers was reached,a process that sometimes took lengthy discussion. Aninitial 78 categories emerged from the data (for example,one category that emerged was “making an emotionalconnection”). These categories were then assigned to 14sub-themes (“making an emotional connection”, forexample, was assigned to the sub-theme “a reciprocalrelationship”). The subthemes were subsequently clus-tered into three overarching main themes (see Table 1).After the groups were concluded, the results werereviewed with an independent observer to provide anelement of peer debriefing.38

Although only four focus groups were held, it wasconsidered that data saturation was achieved as the sameissues began to emerge in both the third and fourthgroup. It was felt to be unlikely that more groups in thesame practice setting would have yielded any furtherinsights.

Table 1 Themes and sub-themes.

Overarchingthemes

Sub-themes

Human connection The patient at the centre of care- As a unique individual- As the focusA reciprocal relationship

Identity As a therapist:- Unique role- Communicator- Advocate- Team member

As an individual- Personality- Gender- Life experiences- Work environment

Technical care Technical care versus patient carePerceived value of technical careDoing your best work

Results

Three overarching themes were identified from the datafrom the focus groups. These were ‘human connection’,‘identity’ and ‘technical care’. Underpinning these themeswere several sub-themes (Table 1).

Overarching theme 1: human connection

The most prevalent overarching theme was human connec-tion. This theme encompasses concepts such as dignity,respect, compassion, empathy and kindness. It centres onthe idea that caring for the patient is based on a fundamentalempathetic human connection between radiation therapistand patient. The radiation therapist sees the patient asa person,with a life history that ismore than just their cancerdiagnosis and subsequent treatment plan.

Sub-themes included:

(i) The patient at the centre of care

� As a unique individual

An important part of caring was relating to the patient as
a person first and foremost, and focusing on their specificneeds. This involved connecting with the patient asa unique individual, with a complex history beyond thecancer centre.
“The disease does not define them as a human being.”

This patient-centered relationship entailed remem-bering specific details about each person (e.g. their inter-ests or their social situation) as well as information relatedto their treatment:

“You change your care appropriately if you will. You’restill giving good care, and you taking into considerationwhat the patient will accept as the level of care thatthey want.”

� As the focus

While the patient is being treated they are the primaryfocus of the radiation therapists caring for them, this wasdescribed as being “fully present” or, as one participantstated:

“I care as a therapist by looking at the patients asa whole person and not just someone who needs to betreated because we’re 30 min behind.”

(ii) A reciprocal relationship

The human relationship with the patient was seen asreciprocal, with a mutual affective component. As theradiation therapist demonstrates care and interest for thepatient, the care and interest is returned and the rela-tionship is reinforced:

“You connect with the patients you treat them asa person, as a living human being and you make thatconnection with them. I think what’s neat is that theyeventually care about you.”


Overarching theme 2: identity

Overlying the idea of caring as a part of being human wasthe concept of caring as part of one’s professionalresponsibility or identity. Caring was also felt to bedependent on individual characteristics or personality.

(i) As a therapist

There were specific caring elements of the radiationtherapist’s professional role identified.


� A unique role:

There was a strong sense from the participants thatradiation therapy was a unique role, with a number ofelements that set it apart from other health care profes-sions. It was suggested that radiation therapists are fairlyunusual because they “choose cancer” when they enter theprofession. Other professions, such as medicine andnursing, allow for specialization after an initial trainingperiod; however radiation therapists make the decision towork with people living with cancer from the beginning oftheir career. Some participants felt that this made radia-tion therapists particularly sensitive to some of the funda-mental issues involved with treating people witha potentially life-threatening illness. It was also com-mented that the therapist-patient relationship is also veryimportant because patients are feeling particularlyvulnerable and:

“When something happens to you like that, yourperspective changes a bit. People that you meet becomemuch more significant to you.”

The fact that fractionated treatments meant thatpatients came to the radiation therapy centre for multipleappointments (usually over a number of weeks) was alsoseen as an important factor. Daily visits by the patientallowed rapport building, and a more detailed knowledgefrom both perspectives.

“We get to know the patient, their family, their lives,what they’re doing for those two months we see them.”

This was contrasted with the single visit that mostpatients make for treatment planning (for example, anappointment for a planning CT scan). Some participants feltthat this negatively impacted the care they gave topatients; while others felt that they made more of an effortto reach out during that single visit:

“I crank it up even more because I’m the first personthey’re seeing; I feel I’m the cover they’re going tojudge the book by.”

