A model as a framework of reference to facilitate wholeness among

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A MODEL AS A FRAMEWORK OF REFERENCE TO FACILITATE
WHOLENESS AMONG THERAPY RADIOGRAPHERS
by
HEATHER ANN LAWRENCE
THESIS
Submitted in fulfilment of the requirements for the degree
DOCTORATE IN TECHNOLOGY
in
RADIOGRAPHY
in the
FACULTY OF HEALTH SCIENCES
at the
UNIVERSITY OF JOHANNESBURG
SUPERVISOR: PROF. M. POGGENPOEL
CO-SUPERVISOR: PROF C.P.H. MYBURGH
May 2012
i
DEDICATION
I dedicate this thesis to my late mother, whose life story is a perfect example
of wholeness. Mom you were a true lady and I love and miss you dearly.
ii
ACKNOWLEDGEMENTS
This research would not have been possible without the love and support of
many people, some of whom I have listed below.

To
my
husband,
Christopher
for
his
support,
patience
and
understanding.

To my children, Nicholas and Matthew for being happy little boys who
never complained when I had to work.

To my dad, Dereck and sister, Jennifer for all the child care and
practical assistance so selflessly given.

To Happiness, for keeping my boys so busy and happy that they never
noticed the hours I spent working while they played.

To all the staff at the radiation oncology department that gave their
time and their stories so willingly to me. I hope that this research will
bring about the change that you so deserve.

To my work colleagues, especially Barbara, whose encouragement
and support made the work of this thesis possible.

To the University of Johannesburg, staff incentive scheme, for the
financial assistance given by way of tuition fees for the Degree.

To my supervisors, Prof. Poggenpoel and Prof. Myburgh, for whom I
have enormous respect and admiration. Your ability to motivate and
guide whilst being mindful of my personal journey was inspirational and
was undoubtedly the single most important factor in the completion of
this work.

My sincere thanks to Glenda Buncombe for the meticulous language
editing of this thesis and to Jenny Seagreen for the care taken to
ensure the layout of the thesis was professionally executed.
iii
ABSTRACT
Therapy radiographers generally start their careers excited to be part of a
medical environment and enthusiastic about the rapid technological
advancement that they can envisage being a part of. Typically, in an oncology
setting, a naive enthusiasm for helping patients with cancer rapidly spirals
into disillusionment as the stress of working in a profession with no room for
error and little opportunity for career advancement takes its toll. Radiography
literature has focused on identifying problems such as stress, burnout and a
lack of organisational commitment without any constructive attempt to look for
the positive attributes of the profession that could assist therapy radiographers
to achieve professional or personal wholeness (Akroyd, Caison & Adams,
2002:818; Rutter & Lovegrove, 2008:140; Makanjee, Hartzer & Uys, 2006:
121; Probst & Griffiths, 2007:22).
The purpose of this theory generating study was to describe the process of
being a therapy radiographer in an oncology department of a tertiary hospital
in Gauteng. This served as the basis for the development of a model to
facilitate wholeness as part of a professional identity for therapy
radiographers. The study utilised a qualitative theory generating research
design, using appreciative inquiry to identify a central concept for the model
development. The philosophy of science that guided the research design was
that of a post-modern constructivist paradigm.
The population for the research were the therapy radiographers employed at
a Radiation Oncology Department in a tertiary hospital in Gauteng.
Purposeful sampling was used to select participants. Data collection utilised
focus group interviews employing an appreciative enquiry interview technique
and reflective field notes were taken during and after each focus group
interview. Data analysis was conducted by means of open coding as
iv
described by Creswell (2003:190-195). The central concept was defined by
identifying central criteria by means of a dictionary and subject literature. The
concepts identified were written into relationship statements in order to
develop a preliminary conceptual model as the framework for the research. A
conceptual model was developed using Chinn and Kramer’s (2011: 152-205)
process for empiric knowledge development. Guidelines to operationalize the
model were described to assist the clinical application of the model in a
radiotherapy setting. The model was evaluated by means of critical reflection.
v
TABLE OF CONTENTS
Page
CHAPTER 1: RATIONALE FOR AND OVERVIEW OF THE
....................................................
1
........................................................
1
RESEARCH
1.1
INTRODUCTION
1.2
CONTEXT AND RATIONALE
1.3
PROBLEM STATEMENT
1.4
PURPOSE AND OBJECTIVES
1.5
PARADIGMATIC PERSPECTIVE
1.5.1
1.5.2
1.6
..........................................
4
...............................................
7
......................................
....................................
Metatheoretical assumptions
11
................................
13
..............................................
13
.................................................
13
1.5.1.1
Person
1.5.1.2
God
1.5.1.3
Environment
1.5.1.4
Wholeness
........................................
14
.........................................
14
Theoretical assumptions
DEFINITIONS
10
.....................................
14
.........................................................
15
1.6.1
Therapy radiographer
1.6.2
Wholeness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
1.6.3
Facilitation
1.6.4
Model
........................................
15
....................................................
17
.........................................................
17
1.7
METHODOLOGICAL ASSUMPTIONS
..............................
17
1.8
RESEARCH DESIGN AND METHOD
...............................
20
1.8.1
Research design
.............................................
21
1.8.2
Research method
............................................
22
1.8.2.1
Step 1: Concept analysis
1.8.2.2
Step 2: Relationship statements
1.8.2.3
Step 3: Description of a model
1.8.2.4
Step 4: Guidelines to operationalise
the model
..........................
22
..................
28
....................
28
...........................................
28
vi
1.9
TRUSTWORTHINESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
1.10 ETHICAL CONSIDERATIONS
1.11 CONCLUSION
.......................................
32
........................................................
33
1.12 ORGANISATION OF CHAPTERS
...................................
CHAPTER 2: RESEARCH DESIGN AND METHOD
......................
36
......................................................
36
2.1
INTRODUCTION
2.2
PURPOSE OF THE RESEARCH
2.3
RESEARCH DESIGN AND METHOD
2.4
2.5
34
....................................
36
...............................
37
............................................
37
2.3.1
Theory generating
2.3.2
Qualitative
....................................................
38
2.3.3
Exploratory
...................................................
39
2.3.4
Descriptive
....................................................
39
2.3.5
Contextual
....................................................
39
2.3.6
Appreciative inquiry
..........................................
40
REASONING STRATEGIES
.........................................
41
2.4.1
Deductive reasoning
.........................................
41
2.4.2
Retroductive reasoning
2.4.3
Inductive reasoning
......................................
42
..........................................
42
THEORY-GENERATING RESEARCH METHOD
2.5.1
Step 1: Concept analysis
...................
43
....................................
43
2.5.1.1
Identification of a central concept
2.5.1.2
Concept definition and classification
.................
43
..............
49
.............................
51
..............................
52
2.5.2
Step 2: Relationship statements
2.5.3
Step 3: Description of a model
2.5.4
Step 4: Guidelines to operationalise the model
.............
55
2.6
TRUSTWORTHINESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
2.7
CONCLUSION
........................................................
59
vii
CHAPTER 3: RESULTS OF APPRECIATIVE INQUIRY INTER.............
61
.......................
62
..............................................
63
VIEWS WITH THERAPY RADIOGRAPHERS
3.1
DEMOGRAPHICS OF THE PARTICIPANTS
3.2
THE CENTRAL STORY
3.3
THEME 1 – LIFE-GIVING FORCES THAT PROMOTE
PERSONAL AND PROFESSIONAL ENGAGEMENT
RESULTING IN A SENSE OF PURPOSE
3.3.1
Personal and professional recognition and appreciation
3.3.2
Fulfilment from helping patients
3.3.3
Close personal involvement with patients and
colleagues
3.3.4
3.4
...........................
....
68
.............................
70
....................................................
Providing a professional service
.............................
73
76
THEME 2 – PROFESSIONAL STAGNATION FROM A LACK
OF SELF-WORTH AND INTERPERSONAL CONFLICT
3.4.1
...........
80
....................................................
80
Lack of self-worth and feelings of professional
stagnation
3.5
67
3.4.2
Interpersonal conflict between team members
3.4.3
Relationship with the professional environment
.............
83
............
88
THEME 3 – FACILITATING CHANGE TOWARDS
WHOLENESS THROUGH HARNESSING THE POSITIVE
ENERGY AND COMMITMENT FOR CHANGE
3.6
.....................
93
3.5.1
Developing a positive relationship with self
3.5.2
Further development of self as a professional
3.5.3
Skills to be developed
3.5.4
New behaviours to be developed . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
3.5.5
Developing positive relationships with others
CONCLUSION
.................
..............
.......................................
94
96
100
..............
108
.......................................................
113
viii
CHAPTER 4: DEVELOPMENT OF A CONCEPTUAL FRAMEWORK
FOR THE MODEL TO FACILITATE WHOLENESS
..................
115
....................
115
AMONG THERAPY RADIOGRAPHERS
4.1
IDENTIFICATION OF A CENTRAL CONCEPT
4.2
CONCEPT DEFINITION AND CLASSIFICATION . . . . . . . . . . . . . . . . . . 118
4.3
4.2.1
Dictionary definition of facilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
4.2.2
Subject definition of facilitation
4.2.3
Dictionary definitions of professional
4.2.4
Subject definitions of professional
4.2.5
Dictionary definitions of identity
4.2.6
Subject definitions of identity
.............................
120
.......................
121
..........................
123
............................
125
...............................
127
CREATING CONCEPTUAL MEANING FOR THE CONCEPT
OF FACILITATION OF A PROFESSIONAL IDENTITY
............
129
................................................
130
4.3.1
A model case
4.3.2
A contrary case
..............................................
131
4.4
CLASSIFICATION OF THE CONCEPTS
4.5
THE DEVELOPMENT OF RELATIONSHIP STATEMENTS . . . . . . . 134
4.6
CONCLUSION
...........................
.......................................................
133
137
CHAPTER 5: DESCRIPTION OF THE MODEL TO FACILITATE
WHOLENESS AS PART OF A PROFESSIONAL
...........
136
.....................................................
136
IDENTITY FOR THERAPY RADIOGRAPHERS
5.1
INTRODUCTION
5.2
AN OVERVIEW OF THE MODEL
5.3
THE DESCRIPTION OF THE MODEL
...................................
137
..............................
139
..................................
140
5.3.1
The purpose of the model
5.3.2
The theoretical assumptions of the model
5.3.3
The context of the model
5.3.4
Theoretical definitions of the model concepts
5.3.5
Relationship statements
.................
141
...................................
143
.............
143
....................................
146
ix
5.4
5.3.6
The structure of the model
..................................
147
5.3.7
The model process
..........................................
150
...........................................
150
5.3.7.1
Planning
5.3.7.2
Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
5.3.7.3
Evaluation
.........................................
GUIDELINES TO OPERATIONALISE THE MODEL
...............
161
.....................................................
161
5.4.1
Planning
5.4.2
Implementation
..............................................
5.4.2.1
Workshop, day 1 – Discover
5.4.2.2
Workshop, day 2 – Dream and design
5.4.2.3
Workshop, day 3 – Improving
interpersonal skills
5.4.2.4
5.4.3
5.5
5.6
160
.....................
162
...........
164
................................
165
Workshop, day 4 – Goal setting and delivery
Workshop evaluation
162
....
166
........................................
168
EVALUATION OF THE MODEL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
5.5.1
Clarity of the model
5.5.2
Simplicity of the model
5.5.3
Generalisability of the model
5.5.4
Accessibility of the model
5.5.5
The importance of the model
CONCLUSION
.........................................
......................................
169
170
...............................
171
...................................
171
...............................
172
.......................................................
174
CHAPTER 6: CONCLUSION, CHALLENGES, RECOMMENDATIONS
.........................
175
.....................................................
175
AND ORIGINAL CONTRIBUTION
6.1
INTRODUCTION
6.2
OVERVIEW OF THE RESEARCH PROCESS
6.3
CHALLENGES
.....................
175
.......................................................
178
6.3.1
Sample size
.................................................
178
6.3.2
Time
.........................................................
179
6.3.3
Audio recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
x
6.4
RECOMMENDATIONS FOR RADIOGRAPHY PRACTICE,
EDUCATION AND RESEARCH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
6.5
6.4.1
Recommendations for radiography practice
6.4.2
Recommendations for radiography education
6.4.3
Recommendations for radiography research
180
.............
181
..............
181
ORIGINAL CONTRIBUTION OF KNOWLEDGE TO THE
PROFESSION OF RADIOTHERAPY
6.6
...............
...............................
182
.......................................................
182
..............................................................
185
CONCLUSION
REFERENCES
xi
LIST OF TABLES
TABLE 2.1
Strategies to ensure trustworthiness
TABLE 3.1
Themes and categories developed from appreciative inquiry
interviews
TABLE 4.1
Dictionary definitions of facilitation
TABLE 4.2
Subject definitions of facilitation
TABLE 4.3
Essential attributes of facilitation
TABLE 4.4
Dictionary definitions of professional
TABLE 4.5
Subject definitions of professional
TABLE 4.6
Essential attributes for professional
TABLE 4.7
Dictionary definitions of identity
TABLE 4.8
Subject definitions of identity
TABLE 4.9
Essential attributes for identity
xii
LIST OF FIGURES
FIGURE 1.1
Job satisfaction and intention to leave model
FIGURE 1.2
The theory for the promotion of health in nursing
FIGURE 1.3
The 4-D model of appreciative inquiry
FIGURE 3.1
The star of practice
FIGURE 4.1
Conceptual map
FIGURE 5.1
A model to facilitate wholeness as part of a professional
identity
FIGURE 5.2
The bottom third of the model
FIGURE 5.3
The middle third of the model
FIGURE 5.4
The top third of the model
FIGURE 5.5
Conflict strategies
FIGURE 5.6
Mypyramid
FIGURE 5.7
The stages of change model
xiii
LIST OF APPENDICES
APPENDIX 1
University of Johannesburg, ethical clearance certificate
APPENDIX 2
University of the Witwatersrand, ethical clearance certificate
APPENDIX 3
Letter of permission from the Director of Radiation Oncology
APPENDIX 4
Example of a participant consent form
APPENDIX 5
Confidentiality agreement from data transcriber
APPENDIX 6
Example of a transcribed focus group interview
APPENDIX 7
Workshop manual
LIST OF ABBREVIATIONS
AI
Appreciative inquiry
HPCSA
Health Professions Council of South Africa
UK
United Kingdom
USDA
United States Department of Agriculture
xiv
CHAPTER 1
RATIONALE FOR AND OVERVIEW OF THE
RESEARCH
The fact is, that to do anything in the world worth doing, we must
not stand back shivering and thinking of the cold and danger, but
jump in and scramble through as well as we can.
Robert Cushing
This chapter deals with the context in which the research was conducted, the
research problem and the research paradigm which guided the research
method and design.
1.1 INTRODUCTION
Radiotherapy is a branch of radiography that deals with the treatment of
cancer patients with radiation (Levin, Sitas & Odes, 1994:349). Radiography
is an umbrella term which covers four disciplines, namely diagnostic
radiography, nuclear medicine, ultrasonography and radiotherapy (www.uj.ac.
za/EN/Faculties/health/departments/radiography). A therapy radiographer is a
member of a multidisciplinary oncology team who is responsible for the
preparation of the radiotherapy treatment in conjunction with a radiation
oncologist and medical physicist. The therapy radiographer is responsible for
the preparation of the treatment via simulation and treatment planning and is
responsible for the administration of the prescribed treatment. He/she is also
responsible for managing radiotherapy side effects and assessing the
patient’s psychological and physical status and is required to refer the patient
as appropriate. During a course of radiotherapy, the therapy radiographer
1
develops a supportive relationship with the patient which is central to their
care (Cox, Halkett, Anderson & Heard, 2010:228). Kyei & Engel-Hills, 2011:13)
In the South African context, registration with the Health Professions Council
of South Africa (HPCSA) is mandatory for a professional wanting to practise
as a therapy radiographer (Health Professions Council of South Africa, [s.a.]).
The Society of Radiographers of South Africa (SORSA) is a non-profit,
professional organisation with voluntary membership. The Society aims to
promote the professional development of radiographers and uses congresses
and the publication of a professional journal as the vehicle through which to
achieve this aim (SORSA information, 2011:6).
Therapy radiographers can be employed in either the provincial hospitals
equipped with a radiation therapy department or in private oncology centres
(www.uj.ac.za/radiography). Typically a therapy radiographer would treat
between 40 and 60 patients in a normal working day. Therapy radiographers
are also responsible for pre-treatment counselling of radiotherapy patients
and for monitoring side effects during treatment (Washington & Leaver, 2010:
19–20).
A course of radiation therapy may be delivered over anything from a single
treatment to eight weeks of daily treatment (Rubin, 2001:104). As high doses
of radiation are delivered in a treatment session, an error not detected before
the treatment session begins has potentially serious consequences to the
health of the patient concerned (Probst & Griffiths, 2009:156). For this
reason, a therapy radiographer does not plan or deliver treatment without a
colleague checking and counter signing for any treatment planned or
delivered.
2
Radiation therapy is a profession that has seen major technological
advancements in recent years. Therapy radiographers are therefore working
in an environment where they are balancing complex technology with the
emotional strain of working with cancer patients in a setting where there is no
room for error whilst still maintaining a high level of patient care and an
empathetic demeanour (Probst & Griffiths, 2007:22; Bissonnette & Medlam,
2010:139). For example, asymmetric radiotherapy treatment portals are
commonplace in a modern radiotherapy treatment plan but have increased
the cognitive quality assurance checking tasks that the radiographer must
perform by 80%. Each check that a therapy radiographer must perform before
delivering a course of treatment increases the likelihood of an error occurring
and therefore increases the stress for the radiographer involved (Probst &
Griffiths, 2009:147). Current national and international staff shortages in the
profession exacerbate an already stressful situation (Probst & Griffiths,
2009:147).
Griffiths (2000:161) highlighted the need for adequate staffing levels in a
radiotherapy department in 2000 but vacancy rates in the United Kingdom
(UK) were reported to be as high as 17% in 2004 (Probst & Griffiths,
2009:147). Probst and Griffiths (2007:21) highlighted the fact that the vacancy
rate for radiographers in the United Kingdom was higher than that for
midwives in 2005 yet the midwife staff shortage made national news
headlines with no media attention being given to the staff shortage in
radiography.
It is hardly surprising then that current literature regarding the status of
radiation therapy makes for depressing reading. High stress levels, high
vacancy rates, an unsatisfied workforce, high burnout levels, role ambiguity,
moderate levels of organisational commitment and questionable levels of
patient care have all been cited in literature both nationally and internationally
3
as common problems amongst radiographers (Akroyd, Caison & Adams,
2002:818; Rutter & Lovegrove, 2008:140; Makanjee, Hartzer & Uys, 2006:
121; Probst & Griffiths, 2007:22). Strategies, if any suggested by the authors,
to alleviate the problems identified tend to be vague and difficult to implement
in practice. For example, Rutter and Lovegrove (2008:142) suggest that
interventions to reduce stress experienced by radiographers should include
balancing the demands of work and home and improving uncertainty about
the nature of the job. Current literature tends to concentrate on specific
aspects of mental health such as stress and burnout and does not tend to
look holistically at the radiographer as a “whole” person.
A qualitative study conducted among therapy radiographers in the UK
focused on job satisfaction as a strategy to recruit and retain therapy
radiographers (Probst & Griffiths, 2009:146–157). The researchers developed
a multidimensional model to describe the factors influencing job satisfaction
of therapy radiographers in the UK. Although the model has not yet been
tested, the researchers recommend that retention strategies focus on three
main areas, namely job characteristics, leadership style and organisational
governance, and job stressors (Probst & Griffiths, 2009:156). What seems to
be missing from current literature is research to determine what therapy
radiographers need in order to feel fulfilled and satisfied as individuals within
the profession of radiotherapy.
1.2 CONTEXT AND RATIONALE
Our plans miscarry because they have no aim. When a man does not
know what harbour he is making for, no wind is the right wind.
Seneca
4
Radiography is a profession plagued with self-doubt, making personal
accomplishment and satisfaction in the workplace a rarity. Radiographers
have been labelled as “followers rather than leaders” (Sim & Radloff, 2009:
205) with the rationale that medical dominance over the profession has
limited the autonomy of the radiographer (Ferris, 2009:e82; Lewis, Heard,
Robinson, White & Poulos, 2008:91;) and has resulted in very little contribution
by radiographers in the generation of new knowledge. Radiographers have
therefore become uncritical consumers of knowledge (Manning & Bently,
2003:4) rather than producers of it, thereby limiting their contribution to the
growth of a rapidly advancing discipline (Forsyth & Maehle, 2010:284) and
arguably therefore limiting their sense of professional accomplishment.
In recent years, developed countries such as the United Kingdom, Australia
and Canada have seen a movement towards advanced practice for
radiographers which expands on the currently accepted scope of practice for
the radiographer. Studies have shown that radiographers, although capable
of advanced practice, are reluctant to accept the additional responsibility
associated with their newly extended role (Dempsy & Burr, 2009:143), again
highlighting the poor self-esteem typical of many radiographers. In a South
African context, the concept of role extension rather than advanced practice
has been discussed but has not been implemented in clinical practice,
making career advancement for the South African radiographer very difficult.
Williamson and Mundy (2010:43) show that graduate radiographers expect
role development opportunities upon entering the working world and show a
significant drop in job satisfaction when this expectation is not met.
It is therefore not surprising then to see that therapy radiographers generally
start their careers excited to be part of a medical environment and enthusiastic
about the rapid technological advancement that they can envisage being a
part of. Typically, in an oncology setting, a naive enthusiasm for helping
5
patients with cancer rapidly spirals into disillusionment as the stress of
working in a profession with no room for error and little opportunity for career
advancement takes its toll (Probst & Griffiths, 2009:155).
Current literature suggests that therapy radiographers have yet to find
effective stress management interventions. High levels of emotional exhaustion
have been reported in American therapy radiographers (Akroyd et al.,
2002:818) and are also evident in the verbatim statements by United Kingdom
therapy radiographers such as “it’s almost as though you don’t see the light at
the end of the tunnel” and “…I thought if another whinging woman whinges at
me again either I am going to burst into tears or I am going to hit somebody...”
(Probst & Griffiths, 2009:154).
In the South African context organisational commitment in radiographers has
been found to be moderate to poor, which is supported in a recent United
States survey which found that radiographers show moderate levels of
commitment to their employers (Akroyd, Jackowski & Legg, 2007:471;
Makanjee et al., 2006:121). Moderate to low levels of organisational
commitment have negative implications for the quality of care radiographers
would deliver to patients and can be correlated with higher actual employee
turnover rates (Akroyd et al., 2007:473), which suggests disillusionment
among staff.
As a therapy radiographer and a radiography educator, the rationale for
undertaking this study was driven by my enthusiasm for the profession of
radiation oncology. I have watched over the past 10 years in education how
my students start the programme enthusiastic and highly motivated, only to
become disillusioned and emotionally drained a few years after graduation.
Upon reviewing the literature, I noticed how I could only find articles that
addressed the negativity among radiographers and detailed stories of
6
emotional exhaustion, burnout, stress, poor patient care and lack of
organisational commitment. I hoped that if I started a research project that
was underpinned in a positive paradigm, such as that found in appreciative
inquiry, I could make a positive contribution to the profession.
Radiography has been declared a scarce skill by the South African Department
of Health and the Department of Education and shortages of therapy
radiographers are commonplace both nationally and internationally (Kresl &
Drummond, 2004:8). I hypothesised that if I could address the concept of
personal and professional wholeness among South African therapy
radiographers, I could start to give therapy radiographers a sense of
professional and personal fulfilment and make a start in changing the
negativity that plagues the profession today. Therapy radiographers who
have achieved personal and professional wholeness are more likely to remain
in the profession, provide a superior level of patient care and stay committed
to the organisation in which they work.
1.3 PROBLEM STATEMENT
Radiotherapy referrals and therefore demand for radiotherapy services are
increasing, partly due to an aging population and greater utilisation of
radiotherapy for certain cancers. Resource planning must therefore include
methods to retain those therapy radiographers currently employed and to
recruit new staff into the profession. High stress levels, high vacancy rates, an
unsatisfied workforce, high burnout levels, role ambiguity, moderate levels of
organisational commitment and questionable levels of patient care have all
been cited in literature both nationally and internationally as common
problems among radiographers (Akroyd et al., 2002:819; Makanjee et al.,
2006:124; Probst & Griffiths, 2009:150; Rutter & Lovegrove, 2008:140).
7
Current literature suggests that therapy radiographers have limited opportunity
for mental challenge at work due to the design of work flow in modern
radiotherapy
departments
(Probst
&
Griffiths,
2007:155).
Therapy
radiographers have limited task identity opportunities as they are often not
able to see a patient from the beginning of the treatment planning process to
the end of the treatment delivery process. Furthermore, because teamwork is
the norm in radiotherapy, therapy radiographers will often not be recognised
for their individual contribution as the team is reviewed as a whole. Skill
variety is limited as radiotherapy departments organise the workload into
similar treatment protocols allocated to one treatment unit which limits the
opportunity for skill variety. Since radiotherapy is protocol driven, therapy
radiographers have limited autonomy, and feedback opportunities on work
performance are scarce.
In a later publication Probst and Griffiths (2009:155) developed a multidimensional model which describes therapy radiographers as passing through
various life cycles in their professional careers. The model shows therapy
radiographers as starting each life cycle as being enthusiastic as they are given
an opportunity to develop new skills and to take on additional responsibility.
Each life cycle ends as job satisfaction decreases mainly due to the monotony
of the job. This cycle of enthusiasm followed by a decrease in job satisfaction
is typical of what therapy radiographers experience in a South African setting.
The model described by Probst and Griffiths (2009:155) is shown in Figure
1.1 below.
8
FIGURE 1.1: JOB SATISFACTION AND INTENTION TO LEAVE MODEL (Probst & Griffiths, 2009:155)
9
Strategies suggested in the literature to alleviate the problems tend to be
vague and difficult to implement in practice. Furthermore, radiography literature
has focused on identifying problems such as stress, burnout and lack of
organisational commitment without any constructive attempt to look for the
positive attributes of the profession that could assist therapy radiographers to
achieve professional fulfilment. However, a retention and recruitment strategy
cannot be developed without an understanding of the process a therapy
radiographer undergoes to become a physically, mentally and spiritually whole
person.
Currently a model to describe such a process does not exist and would be
fundamental in understanding what strategies should be put into place to
facilitate wholeness and therefore professional and personal fulfilment among
therapy radiographers. The research questions that arose from the problem
statement for this study were: What is the process of being a therapy
radiographer? What can be done to facilitate the process of becoming a
physically, mentally and spiritually whole therapy radiographer?
1.4 PURPOSE AND OBJECTIVES
Nothing contributes so much to tranquilize the mind as a steady purpose-a point on which the soul may fix its intellectual eye.
Mary Shelley
The purpose of this theory-generating study was to describe the process of
being a therapy radiographer in an oncology department of a tertiary hospital
in Gauteng. This served as the basis for the development of a model to
facilitate wholeness among therapy radiographers. At this stage in the
research, the process of being a whole therapy radiographer was generally
10
defined as the process of becoming a physically, mentally and spiritually whole
person.
The research objectives were to:

