Development and pilot of an international survey: ‘Radiation Therapists and Psychosocial Support’

Abstract Introduction Up to one third of radiation therapy patients are reported to have unmet psychosocial needs. Radiation therapists (RTs) have daily contact with patients and can provide daily psychosocial support to reduce patient anxiety, fear and loneliness. However, RTs vary in their values, skills, training, knowledge and involvement in providing psychosocial support. The aims of this study were to: (1) develop an online survey instrument to explore RT values, skills, training and knowledge regarding patient anxiety and psychosocial support, and (2) pilot the instrument with RT professionals to assess content validity, functionality and length. Method An online cross‐sectional survey, titled ‘Radiation therapists and psychosocial support’ was developed. Items included patient vignettes, embedded items from RT research, and the Professional Quality of Life Scale (ProQOL5). Four radiation oncology departments volunteered to pilot the survey; each nominated four RT staff to participate. Survey data were analysed descriptively and qualitative feedback grouped and coded to determine whether the survey needed to be refined. Results Thirteen of sixteen RTs completed the pilot survey and feedback form. Median time to completion was 35 mins, with 54% of respondents stating this was too long. Respondents reported content, questions and response options were relevant and appropriate. Feedback was used to: refine the survey instrument, minimise responder burden and drop out and improve functionality and quality of data collection. Conclusion This pilot of the ‘Radiation therapists and psychosocial support’ survey instrument demonstrated content validity and usability. The main survey will be circulated to a representative sample of RTs for completion.


Introduction
People diagnosed with cancer are likely to experience some psychosocial distress across their cancer trajectory including emotional, social, spiritual and psychological concerns 1 . Both Australian and international statistics reflect the significant issue of psychosocial concerns affecting cancer patients. In Australia, up to 66% of people with cancer experience long-term psychological distress, and clinically significant anxiety and depression rates have been reported to be 30% and 20-35% respectively 2 . Furthermore, 75% of cancer patients with clinically relevant anxiety and/or depression did not receive counselling or psychological treatment. 3 These high levels of psychosocial distress and unmet needs in people with cancer have been recognised globally, and have led to the development of psychosocial care guidelines for clinicians in Australia, Canada, United States of America and Europe. 1,2,[4][5][6][7] These guidelines state that psychosocial care involves all health care professionals (HCP) in cancer care, 2 however, no clear evidence exists demonstrating the implementation of these guidelines by radiation therapists (RTs) into routine practice.
It was estimated that 134,174 Australians would be diagnosed with cancer in 2017 8 and approximately half could benefit from radiation therapy. 9 In research conducted in a radiation oncology environment, Mackenzie et al. found that up to 31% of radiation therapy patients reported their care and well-being could have been improved across two or more patient-centred care domains of psychosocial care. The most frequently reported categories were: information and communication; emotional and spiritual support; management of physical symptoms; and involvement of friends and family. 10 Possible reasons for this include lack of multidisciplinary teams, sub-optimal co-ordination of care, lack of/or overburdened services, and/or lack of professional knowledge in psychosocial care domains.
RTs are members of the multidisciplinary oncology team responsible for radiation therapy treatment planning and delivery. RT roles include technical and patient care such as communication regarding procedures and technical aspects of treatment, hygiene and self-care during treatment and appointment scheduling. 11 As the only members of the radiation oncology team engaging daily with patients throughout their radiation treatment, RTs are uniquely positioned to provide psychosocial support such as patient education and information, or referral to psychosocial services. RTs are motivated to deliver this support according to Hulley who reported 85% of RTs surveyed entered the profession to provide care and emotional support to patients. 12 Furthermore, Bolderston identified altruism and a desire to help people with cancer, as a common motivator to become an RT. 11 Despite this high level of motivation, RTs are reported to lack confidence and feel inadequately trained or prepared to discuss psychosocial issues. 11,[13][14][15] Trained professionals with expertise in providing psychosocial care include psychologists, psychiatrists, social workers, counsellors and pastoral carers. We are not proposing RTs fulfil the role of these professionals; rather, RTs are part of the multidisciplinary team who share the responsibility of facilitating holistic care, including psychosocial support. The extent of RT involvement in psychosocial care will vary based on knowledge, confidence, experience, professional networks and local services available and importantly patient needs.
Most research investigating psychosocial support for cancer patients has not included RTs. 16,17 We conducted a systematic review focused on RT led psychosocial support and its impact on patient anxiety. Of 12 publications identified, three were specific to 'Patient Perspectives' (qualitative), five to 'Patient Information/ Education' and four to 'Screening and Needs Assessment'. The review indicated RTs do provide daily supportive care that can reduce anxiety, fear and loneliness. To achieve this, RTs build rapport with patients and provide emotional comfort, information and education. 18 RT use of screening and needs assessment tools was shown to be feasible and resulted in increased communication and knowledge of patients' psychosocial concerns. 17,[19][20][21] RT motivation to use screening tools varied, but training appeared to increase RT co-operation. 18 Our review summarised current knowledge of RT-led provision of psychosocial care and identified gaps in the literature. 18 Four areas requiring further investigation were recognised: RT role clarification; availability and uptake of communication skills training; knowledge of psychosocial referral pathways; and RT involvement in screening and needs assessments. 18 Consequently, we proposed to conduct an online survey exploring RT perceptions of, and experience in, identifying and managing psychosocial distress. The aims of this paper were to report: 1 the development of an online survey instrument 'Radiation Therapists and Psychosocial Support Survey'; and 2 the pilot of this instrument with RT professionalsassessing content validity, functionality and length