There was an inevitable comparison with other healthcare roles, including medicine, nursing and other medicalradiation technologists (radiographers). It was speculatedthat the physician-patient relationship might be moreformal than the relationship between the patient and theradiation therapist. The patient might be more likely tobring up concerns with the radiation therapist to avoid‘bothering’ the doctor, and the increased time spent with

the patient may allow more opportunity for support andinformation exchange.

“You get to know the patient better than the doctorbecause you see the patient on a daily basis, you seetheir family members. The physician sees them ona weekly basis and sometimes the patients are moreopen with you than with the physicians, you may geta more honest story from the patients than the physiciandoes”

There was a perception that “doctors treat the disease,not the patient” because the physician, out of necessity,needs to be more objective. A few participants commentedthat the relationship a nurse might have with the patientwould be similar in some ways to the radiation therapist,particularly if the nurse saw the patient for a protractedtreatment (for example, chemotherapy or dialysis).

The rapport built during weeks of treatment was alsodiscussed when comparing radiation therapy to diagnosticimaging. It was perceived that:

“Caring is different because when you’re going in fora one time X-ray or something like that, you don’texpect that much care. I want you to scan it and get meout of there, quick and easy”

� A communicator

The role of communicator also encompasses theconcepts of informer or educator and was seen as a vitalaspect of the radiation therapists’ role. As well as formaland informal patient education, the therapists discussedproviding patients with procedural information (e.g.,what will happen during treatment, how it will feel andso on).

“Like being on an airplane, I’m always scared becauseit’s bumpy, but if someone comes on and explains itmakes a big difference.”

They also identified the importance of updating patientson treatment delays, reminding them of other appoint-ments etc.

Communication can also be non-verbal, and radiationtherapists in the focus groups discussed the role of physicaltouch in caring for their patients:

“We just show it in our touch. When we go to help themoff the bed, it’s just a gentle touch on their back and soon”

An uncaring behaviour that was often cited was movingthe patient roughly during treatment set-ups:

“Rough handling e I’ve seen people man-handle patientsand it always makes me react physically. That’s theworse I’ve seen”

� An advocate

The participants felt strongly that their role includedspeaking or advocating for the patient using their knowl-edge and experience to help them to navigate through thesystem as well as to make patient-centered treatmentchoices.


� A team member

The role of team member includes both therapist-onlyand interprofessional teams (for “sharing the caring”).Within the group of therapists working together on a treat-ment unit, the caring and the tasks may be divided:

“I like how we have a team, because every member isa little different, they each care in their own way, so allthe bases are covered. One person remembers that thekids go to soccer, and they ask how the game was.Someone else will remember a certain side effect.Someone else will follow up to make sure a boost isbooked.”

Participants also commented that because this mutualinterdependence may be taken for granted, it is sometimesan unpleasant surprise when team members don’t feelcared for (for example, when therapists on other treatmentunits don’t provide help or support).

Caring as members of the larger interprofessional team(that includes doctors, nurses, physicists and other clini-cians) was noted as being important:

“Caring is making them understand that there arepeople beyond us, when they see us, that there’s a teamof multi-disciplinary people working, like volunteers,doctors and other professionals”

(ii) As an individual

The human caring relationship between patient andradiation therapist was seen as being influenced by severalfactors that related predominantly to the “carer” or radi-ation therapist, namely:

� Personality

This was seen to be multifaceted, the personality of thetherapist as well as the patient both influenced therelationship.

“You click with some people more than you do withothers”

In addition, it was held that some types of personalitymight be more suited to the role of radiation therapist thanothers:

“You can tell pretty early on, particularly if someone isgoing to be really good or really horrible and probablyshould be doing something else.”

Given these perceptions there was some discussionwhether caring could be taught if it wasn’t an inherentelement of the radiation therapist’s personality.

“You can describe it to a student, perhaps you couldmimic some of it, but would they actually be doing itgenuinely? I don’t know. They may eventually be able tolearn to a little better job, but I don’t think they’d beable to last long.”

However, one radiation therapist noted that there mightbe a natural variation in the amount of caring provided byradiation therapists but stated that “we all connect in someway with our patients.”

� Gender

There was considerable discussion about whether thegender of the radiation therapist has an effect on caring. Asthe profession of radiation therapy has a high preponder-ance of females, some people felt that women tend toforge more caring relationships with their patients. Some-times roles were divided on the treatment units, with thefemale therapists taking more of the responsibility for theemotional support of patients.