Utilise appreciative inquiry to describe the process of being a therapy
radiographer and to identify the central concepts for the model
developed from the results of the appreciative inquiry interviews.

Describe a model to facilitate the process of becoming a physically,
mentally and spiritually whole therapy radiographer.

Develop guidelines to operationalise the model.
1.5 PARADIGMATIC PERSPECTIVE
The searching-out and thorough investigation of
truth ought to be the primary study of man.
Cicero
As research in radiography is in its infancy internationally and is only just
beginning in South Africa, the theory of health promotion in nursing has been
adopted and accepted for this research study (University of Johannesburg,
2009:4).
The theoretical assumptions that guide the theory of health promotion in
nursing are congruent with my personal belief system and are transferable to
a radiotherapy context. This theory is presented in Figure 1.2 below.
11
FIGURE 1.2: THE THEORY FOR HEALTH PROMOTION IN NURSING (University of Johannesburg, 2009)
12
1.5.1 Metatheoretical assumptions
The metatheoretical assumptions that guide the theory (University of
Johannesburg, 2009:4) assume that a person is holistic, that they have an
internal and an external environment and that health is an interactive, dynamic
process that requires the mobilisation of resources. The discussion that follows
aims to illustrate how the metatheoretical assumptions that guide the theory
are transferable to a radiotherapy context and have therefore been adopted
for use in this research study.
1.5.1.1 Person
For the purpose of this study, a person refers to an individual who is
registered with the Health Professions Council of South Africa as a therapy
radiographer. All therapy radiographers are whole people and therefore a
holistic understanding of them includes describing the therapy radiographer
as a person who has physical, mental and spiritual facets of their person. Of
course, one cannot separate the person from their environment and in this
case, the therapy radiographer functions in an integrated, interactive manner
with their environment.
1.5.1.2 God
In this study God is referred to from a Catholic perspective as this is the belief
structure that guides my metatheoretical assumptions. Catholics believe in
the Holy Trinity (God the Father, God the Son and God the Holy Spirit). Entry
into the Catholic faith is through baptism by water. Fundamental to the Catholic
belief system is the principle that faith alone cannot save you but that faith
must be combined with good deeds. Upholding the Ten Commandments is
paramount to the social paradigm of the Catholic community (www.catholic.
org/prayers/beliefs.php).
13
1.5.1.3 Environment
The theory for health promotion in nursing (University of Johannesburg,
2009:5) describes a person’s environment as a combination of both the
internal environment (body, mind and spirit) and the external environment
(physical, social and spiritual). For the purpose of this study the external
environment consisted of the radiation therapy department at a tertiary hospital
in Gauteng, colleagues within the department and the ethos of the
department. The internal environment encompassed the physical, mental and
spiritual needs of the individuals participating in the study. The synergy
between the internal and the external environment will determine how well
therapy radiographers are able to achieve wholeness within the profession of
radiotherapy.
1.5.1.4 Wholeness
For the purpose of this study, wholeness is described using a more biblical
rather than a modern definition. Meyer (1989:120) describes wholeness as
finding an ideal state and total harmony in daily relationships, life experiences,
well-being, an inner peace, prosperity and righteous living before God.
Embedded in this definition is the understanding that one cannot separate the
person from their environment (Cowling, 2000:17). This is the description of
wholeness that is conceptualised in this study.
1.5.2 Theoretical assumptions
The following theoretical assumptions were made to conduct the study:

Every person has the ability to become whole.

Therapy radiographers are responsible for their own personal and
professional development.