Survey development
A multidisciplinary research team was formed, including one radiation oncologist, two radiation therapists and one behavioural scientist. An online survey was designed using Qualtrics survey software. Use of an online data collection strategy was selected as it is inexpensive, wide reaching and facilitates complete and accurate data collection. 22 Survey construction was influenced by published guidelines and tailored to an RT population. [22][23][24] Ethics Ethics approval was granted by the University of Sydney Human Research Ethics Committee (project number 2016/227).

Survey items
The 'Radiation Therapists and Psychosocial Support Survey' instrument comprised 147 items grouped into 11 sections (Table 1). This included items and patient vignettes developed for this study, as well as existing questionnaires. All items were reviewed by the research team to ensure study objectives were met. Items were designed to include qualitative and quantitative  • question and response types • question and response clarity • logical grouping and order of topics/questions • maintaining anonymity and confidentiality Other survey instrument sections not detailed above were: Section 1 -Participant Information Statement including instructions, ethics and consent; Section 2 -Demographics -Individuals and place of employment; Section 9 -Communication Skills Training (post-test); Section 11 -Additional Information including free text comments, and requests to receive CPD points, study results and/or to be notified of future research.

New items
New items were developed to explore the following knowledge gaps (Table 1): RT role definition (section 3); RT communication skills/training (section 3); RT skill in identifying emotional distress (section 6) and use of screening and needs assessment tools (section 7). RT communication skills have been associated with RT confidence and burnout, therefore items were developed to explore this relationship (section 10). 14,25

Patient vignettes
To assess RT ability to detect and manage patient anxiety, three vignettes based on common presentations of radiation therapy patients with psychosocial needs were developed. Using structured vignettes is an informative approach to assessing skills, and examining factors that influence respondents. 26 Guided by previous research, the vignettes describe three fictitious patients in a radiation therapy setting, with non-gender-specific names and diagnoses to minimise potential gender biases. 26,27 The vignettes depicted patients with varying levels of anxiety and were followed by these four questions (Table 1, section 6): select appropriate descriptors for each patient, list key indicators leading to the selection of these descriptors, list appropriate management for each case, and indicate appropriateness of psychosocial referral.