“Maybe females are more nurturing and willing to acceptthat role. If there is a female and she’s good at thepatient care the men kind of let the women do that”

On the other hand, some people felt that care dependedon the individual, not their gender.

It was also claimed that patients respond to male andfemale therapists differently, a female therapist remarkedthat “sometimes [the patients] tell you things if you’rea woman”. A male therapist agreed and commented, “Iwould say, it’s kind of harder to build those kinds ofconnections sometimes, although all the old ladies loveme.”

� Life experiences

As radiation therapists accumulate various life experi-ences, such as having children or losing someone close tothem through illness, they may relate to patients ina different way:

“I already think of me as a patient, whereas I neverthought of that before. The older you get the more likelyyou are that you will be a patient”

Gaining clinical experience can also lead to improvedinterpersonal skills as radiation therapists may generatea mental repertoire of similar scenarios to call upon. On theother hand, some participants felt that older staff couldbecome more cynical (and less caring) therefore staff withless years of experience might care more.

� Work environment

Where a person worked as well as the circumstancesthat they worked under were also seen as influences intheir ability to care. Many participants noted barriers tocare that included a busy daily patient schedule and aninadequate amount of time per patient. The culture of thecancer centre was also seen as influential:

“I think it also depends on the department, who themanager is, what they see as being the focus.”

Overarching theme 3: technical care

The role of the radiation therapist involves a unique blendof patient care skills and technical expertise. Howevera difference of opinion arose around the concept of tech-nical competency as caring. For example, there wasa disparity of opinion between participants when discussingplanning or dosimetry roles. Questions that emerged duringthe groups on this topic included, “Can you produce a plan


in a caring way if there is no contact with the patient duringthe process?” and, “Is the performance of a treatment setup with accuracy considered to be caring?” The dissonanceseemed to occur when the radiation therapists in the focusgroups felt there was no patient relationship or interactioninvolved in the work. However there was almost universalagreement that translating technology was caring e theconcept that the radiation therapist was the interfacebetween the patient and the equipment.


(i) Technical care versus patient care

There was agreement that a radiation therapist’s roleincluded both technical skills and patient care. Oneparticipant commented that, “most radiation therapists aregood at both of those things, but some people definitelyhave more skills one way or the other”. Some participantssaw technical skill and patient care as two separate roles orskill sets and others felt they were somehowinterconnected.

“I just think that if that’s all our job is (the technicalside) then there’s not a caring part to it.”

Another piece of this discussion was reflected in thedisagreement between participants as to whether non-patient contact roles/responsibilities, such as dosimetry orplanning, could be deemed caring:

“If you never see the patient, you have less buy inbecause you don’t even know who the patient is you justknow their name. So there’s the technical caring part ofit, but there is definitely something that is lacking there.You don’t even know who it is.”

Although there was disagreement with the concept thattechnical work could be seen as caring there was almostuniversal agreement that “caring as a therapist is demys-tifying that technology and making it less fearful”.

(ii) Perceived value of technical care

Participants felt that soft skills such as caring weresometimes undervalued, or seen to be less important thantechnical skills. In addition, caring often wasn’t measuredin any meaningful way. The only indicators that seemed tomatter were the number of patients treated, overtimehours and incident reports (i.e. indicators of output andtechnical accuracy).

“There’s no result just from being kind to someone, orlistening to them. How do you evaluate what that reallydid for someone? Whereas the technical part of it, like ifyou take a good image or match the cone beam, it’smuch easier to evaluate those things”

(iii) Doing your best work

This concept of best work includes taking the time toverify all machine and patient set up parameters, as well astreating patients according to policies and standards ofpractice. There was some disagreement over this concept.Some participants felt that caring could be “showing

patients the best expertise”. Whereas others felt that thereis “a standard of care there that all the professions have tomeet” and that is simply an expectation of the theme 1:human connection

Discussion

Overarching theme 1:human connection

To be cared for is a basic human need.3 Study participantsreflected that the patient-therapist relationship reflectedthis essentially human connection which was also expressedas respect, dignity, empathy and compassion. Many of theparticipants in the focus groups said that they had chosenradiation therapy specifically because they wanted to helppeople. This concurs with the allied health literature wherethe desire to help others is usually the most common reasonfor choosing a health care career.5