Wholeness is important for the profession of radiotherapy to develop
and move forward.
14
1.6 DEFINITIONS
The following concepts are important to the reader’s understanding of this
report:
1.6.1 Therapy radiographer
A therapy radiographer is a radiographer who is trained to plan and deliver a
course of radiation therapy as prescribed by an oncologist. Care of the patient
during the radiotherapy treatment is integral to the work performed by the
therapy radiographer (Washington & Leaver, 1996:39). Therapy radiographers
are also referred to as radiotherapists or radiation therapists.
1.6.2 Wholeness
For the purpose of this study wholeness is defined as the process of becoming
a physically, mentally and spiritually whole person (Meyer, 1989:116).
Embedded in this definition is the understanding that one cannot separate the
person from their environment (Cowling, 2000:17).
Within the context of radiation therapy, becoming a mentally whole person
implies identifying the intellectual needs of therapy radiographers in order to
maintain an interest in the profession as a motivating force behind encouraging
professional development. Probst and Griffiths (2009:150) highlight the fact
that therapy radiographers feel more satisfied at work when they are learning
new skills and taking on new challenges. Furthermore, therapy radiographers
feel frustrated when they are not given an opportunity for mental stimulation
by attending continued professional development activities and are frustrated
by a perceived career plateau when they are not given an opportunity to
develop new skills (Probst & Griffiths, 2009:151). Kalliath and Morris (2002:
653) found that education to upgrade job skills in professional nurses helps to
reduce job stress and enhances self-confidence, which results in a reduction
15
in emotional exhaustion. Powers and Dodd (2009:3) believe that maintaining
good intellectual health increases problem solving ability, provides a platform
for continuous learning and provides a sense of fulfilment which is a
requirement for anyone hoping to enjoy a state of good health or wellness.
Furthermore, mentally, a whole therapy radiographer is defined as a person
who is able to manage the emotional demands of the job while being able to
maintain and develop positive intrapersonal and interpersonal relationships
both at work and at home. Johnson (2006:6) argues that it is only through
good interpersonal skills that relationships can be initiated, built and
maintained. Furthermore, interpersonal skills have a direct implication for a
person’s ability to interact effectively with other people, and stress
management is part of the skills needed to build and maintain effective
relationships (Johnson, 2006:7–8). Powers and Dodd (2009:3) suggest that
the cornerstone of good emotional health is directly linked to a person’s ability
to manage the daily stresses of interpersonal interactions effectively.
A spiritually whole therapy radiographer refers to a person who has found
meaning and purpose (Baldacchino & Draper, 2001:833) in their professional
life and is a concept which transcends religion (Carr, 2000:3). Professionally,
spirituality may be the core value system which unifies therapy radiographers
as a professional group and may help to make sense of the often complex
and sometimes controversial treatment decisions commonplace in oncology.
Carr (2000:7) highlights in his article how spirituality has a social function as it
helps to unite people around a central theme regardless of religion or ethnicity.
A central theme may be the catalyst that helps therapy radiographers to
develop a superordinate identity (Johnson, 2006:356–357) which may be
used to unite individual therapy radiographers into a community of therapy
radiographers with a common paradigm and a sense of belonging.
16
Physical wholeness implies being able to make conscious decisions about
healthy lifestyle choices. Appropriate physical exercise, healthy eating habits
and paying attention to one’s physical appearance are all part of achieving
physical wholeness (Meyer, 1989:120).
1.6.3 Facilitation
Facilitation can be defined as an activity which makes tasks achievable for
others (Ewles & Simnett, 2005:335). Facilitation in this study refers to the role
that the researcher plays in creating an environment in which participants
could feel free to express themselves and thus participate in the development
of a strategy to facilitate wholeness.
1.6.4 Model
A model is a symbolic representation of a theoretic relationship in words,
pictures, diagrams, mathematic notations or physical structures (Chinn &
Kramer, 2011:252). It is a set of highly abstract, related constructs that reflect
the philosophical ideas of a researcher (Burns & Grove, 2005:128). A model
uses symbols or diagrams to represent relationships among phenomena in a
structured way so as to provide a framework through which a phenomenon
can be viewed (Brink, 2006:23).
1.7 METHODOLOGICAL ASSUMPTIONS
As research in the field of radiography is limited, and calls to expand the
research base by radiographers are gaining momentum (Malamateniou,
2009:3), a theory-generating research design was deemed appropriate for
this research. Furthermore, a qualitative methodology was chosen in order to
explore and describe the phenomenon of wholeness in as much depth as
possible. To counteract the negativity in the research currently published in
the field of radiography, a positive approach to exploring the phenomenon of
17
wholeness was selected. For this reason a qualitative, theory-generating
research design utilising an appreciative inquiry method has been applied.
Appreciative inquiry has evolved from the socio-rationalist paradigm whose
ontological assumptions rely on the belief that social systems can be changed.
It is a form of action research and aims to create new theories that aid change
in organisations based on generating ideas through collecting stories of
something at its best (Bushe, 1995:14–15).
A theory is a “creative and rigorous structuring of ideas that projects a tentative,
purposeful, and systematic view of phenomena” (Chinn & Kramer, 2011:257).
Theory-generating research aims at developing a set of well-defined concepts
in order to describe and explain a phenomenon (Burns & Grove, 2005:37).
Concepts are the building blocks of theory and can be highly abstract in
nature (Brink, 2006:25). In this study concepts were identified inductively from
the data collected during appreciative inquiry interviews. Relationship
statements were then deductively developed to suggest relationships between
the concepts identified. Once the relationships between the concepts had been
defined, a model was developed to graphically represent the relationships
identified.
The research is contextual in nature which is supported by the qualitative
ontology in that reality is based on perceptions which are different for each
person and change over time. Theory can therefore only have meaning within
a specific context (Burns & Grove, 2005:52). Radiotherapy is a very specialised
discipline and therefore the focus group interviews were conducted in a
radiotherapy-specific context with information-rich participants.
Babbie and Mouton (2001:29) suggest that qualitative research is based on
two assumptions or postulates: the postulate of logical consistency and the
18
postulate of adequacy. Logical consistency requires that research conducted
in the social sciences must be internally consistent and therefore aligned with
that of the larger world of social science. Therefore, in this research study, I
have attempted to describe the context in which the research took place in
enough detail to enable the transfer of the findings to a larger radiotherapy
context where appropriate.
The postulate of adequacy requires that research participants be able to
recognise their own voice in the theories developed by social science
researchers. In this study, therefore, member checking of the interview findings
was performed to ensure that the therapy radiographers recognised their
voice in the themes and categories developed. Furthermore, the logic used in
the development of the model ensured that the model I developed stemmed
from the stories told by the participants so that the therapy radiographers
could own the model and see themselves in it. Lastly, the research article
(Lawrence, Poggenpoel & Myburgh, 2011) based on the findings of the focus
group discussions which has since been published was shared with the
research participants while still in draft form so that it became an article which
they owned and were proud to be a part of.
The final methodological assumption upon which this research study is based
is that of rigour in qualitative research. Babbie and Mouton (2001:274–278)
discuss two approaches to establishing objectivity and validity in qualitative
research. The first approach, Munchhausen objectivity, is based on the work
of a Dutch philosopher, Adri Smaling, and is based on doing justice to the
object of study. For the purpose of this study, however, I used the approach
developed by Lincoln and Guba (1985:301–331), which is the notion of
trustworthiness.
19
Trustworthiness has been described by Babbie and Mouton (2001:276–278)
as simply putting measures into place that persuade the researcher and the
research audience that the results of the study are credible. Credibility was
ensured by asking myself the question: “Do my findings sound like they ring
true?” I based my affirmative answer to this question on the knowledge that I
knew the research participants and the research context well enough to be
comfortable that the themes and categories I developed fitted into my
understanding of radiation oncology. Furthermore, the participants themselves
were satisfied with the themes and categories developed and could hear
themselves in the verbatim quotes that I read to them in support of the themes
and categories developed.
I then asked myself: “Can I see my results being transferred to another
radiotherapy setting?” Again, my answer to this question was “yes”. I reflected
on other radiation oncology departments with which I am familiar, and can
hear the therapy radiographers in those departments telling me the same
stories. I have attempted in this report to provide a thick description of the
research process to allow the research audience to reflect on the transferability
of the findings to their specific radiotherapy context. I am also confident of the
dependability of the findings, as the research has been shown by an
independent coder to be internally consistent and I am confident that I have
established throughout the research process an audit trail to reflect that the
results presented are a direct result of the research inquiry rather than as a
result of my own biases.
1.8 RESEARCH DESIGN AND METHOD
20
Some men give up their designs when they have almost reached
the goal; while others, on the contrary, obtain a victory by exerting,
at the last moment, more vigorous efforts than before.
Polybius
A description of the research design utilised and the method employed is
essential to the understanding of this research report.
1.8.1 Research design
The study utilised a qualitative theory-generating research design, using
appreciative inquiry to identify a central concept for the model development.
The philosophy of science that guided the research design was that of a
postmodern constructivist paradigm.
Postmodernism has been defined by Babbie (2010:G8) as “a paradigm that
questions the assumptions of positivism and theories describing an ‘objective’
reality”. Postmodernism is concerned with subjectivity and individual identity
(Allen & Turner, 2000:374), it encourages diversity and creativity while still
grounded in rigorous standards of enquiry (Kilduff & Mehra, 1997:455). Kilduff
and Mehra (1997:461, 466) have shown how postmodernism epistemology
can be used successfully in organisational research as it allows for the
systematic enquiry into organisational phenomena in such a way that it
informs, enriches and directs research enquiries. Postmodernism therefore
allows the researcher to build an understanding of a topic that is contextual
and detailed, bringing authenticity to a research report.
Constructivism is a research paradigm that embraces the concept that reality
is socially constructed and rejects the concept of an objective reality (Mills,
Bonner & Francis, 2006:2). Constructivists as researchers acknowledge that
the beliefs and theoretical positions held by them ultimately guide the
21
development of the research problem, the selection of the research design
and the data analysis. Therefore the researcher and the research participants
are partners in the research process as theory and practice cannot be
separated (Mir & Watson, 2000:941–943).
Postmodernism allowed me as a researcher to use a design such as
appreciative inquiry as a tool to identify a central concept, rather than as an
action research design as it gives a researcher creativity and freedom to
explore a phenomenon in a non-traditional approach while maintaining the
rigour required in scientific enquiry. A constructivist approach allowed me to
explore the world of the therapy radiographer and to construct a theory of
what it means to be a therapy radiographer using a subjective approach to
produce rich, meaningful data in a specialised context.
However, in order to stay true to the postmodern constructivist paradigm
guiding this research design, I attempt in this report to detail my assumptions
throughout the research process and to remain reflective and reflexive
throughout the process.
1.8.2 Research method
The research was conducted in four steps. In the first step concept analysis
took place. In the first phase of concept analysis the central concept was
identified by means of appreciative inquiry. In the second phase the central
concept was defined and classified. In the second step the concepts were
placed into relationships with each other. The model descriptor was done in
the third step. The fourth step involved describing the guidelines to
operationalise the model.
1.8.2.1 Step 1: Concept analysis
Concept analysis took place in two phases described below.
22
a) Phase 1: Identification of a central concept
During phase 1 the experiences of the therapy radiographers were
explored by means of appreciative inquiry incorporating focus group
interviews as field research. The population for this phase of the research
consisted of the therapy radiographers employed at a radiation oncology
department in a tertiary hospital in Gauteng. Purposeful sampling was
used to select participants (Creswell, 2007:185). Participants needed to
be employed as a therapy radiographer by the department concerned.
This meant that students were excluded from the study. The participants
also needed to be comfortable sharing their story of being a therapy
radiographer with their colleagues in a group setting, and needed to be
comfortable conducting the interview in English. This method ensured that I
was able to select participants who were “information rich” and were able
to provide information specific to the central theme of the research.
Data collection for this phase of the research entailed focus group
interviews and reflective and reflexive field notes taken during and after
each interview. The focus group interviews using appreciative inquiry were
conducted using the 4-D model (Watkins & Mohr, 2001:43) as illustrated
in Figure 1.3 below.
23
FIGURE 1.3: THE 4-D MODEL OF APPRECIATIVE INQUIRY (Watkins &
Mohr, 2001:43)
Appreciative inquiry as an interview technique was deemed appropriate
for the research question and context as I intended to explore in a positive
paradigm how participants experienced being a therapy radiographer. I
believe that their experiences were socially constructed and were subject
to change, making appreciative inquiry an ideal fit in this setting.
Furthermore, appreciative inquiry has also been successfully used to
explore the professional setting in a nursing context (Chapman & Giles,
2009:297–305), a context in many ways similar to that found in radiation
therapy. The 4-D model was used to structure the focus group interviews
24
as it has been widely used in appreciative inquiry research and incorporates
all the elements of appreciative inquiry suggested by Cooperrider and
Srivastva (Watkins & Mohr, 2001:42). The 4-D model also allowed me to
stay true to a postmodern constructivist research paradigm because it
asks open-ended, broad questions which gave participants the freedom
to construct their own dreams for the profession without me developing
questions from my own ethic construction. The model therefore was an
ideal fit for the research question.
During the focus group interviews participants were encouraged to share
stories of what it is like to be a therapy radiographer within the following
phases: discover, dream, design and deliver.
Firstly, participants were asked to share stories where they Discovered or
focused on times when being a therapy radiographer made them feel
alive and fulfilled. Participants were asked the question, “When did you
feel most alive and vital at work?”
Next, participants shared stories where they Dreamt and were challenged
to envisage a profession with unlimited potential. The question, “Where
would you like to see radiotherapy going to in the future?” was posed.
The Design phase followed where participants were asked to create the
social architecture of the profession and share the qualities and behaviours
that would enable them to become a whole person within a radiotherapy
context. Participants were asked the question, “What is needed to reach
that?”
The final phase is the ongoing Delivery phase where participants were
asked to develop ways in which the new qualities and behaviours could
25
be implemented in the clinical radiotherapy setting. Participants were
asked the question, “What can we do to achieve that?”
My role during the interview was to facilitate discussion rather than direct
it. I therefore allowed the participants to move freely from question to
question and on occasion found that participants naturally started
discussing ways to implement qualities and behaviours into clinical practice
without necessarily being asked the question.
Descriptive and reflective field notes were compiled during and after each
focus group interview (Creswell, 2003:189). Observational, personal,
methodological and theoretical notes were kept. Observational notes
centred on my observations of group dynamics and non-verbal cues
observed during the interview process. Personal notes were used to
document my feelings and experiences during the interview process. I
used the opportunity to write personal notes as a means of ensuring that
my personal radiotherapy story could be bracketed before my analysis of
the data took place. Methodological notes were made in an attempt remind
myself about slight changes that I wished to make in the next interview to
better enhance the interview process. Theoretical notes were my initial
thoughts on the possible themes that could be emerging and topics which
I could later bring into my literature review.
i)
The role of the researcher as the main data collection tool
Throughout the data collection process, I was aware of how my actions
could shape the data collection and the analysis of the data. I was
therefore cognisant of the need to reflect on my actions so as not to
direct the participants in their storytelling and not to over-identify with
what they were saying. I viewed my role as a facilitator of the
26
discussion and put my own personal story aside while I listened to
participants tell theirs.
ii) Data analysis
Data analysis was conducted by means of open coding as described
by Creswell (2003:190–195). Firstly, the data was organised and
prepared for analysis by transcribing interviews and typing up field
notes. The data was then read in order to obtain a general sense of
the data and to reflect on its meaning. The data was coded by
categorising the data and labelling the categories/themes with a
descriptive term.
An independent coder was used to verify the themes generated
(Creswell, 2003:196). A consensus meeting was held between myself
and the independent coder to reach an agreement on the themes
identified. Once final agreement on the themes identified had been
reached, I held a meeting with the members of the focus group
interviews and other interested staff members to discuss the themes
identified. The participants were given an opportunity to discuss their
impressions of the themes identified and to verify that the themes
were a true reflection of the experiences discussed in the focus group
interviews. I also shared with participants a journal article I later
published based on the results of the focus group interviews and
allowed them to comment on and suggest changes to the article
before it was submitted for publication.
A literature review was conducted in order to contextualise the results
into the literature. The results were positioned in terms of relevant
literature and the results of similar studies.
27
b) Phase 2: Concept definition and classification
The central concept was defined by means of identifying central criteria
using a dictionary and subject literature. This procedure involved reflecting
on the various ways in which a term is used and then identifying the
characteristics that best reflect the ideas to which the concept will be
applied (Burns & Grove, 2005:122). The defined concept was then
classified by means of the survey list of Dickoff, James and Wiedenbach
(1968:422–435).
1.8.2.2 Step 2: Relationship statements
In this step the concepts identified in step 1 were written into relationship
statements in order to develop a preliminary conceptual model as the
framework for the research.
1.8.2.3 Step 3: Description of a model
In this step, a conceptual model was developed using Chinn and Kramer’s
(2011:152–205) process for empiric knowledge development. The process
includes creating conceptual meanings, structuring and contextualising theory,
generating and testing theoretical relationships and deliberately applying
theory.
1.8.2.4 Step 4: Guidelines to operationalise the model
Guidelines to operationalise the model were described to assist the clinical
application of the model in a radiotherapy setting. The model was evaluated
by means of critical reflection as described by Chinn and Kramer (2011:196–
205).
28
1.9 TRUSTWORTHINESS
The way to gain a good reputation is to
endeavour to be what you desire to appear.
Socrates
A model of trustworthiness by Lincoln and Guba (1985:301–331), Murphy and
Yielder (2010:62–67) and Babbie and Mouton (2001:276–278) was used to
ensure trustworthiness.
Truth value or credibility represents the accuracy between the participants’
views and the researcher’s representation of them (Murphy & Yielder, 2010:
65). Credibility was ensured in this research by implementing the following
strategies: prolonged engagement, reflective field notes, triangulation, peer
review, member checking and in-depth interviews (Babbie & Mouton, 2001:
277).
I am a therapy radiographer and have prolonged and varied field experience
in radiotherapy including working in provincial and private hospital settings in
South Africa and in the National Health Service (NHS) in the United Kingdom.
The participants were all familiar with me as I had been actively involved in
teaching the radiotherapy programme. The radiotherapy department in which
the data collection took place is one of the training hospitals accredited with
the radiotherapy programme. As radiotherapy is a very specialised discipline
with small numbers of staff, I was familiar with the participants either as
previous students or as colleagues with whom I had previously worked. I
therefore had easy rapport with the participants, I was welcomed into the
department and was able to continue with data collection until data saturation
29
occurred. During data collection, I reflected on my role and thoughts of the
interview process in reflective field notes.
Sharing the themes identified with therapy radiographers who participated in
the focus group interviews was a strategy employed to ensure that I had
accurately translated the viewpoints of the participants into the data (Babbie
& Mouton, 2001:277; Creswell, 2007:209; Krefting, 1991:11). It also gave me
an opportunity to assess the overall quality of the data by reflecting on the
participants’ comments made while sharing the themes and categories with
them, and allowed me to correct for any obvious errors.
Triangulation of data was performed by combining the interview data with the
data collected by means of descriptive and reflective field notes during the
interview process (Babbie & Mouton, 2001:277; Creswell, 2007:208;). The
findings of the study were discussed in the forum of a doctoral committee
consisting of peers and colleagues who were impartial to the study and who
had experience in qualitative research techniques (Krefting, 1991:12). The
findings were presented at an international conference in Belfast, Ireland in
May 2010 (Lawrence, Poggenpoel & Myburgh, 2010) and comments and
critique given were incorporated into the results presented. The results of the
focus group interviews were also written into a journal article which has since
been subjected to a peer review process and published in a journal (Lawrence,
et al., 2011).
The model was evaluated by the research supervisors who are experienced
in qualitative research and model evaluation. It was also presented at a
national research forum in May 2012, where it was further evaluated by model
specialists (Lawrence, Poggenpoel & Myburgh, 2012).
30
Transferability or generalisability of the research findings was ensured by
including in this research report sufficient descriptive data to allow for
comparison with another setting or population (Babbie & Mouton, 2001:277;
Krefting, 1991:14). A dense description of the participants and the study
setting is provided in the research report (Creswell, 2007:209). Although
generalisability is not a goal in qualitative research, the methods employed in
this research study should allow the reader to consider a case-to-case
transfer of the findings (Murphy & Yielder, 2010:65).
Dependability strategies enable a researcher to conceptualise emerging
theory by following a well-defined audit trail supported by knowledge and
documentation (Murphy & Yielder, 2010:65). Dependability strategies employed
in the study described in detail the methods used to gather and analyse data
in order to ensure that the study could be repeated in another context (Babbie
& Mouton, 2001:278; Krefting, 1991:14).
Confirmability of the data collection and data analysis was ensured by
undertaking a confirmability audit which involves providing a chain of evidence,
triangulation and reflexivity (Krefting, 1991:8). Reflexivity allowed me to
continuously reflect on my own characteristics so that I was aware of how
they might influence the collection and analysis of data. This was done by
making use of field notes detailing my thoughts and ideas during interview
sessions with the participants (Krefting, 1991:10). Creswell (2007:208) also
suggests clarifying researcher bias from the beginning of a study. I have
therefore included in this report the metatheoretical assumptions on which the
report is based.
Murphy and Yielder (2010:65) argue that underpinning all of the above criteria
is reflexivity. This is the ability of the researcher to recognise their role in the
study and then to act upon it. For this reason, my personal story will be a
31
golden thread throughout the research report as I continuously reflect upon
how my experiences could shape the research outcomes.
1.10 ETHICAL CONSIDERATIONS
Ethical permission to undertake the research was granted by the University of
Johannesburg’s Faculty of Health Sciences Academic Ethics Committee
(Appendix 1) and by the University of the Witwatersrand Human Research
Ethics Committee (Appendix 2). Permission was also sought and granted by
the radiation oncologist who headed the department concerned (Appendix 3).
The ethical principles of respect for autonomy, non-maleficence, beneficence
and justice were adhered to throughout the research process (Dhai &
McQuoid-Mason, 2011:43–44). The participants’ autonomy was respected by
inviting participation and obtaining written consent from each participant
(Appendix 4). The consent included a description of the research aim, the data
collection procedure and contact details of the researcher, the supervisors and
the Chair of the University of Johannesburg, Faculty of Health Sciences Ethics
Committee.
Written consent was given for participation in the focus group discussion and
separately for the interviews to be audiotaped. Participants were asked to
respect one another’s confidentiality by not discussing the interview outside of
the interview room. The participants were also free to withdraw participation
at any stage of the research process. The audiotapes were stored in a locked
drawer and on my home computer, which is password protected. The
audiotapes will be destroyed two years after publication of the research. The
data transcriber signed a confidentiality agreement at the time of the data
transcription (Appendix 5). Furthermore, this research report and any
subsequent publications do not contain the names of any of the participants,
thereby respecting their confidentiality.