Existing items and instruments
Permission was obtained to embed the Professional Quality of Life Scale (ProQOL5) and items designed by Hulley in research regarding RT interactions with emotional patients.
ProQOL5 is a freely available instrument assessing burnout in 'helping professions'. It has been widely used in healthcare groups and demonstrated good construct validity. It consists of 30 items, in three sub-sections, and uses a five-point Likert response scale. It generates three scores: (i) compassion satisfaction; (ii) compassion fatigue burn out; and, (iii) compassion fatigue secondary traumatic stress. The reported reliability and validity value for the compassion satisfaction and burnout scales are a = 0.88 (n = 1130); and a = 0.75 (n = 976) respectively. 28 Twenty-six items designed by Hulley, explored the perceived value of RT interactions with emotional patients, and the perceived availability of resources in the work environment to enable RTs to support emotional patients (Table 1,

Pilot survey and pilot feedback form
Radiation therapy departments volunteered to participate in the pilot, following a presentation (by the first author) at the New South Wales Radiation Therapy Research Showcase. A representative in each department was asked to invite four RTs to assess survey feasibility by completing the online survey and pilot feedback form. Guidelines suggested that invited RTs include a range of: sex, age, experience, interest in patient care and clinical/ non-clinical responsibilities. An email invitation, survey link and feedback form was forwarded to RTs. The participant information statement was available to participants prior to commencing the survey and outlined the following: the purpose of the study, participation is voluntary, ethics approval details and contacts, consent was implied by survey submission, and contact details for two of the researchers. The feedback form consisted of 12 open-ended questions to encourage qualitative feedback regarding survey content validity, clarity, internal consistency, appropriateness, intent, length and flow. 29 The pilot survey and feedback form can be found in Data S1-S2 or requested from the corresponding author.

Pilot process
Three distinct groups, with expertise in medical radiation sciences, medicine, and/or psychology, assessed content validity, clarity of items and item groupings. These groups offered differing perspectives on the relationship of items to the conceptual domain of the survey, which led to survey refinement.
The first group, pilot respondents, completed the survey and the pilot feedback form. The second group consisted of professional association representatives and academics who provided written feedback regarding content validity and survey relevance to international RTs. Thirdly, the research team formed the panel of experts to finalise survey content, based on feedback from groups 1 and 2. 29

Results
Invitations to participate in the pilot were sent to 16 RTs in four radiation therapy departments. These departments included a mix of urban, outer metropolitan, public and private organisations. Thirteen RTs (81% response rate) completed the pilot survey (online) and feedback form (via email). Twelve participants responded within two weeks of the email invitation. A reminder was sent two weeks post-initial invitation, generating receipt of one further survey and feedback form. Of note, one feedback form was returned incomplete ( Table 2). The 81% response rate demonstrated acceptability of the survey concept by the target group. Demographics collected, showed a range of personal and work place characteristics (Table 3). No data were collected from the three nonresponders.
Responses to feedback questions were compiled into four thematic groups: (i) time/survey length; (ii) content; (iii) functionality and (iv) other. The responses were discussed by the research team and consensus reached regarding how to amend the survey instrument (Table 4).
i) Time/Survey Length Seven of 13 respondents reported time to complete the survey was too long (median 35 min, range 20-50 min). To reduce the survey length and respondent burden, the following items were removed: • one item (2.8) requesting postcode of the radiation therapy department; • two post-vignette items (9.2 and 9.3 repeated before and after the vignettes) related to the 'perceived need and motivation for communication skills training'; • one vignette and related items (6.12-6.16) as suggested by two respondents. One respondent suggested removing all vignettes; however, based on overall feedback and research team preference, two vignettes were retained.

ii) Content
Survey questions and response options were clear, appropriate and relevant according to 11 of 13 respondents. Three comments suggested neutral response options to three items (4.2, 8.2 and 8.4) would be preferable. These were existing items from survey tools, hence this change was not made, as the research team wanted to ensure comparability of results with previous studies.
One respondent noted requesting date of birth (DOB) may deter RTs from completing the survey. Researchers felt DOB was useful to enable more accurate data reporting and that participants were not at risk of being identified due to confidentiality protocols and the large sample size of the main survey. Consequently, DOB was changed to a non-mandatory field.
Following feedback from one respondent, one item (3.7) regarding training in the area of patient care, was reworded to include both face-to-face and online training.
iii) Functionality Three respondents highlighted the absence of a 'back' button to view previous information. Therefore, a 'back' button was added.
iv) Other Two respondents provided positive comments relating to the survey and research concept.