The distinction made by Widmark-Petersson et al.,17

that nursing care has both an expressive and instru-mental focus, is perhaps similar to the theme of humanconnection emphasizing the expressive aspect of caring.In radiation therapy, Colyer30 has called this “theempathic reaching out of one person to another” (p. 19)and makes the case that this is not a specialized profes-sional activity, but rather part of normal human behav-iour which is what most radiation therapy patients needand want. Similarly, a study by Halkett and Kristjanson39

found that that patients receiving treatment perceivedthe establishment of a personal relationship with theirtherapists to be of primary importance. This allowedpatients to achieve a sense of emotional comfort andfacilitated a two-way flow of communication, so patientscould access the information they needed during thetreatment process.

The concept of the patient at the centre of the treat-ment experience is an important component of manynursing caring theories.40,41 It is also the primary tenet ofthe patient-centered care movement, which "consciouslyadopts the patient’s perspective. about what matters.42”(p. 28). The idea of the patient as the focus of the thera-pists’ work described by one participant as being “fullypresent” is similar to the idea of providing presence foundin the nursing literature. This concept describes bothphysical and emotional presence e with appropriate eyecontact, body language, touch and receptive attitude.43

However, in nursing, it is also related to the idea that thenurse is at the client/patient’s disposal, for example, in aninpatient unit where a patient needs physical care requiringthe nurse’s presence. In radiation therapy, there are timeswhen the therapist is not physically with the patient.However, therapists may feel the importance of creatinga strong sense of presence (e.g. using an intercom orcamera to communicate) to counter the patient’s feelingsof isolation in the treatment room.

Participants spoke of seeing the patient as more thanjust a diagnosis and the importance of tailoring theirapproach holistically to take into account the “physical,developmental, emotional, social, intellectual and spiritualdimensions11” (p. 284) of patient care. In nursing, thisconsideration is seen as a pre-requisite to a functional and


therapeutic client-nurse relationship43 and the therapists inthis study seemed to support this idea.

The study participants felt a strong sense of emotionalreward and professional satisfaction from reciprocal rela-tionshipswith their patients. As the connection develops boththe therapist and patient learn about each other, allowinga supportivemutual relationship betweenpatient andcarer.44

The reciprocity of caring is a common theme in the nursingliterature. This relationship is seen as being transformative, inthat it changes both the patient and the carer.45

Overarching theme 2: identity

Although caring is a common concept, how it is expressed,delivered and received may vary. In this study, the carer isa healthcare professional whose roles and responsibilitiesare circumscribed by their professional boundaries e bothovert, such as policies, ethical guidelines and scopes ofpractice, and implicit, such as tacit professional mores. Thetherapist is also a unique individual with associated lifeexperiences, cultural background, gender and personalitytraits. Thus, the theme of identity encompasses both thecarer as a therapist and as an individual.

As a therapistA radiation therapist requires a balanced set of technicaland affective competencies46 and job satisfaction has beenlinked to the ability to use affective aspects of the role.47

The study participants, although acknowledging theirtechnical expertise, were conscious of the fact that theywere in a position to establish a relationship with thepatient that went beyond the delivery of the radiationtherapy treatment. “Choosing cancer” as a profession wasseen as a commitment on the part of the therapist to thepsychosocial aspect of patient care because people withcancer may require additional support. Furthermore, theopportunities afforded by daily treatment appointmentsallowed a strengthening of rapport.

One major difference between diagnostic imaging andradiation therapy is the amount of time the radiographerspends with the patient,25 which can significantly influencethe practitioner-patient relationship. Both the diagnosticimaging and radiation therapy environments are subject tothediminishment in care thatmay follow fromaprimary focuson maximum efficiency and throughput.21 However the shortsingle patient visit to an imaging department necessitateshighly accelerated rapport-building. Itwas perceivedbymanyparticipants in this study that the caring, or affective,component of the therapists’ role could be seen as “the dis-tinguishing factor that sets radiation therapy apart from theother radiologic science disciplines26” (p. 11).