32
The principle of non-maleficence was respected by avoiding harm and by doing
as little harm as possible. The benefits for the participants included being
given an opportunity to tell their stories in a positive, supportive environment
in order to promote positive change within the radiotherapy department.
Participants were assured at the time of recruitment that they would be
appropriately referred should they suffer any undue mental distress during the
data collection process. At no time did any participant become unduly
distressed; conversely, participants experienced the interviews as positive.
The principle of beneficence was respected by ensuring that the research
study was in the best interest of the participants and the profession at large.
The research topic can be justified in the context of current radiotherapy
literature and the focus group interviews were conducted using appreciative
inquiry, which is a positive interview technique examining what is going right
in a profession. The research questions posed were carefully considered for
their suitability in focus group discussion setting and were considered by myself
and research supervisors not to be sensitive in nature and therefore suitable
for a focus group discussion (Wright, Schneider-Kolsky, Jolly & Baird, 2011:4).
The principle of justice was ensured by inviting the entire staff complement to
participate in the research study. At no time was any staff member victimised
for participation or for non-participation in the study. As the interviews were
conducted mainly over lunch hours in an attempt to cause minimal disruption
to the radiotherapy service offered, I provided lunch for the entire staff
complement.
1.11 CONCLUSION
Radiotherapy is a specialised discipline within the field of radiography. Limited
research in the field of radiotherapy has identified a stressed workforce
operating within complex technical and emotional settings. No research has
33
been conducted to develop a framework to assist therapy radiographers
achieve wholeness within the professional setting. Not surprisingly then
recruitment and retention problems exist nationally and internationally among
therapy radiographers. Theory-generating research is warranted and long
overdue in this setting.
1.12 ORGANISATION OF CHAPTERS
Chapter 1 – Rationale for and overview of the research
This chapter describes the context in which the research was conducted. The
research problem is explained and the research paradigm which guided the
research method and design is presented.
Chapter 2 – Research design and method
This chapter details the research design and method employed during the
research. A justification of the methods selected is provided and a description
of how the research method allowed the research questions to be answered
is provided.
Chapter 3 – Results of appreciative inquiry interviews with therapy
radiographers
This chapter presents to the reader the results of the appreciative interviews
conducted during the field work phase of the research. A dense description of
the participants is provided to assist with the transferability of the research
into another setting. The themes and categories identified are presented and
are positioned within the context of current literature.
34
Chapter 4 – Development of a conceptual framework for the model to
facilitate wholeness among therapy radiographers
This chapter details how the conceptual framework for the model to facilitate
wholeness among therapy radiographers was developed. The central concept
for the development of the model is described and classified and a conceptual
map is presented.
Chapter 5 – Description of the model to facilitate wholeness as part of a
professional identity among therapy radiographers
This chapter describes the model for the facilitation of wholeness as part of a
professional identity for therapy radiographers. The model is presented visually
and the purpose, assumptions and structure of the model are described.
Guidelines to operationalize the model and an evaluation of the model are
presented.
Chapter 6 – Conclusion, challenges, recommendations and original
contribution
This chapter provides a critical reflection on the research process. Challenges
faced during the research are described and the research is evaluated for its
contribution of knowledge to the profession.
35
CHAPTER 2
RESEARCH DESIGN AND METHOD
Knowing is not enough; we must apply.
Willing is not enough; we must do.
Johann Wolfgang von Goethe
The purpose of this chapter is to detail the research design and method
employed during this research and to justify that the methods chosen allowed
the research questions to be answered.
2.1 INTRODUCTION
The research questions that arose from the problem statement for this study
were: What is the process of being a therapy radiographer? What can be done
to facilitate the process of becoming a physically, mentally and spiritually whole
therapy radiographer? For this reason a qualitative, theory-generating research
design was chosen.
2.2 PURPOSE OF THE RESEARCH
We have to dare to be ourselves, however
frightening or strange that self may prove to be.
May Sarton
The purpose of this theory-generating study was to describe the process of
being a therapy radiographer in an oncology department of a tertiary hospital
in Gauteng. This served as the basis for the development of a model to
36
facilitate wholeness among therapy radiographers. At this stage in the
research the process of being a whole therapy radiographer was generally
defined as the process of becoming a physically, mentally and spiritually whole
person.
2.3 RESEARCH DESIGN AND METHOD
We are all inventors, each sailing out on a voyage of discovery,
guided each by a private chart, of which there is no duplicate.
The world is all gates, all opportunities.
Ralph Waldo Emerson
The design used in this research study was a theory-generating, qualitative,
exploratory, descriptive and contextual design which incorporated appreciative
inquiry to identify the central concept.
2.3.1 Theory generating
Chinn and Kramer (2011:257) define a theory as “an expression of knowledge
within the empirics pattern; the creative and rigorous structuring of ideas that
project a tentative, purposeful, and systematic view of phenomena”. Babbie
(2010:G12) supports this definition by defining a theory as “a systematic
explanation for the observations that relate to a particular aspect of life”. Since
research in radiography is in its infancy (Adams & Smith, 2003:193), a call for
radiographers to develop the profession by becoming actively involved in
theory generation for the profession has been made (Cox, Halkett, Anderson
& Heard, 2011:235; Davies & Rawlings, 2009:106; Reid & Edwards, 2011:207).
A theory-generating design was therefore appropriate for this professional
setting.
37
The purpose of the theory generated in this study was to facilitate wholeness
among therapy radiographers and thus contribute to the development of the
profession. Theory should be generated systematically and should be a true
reflection of reality (Chinn & Kramer, 2011:155). For this reason, methods to
ensure trustworthiness were applied throughout the research process.
2.3.2 Qualitative
Qualitative designs allow a researcher to explore the meaning of life
experiences in order to gain insight into and an understanding of phenomena,
which is important in the process of theory development (Brink, 2006:113;
Burns & Grove, 2005:52). As no research pertaining to the wholeness of
therapy radiographers is available, a qualitative design was deemed
appropriate to explore this unknown phenomenon in such a way as to generate
a rich, complex understanding of the phenomenon of wholeness in order to
generate new theory. Ng and White (2005: 224) support the use of qualitative
research designs in radiography research and suggest that qualitative designs
can successfully be used to study intraprofessional and interprofessional
issues within radiography.
The ontology of qualitative research is idealistic which fits with the theoretical
assumption of this research in that I believe that every person has the ability
to become whole. Furthermore, the foundation of qualitative methodology is
the notion that reality is based on individual perceptions which are contextually
bound and change over time (Burns & Grove, 2005:52). For this reason,
information-rich participants were chosen to participate in the focus group
interviews and the transferability of the research findings and therefore the
applicability of the model developed will depend on the setting and the context
into which the results are transferred.
38
2.3.3 Exploratory
Exploratory research designs aim at increasing knowledge in a field of study
and are not intended for generalisation of the results to large populations
(Burns & Grove, 2005:357). Babbie (2010:92) suggests that research is
exploratory when a researcher examines a topic or field of study that is
relatively new in order to gain a new understanding of the phenomenon. As
very little work has been undertaken in the field of therapy radiographers’
physical, mental or spiritual health, an exploratory design was deemed an ideal
fit for the research question.
2.3.4 Descriptive
Descriptive studies provide a knowledge base to develop potential hypotheses
derived from a description of a phenomenon studied (Burns & Grove, 2005:
26). They are used in studies where more information is required about a
phenomenon as it occurs naturally. The researcher generally observes a
phenomenon and then describes what has been seen (Babbie, 2010:93). The
design therefore does not allow for the determination of cause and effect but
rather aims at describing the relationship between variables (Brink, 2006:102).
For the purpose of this study a descriptive design was deemed appropriate as
new knowledge was required to understand what therapy radiographers need
in order to become “whole”, with the aim of generating a new theory, in the
form of a model, which could then be tested in further research.
2.3.5 Contextual
Philosophically, qualitative research and appreciative inquiry assume that a
person can only be truly understood in a defined context and that a person’s
reality is subject to change (Burns & Grove, 2005:732; Bushe, 1995:14).
Mouton (2006:169) proposes that a contextual research design is one in which
the researcher focuses on a small number of cases in a specific context by
39
staying close to the participants and by using data analysis methods that are
holistic, synthetic and interpretive. The research questions posed in this study
are very specific to the profession of radiotherapy and the interview data
collected required an interpretive data analysis method, making the research
contextual in nature. The results of this study are therefore difficult to
generalise and should be viewed within the context of radiotherapy.
2.3.6 Appreciative inquiry
Appreciative inquiry (AI) has evolved from the socio-rationalist paradigm
whose ontological assumptions rely on the belief that social systems can be
changed. It is a form of action research and aims to create new theories that
aid change in organisations based on generating ideas through collecting
stories of something at its best (Bushe, 1995:14–15). The design is one which
seeks
socio-rational
knowledge
through
interpretive
data
collection,
collaborative dialogue and a consensus of “what should be” in an organisation
(Cooperrider & Srivastva, 1987:129–169). Cooperrider and Srivastva
(1987:129–169) are widely regarded to be the founders of appreciative
inquiry and suggest that it contains four dimensions.
Firstly, a researcher should assume that all social systems work to some
degree and therefore research should begin with appreciation. Secondly, all
research should be applicable to a social context and therefore any
knowledge gained through research should be used to bring about change.
Thirdly, research should be provocative. This means that a researcher should
work from the premise that any organisation is capable of becoming more
than what it is and that the people involved in the organisation should play an
integral part in making changes. Lastly, organisational research should be
collaborative, engaging both the researcher and the members of the
organisation in the research process.
40
Appreciative inquiry therefore takes the attention away from negativity and
problems within organisations and focuses on positive aspects, thereby
shaping future behaviours based on the “best” of past experiences (Bushe,
1995:15). This research design is therefore ideal to enable health care workers
to explore possibilities for change without the restrictions of the problems they
are currently experiencing (Richer, Ritchie & Marchionni, 2009:948).
The design was therefore an ideal fit for the research problem and question
as it allowed therapy radiographers to work together in open dialogue to build
a superordinate identity of what an idealistic radiotherapy profession could
be like based on their shared positive experiences of being a therapy
radiographer.
2.4 REASONING STRATEGIES
Not the cry, but the flight of a wild duck, leads the flock to fly and follow.
Chinese Proverb
According to Mouton (2006:80), there are three types of reasoning found in
social research: deductive, retroductive and inductive reasoning. All three
types of reasoning strategies were used in the development, description and
evaluation of the model detailed in this research report.
2.4.1 Deductive reasoning
In order to operationalise the model developed in this research, deductive
reasoning was required. Burns and Grove (2005:733) define deductive
reasoning as moving from the general to the specific as logical conclusions
are inferred from a general premise. Babbie (2010:48) contends that deductive
reasoning moves a researcher from a general theoretical understanding to a
41
testable hypothesis. As a model tends to be abstract in nature, deductive
reasoning is required to move from the abstract concepts in a model to welldefined strategies needed to operationalise a model in a clinical setting.
2.4.2 Retroductive reasoning
Mouton (2006:81) contends that researchers must develop plausible
explanations of phenomena occurring in society. To do this, they must see
past the evidence presented, in a process called retroductive reasoning.
Kolcaba (2001:89) explains that retroductive reasoning is a form of reasoning
that originates ideas. This form of reasoning is therefore applicable in theory
generating research in a field where there are few available theories. In this
research, retroductive reasoning is used to develop theory based on concepts
identified during the data collection and analysis process. Wholeness is a
concept which has not been researched in a radiotherapy setting, therefore
requiring the use of retroductive reasoning to develop the theory which will be
a unique contribution to the field of radiotherapy.
2.4.3 Inductive reasoning
Inductive reasoning, also known in qualitative reasoning as analytic induction,
is used when it becomes necessary to generalise from a small sample to a
wider population (Mouton, 2006:81), or when specific instances are combined
to form a general statement (Burns & Grove, 2005:739). Babbie (2010:51)
describes inductive reasoning as beginning with an observation and then
finding patterns in what has been observed. For the purpose of this study,
inductive reasoning was used during the stages of model development and
evaluation as I used the tools of observation, reflection and insight to analyse
the qualitative data generated by the interviews to find the central concept
around which the model was developed and evaluated.
42
2.5 THEORY-GENERATING RESEARCH METHOD
If your actions inspire others to dream more, learn
more, do more and become more, you are a leader.
John Quincy Adams
The steps utilised in the research method are described below.
2.5.1 Step 1: Concept analysis
The first step in the research method was to identify, describe and classify the
concepts which were utilised in the model development. A concept analysis
involves a process through which the attributes that are essential to the
meaning of the concepts are identified (Burns & Grove, 2005:731). Walker
and Avant’s method of concept analysis (2011: 157–176) was utilised in the
concept analysis process because the framework described by these authors
provides a clear and systematic method with which to develop meaningful
results (Rhodes, 2012:186). The first step described by Walker and Avant
(2011:159) is to identify a concept that reflects the topic of greatest interest.
2.5.1.1 Identification of a central concept
During step 1 the experiences of the therapy radiographers were explored by
means of appreciative inquiry incorporating focus group interviews.
Once ethical clearance had been gained from both the University of
Johannesburg and from the University of the Witwatersrand Human Research
Ethics Committee, I arranged to meet the entire radiotherapy staff
complement at the hospital concerned during a staff meeting. I explained the
nature of the study and what participation in the study would involve. I
43
explained that my sampling criteria were that participants had be employed as
a therapy radiographer and that they had to be comfortable telling their story
in a group setting with English being the language in which the interviews
would be conducted. I then left consent forms and a participant information
sheet for staff to read at their leisure. Staff that were willing to participate in
the interviews were required to leave a signed consent form in a sealed box
placed in the staff tearoom. I collected the completed forms one week later.
As the radiotherapy department was extremely short staffed at the time of the
interviews, with a 50% vacancy rate, arranging the interviews at a time suitable
for the running of the department was crucial. I therefore worked closely with
the therapy radiographer in charge of staff allocations to select dates and
times where staff that had agreed to become participants in my study could
be released to participate in the focus group discussions.
The focus group interviews were held in a quiet office to facilitate the
audiotaping of the interviews. The first interview was interrupted by staff
needing treatment files which were located in the office. The remaining
interviews were then moved to a more remote office within the department. I
arranged a light meal and drinks for the participants as they frequently had to
forgo lunch breaks to participate in the interviews.
The interviews were conducted using the 4-D model (Watkins & Mohr, 2001).
The interview questions were handed to the participants on a typed card
before the interview session began. I reasoned that this relaxed participants
as they could immediately see that the questions were not sensitive in nature.
I also verbally asked the questions to start the conversation and to keep the
conversation flowing. I followed the guidelines suggested by Babbie and
Mouton (2001:252–254) during the interview session. I kept my demeanour
pleasant and friendly, I knew the interview questions well and could therefore
44
ask them naturally in a conversational style. I paraphrased the discussion
once all participants had had a chance to answer the questions and clarified
with them whether my understanding of what they had told me was accurate.
An example of this can be found in Appendix 6.
The audio recorder was passed from participant to participant to allow for the
accurate recording of the discussion. I probed participants for further
information where appropriate and encouraged quieter members of the group
to participate. Once the interview was complete, I thanked the participants for
their time and for sharing their stories with me. I found that the participants
were reluctant to leave the interview room at the end of the session and so I
would remain with them and enjoyed talking to them as they shared with me
what it was like for them to participate in the interview. The participants were
excited at the end of the interviews that they had been given an opportunity to
discuss what it is like to be a therapy radiographer and to dream of a better
future. At the end of each session, I wrote my own personal field notes.
Once data saturation had been reached, I gave the audio files to a data
transcriber for the verbatim transcription of the interviews. Once the interviews
were transcribed, I made two hard copies of the transcribed data. One copy
was for my personal use and the other copy was given to an independent
coder. The data was analysed using the method of data analysis described
by Creswell (2003:190–195) in the following way:
The first step was to read through the data in order to obtain a general sense
of the information. I then allowed myself several days to reflect on the overall
meaning of the data. I read again the interview which seemed to me to be the
most interesting of all the interviews and reflected on the general meaning of
what the participants were telling me.
45
I then took a sheet of A5 paper and divided it into four squares, one for each
interview question. I reflected again on the most interesting of the focus group
interviews and started to cluster similar concepts for each question in the
block allocated to that particular question. I repeated this process for the
remaining interviews. Once this process was complete, I sat with my A5
paper and reflected on the concepts that I had jotted down for each interview
question. I then looked at my field notes and reflected on how my thoughts
fitted with the concepts I had now identified. I developed themes and
categories from the concepts identified. I then read through the entire interview
data again, and identified verbatim quotes that fitted with each of the categories
developed.
Once I was comfortable with my data analysis, I met with the independent
coder and consensus was reached for the final naming of the themes and
categories developed. I then scheduled a meeting with the participants to
share with them the themes and categories developed and to check that they
could hear themselves in the data analysis.
Once I was satisfied that the themes and categories were a true reflection of
the stories told by the participants, I combined the themes using an inductive
reasoning process to identify a central concept for the development of the
model.
As in any qualitative study, I was the main data collection tool, thereby bringing
my personal interpretation into the study (Creswell, 2003:182). I was therefore
very aware that I needed to reflect periodically on how my personal story
would shape the study.
I started my radiotherapy career as a student at the radiation oncology
department where this study was conducted after completing a National
46
Diploma in Radiography (Diagnostic). Everything about radiotherapy was
exactly as I had hoped it would be. I enjoyed the relationships that I built with
patients and found the staff to be very supportive and encouraging. I was
prepared for and coped well with the emotional strain of working with oncology
patients, largely due to a supportive family structure.
After graduating, I worked for a year in the same department and then moved
to the United Kingdom for 18 months. During this time, my experiences in
radiotherapy were vastly different from anything I had experienced at home.
The staff were hostile, aggressive, competitive and generally draining. I no
longer enjoyed my work and dreaded getting up to go to work in the mornings.
The patients seemed to complain far more than any patient I had encountered
at home and were very demanding. I reached a stage in my career where I
felt emotionally burnt out.
Upon my return to South Africa, I was employed in a private oncology
department in Johannesburg. There, I once again found my passion for
radiotherapy. I built good friendships with the staff and enjoyed caring for
patients. When an opportunity to teach at the Technikon Witwatersrand arose, I
jumped at it as I was confident that I could contribute to the profession by
becoming actively involved in teaching. I was responsible for the radiotherapy
programme for seven years and enjoyed it tremendously. Teaching gave me
an opportunity to shape the students for their career in radiotherapy but also
kept me in contact with staff in many of the oncology departments in
Gauteng. I was therefore known to the participants in the study.
My role in the data collection procedure included guarding against overidentifying with any of the participants whilst ensuring that I conducted the
interviews in a professional manner. Basic interview techniques were used to
47
overcome this problem (Burns & Grove, 2005:540–544; Creswell, 2003:185–
190; Henning, 2004:74–79; Johnson, 2006:152).
Firstly, an environment allowing for a comfortable conversation was
established. I arranged the seating in a circle and made a finger lunch and
drinks available to the participants. The decision to host the interviews in the
radiotherapy department during working hours was made in consultation with
the assistant director and the staff.
As the department was short staffed at the time, extended working hours
were the norm, which made scheduling interviews after hours difficult. The
interviews were arranged mainly over lunch breaks on days where one of the
treatment units was scheduled for a full-day service. This then freed staff for a
focus group interview. This arrangement also made certain that the participants
were relaxed during the interview as they were confident that there was a staff
member available to free them to participate in the interview. The arrangements
also restricted any disruption to the radiotherapy service provision, thereby not
impacting on patients or their treatment.
I also paid special attention as to what I would wear in the interviews. I did not
want to appear intimidating by dressing formally, but I wanted to convey to
participants that I was taking the interview process and what they were saying
seriously. I therefore opted for a smart casual appearance.
Before starting the interview, I spent a few minutes talking to participants in
an attempt to put the participants at ease and develop a relaxed atmosphere.
I noticed that participants would come into the interview room looking rather
nervous, as they did not really know what to expect. I explained to them the
purpose of the interview and also let them take a look at the audio recorder,
which seemed to put them at ease.
48
I had memorised the interview questions so that they could be asked as
naturally as possible, but I also wrote them down as a backup. I made a
conscious attempt to appear relaxed, affirmative but as natural as possible.
Whilst the participants were telling their story, I made certain that my nonverbal responses were consistent with what they were saying. I probed for
more information when necessary but made certain that I allowed the
conversation to flow naturally by facilitating rather than participating in the
conversation. I also encouraged the quieter group members to participate in
the conversation. Before asking the next question, I paraphrased the
responses to the question the participants had just answered. This reassured
participants that I had been listening attentively to what they were saying and
allowed them to verify the accuracy of my understanding of what they were
telling me.
2.5.1.2 Concept definition and classification
The second step in the Walker and Avant (2011:159) method of concept
analysis is to determine the aims of the analysis. This process requires the
central concept to be defined and its meaning to be clarified. The following
steps require that the uses of the concept be identified in dictionary and
subject literature and then that the attributes that define the concept be
determined. Walker and Avant (2011:159) then suggest that a model case be
constructed that includes all the critical attributes of the concept and that a
contrary case describing what the concept is not about be developed.
For the purpose of this study, the central concept identified for the model
development was defined and classified in three steps. Firstly, it was defined
using a variety of dictionary definitions. Then it was defined using definitions
found in relevant subject literature. The definitions were then reviewed to
formulate what I considered to be the essential criteria for the central concept.
The final step was to develop a model case and a contrary case to identify
49
what is experienced in the central concept and what the central concept does
not reflect. The essential criteria which form part of the definition of the central
concept are reflected in the model case which then becomes a true example
of what is reflected in the central concept.
Copi and Cohen’s rules for well-formulated definitions (1994:192–196) were
applied to formulate the final definition of the central concept. The rules state
that a definition should incorporate the attributes of the concept and should
reflect the conventional relationship of the concept. Furthermore, a definition
should not be circular, too broad or too narrow. A definition should be
expressed in language that is not ambiguous, figurative or vague and should
be stated in the affirmative whenever possible.
The defined concept was classified by means of the survey list of Dickoff et
al., (1968:435) by answering the following six questions:

Who is the agent?

Who is the recipient?

What is the context?

What are the dynamics?

What is the process?

What is the terminus?
The agent is the person or the entity that performs an action. The recipient is
the person to whom the agent performs the action. The context represents
the area in which the action takes place. The dynamics refers to the internal
motivation of the agent and the recipient that contributes to reaching the
desired outcome of the agent. The process is the procedure of the action
performed by the agent. The terminus is the results of the procedure
performed by the agent on the recipient.
50
2.5.2 Step 2: Relationship statements
In this step the concepts identified in step 1 were written into relationship
statements in order to develop a preliminary conceptual model as the
framework for the research. Walker and Avant (2011:84) have described a
relationship statement as a statement that declares a relationship between
two or more statements. Relationship statements are used to structure the
concepts of the theory in such a way that the interactions of the concepts
become apparent (Chinn & Kramer, 2011:180).
For the purpose of this study, relationship statements were used to describe
and explain the interactions between the concepts identified in step 1. The
development of the relationship statements was undertaken by making use of
the process for relationship statement development described by Burns and
Grove (2005:137–139) and Chinn and Kramer (2011:180–181). A portion of
theory that discussed a relationship between two or more of the concepts
classified in step 1 was consulted. A sentence from the theory was written
down that seemed to propose a relationship. The relationship was then
described diagrammatically. Once all the statements had been expressed,
linkages between statements were identified and a conceptual map developed.
2.5.3 Step 3: Description of a model
In this step, a conceptual model was developed using Chinn and Kramer’s
guidelines (2011:184–205) for the description and reflection of empiric theory.
The process includes creating conceptual meanings, structuring and
contextualising theory, generating and testing theoretical relationships and
deliberately applying theory. Chinn and Kramer further suggest that a theory
has six components which should be described in order to ensure that the
model developed is based on a theory and helps to identify which type of
51
theory was developed (Chinn & Kramer, 2011:186–195). The descriptive
components are posed as questions which are:

What is the purpose of this theory? Answering this question allows
the context and the situation in which the theory applies to be made
specific (Chinn & Kramer, 2011:186–188). The model developed in this
research study aimed at understanding phenomena which would allow
features that could empower a professional group to be identified and
described. The overall purpose of this research study was to provide a
context in which the concept of wholeness becomes meaningful for the
profession of radiotherapy.

What are the concepts of this theory? Identifying concepts and the
relationships between them allows the researcher to determine which
concepts are central to the theory developed (Chinn & Kramer, 2011:
1188–189). In answering this question researchers must identify key
ideas and determine how they relate to one another. The next step is to
separate the major from the minor concepts and the empirical from the
abstract concepts. The concepts are then examined for quantity,
character, emerging relationships and structure.

What are the definitions in this theory? In answering this question
the researcher is required to take the concepts included in the theory
and express them in words which allow an abstract idea to be
formulated in reality (Chinn & Kramer, 2011:189–190). In this way an
explicit or an implicit meaning is conveyed for each concept identified.

What are the relationships in this theory?
Posing this question
allows links between concepts to be identified and written into
relationship statements. Relationships between concepts can be
52
descriptive, explanatory or predictive. Descriptive relationships create
meaning without explaining whilst explanatory relationships provide an
understanding of a phenomenon. Predictory relationships project
circumstances that create or alter a phenomenon (Chinn & Kramer,
2011:190–191).

What is the structure of the theory? The structure emerges from the
relationships of the theory and gives overall form to the conceptual
relationships within it. It is not unusual to find a theory with several,
often competing, structural forms (Chinn & Kramer, 2011:191–194).

What are the assumptions in this theory? Assumptions are “the
structural component of theory that is taken for granted or thought to
be true without systematically generated empiric evidence” (Chinn &
Kramer, 2011:245). Identifying the assumptions made by the
researcher whilst developing the theory is critical to understanding the
context of the theory. Assumptions are commonly written as factual
assertions or as value positions (Chinn & Kramer, 2011:194).
The model was evaluated by means of critical reflection as described by Chinn
and Kramer (2011:196–205). Critical reflection entails asking five generic
questions to which there are no correct answers. Instead, the questions are
tools which are used to encourage academic debate which may assist in
further developing the theory. The questions that are posed are:

How clear is this theory? This question refers to how well the theory
can be understood and how consistently ideas are conceptualised.
Semantic clarity and consistency are implied in this question and refer
to how clearly concepts are defined and how consistently the
definitions are applied to the concepts. Furthermore, structural clarity
and consistency should be considered when answering this question.
53
Structural clarity refers to how well concepts are connected and
organised to form a conceptual framework for the theory. Structural
consistency refers to the consistent use of structural form within a
theory.

How simple is this theory? A simple theory is one in which there are
a limited number of concepts defined in the theory with a
correspondingly limited number of relationships between concepts.
Complex theories are common in emerging theories and generally
become simpler as the theory develops. As the goal of this study was
to operationalise the model, a simple theory was preferable to a
complex one.

How general is this theory? A general theory can be applied to a
wide range of situations. As the model developed in this study is
contextually bound, the theory developed has a narrow scope and
purpose.

How accessible is this theory? The theory developed in this study
needed to have a high level of accessibility. This was ensured by
testing relationships between concepts, deliberately applying the
theory and by clarifying conceptual meanings.