Interviews
The pilot feedback form asked participants to provide consent and contact details if they were willing to be contacted for an interview. Five participants provided these details, however, the research team decided not to conduct interviews as the feedback was clear and consistent, and no further information would be gained.

Additional Information
In addition to the pilot process, three medical radiation professionals (identified by professional medical radiation associations in Australia, New Zealand (NZ) and Canada) as well as one medical radiation academic reviewed the survey instrument and provided written feedback. The survey was sent to these reviewers as a word document via email and feedback was returned to the first author. This process was conducted after the pilot. This feedback was supportive and highlighted the value of this research. The concerns raised were survey length and the sensitive nature

Discussion
An online survey was selected as an effective method to explore RT values, skills, training and knowledge regarding psychosocial support for patients undergoing radiation therapy. An online survey is an inexpensive, wide reaching approach, which enables collation and analysis of large volumes of data in a short timeframe. 22 Other multicentre surveys targeting RTs have yielded encouraging response rates in Australia, NZ and Canada, of 37-41%, 48% and 21-36% respectively 7,12,14,[30][31][32][33][34] .
The 'RTs and Psychosocial Support Survey' instrument was developed to address gaps in the literature regarding provision of psychosocial support in the radiation RT, radiation therapist.  (Table 1). Existing items were embedded and literature-guided survey development to ensure data could be compared. Piloting a survey is an important component of the development, feasibility and evaluation process. 23,24,35 The pilot was conducted to test the acceptability and suitability of the online survey and recruitment process among a convenience sample of RTs. RTs provided valuable information on content validity, face validity, length of survey and functionality. An 81% response rate and positive feedback indicated strong support for the survey and psychosocial care research in radiation therapy. This feedback was reinforced by professional associations who agreed to support, circulate and promote the main survey to their membership.
The pilot study resulted in a more concise survey instrument, with increased likelihood of completion by busy RTs. This survey instrument is potentially applicable in multiple radiation oncology departments globally, to assess RT values, skills, training and knowledge specific to detecting and managing patient anxiety. This instrument provides a contribution to the field of radiation therapy 22 that may be used by others in future research, with potential to improve the delivery of psychosocial care and reduce the number of patients with unmet psychosocial needs.
Following the pilot and instrument refinement, the main 'Radiation Therapists and Psychosocial Support Survey' was launched via Qualtrics to RTs in Australia, NZ and Canada. These countries formed the target demographic due to similarities in training, workforce and clinical practice. Publications related to RTs, psychosocial support and burnout produced by these countries further strengthened the decision to invite them to participate. Data yielded from this survey will be compared to existing literature to test generalisability across a larger sample. Results of the main survey will be detailed in future publications.
There were limitations to this study. First, surveys are susceptible to responder bias and we did not collect demographics of non-responders, or reason for not responding. Second, the survey was estimated to take 30 mins to complete and requested sensitive information. These factors may have led to RTs not completing the pilot survey. Lastly, all pilot participants were recruited from one Australian state. To address this issue of convenience sampling and assess survey content validity for a wider audience, the pilot survey was reviewed by local and international academics and professional associations.

Conclusion
Piloting the online survey instrument was informative. Feedback provided by participating RTs resulted in modifications to reduce survey length, clarify content and increase functionality of the instrument. The pilot process resulted in a refined survey instrument, which will minimise responder burden and drop out, and improve the likelihood of obtaining a representative sample of RTs in the main survey. These results demonstrate that the 'Radiation Therapists and Psychosocial Support Survey' is a useable instrument likely to yield informative results in exploring RTs values, skills, training and knowledge regarding patient anxiety and psychosocial support.