Clinical reasoning in image guided radiotherapy: A multimethod study

Introduction 3D Image Guided Radiotherapy (IGRT) using cone beam computer tomography has been implemented into the UK over the last decade. There is evidence to suggest that the training of therapeutic radiographers and the development of departmental processes may not have kept pace with the implementation. A literature review highlighted a paucity of evidence relating to how therapeutic radiographers make clinical decisions during image interpretation in the IGRT processes. Purpose The study aimed to investigate the types of decision-making processes used by therapeutic radiographers during image interpretation in IGRT. In addition, the study aimed to investigate the factors that impact on the decision-making processes of therapeutic radiographers during IGRT. Method A multimethod research design was adopted that utilised a think-aloud observational method with follow-up interviews. Thirteen participants were observed and interviewed across three United Kingdom (UK) radiotherapy centres. Participants were observed reviewing and making clinical decisions in a simulated environment using clinical scenarios developed in partnership with each centre’s Clinical Imaging Lead. Protocol analysis was used to analyse the observational data. Thematic analysis was used to analyse the interview data. Member checking was carried out using an online presentation and questionnaire, along with periodic peer debriefing by the supervisory team. Findings from the observations and semi-structured interviews were then combined using a triangulation protocol. Results Therapeutic radiographers were observed using one of three decision-making processes. These assume the titles simple linear process, linear repeating process and intuitive process. Participants were found to prioritise the target volume to be treated over the organs at risk. There were notably mixed opinions on the impact of overall therapeutic radiographer experience on decision-making. The findings of the study align with general principles of expert performance, which claims that expertise is only improved by seeking out particular kinds of experience and carrying out deliberate practice in this specific task or specific area of practice. A descriptive module was developed to demonstrate the factors that impact on decision-making. The centre structure, training and the wider involvement of the multidisciplinary team were all found to be key factors that impacted on the decision-making process during IGRT. Staffing levels and communication patterns between the multidisciplinary team were found to be highly variable across the three centres. Greater communication and involvement of the multidisciplinary team was found to improve therapeutic radiographers’ confidence in making clinical decisions. Issues in relation to pre-registration training were highlighted, with a consensus that recent graduates do not always demonstrate the skills and experience required to make clinical decisions. A lack of education in relation to clinical decision-making was highlighted at both pre-registration and post-qualification levels. A conceptual model to improve clinical decision-making in image interpretation during IGRT was developed and is presented in the thesis. Conclusion This research has provided new and original insight into the decision-making processes of therapeutic radiographers. It has demonstrated that therapeutic radiographers utilise complex processes during image interpretation in IGRT. It has shown that numerous factors affect the decisions that therapeutic radiographers routinely make, and that with improvements in education and radiotherapy centre infrastructure, therapeutic radiographers can be better placed to make safer, more effective decisions during the IGRT process.