How important is this theory? A new theory should be grounded in
practice and should create a reality that is important to the profession.
In other words, the theory should be based on sound theoretical
assumptions and have a well-defined purpose. In this way, the theory
developed will be able to guide further research and professional
practice.
54
2.5.4 Step 4: Guidelines to operationalise the model
You've gotta dance like there's nobody watching,
Love like you'll never be hurt,
Sing like there's nobody listening,
And live like it's heaven on earth.
William W. Purkey
Guidelines to operationalise the procedure (process) of the model are described
to assist the clinical application of the model in a radiotherapy setting. For each
guideline described, an objective is stated as well as an action to achieve the
objective.
2.6 TRUSTWORTHINESS
A model of trustworthiness by Lincoln and Guba described in Krefting (1991:
156–159), Babbie and Mouton (2001:276–278), De Vos (2011:443–444) and
Murphy and Yielder (2010:62–67) was used to ensure trustworthiness (see
Table 2.1).
55
TABLE 2.1: STRATEGIES TO ENSURE TRUSTWORTHINESS
Criteria
Strategy
Truth value by
 Prolonged engagement within the field
means of
 Reflective field notes
credibility
 Triangulation
 Peer review
 Member checking
 In-depth interviews
Applicability by
 Purposive sampling
means of
 Description of the demographics of the sample
transferability
 Dense description of the results of the interviews
and of the model development
Consistency by
means of
dependability
 Dense description of the research methodology
of theory generation and model development
 Step-wise replication of research method
 Code-recoding of results
 Dependability audit
Neutrality by means
 Providing a chain of evidence
of confirmability
 Triangulation
 Peer review
 Confirmability audit
Truth value or credibility was ensured by implementing the following
strategies: prolonged engagement, reflective field notes, triangulation, peer
review, member checking and in-depth interviews.
56
I am a therapy radiographer who has prolonged and varied field experience in
radiotherapy including working in provincial and private hospital settings in
South Africa and in the National Health Service in the United Kingdom. The
participants were all familiar with me as I was actively involved in teaching the
radiotherapy programme, with the department concerned being one of the
training hospitals accredited with the radiotherapy programme. Radiotherapy
is a very specialised discipline which meant that I had worked with a number
of the participants as a clinical therapy radiographer. The participants were
therefore comfortable with me and were willing to share their stories openly in
my company.
During the interview process, I kept reflective field notes which assisted in
ensuring that my feelings and experiences were kept in check and did not
dictate the data analysis process. Triangulation of data was performed by
combining the interview data with the data collected by the researcher using
descriptive and reflective field notes during the interview process (Creswell,
2007:208).
The findings of the study were discussed in the forum of a Doctoral Committee
consisting of peers and colleagues who were impartial to the study and who
had experience in qualitative research techniques. The results of the focus
group interviews were presented at an international conference in Belfast,
Ireland in May 2010 (Lawrence et al., 2010) and the model was presented at
a national congress in May 2012 (Lawrence et al., 2012) The results of the
focus group interviews were also subjected to a peer review process as a
journal article based on the results of the study was published in 2011
(Lawrence et al., 2011).
Assessing the themes identified with the therapy radiographers who
participated in the focus group interviews was a strategy employed to ensure
57
that I had accurately translated the viewpoints of the participants into the
data. Member checking was done by reflecting with the participants what the
main concepts discussed during each phase were, at the time of the interview
allowing each member to contribute to and confirm the authenticity of my
reflection. Once the data had been analysed and the themes and categories
developed, I returned to the department and presented the themes and
categories to all the departmental staff to verify the themes and categories
generated (Creswell, 2007:209; Krefting, 1991:11). The journal article published
was also given to participants to read and comment on whilst still in draft
format, thereby ensuring that the participants could recognise their own voice
in the article.
Finally, credibility is also demonstrated in this research by the in-depth
interviews that were conducted. This allowed me to gain a deep understanding
of what it meant to participants to be a therapy radiographer and to gain insight
into their dreams for the profession. Such an understanding could only be
achieved by giving participants time to share their experiences in an interview
setting by allowing them to tell their unscripted stories.
Transferability of the research findings was ensured by including in the
research report sufficient descriptive data to allow for comparison with another
setting or population (Babbie & Mouton, 2001:277; Krefting, 1991:14).
Purposeful sampling (Mouton, 2001:277) of the participants allowed me to
select participants who were comfortable speaking in English about their
experiences as a therapy radiographer from a range of participants, allowing
me to build a dense description of the experiences of a wide range of therapy
radiographers. A dense description of the participants, the study setting, the
results of the interview and the development of the model are provided in the
research report to allow the reader to consider the transferability of the model
to another setting (Creswell, 2007:209).
58
Dependability strategies employed in the study entailed describing in detail
the methods used to gather and analyse data in order to ensure that the study
could be repeated in a similar context with similar results (Babbie & Mouton,
2001:278; Krefting, 1991:14). A dense description of the research methodology
of theory generation and model development is therefore provided in this
report to allow for a step-wise replication of the research method in a similar
setting. The results of the interviews developed as a result of a data analysis
process performed by myself was then verified by a recoding procedure
undertaken by an independent coder who was blinded to my interpretation of
the results.
Confirmability of the data collection and data analysis was ensured by
undertaking a confirmability audit which involves providing a chain of evidence,
triangulation and reflexivity (Krefting, 1991:8). Reflexivity ensures that the
researchers continuously reflect on their own characteristics so that they are
aware of how they might influence the collection and analysis of data. This
was done by making use of field notes detailing my thoughts and ideas during
interview sessions with the participants (Krefting, 1991:10). Creswell (2007:
208) also suggests clarifying researcher bias from the beginning of a study. I
have therefore included in the researcher report the metatheoretical
assumptions on which the report is based. In order to ensure that the findings
were not based on my experiences and thoughts of being a therapy
radiographer, a process of peer review was followed at regular intervals
throughout the research process.
2.7 CONCLUSION
The design chosen for this study aimed to develop new theory which is
specific to the profession of radiotherapy and which will aid in the personal
and professional development of therapy radiographers. A limitation of the
design may be incorporating an action research strategy, appreciative inquiry,
59
into a theory-generating design without following the path of action research.
However, appreciative inquiry may also be the catalyst needed to bring about
positive professional change at a time when current research trends in
radiography are to explore the negative aspects of the profession. A dense
description of the research methodology employed in this research has been
given to assist in the transferability of the findings into a similar context.
In closing, the research design and method selected for this study were in
essence to facilitate a better future for therapy radiographers. Therefore, I
close this chapter with the words of Ralph Waldo Emerson for reflection and
inspiration.
To laugh often and much; to win the respect of intelligent people and
the affection of children; to earn the appreciation of honest critics and to
endure the betrayal of false friends. To appreciate beauty; to find the best
in others; to leave the world a bit better whether by a healthy child, a
garden patch, or a redeemed social condition; to know that even one life
has breathed easier because you have lived. This is to have succeeded.
Ralph Waldo Emerson
60
CHAPTER 3
RESULTS OF APPRECIATIVE INQUIRY INTERVIEWS
WITH THERAPY RADIOGRAPHERS
The secret of many a man's success in the world resides in his
insight into the moods of men and his tact in dealing with them.
J.G. Holland
The aim of this chapter is to present to the reader the results of the
appreciative inquiry interviews held with 14 therapy radiographers. The themes
and categories identified will be explored and positioned within the context of
current literature. A dense description of the participants and the themes will
be provided with supporting verbatim quotes from the participants.
Research conducted by therapy radiographers is limited both in Africa (EngelHills, 2009:95) and internationally (Cox et al., 2011:228; Davies & Rawlings,
2009:105). Although radiographers in general are beginning to become more
involved in research opportunities (Reid & Edwards, 2011:207), there is
limited opportunity for the publication of radiation oncology articles by therapy
radiographers. For example, there are no dedicated radiation therapist
journals on the African continent and less than 0,5% of articles published in
international journals originate from studies in Africa (Engel-Hills, 2009:95).
The literature review for this study was therefore limited by a lack of published
articles specific to the discipline of radiation oncology. For this reason, allied
health care literature such as that of nursing was included in the literature
review.
61
3.1 DEMOGRAPHICS OF THE PARTICIPANTS
The appreciative inquiry interviews took place in the radiation oncology
department at a tertiary hospital in Gauteng. At the time of the interviews the
staff complement consisted of 24 therapy radiographers. I invited all 24
radiographers to participate in the interview process. Those that agreed to
participate were grouped into interview groups depending on availability of
staff so as not to interrupt the workflow of the department. Interviews were
arranged in consultation with the assistant director at times which were
suitable to the staff concerned.
Fourteen therapy radiographers participated in four focus group interviews
until data saturation occurred. There were five male and nine female
participants. The age of participants ranged from 21 to 55 years. The
participants’ experience within radiation oncology ranged. Many participants
had worked in more than one oncology centre. The qualifications of the
participants ranged from those with a national diploma to those with a bachelor
of technology degree and one participant was busy with master of technology
studies. Participants were from various cultural backgrounds and reflected the
multicultural community typical of the South African population.
All participants were known to me as I had been actively involved in teaching
both the national diploma and bachelor of technology degree for six years
prior to the interviews. I had also worked with a number of the participants at
the start of my own oncology career. As radiation therapy is a small, very
specialised discipline, most therapy radiographers are well acquainted with
one another.
All the participants and the oncology department as a whole were very
supportive of the research process. This was evidenced by the way in which
the entire staff complement rallied to support one other to allow staff members
62
to take time away from their workstations to participate in the interviews.
Several participants told me after the interview was complete that they
enjoyed being given an opportunity to talk about the profession in a positive
way and that because of the experience they felt excited about the profession
again. This positive energy also transcended to the staff that did not participate
in the interviews but that ultimately played an invaluable role in the process
and were always eager to assist in any way possible. During the member
checking phase of the research process, the entire staff complement asked to
be allowed to hear the results of the study and actively participated in giving
feedback.
3.2 THE CENTRAL STORY
Energy and persistence conquer all things.
Benjamin Franklin
Participants were interviewed in a focus group setting utilising an appreciative
inquiry interview technique using the 4-D model developed by Watkins and
Mohr (2001:42–45).
Firstly, participants were asked to share stories where they Discovered or
focused on times when being a therapy radiographer made them feel alive
and fulfilled. Participants were asked the question, “When did you feel most
alive and vital at work?”
Next, participants shared stories where they Dreamt and were challenged to
envisage a profession with unlimited potential. The question, “Where would
you like to see radiotherapy going to in the future?” was posed.
63
The Design phase followed where participants were asked to create the social
architecture of the profession and share the qualities and behaviours that
would enable them to become a whole person within a radiotherapy context.
Participants were asked the question, “What is needed to reach that?”
The final phase is the ongoing Delivery phase where participants were asked
to develop ways in which the new qualities and behaviours could be
implemented in the clinical radiotherapy setting. Participants were asked the
question, “What can we do to achieve that?”
Participants were given all four interview questions at the start of the interview
process and often seemed to move seamlessly between the design and
delivery interview question without having the question necessarily posed to
them. The central story that emerged from the interview data is described
below.
The central story guiding this research is one of a group of professionals
finding themselves at a professional and personal crossroads. Their dreams
for themselves and for the profession of radiography are simple, yet their
perception of themselves and the profession devalues their self-worth and
hampers the possibility of growth and development. They have become “stuck”
at the crossroads and can either harness the positive energy to develop
personally and professionally or remain at the crossroads dreaming of what
might be found on the road ahead.
When asked to describe what made them feel alive and vital at work, stories
were told describing marginalised life-giving forces that gave the participants
a sense of purpose. Stories told focused on building relationships with patients
and their families and working closely with colleagues. An altruistic theme
64
was apparent as participants often reflected on times when helping patients
gave a sense of purpose in life.
When the discussion moved on to the dream phase of the interview,
participants told stories of wanting to be recognised as a valuable professional
within the health care sector in general and more specifically within oncology.
A need for a clear career pathway became apparent in the dream phase and
a willingness to develop skills in order to take on additional responsibilities to
move the profession forward was evident.
The design phase of the interview saw participants focus on a need for further
education in radiotherapy and a need to change the profession from within. A
need to develop both interpersonal and intrapersonal skills was voiced as well
as a need to develop a culture of lifelong learning within radiotherapy.
However, a devalued sense of self and interpersonal conflict made delivery of
the dreams identified difficult to imagine, creating a professional and personal
crossroads.
The themes and categories identified from the transcribed interviews are
presented in Table 3.1 below and will form the basis for the discussion of the
results.
65
TABLE 3.1: THEMES AND CATEGORIES DEVELOPED FROM APPRECIATIVE
INQUIRY INTERVIEWS
Theme
Life-giving forces that
promote personal and
professional engagement
resulting in a sense of
purpose
Category
1.1 Personal and professional recognition
and appreciation
1.2 Fulfilment from helping patients
1.3 Close personal involvement with
patients and colleagues
1.4 Providing a professional service
Professional stagnation
from
a lack of self-worth and
interpersonal conflict
2.1 Lack of self-worth and feelings of
professional stagnation
2.2 Interpersonal conflict between team
members
2.3 Feelings of inferiority within the
oncology team environment
Facilitating change towards
3.1 Developing a positive relationship with
wholeness through
self
harnessing the positive
3.1.1 Further development of self as
energy and commitment to
change
a professional
3.1.2 Skills to be developed
3.1.3 New behaviours to be
developed
3.2 Developing positive relationships with
others
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3.3 THEME 1 – LIFE-GIVING FORCES THAT PROMOTE
PERSONAL AND PROFESSIONAL ENGAGEMENT
RESULTING IN A SENSE OF PURPOSE
“Every day do something that will inch you closer to a better tomorrow.”
Doug Firebaugh
Stories told around this theme focus on a deep need for recognition and
appreciation. As radiotherapy requires working in a team setting, a need to
work with a dedicated team that is able to provide a professional service to
the patients also became apparent.
From a personal perspective my happiest times as a therapy radiographer
were centred on patients who touched me in a special way that made me
relook at my priorities and around working well in a team environment. A
visitor to a radiotherapy department will also notice how the therapy
radiographers display the thank-you cards received from patients. The cards
are usually prominently displayed around the console of the treatment machine
and are treasured by staff. The department at which the interviews were
conducted is no exception to this and thank-you cards were on display at each
treatment unit.
The atmosphere in a radiotherapy department is directly linked with how well
the team is performing. A team that is working well is one that is organised
and is therefore not making errors in treatment delivery. A team in which the
dynamics are poor results in chaos and multiple treatment errors with serious
consequences for the patient and the staff involved. The stories that were told
therefore fit well with my personal radiotherapy journey and echo my
67
sentiments around the importance of the patient and the team with whom one
is working.
3.3.1 Personal and professional recognition and appreciation
Sometimes our light goes out, but is blown again into instant
flame by an encounter with another human being.
Albert Schweitzer
As soon as participants started telling stories of how they enjoyed feeling
appreciated for the job that they were doing, one could see how their faces lit
up and the atmosphere in the room became relaxed but energised. Any
gesture of appreciation was treasured by participants and gave a sense of
purpose to their working day. The quotes below reflect how important a simple
“thank you” was to the participants.
“…when they come to you and say ‘Thank you for the wonderful
work’, it makes you feel you are doing something good”
“And some of those patients, they can even come back to you
and say ‘thank you’. And then you start to feel like ‘at least I did
something to this person’”
“The few when the patients say...when the patients come to me
and tell me that they think…(Inaudible)…a good job. I was
organising, and I’m a good person, I’m doing a good job. It was
not just once, many a times by the patients.”
68
“I noticed when I am here, then everybody like comes and say
‘Oh, whenever you come here we do get help, you just drop
everything and pay attention to me’. Oncologists also, and the
nurses…”
“I mean, we had so many gifts”
“So ja, recently I started working and last week I felt good
because you know you back into people appreciating you for
what you do. You know that respect that you get from your
patients. Not necessary the respect but the jest of them saying
‘thank you for helping us’. It makes one feel good you know
especially if you’ve been off for some time, then you find that
you have a purpose in life.”
Willis-Shattuck, Bidwell, Thomas, Wyness, Blaauw and Ditlopo (2008:247)
show in a literature review of 20 articles that recognition and/or appreciation
is a theme found in 70% of studies as being an important motivating factor for
health care workers. Taking care of people and feeling valued are found to be
a crucial aspect of health care worker motivation. Dieleman, Viet Cuong, Vu
Anh and Martineau (2003: 8) support this concept and found that health care
workers in Vietnam were motivated by recognition and respect from managers,
colleagues and from the community.
Of course, the need for recognition as a motivating factor was described in
Hertzberg’s motivation theory as far back as the 1960s (Hertzberg,1968). The
theory identified five factors which Hertzberg believed determined how
satisfied people would be in their jobs. The factors are achievement,
recognition, the work itself, responsibility and advancement. Probst and
Griffiths (2007:24) suggest that many of the factors identified by pioneers in
69
the field of neo-human relations such as Hertzberg, Maslow and McGregor
are still relevant in today’s radiotherapy workforce. From the themes identified
in the current study, it appears as if the therapy radiographers in this study are
no exception.
The quotes above also seem to indicate that the therapy radiographers in this
research sought positive feedback from patients and colleagues in order to
secure a sense of personal self-worth. Hepper and Carnelley (2010:449, 450)
suggest that people seek feedback frequently in their everyday lives in an
attempt to regulate how they feel about themselves. The authors believe that
people who seek positive feedback have a lower self-esteem due to the fact
that individuals with high self-esteem generally self-enhance more than those
with a lower self-esteem. A visit to any radiation oncology department, in my
experience, will highlight this deep need for positive feedback among therapy
radiographers. This may go some way to explain why any radiotherapy
treatment unit visited will display publically a range of thank-you cards received
from patients.
3.3.2 Fulfilment from helping patients
How wonderful it is that nobody need wait a single
moment before starting to improve the world.
Anne Frank
Participants told stories of how knowing that they were helping somebody
made them feel fulfilled and gave them a sense of purpose. Fulfilment from
helping patients was often the first story told by participants when asked what
made them feel alive and vital at work. Whilst such stories were being told,
70
heads nodded all around and participants were eager to share their special
“caring” story. A selection of the stories told is reflected in the quotes below.
“I think it is a good career, especially when you are working with
cancer patients because when you are helping a cancer patient
you feel fulfilled. Like if a patient comes and…how can I put
it…like he’s very very sick, and then you help that person and
you see that person recovering, you feel fulfilled.”
“And it was a breast cancer patient and we were treating mets
(metastasis) to the spine and after some time, I think two or three
weeks later the patient actually walked because we were preempting cord compression. And that was…the feeling was pretty
good. It made me feel I’m doing the right stuff.”
“But that really makes me feel proud of myself that at least you
can help somebody and they can still remember you because in
this world not a lot of people remember what you do for them.
And if there is only one person who really appreciates what you
doing for them, it’s very good for yourself I think.”
“So those are definitely the moments you feel proud about your
profession that you are definitely doing something for somebody
that needs your help.”
“So ja that also makes me feel good to come to work and
knowing that you can help somebody and that person always
remembers you. Even if I am not in the department she still
comes and looks for me and then afterwards she comes again
and say I was here and I was looking for you and she still brings
me cool drink (laugh) and things like that.”
71
“I think I will say the same thing because on the 25th of December
I had a phone call from one of our patients that we treated in L4,
she called me and said Merry Christmas and even the husband
and the daughter were saying ‘You’ve helped us a lot’.”
Very little literature can be found on what therapy radiographers enjoy about
their work. However, Probst and Griffiths (2009:148) asked the question, “Can
you tell me about a time when you felt satisfied working as a therapy
radiographer?” in a study conducted among United Kingdom therapy
radiographers. Unfortunately, the results reported in the literature focus on
the negative, but one quote states “…a lot of the reasons that I went into
Radiography was to do with patient care…” (Probst & Griffiths, 2009:150).
Bolderston, Lewis and Chai (2010:206, 202) found that caring for patients is
fundamental to the role of a therapy radiographer and that therapy
radiographers see themselves unique as they “choose cancer” when they
enter the profession.
A review of educational websites also results in “caring for patients” as a
description of what therapy radiographers do. The American Society of
Radiologic Technologists (ASRT) describes a therapy radiographer as “a
highly skilled medical specialist educated in physics, radiation safety, patient
anatomy and patient care”. The site gives the testimony of a therapy
radiographer who states that she enjoys her work largely because of the
rapport she builds with the patient and her involvement in patient care which
is in contrast with her experiences in diagnostic radiography (www.asrt.org/
content/abouttheprofession/Who_Are_RTS.aspx).
The University of Cardiff website supports the views of the ASRT by