Effective patient communication can help alleviatepsychosocial problems such as stress and anxiety.48,49

Patients having radiation therapy often feel that beinginformed is a major part of the support required from staffwho are “caring, sympathetic and prepared to take thetime to listen50” (p. 466). Relationships established withradiation therapists can allow patients to gain the infor-mation they need during their treatment experience.39

Therapists in this study confirmed that verbal and non-verbal communication was a vital aspect of their role and

physical touch was also identified as a way to conveycomfort and concern. Caring touch has been discussed innursing as a way to allow the nurse to connect with theclient, and to show acceptance of them as an individual.51

Good health care is predicated on effective and well-functioning teams.52 Teamwork is an integral part of prac-tice for radiation therapists22,53 as well as an importantcomponent of today’s interprofessional collaborativehealthcare environment.54 Participants had a strong senseof themselves as part of a larger team, and relied on theother members to share the care because the quality oftheir day could be dependent on the attitudes and theactions of their team.

As an individualCaring has been called “a product of the person’s culture,values, experiences and relationships11” (p. 288) includingwhere they were educated and the organization in whichthey work.14 Patients also have individualized concepts ofcaring and how it should be expressed.55 This was reflectedin the focus group discussions e the unique perspective ofthe radiation therapist would influence the care theyprovide. In nursing it has been noted that practitionersshould assess and be aware of their own perceptions ofcaring14 and the same would seem to apply to radiationtherapists.

Kerr Wood11 claims that “scholars disagree as to whethercaring can be taught or is more fundamentally a way ofbeing” (p. 288). The participants of this study had the samereservations. There have been numerous attempts toquantify and measure caring in an attempt partly todetermine if students and practitioners are “doing itright6”. However, problems remain in “defining and oper-ationalizing humanism and its components8” (p. 490). Inradiography Dowd has noted that “the subject must bedefined before it can be taught56” (p. 242).

Participants reflected that their work environmentsignificantly influenced their ability to care which includedthe organizational culture and more practical issues such aslack of time. Common barriers to caring found in thenursing literature include a decrease in available time tospend with patients/clients as well as increasing relianceon technology and institutional efforts to streamline workprocesses that can sometimes cause clients to feel deper-sonalized.11 Similar barriers have been identified in radi-ography, with the addition of a potential lack of training incommunication and comfort in using caring skills.24,56

Overarching theme 3: technical care

Recalling the distinctions made by Widmark-Peterssonet al.,17 between expressive and instrumental care, thepotential difficulty in relying too heavily on nursing defini-tions of care and caring is evident. Nursing instrumentalcare is always carried out with the patient present (e.g.measuring vital signs, making them comfortable in bed,administering medication etc). Although most radiationtherapy patient-related tasks are also done with thepatient present, there are some that are not (for example,dosimetry or planning). This perhaps leads to the disso-nance seen in the study where therapists seemed tostruggle with the idea of caring in the absence of a patient.


Some focus group participants envisaged a sort of caringspectrum with planning/dosimetry at the low caring end.This end represents high technology with little or no actualpatient communication or contact. The high caring endinvolves no technology with a lot of direct patientcommunication or contact that consists of one-on-oneemotional and educational support. Radiation therapytreatment set ups were seen as being somewhere in themiddle of the spectrum with a mix of both patient contactand high technology. However, some participants did feelthat high technology/low patient contact activities couldstill be performed in a caring way.

In a study examining the attitudes of radiation therapiststo participating in highly technical treatments (intensity-modulated radiation therapy) a similar result was found.57

Technology and patient care were hard to separate forthe participants and were not seen as mutually exclusive.Participants generally enjoyed working with new tech-nology and found it stimulating, but also maintaineda strong patient focus.

Ekmekci and Turley26 analyzed job advertisements andrecruitment material for radiation therapy schools andcolleges in the US using content analysis. They found thatsuch public images are overwhelmingly technical in nature(e.g. images of treatment units, planning computers and CTscanners) rather than emphasizing patient care andcontact. This is not surprising given that symbols of scienceare usually deemed more prestigious than symbols of caringor humanism.21 What is interesting, however, is that thestudy looked at images aimed at future (i.e. potentialstudents) and current radiation therapists, rather than thelay public. This may suggest that colleges, schools andemployees feel that radiation therapists themselves placemore value in the technical side of their profession. Thisaccords with themes found in this study where participantsfelt that caring was not as valued, or routinely captured, astechnical competence. Similar grievances are heard innursing, where nurses feel they are not “emotionally,socially or economically recompensed for the time andenergy they spend on caring14” (p. 488).