describing the work of a therapy radiographer as providing a “patient-centred
72
service” to oncology patients (www.cardiff.ac.uk/sohcs/degreeprogrammes/
undergraduate/radiotherapyoncology).
3.3.3 Close personal involvement with patients and
colleagues
Simplicity, patience, compassion.
These three are your greatest treasures.
Simple in actions and thoughts, you return to the source of being.
Patient with both friends and enemies,
you accord with the way things are.
Compassionate toward yourself,
you reconcile all beings in the world.
Lao Tzu, Tao Te Ching
Radiotherapy is a profession in which patients are treated by the same staff
members each day for a period of up to eight weeks. Teamwork is unavoidable
as legislation does not permit a therapy radiographer to treat a patient alone.
It is therefore not surprising to hear stories from participants that describe
how important it is to them to have a positive relationship with both the patients
under their care and the team members with whom they work. The quotes
below reflect examples of some of the stories told.
“Even now, I was working with xxx so I just felt like really
appreciated. But it really has to do with the other person you are
working with. If you are both dedicated and you love what you
are doing”
73
“But if the environment is not good…your work colleagues are
just not there for you to support you as a friend, to go through
the emotions with you, you really don’t feel like coming to work.”
“And I remember when I was working with xxx and then I went to
xxx and I told her that I think me and xxx were a match made in
heaven (Laugh)”
“You know, in as much as we can’t bring our personal
relationship to work, sometimes it helps when you know xxx has
got a child who is six years old. If xxx can come to you and say
‘Hey, my baby is sick’ you would then understand. If xxx...but we
don’t know anything about each other.”
“… and some of those patients, they really touched me. They
were like my mothers, my sisters, my brother to me. So I started
feeling like they are my family too.”
“What I want to say now is like when you come into contact with
the patients, that feeling. You feel very very good because
compared to those that diagnose the patients, x-ray patients and
you don’t see that patient anymore but we see the patient every
day.”
“I think it has to start with how we view our career and then how
we view the patients because patients are very important. They
are very important to us as radiotherapists. So that’s the reason
why we are here; we are here for them. Patient care.”
“But you know I could adopt the lifestyle, even though sometimes
I feel like I took a wrong turn but you know like, ok now I am
74
working with patients, I love patients, they love me and I actually
adapted.”
Caring is a fundamental aspect of a therapy radiographer’s job description
and feelings of altruism have long been considered as a reason for people to
enter into a caring profession such as radiotherapy (Bolderston et al., 2010:
198). Ekmekci and Turley (2008:11) suggest that therapy radiographers often
promote the idea that caring for patients and their families is the distinguishing
factor that sets therapy radiographers apart from their diagnostic colleagues.
Bolderston et al. (2010:211) identify how a caring relationship between the
patient and the radiotherapist develops into a reciprocal relationship as the
treatment progresses. This concept of a mutually caring relationship between
the patient and the therapy radiographer was seen by the radiographers in
that study as being fundamental to their identity of being a caring therapy
radiographer. Furthermore the study identified that a therapy radiographer’s
perception of caring also extends into caring for therapy radiography colleagues
and caring for other members of a wider interprofessional team (Bolderston et
al., 2010:203).
Makanjee, Hartzer and Uys (2006:125) found that South African radiographers
feel obligated to remain working in an organisation largely because of the
people in it. Rutter and Lovegrove (2008:141) show that social support from
colleagues is crucial to reduce perceived stress levels of radiographers in the
UK. Verrier and Harvey (2010:122) suggest that organisations wishing to
reduce work-related stress in diagnostic radiographers should promote teambuilding exercises in order to encourage radiographers to support each other.
Milburn & Colyer (2008:320) suggest that radiographer-led independent
practice in the UK is increasingly driven around patient-centred care that
75
requires close interprofessional teamwork for the benefit of patients under the
care of radiography staff.
A lack of social support has been cited in nursing literature as contributing to
burnout levels by a number of authors. Coffey and Coleman (2001:405) found
that nurses who cannot discuss work problems with their colleagues are more
likely to have higher emotional exhaustion scores and concluded that workrelated support is a significant factor in predicting stress and burnout among
nurses. This finding is supported by Papadatou, Anagnostopoulos and Monos
(1994:194), who found that a lack of support by senior colleagues is associated
with high stress levels. Levert, Lucas & Ortlepp (2000:40) and Kilfedder,
Power & Wells (2001:390) also support this finding and demonstrate that lack
of support by colleagues correlates significantly with high levels of burnout.
3.3.4 Providing a professional service
He who has never learned to obey
cannot be a good commander.
Aristotle
Providing the patient with a service that was seen to be professional was of
great importance to the participants. They told stories of how good it made
them feel to work in an environment in which the service provided was of a
high standard. In order to do this the work environment needed to be organised
and the service needed to be run efficiently, according to schedule. Respect
for the patient and other members of the team was seen as a critical element
to providing a professional service, as is demonstrated below.
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“Like as xxx was saying about coming in on time; I think that is
very important because you are also respecting other people,
you are respecting the patients. So maybe you come early, you
do them early, then they can also go to work”
“Because if you are not on time, even patients look at you like
‘first of all, you don’t even respect your job, you don’t respect
us, you don’t respect what you do and you also don’t even
apologise to the patients’.”
“When I worked with xxx and xxx, both of us were like really
dedicated. And I remember we would be at work on time, so we
start on time. So almost all our patients were happy that they
don’t wait for long. You know, they come and they go inside the
room, we treat them and they really appreciated that.”
“And then I also think that it can also help you to organise
yourself, otherwise if you look like you are disorganised the
patient will distrust you and I don’t think they would want to be
treated by someone who’s forever late and sometimes is not at
work”
“I think on my side is coming back to here, to Johannesburg
Hospital, and (short silence) it, it actually started to feel like I am
back the moment I started doing QA. Because when I started
here I thought wow, wow, wow what a waste of time and energy.
But started to do the QA and realising that people can still take
therapy back to where it should be. Really, that made me really
happy.”
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The verbatim quotes above seem to indicate that the therapy radiographers in
this study perceived a professional service to be one which is efficient and
effective and where staff members are reliable and punctual. However, there
has been considerable debate in radiography literature about whether
radiography has reached a point where it can be called a true profession.
Sim and Radloff (2009:204) suggest that a profession can be identified by
traits such as specialist knowledge, representation via a professional
organisation, a code of professional conduct, autonomy and altruism. They
contend that radiography in an Australian context has all but two of the
characteristics listed. Autonomy, they believe, is not completely possible
because, as with all health care professions, the health care system limits
autonomy in the name of accountability and transparency. The authors also
believe that there is a climate of “what’s in it for me” among radiography staff
which is limiting the quest for altruism and is therefore hampering the
transformation of radiography from an emergent profession to that of a true
profession. However, the therapy radiography staff that participated in this
study did seem to exhibit signs of altruism as they were most concerned with
the wellbeing of the patient and stories told focused around the importance of
patient care. Kowalczyk and Leggett (2005:24) believe that radiographers in
the United States have failed to achieve professional status and are referred
to as “technicians” due to their educational training which does not equate to
a bachelor’s degree, which is considered to be the benchmark for gaining
professional status.
Wright, Jolly, Schneider-Kolsky and Baird (2011:6) have suggested that health
care professions in the United Kingdom and Australia are moving away from
the concepts of professionalism and competence and are replacing the terms
with a concept called “fitness to practise”. This broader framework includes
the attributes of professional behaviour, attitudes, observable skills, freedom
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from impairment and a legislative component (Wright, Jolly, Schneider-Kolsky
& Baird 2011:7). The authors combine the key attributes of fitness to practise
described in the literature into a “star of practice” which they used as a
framework for a study to define fitness to practise in a radiation therapy
context. The star of practice is illustrated in Figure 3.1 below. The participants
in my study seemed to conceptualise professionalism in much the same way
as that described by the star of practice. My participants talked about factors
such as coming to work on time, not being absent and providing an efficient
service as key to being professional rather than the traditional aspects of a
degree, autonomy and altruism. The star of practice suggests that attributes
such
as
self-regulation,
self-awareness,
accountability,
conduct
and
competence are key to being a professional in much the same way as the
participants in this study expressed.
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FIGURE 3.1: THE STAR OF PRACTICE (Wright, Jolly, Schneider-Kolsky & Baird
2011:8)
3.4 THEME 2 – PROFESSIONAL STAGNATION FROM A
LACK OF SELF-WORTH AND INTERPERSONAL
CONFLICT
Be not afraid of growing slowly; be afraid only of standing still.
Chinese Proverb
Sadly a number of stories were told that reflected a devaluated perception of
self among participants and described radiotherapists as “unseen” in the
professional environment, causing feelings of demotivation and depression.
Interpersonal team conflict, lack of managerial trust and support further hamper
perceived prospects for growth and engagement, causing participants to feel
“stuck” in a profession that was considered less worthy of recognition than the
other members of the oncology team such as physicists and oncologists.
3.4.1 Lack of self-worth and feelings of professional
stagnation
Knowing yourself is the beginning of all wisdom.
Aristotle
Perhaps the saddest moments for me were when participants told stories that
reflected a lack of self-worth and feelings of being “stuck” in a profession with
limited opportunities for growth and development. I often found myself looking
at a participant whom I knew as a bright-eyed bushy-tailed student and
80
wondering where that enthusiasm and energy had gone. As can be seen from
the quotes below, words such as “not growing” and “just a radiotherapist” were
used frequently by participants.
“To me, when I look in terms of growth, I think the therapy is not
growing, or radiography in general. Especially when I compare it
to other things, like nursing. If you look at nursing, I think they
are growing and they are expanding. Where with us, you reach a
point where you are saturated, like you can’t go further. Like
myself, when I look at myself, I’m saturated. Like I don’t want to
learn any other things like…I can’t say there is no interest, but
you are saturated. Like you look at nursing for example, and you
look at the research that has been done, you will find a lot of
articles, but in radiography you don’t find anything. We are not
growing.”
“I think money will make all the difference (Laugh). Because with
my husband, at the end of the month and I have to show him my
payslip, I don’t know, mine is like change or what (Laugh) but
this is my salary. And also I just think about him; how does he
view…I don’t know, but he doesn’t complain about the salary,
but I sort of like look at my salary like this is what I’m bringing
into my home. Ja, it’s not good enough (Laugh).”
“I think it does affect how you view yourself because sometimes
people see you are in radiotherapy and when they look at your
salary they look down on you.”
“I feel radiographers do not see themselves beyond certain
things. I feel they are restricted – if I may put it that way – and
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they will always want to justify their existence by comparing
themselves for instance to other professions; physicists,
doctors and so on. And because they have no pride in what they
actually do as radiographers, they cannot stand up to defend
themselves.”
“And I think that will give a chance to challenge the doctors in a
way you know. It will make…you know like you won’t be just a
radiotherapist…”
“Ja because right now I am just a radiotherapist, (laughing). You
know and I get my minimal salary. It changes your attitude. So
what I’ve just got a national diploma. I will do that amount of
work that is qualified for a national diploma. So it changes your
attitude completely.”
“So maybe the start point will have to be to inflate our egos
more during training and to have that in you that you are
somebody that’s worth something.”
Low self-esteem results when individuals evaluate the group that they belong
to against other groups and decide that the group they belong to is inferior. A
negative social identity develops and individuals may try to align with groups
that they view as having a high status (Farrell, 2001:29). From the quotes
above it appears as if therapy radiographers view the group that they belong
to as inferior and are striving to belong to a more “superior group” such as the
oncologists or physicists, thereby seeing themselves as more than “just a
radiotherapist” with limited opportunities for professional growth.
Lewis et al., (2008:94, 95) describe Australian radiographers’ experiences and
feelings of medical subordination as the “just the radiographer” syndrome.
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The authors report that the radiographers in their study felt inferior to the
radiologists and to medical practitioners in general. The radiographers in the
study also reported that role development would enhance their professional
status. Disturbingly, radiation oncologists such as Trotti (1999:543) have in
the literature described a therapy radiographer as “the person who turns on
the machine” whilst the radiation oncologist is “the person with the body of
knowledge”.
Probst and Griffiths (2009:150) explain that therapy radiographers in the
United Kingdom find the work monotonous and repetitive, with many not truly
prepared for what working as a therapy radiographer would involve. Limited
opportunities for career development have left United Kingdom therapy
radiographers feeling as if they have reached a professional plateau as they
have limited opportunities to develop new skills. As radiotherapy is driven
mainly by protocol with an emphasis on productivity, therapy radiographers
are accustomed to working within well-defined roles with low functional
autonomy. This creates an apathetic attitude towards learning new skills,
thereby limiting possibilities for professional development (Sim & Radloff,
2009).
3.4.2 Interpersonal conflict between team members
A general is just as good or just as bad as the
troops under his command make him.
General Douglas MacArthur
Interpersonal conflict between team members was a common source of
concern among participants. Conflict resulted in splitting of alliances and
blaming, creating a negative atmosphere within the workplace sometimes
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described as a “virus” infecting all staff. Compromised communication with
management added to the negativity expressed by participants. The negative
stories were usually told when the interview moved into the design phase of
the interview process, as many participants could not see how it would be
possible to achieve their dreams for the profession against the background of
the interpersonal conflict and managerial problems that they were
experiencing.
Interestingly, when I returned to the department for the member checking
phase of the interview, participants identified more with this category than
with any of the other categories. The quotes below reflect just how destructive
this negative energy within the department had become.
“Most of the dynamics that I’ve seen here are interpersonal fights
between for instance department, it has caused alliances even
within the radiography fraternity. Others are lining to this. If that
were broken down and everybody sees the trail on top as a group
working together they would not feel the need to align to any
particular one.”
“I think we are like really divided here, you know. Physicists are
physicists, we are here this side and then doctors are that side.
Even when we are having our parties, you know they have their...
we are going to have a Christmas party next week, but it will just
be us, you know. It’s never like a combined thing. So we really
have to work on that.”
“Because it is more, I think it is like a virus going into our minds
and corroding the minds with all the negative things. But you
must have something positive; I don’t know what, that is given
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to the people. Not money as such but encouragement you know
talking more about our career and how we can improve it and
how good and special we are. I think that will encourage people
and that will give them a positive attitude towards the
profession.”
“And I think the...hopefully people who don’t really know
anything, that are coming from outside and come into our
department, we mustn’t when they come in pollute them like I
was saying with a virus. We immediately pollute them with this
negativity. Try to you know, hold back the negativity and see
what the fresh and new ideas are gonne do for us. We can’t stop
or hinder if people come up with new ideas and ‘no that’s not
gonna work, no this is the way I am use to doing it’ or ‘no, I just
know she is not going to say yes to that, no, me, you know’.
Start using, maybe we must start using the word yes more often
than no.”
“But it’s sad from when you come in, especially this department,
when you come in, the first thing people will tell you is that ‘so
and so, don’t trust so and so, don’t do this’. And you get worried
and say ‘how did these people survive, because none of them
seems to be coming with anything’. I don’t know if they were as
bad as they were to me, to me there was not a single one of them
who gave me something positive. Everything was just; ‘you are
not going to survive’.”
“That is what worried me about the students, the students last
year, you know the students in the department, the therapy
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students. When you see them you get worried that they are
copying the negativity of the seniors.”
“Maybe I should mention the issue of management. I think what
they do sometimes it also affects the morale of the staff, if you
don’t have a good management. For example radiographers,
doctors, or our own management I think also affect the morale of
the people and I think it can affect maybe even patient care.
Because sometimes you are working and then you are angry and
it will affect you.”
“I think there is a lack of communication between the management
and the staff. Because I think the management, sometimes they
just implement things in the department without consulting the
staff members. And then the other things is like things are not
transparent in our department. If they can maybe make things
transparent so that everyone can have an access to those things,
I think that will help us as radiotherapists.”
“I was thinking when we speak about management teams, me I
think the people on top, they don’t have management skills. Like
he’s just a doctor who happens to be head of department. Like
they don’t have leadership skills. Like they are just there because
of so much experience in radiotherapy. So if also then they can
maybe when they are in positions of power they start reading on
maybe what is management or what is leadership. Maybe we
won’t be seeing these conflicts that is happening between
physicists and...”
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Interpersonal conflict among staff members has been seen to be a leading
cause of stress and burnout in health care literature (Kalliath & Morris, 2002:
653; Levert et al., 2000:41; McNeese-Smith & Crook, 2003:268; Sargent,
Sotile, Sotile, Rubash & Barrack, 2004:1585). Nursing literature has reported
staff concerns that intrastaff aggression is more stressful than patient-nurse
violence or aggression from staff in other disciplines (Farrell, 1997, 1999) and
that nurse-to-nurse verbal abuse is a leading factor of work-related conflict
(Ramos, 2006:37). Baltimore (2006:28) describes interpersonal conflict among
nurses in terms of the more experienced nurses “eating their young”, while
Brinkert (2010:145) maintains that management of nurse conflict is an issue
that needs to be addressed in terms of theory, research and practice.
Based on the comments by the participants, it appears as if the therapy
radiographers in this study are unable to effectively manage their feelings of
anger and aggression, leading to unresolved conflict, described as a “virus” in
the department. Johnson (2006:311–319) suggests that an important tool to
managing anger and aggression effectively is to follow a set of steps for
constructive anger management. The steps imply that a person, when angry,
should be taught to acknowledge their anger, clarify the other person’s intent,
decide whether or not to express their anger and then to analyse and reflect
on the decision made.
The participants in this study seemed to foster feelings of anger, resulting in
fractions and alliances forming within the team. Kim, Kim and Kim (2011:201)
have even suggested that conflicts among radiography staff are partly caused
by ineffective leadership and suggest that leaders adopt a transformational
leadership style and develop a consensual culture within radiography
departments. The participants in this study seemed to align with the study by
Kim et al. as dissatisfaction with management and a lack of consensus and
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transparency in decision making was voiced as adding to interpersonal conflict
among staff members.
Dissatisfaction with management has been widely documented in radiography
literature. Cox et al. (2010:34) found that management and staff issues were
ranked as the third most important area for further research by Australian
radiographers. Verrier and Harvey (2010:121) report that a lack of
management support significantly impacts on stress levels of radiographers.
Makanjee et al. (2006:122) found that South African radiographers in
management positions fail to accurately and adequately communicate
decisions to staff and felt that management procedures would need to be
reviewed in order to retain radiographers. Akroyd et al. (2007:474) suggest
that radiography managers are often promoted into management positions
due to excellence in the clinical environment and may not necessarily be
prepared to manage effectively. Furthermore, Akroyd, Legg, Jackowski &
Adams (2009:119) maintain that managers who exhibit transformational
leadership styles are more likely to instil higher levels of organisational
commitment among staff.
3.4.3 Relationship with the professional environment
Do not go where the path may lead, go instead
where there is no path and leave a trail.
Ralph Waldo Emerson
Participants described being bored with radiotherapy and saw very little
opportunity for professional development or career advancement. They
viewed themselves as having less worth than the other members of the
multidisciplinary oncology team. They felt that they had no voice and that their
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professional knowledge and expertise were widely unrecognised. They felt
isolated and unseen within a multidisciplinary setting and within a radiography
setting. The quotes below show how the participants dreamt of stimulating
work, career progression and an identity that was recognisable and respected
in the medical and social domain.
“I think with once you qualify and you feel like it’s the same thing
every day it becomes like boring.”
“Ja, in terms of…like I think I know a lot of things but they don’t
interest me anymore.”
“Because with the nurses I understand they can even move to
SANCA you know, lots of doors open for the nurses, whereas
with radiography we are just stuck. It’s us, the department and
the patient. There’s no where we can move to even the
institutions like UJ, it’s not easy to get there as a lecturer.”
“It’s like even if you have your diploma, you know...there is xxx;
she’s got her master’s but she’s still doing what we are doing.”
“If in our department you study, there’s no reward. You’re still
doing the same chores, let me put it like that.”
“I find that therapy has gone extremely dull. I personally, as I say
I came back home and when I saw what was happening, so that I
just feel that something is seriously not right in therapy, people
don’t care anymore. People are just interested in just getting the
salary at the end of the day but not taking that responsibility on
taking, I mean looking, owning the job.”
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“For instance if we could have our profession rated on the same
footing as a physicist; physicists once they qualify they go into
an entry level, which is even higher than the entry level of a chief
radiographer who’s been practising for the past twenty years. So