Over the last decade, practitioners in nursing have beenincreasingly reliant on technology and certain areas of theprofession have become highly computerized (e.g. criticalcare). This would seem to be in direct conflict with nurs-ing’s professed high touch focus and emphasis on humancaring as an essential nursing competency. Indeed thenursing literature documents the profession’s struggle tomarry the traditional view of hands-on nursing with thegrowing use of machinery. McConnell58 has called nursesworking in high-tech areas “expert symphony conductors”who balance the so-called art and science of nursingpractice. Some nursing scholars, however, see this tech-nological competence as essentially removed from the corebusiness of nursing, and view technical proficiency andpatient care as opposite ends of a spectrum. The attemptto marry the two elements of modern nursing is a source ofmanifest tension e and has been deemed technical disso-nance.59 It is unsure whether dissonance is too stronga term for the debate seen in this study, however partici-pants often struggled over the technical aspects of theirrole when trying to relate them to caring. While acknowl-edging the essential nature of technical expertise, they

often expressed difficulty fitting the idea of technology,including planning and dosimetry, into the concept of care.

Humanizing technology, or softening the impersonaltechnological aspects of radiation therapy treatment, wasseen unequivocally as an important radiation therapist role.The technology-humanism dualism and the struggle toreconcile them is a common topic in the literature7 so it isperhaps unsurprising that it was also observed in this study.However participants usually acknowledged that there isa need for a balance between the technologist role andcarer role in the profession. The idea of the dual role of theradiation therapist has been established22,26,28,57 butperhaps more focused attention needs to given towardsdeveloping technologic consonance.59

Conclusions

In general, radiation therapists clearly articulated theconcept of human caring, and how it is encompassed bytheir role. It was less clear (and somewhat contentious)how the technical aspects of the role represented caring.When compared to nursing, there has been scant explora-tion of caring in radiation therapy. While nursing providesguidance in the definitions of caring, we must be aware ofthe differences between the professions. Nursing hasevolved from a hands-on profession with little or no tech-nology and it has been said that technology extends theability of the nurse to deliver care, but nurses are notdependent on it.58 Radiation therapy, on the other hand, isa splinter profession of radiography and has evolved toutilize a specific technology. It could be strongly arguedthat radiation therapists are dependent on technology, asthe profession could not exist without it.

There is some evidence that radiation therapists feelsomewhat undervalued and misunderstood.60 To counterthis feeling, it is important that radiation therapists utilizeand value all aspects of their role. Job satisfaction is linkedto intrinsic rewards, such as the ability to utilize patientcare skills, and roles should therefore be designed to allowtherapists to perform aspects of their role that they (andpatients) value.46,61,62 It is noteworthy that many of theadvanced roles developing in Canada, Australia and theUnited Kingdom63 emphasize patient care and support.These roles build on and expand the radiation therapists’humanistic competencies and perhaps could be said to“facilitate the coalescence of technology and humanism58”(p. 27).

Nurses and patients often have a different idea of whatconstitutes caring14,64,65 and it is likely that the samedisconnect exists in radiation therapy. Individualizing thecare can assist with this but further research is importantto explore radiation therapy patients perceptions ofcaring. Strategies identified in nursing to increase caringbehaviours (aside from individual commitment) includegreater work flexibility, rewards for nurse mentors,improving staffing levels and increasing autonomy. Healthcare professionals, such as radiation therapists, practicingin the high stress environment of cancer care needcontinuing support after graduation in the area ofcommunication to develop and maintain their skills.66

Clinical supervision, mentorship, reflection and


professional development may all be useful sources ofsupport that could be explored.

Other measures include acknowledging the value andimportanceof caring, bymaking caringpart of thephilosophyof the work environment, and standards of professionalpractice.11 Arguably, most of those strategies could also beemployed in a radiation therapy setting but such interven-tions would need to be evaluated for their effectiveness.

This is a preliminary small-scale qualitative study;therefore the findings should not be overstated andconclusions drawn may not hold true for all institutions andpractice settings. The results can, however, provide infor-mation about a specific situation and may serve as a guidefor similar investigation in other areas. It is clear, however,that discussion, debate and further research are needed toproduce “an ontology of caring56” (p. 242) for therapists topractice, teach and value the caring they offer theirpatients.

Acknowledgements

The authors would like to thank Lisa DiProspero (OdetteCancer Centre) and Heidi Probst (Sheffield Hallam Univer-sity) for their generosity in editing this article.

Funding for this project was received from the OntarioAssociation of Medical Radiation Technologist’s M.E. (Beth)Wastle Bursary.

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