no matter what you do you are always stuck up to a certain
level.”
“And I think that will give a chance to challenge the doctors in a
way you know. It will make...you know like you won’t be just a
radiotherapist. You know you’re challenged and you challenge
them more.”
“I think in terms of that, maybe people will start respecting our
profession in general.”
“Well, I just want that this profession should be recognised
more. People don’t know what we do, you know. I don’t think we
get enough exposure.”
“…our profession is not recognised well. We are working like we
are social workers, we are doctors and people don’t know when
you talk about a therapy radiographer...”
“And the government, yes it doesn’t recognise it because I
remember when they were fighting for diagnostic, they only
know diagnostic. You know, the therapy they don’t know what’s
happening there.”
“We are doing so much for patients and definitely, honestly we
need to be recognised as the profession.”
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“…we’ve got radiographers who don’t know about therapy. So
we are sort of isolated so maybe if we can open up our own
society of radiographers that people will say ‘Oh ok, therapy’
you know. I mean therapy, it’s more…they would like to know
more about therapy and will be sort of well recognised.”
“My kids one day told them ‘My mother is a radiographer’ they
didn’t know – the teacher. Then she said ‘My mother treats
patients’ (Laugh). So then the teacher said ‘I wonder what is this
mother doing treating patients? Is she a doctor or what?’ you
see, they don’t know. I mean teachers!”
“Places like cancer associations, they do this cancer wellness
but people that you’ll find there are people that don’t know
what’s going on with radiation therapy. So what information are
they giving the society?”
Job satisfaction among therapy radiographers has been a subject of discussion
in the literature in a United Kingdom setting. Probst and Griffiths (2007:23)
identify three main areas that influence job satisfaction and intention to leave
the profession. The areas are job design, leadership and organisational
governance, and stress and burnout. Similar to the participants in my study,
Probst and Griffiths (2007:24) also identify a need for more challenging work
among therapy radiographers.
Upon reviewing the job characteristics model (JCM) proposed in 1976 by
Hackman and Oldham, Probst and Griffiths (2007:25) list the factors indicating
mental challenge in relation to a therapy radiographer’s role. Probst and
Griffiths show that job design and leadership impact on the amount of mental
challenge a therapy radiographer experiences at work. For example, skill
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variety is reduced and therefore monotony increases by the common practice
of allocating patients requiring treatment using the same radiotherapy protocol
to one treatment unit. The degree to which an individual regards their work as
being important and the amount of feedback and autonomy given to the
therapy radiographers impact significantly on opportunities for mentally
challenging work.
The participants in my study seemed to reflect exactly what the Probst and
Griffiths study demonstrated. The workload in the oncology department where
my study was conducted is organised exactly how Probst and Griffiths explain,
with patients requiring the same treatment protocol allocated to a single unit.
This may explain to some degree why my participants complained of the
monotony of the job. My participants also complained of no longer being
interested in the work and even described their work as a “chore”. Probst and
Griffiths would argue that this could be because of a lack of mental challenge
due to the job design.
Sim and Radloff (2009:204) describe radiographers as “an emerging group of
professionals struggling to be recognised as a profession”. The authors site a
low public profile and a lack of recognition from health care professionals as
contributing to low self-esteem evident in Australian radiographers. Ekmekci
and Turley (2008:8) found that therapy radiographers lack a clear identity and
that health care professionals and the general public are unaware of what
therapy radiographers do, resulting in therapy radiographers feeling
unappreciated.
McNair (2005:456) believes that students in health care professions are not
adequately prepared to engage in a multidisciplinary setting. A lack of
interprofessional knowledge affects teamwork and respect levels offered to
different professionals. As radiotherapy is a small, specialised discipline, it is
not surprising to hear from participants that their role in the oncology setting is
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not widely known and recognised. However, it is concerning to hear from
participants that oncology health care professionals such as medical physicists
with whom they work are unsure of the role of a therapy radiographer. Milburn
and Colyer (2008:320) suggest that identifying common areas of professional
knowledge, for example that between the physicist and the therapy
radiographer, could lead to an environment where radiographers could
question, challenge and develop common practice.
3.5 THEME 3 – FACILITATING CHANGE TOWARDS
WHOLENESS THROUGH HARNESSING THE POSITIVE
ENERGY AND COMMITMENT FOR CHANGE
Life should not be a journey to the grave with the intention
of arriving safely in a pretty and well preserved body, but rather
to skid in broadside in a cloud of smoke, thoroughly used up,
totally worn out, and loudly proclaiming "Wow! What a Ride!
Hunter S. Thompson
As a therapy radiographer myself, I can associate with many of the stories told
by my participants. Some of my happiest moments in my clinical radiotherapy
career centred on my patients and colleagues. I can relate to both the acts of
altruism told by some participants and the feelings of being inferior told by
others. However, as a researcher and as a therapy radiographer, the overall
feelings that I sensed during the interview process were ones of a group of
professionals desperately clinging to the positive aspects of the profession
and an energetic workforce waiting for some guidance to break through the
perceived barriers to take the profession forward, culminating in professional
and personal wholeness.
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3.5.1 Developing a positive relationship with self
When I was 5 years old, my mother always told me that happiness was
the key to life. When I went to school, they asked me what I wanted to be
when I grew up. I wrote down ‘happy’. They told me I didn’t understand
the assignment, and I told them they didn’t understand life.
John Lennon
Just as one of the factors limiting growth is a devalued perception of self,
developing a positive intrapersonal relationship is paramount if wholeness is
to be achieved. While the participants in this study clearly demonstrated a
devalued sense of self-worth, they did voice the belief that any change in the
way in which other people view them must start with a change in the way in
which they view themselves. It was encouraging for me to hear from the
participants that they recognised that change needed to come from the
therapy radiographers themselves. The quotes below clearly indicate that the
participants were willing to take ownership of self in order to move forward
professionally.
“So the change must come first from within the way radiographers
perceive themselves first.”
“So maybe the start point will have to be to inflate our egos
more during the training and to have that in you that you are
somebody that’s worth something.”
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“It has to start with us internally, having respect for our own
profession before we can expect other people to have respect
for our profession.”
“I think internally like, in order to attract from outside, internally
people who are inside they need to change as because we can’t
change outside environment. You cannot attract other people to
us, if it’s us who are not ready for the change.”
“Ok ne, adding on what he is saying, I think to change the inside,
we have to like he is saying have a change of mind for all of us.
And that, I don’t know, maybe the whole teambuilding, some
things like that we need to do.”
“I think more than anything we as radiotherapists, we need to
work on ourselves because when these kids – sorry to call them
kids – when they come from high school, I mean they don’t know
what is this course all about. And they watch us, so they learn
from us. So if there is like any bad habits, they will pick it up
from us, you know.”
The concept of personal satisfaction or fulfilment from one’s job has attracted
some interest in health care literature. There seems to be consensus in the
literature that health care professionals define personal fulfilment as finding a
balance between a satisfying personal life (spending time with friends and
families and finding time for relaxation) and a satisfying professional life
(achieving professional goals and making a difference) (Pololi, Dennis, Winn
& Mitchell, 2003:26; Shanafelt, Chung, White & Lyckholm, 2006:4025; Thorpe
& Loo, 2003:328;).
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Fallowfield (1995:1132) suggests that unrealistic expectations placed on
oncologists explain the high rates of suicide, divorce and illness that plague
the medical profession. He infers that the only way in which to improve the
professional and personal fulfilment of oncologists is to teach constructive
communication and management skills. Constructive communication skills, he
believes, would equip doctors with the skills required to express their own
emotions and would buffer the stressful nature of the job. Management skills
are required as doctors are expected to become effective business managers,
a skill for which they are not adequately prepared. The participants in my
study seemed to have fallen prey to the same fate of poor personal and
professional fulfilment, but did show a willingness to work on themselves to
turn the situation around.
3.5.2 Further development of self as a professional
I wanted a perfect ending. Now I've learned, the hard way, that some
poems don't rhyme, and some stories don't have a clear beginning, middle,
and end. Life is about not knowing, having to change, taking the moment
and making the best of it, without knowing what's going to happen next.
Delicious Ambiguity.
Gilda Radner
Many participants spoke of a need to further develop themselves professionally
to enable role extension which they hoped would make the profession more
fulfilling. Again, the quotes below reflect the recognition by the participants
that they had to take ownership by developing themselves academically in
order to develop professionally.
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“So I would like growth or an expansion in that kind of direction.
We need to take on more than what we are currently doing.”
“So what I would like to see in future is more of the articles
being published here in South Africa. And then I would also like
to see more radiographers studying further.”
“I think from studying, because when you are studying you are
empowering yourself.”
“…if people can be able to do research, they will be more
innovative in the way they think and so on. Going through this
process myself of studying, I have...it’s opened my mind to a
whole lot of things that I was not previously exposed to. I think
that experience is a necessary experience for everybody.”
“So this is my point; the start point is we need to encourage
radiographers to actually read. It’s a shame that we probably only
have three radiographers with PhD in the country.”
“There must be a path for your career. Now it only seems like
you can study and study and you will still just be a radiographer
working on the machine. And I think that you know it is very
discouraging for a lot of people.”
“But you had, I mean the more you study the more you know
you’ll be doing something better. You won’t just be told what to
do; you’ll be doing something better.”
“But if you continue education, that will bring us back to reality
and that will give us that chance to feel proud of what we are
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doing. And once we have challenges, it will make our life easier.
It will make the profession to look like a profession. Not like we
are like button pushers. But will be professional people.”
“But if there will be lots of doors opening for radiography, maybe
that will make us like our profession more than the way we are.”
“So if we’ve got more opportunities, like maybe more promotion
or maybe extra courses, maybe advances in radiography, patient
care, then I think those things will encourage us radiation
therapists to study further”
“I wish that if you were to study further, that you will actually see
some kind of a difference. You would not gonna be still working,
running on machines you know. I really wish that there was
some big, I don’t know, not even an incentive as such but you
know you can see your progress, you change. As you study you
also change you know, if you go...”
Continuing professional development (CPD) for radiographers has been a
requirement for registration with the Health Professions Council of South
Africa for many years. Updating professional knowledge is central to CPD
philosophy as it allows health care professionals to stay up to date with
current trends in their profession (Chapman, Dempsey & Warren-Forward,
2009:166). Shanahan, Herrington and Herrington (2010: 275) have shown the
commitment of Australian radiographers to updating their professional
knowledge through professional reading of journal articles. Furthermore, the
authors established that time spent reading journals among therapy
radiographers was significantly higher than the time reported by diagnostic
radiographers. CPD is, however, receiving less attention in radiography
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literature than role extension and advanced practice, which are concepts that
require additional education and skill building.
Williamson and Mundy (2010:41) postulate that if a misalignment exists
between newly graduated radiographers’ anticipated job satisfaction and
actual satisfaction experienced, withdrawal behaviours such as lateness,
absenteeism and job turnover are likely to occur. A study these researchers
conducted showed that the majority of final-year Radiography students
expected to be given role extension opportunities upon graduation and a
significant correlation between job satisfaction and role extension opportunities
was seen.
Role extension refers to an extended scope of practice that requires postqualification skill development with additional professional responsibility and
accountability. Moran and Warren-Forward (2011:272) and Schick, Sisson,
Frantzis, Khoo and Middleton (2011:185) have shown in recent publications
that both therapy radiographers and diagnostic radiographers are willing to
take up new responsibilities in the form of role extension. Although
postgraduate qualifications are not essential in role extension, many UK
radiographers hold a master’s qualification (Hardy & Snaith, 2006:328).
However, advanced practice requires the radiographer to work autonomously,
be reflective and accountable and demonstrate developed judgement and
decision-making skills and to have consequently progressed to a “higher” level
than those radiographers who have extended their roles (Hardy & Snaith,
2006:329). Achieving a master’s degree therefore becomes more important
(Forsyth & Maehle, 2010:281).
While the concept of advanced practice for radiographers is well established
in counties such as the UK and the USA, it is only just beginning in South
Africa (Hardy, Legg, Smith, Ween, Williams & Motto, 2008:e16; Smith &
99
Reeves, 2009:108). The educational development of advanced practitioners
still needs to be debated in higher education institutions, although there has
been considerable debate on this issue in radiography literature.
Price and Patterson (2002:97) suggested nearly a decade ago that for
radiographers to have anything less than a doctoral qualification in their quest
to develop as consultant practitioners would be like a lightweight in a
heavyweight ring. Manning and Bently (2003:3) support this call and add that
the research skills mastered as part of a doctoral qualification would aid in
transforming radiographers from “uncritical consumers of research” to
professionals who would be capable of generating their own knowledge base.
Furthermore they see a doctoral qualification as the vehicle through which
consultant radiographers could achieve an “equal footing with other
professionals” (Manning & Bently, 2003:5).
However, more recently the focus on obtaining a doctoral qualification as a
requirement for the development of consultant radiographers has been
challenged. Disappointingly, many of the consultant radiography posts created
by the National Health Service in the United Kingdom have been lost with
suggested reasons being opposition from inside and outside the profession
and a lack of suitable candidates (Ford, 2010:5). Price and Edwards (2008:
e67) argue that strategic vision and interpersonal intelligence are just as or
more important to have as a consultant radiographer than a doctoral degree.
Consultant radiographers should aim to define themselves in their own scope
of practice instead of trying to mimic radiologists and oncologists.
3.5.3 Skills to be developed
Life is like riding a bicycle. To keep your balance, you must keep moving.
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Albert Einstein
Decision making skills were identified by participants as being fundamental to
moving radiotherapy forward. Participants spoke of a need to take on more
responsibility at work as is evident in the quotes below. In a radiotherapy
setting, responsibility is traditionally given to the more senior staff members
which can be frustrating for eager junior staff. However, as an error in
radiotherapy has serious and irreversible consequences to the patient, giving
responsibility to junior staff members is often difficult for radiotherapy
managers. Problem solving ability is critical in the radiotherapy setting because
a treatment cannot be delivered unless all treatment parameters are within
tolerance to reduce potential tumour misses. This ability to problem solve is
usually expected in the senior staff members and hence the additional
responsibility that comes with a more senior post.
“So I feel personally that we want to be like a whole radiographer
of who can have, who is given more responsibility. Not approval
is given to this one and to that one. You’ll never know the right
thing to do if you are not given the chance to do it.”
“Ja I think most people like to take decisions, so me as I like to
take more responsibility, and more decisions for my patient. If I
can be allowed to sign, to sign the reference and prescribe and
everything I think I’ll be more, I will be more interested into
staying in radiotherapy. Because they’ve got more, besides the
fear of having a PhD or anything, but having that big
responsibility on your shoulder, and not taken as a minority but
as an equal member of the radiation therapy team.”
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“…we don’t have to have somebody who’s specialised in one
area. Then if that person is not there then the whole unit is a
stand still. Everybody in the department as a radiographer should
have…well experience in everything. So that you become, even
if you go outside, you know that you have experience in
everything as a whole radiographer. Not just some can do this,
others can’t do this. As a radiographer you just have to know
everything so that you are whole.”
“Yes. You do want to, you do want to make decisions and you
pray and hope that the decision that your making, it should as a
radiographer be the right one, at all times. I mean you’ve been to
school, you know what to do. So you do feel good from saying,
pointing out something that has not been recognised or been
overlooked at you know, technically when it comes to planning
and stuff. You do want to make those decisions.”
While it is encouraging to hear from the participants that they would like to
accept additional responsibility, accepting responsibility seems to be
problematic when radiography literature is consulted. Dempsey and Burr
(2009:143) argue that Australian therapy radiographers have relatively poor
professional autonomy and have great difficulty in accepting responsibility.
The reason given most often for this was a lack of confidence in the clinical
decision making ability of the radiographers by the radiographers themselves.
Sim and Radloff (2009:205) argue that radiographers lack lifelong learning
attributes as the profession is protocol driven, driving practitioners to be
“followers” and not “thinkers”. They describe radiography as having a culture
of conformity which discourages reflection and critical thinking, and therefore
stunting professional development.
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Critical thinking skills allow health care practitioners to become outcomes
driven, analytical, innovative, assertive, “out of the box” thinkers which are
skills needed in a rapidly changing health care environment (Popil, 2011:204).
Critical thinking skills allow health care professionals to problem solve and
make appropriate clinical decisions. These skills are not easy to teach but
nursing literature has shown that case studies can be an effective vehicle
through which real clinical situations can be turned into teaching experiences
which assist in the development of critical thinking (Popil, 2011:205). Castle
(2009:70) argues that radiography students are often not taught to think
critically during their undergraduate training. He goes on to define what he
believes are important critical thinking skills for radiography students to
develop, namely investigation, discrimination, judgement, inference, evaluation
and analysis.
Developing reflective practice in therapy radiographers is another method by
which radiotherapists can improve their decision making and problem solving
skills. Reflective practice is a method by which therapy radiographers can
reflect on a situation experienced at work and turn the experience into a
learning situation whereby future practices can be altered (Jarvis, 1992:174).
Sim and Radloff (2009:206) argue that the key to addressing low professional
self-esteem in radiography is empowerment through reflection. Since all
decisions made in radiotherapy are subjected to peer review before a
treatment is delivered, it can be argued that therapy radiographers already
participate in informal, usually undocumented reflective practice (Chapman et
al., 2009:167).
Newnham (1999:109) suggests that structured reflective practice in
radiotherapy has the potential to improve decision making abilities among
therapy radiographers, which would allow techniques and developments to be
evaluated. This has benefits to the therapy radiographer, the patient and the
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profession. Hamilton and Druva (2010: 344) maintain that appropriate
reflective learning in an undergraduate setting would allow radiographers to
become “insightful observers” of both themselves and others. This would then
allow radiographers to reflect critically on their experiences which could
enable professional development. Tan, Cashell and Bolderston (2011:4) have
shown that professional development workshops aimed at encouraging
reflective practice can develop and sustain interest in refection and its impact
on clinical practice in a radiotherapy context.
Chapman et al. (2009:168) promote the use of reflective journaling for therapy
radiographers which can be completed daily, monthly or randomly as an ideal
platform for actively involving the therapy radiographers in their own learning.
They advocate that reviewing reflective journals will aid the therapy
radiographer in making improvements to their clinical practice.
3.5.4 New behaviours to be developed
Life is an opportunity, benefit from it.
Life is beauty, admire it.
Life is a dream, realize it.
Life is a challenge, meet it.
Life is a duty, complete it.
Life is a game, play it.
Life is a promise, fulfill it.
Life is sorrow, overcome it.
Life is a song, sing it.
Life is a struggle, accept it.
Life is a tragedy, confront it.
Life is an adventure, dare it.
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Life is luck, make it.
Life is too precious, do not destroy it.
Life is life, fight for it.
Mother Teresa
Interestingly, when participants were asked the Delivery question: “what can
we do to achieve that?”, the conversation that followed embraced the concept
that the therapy radiographers need to take up the challenge and do
something themselves to move the profession forward. The impression that
formed in my mind whilst listening to the conversation was that at the
moment, therapy radiographers are externally driven, and are playing the role
of the oppressed, powerless professional, but that the participants strongly
recognised that if change is to happen, the impetus for that change must come
from within the profession. Many of the participants, as can be seen from the
quotes below, were passionate about the idea of changing from within, in other
words developing an internal locus of control. The participants also recognised
that in order to move the profession forward they needed to take care of
themselves emotionally and physically, as the nature of oncology takes its toll
on the well-being of the staff.
“…we have to take responsibility. We have to. Or else our
profession will stay like this until somebody you know, take
responsibility to change the way things are done from the way
we do things at the moment.”
“…we must take a lead and do something. So instead of
complaining about something, you will then bring up a solution
to a problem. So you know, for me it does not help to complain
every day about something. You need to come up with an
alternative to whatever you are doing and that’s what I mean; we
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need to come up from that mindset that a radiographer must
wait for somebody to do something for them. We must do
something for ourselves.”
“That’s why I was talking earlier about changing our mindset; we
always think somebody somewhere will do something for us. It
is us who need to change and they must deliberate on
radiographers to get involved in the systems that are there, get
involved in the politics of administration, get involved in the
union
issues,
get
involved.
Because
I’ve
never
seen
radiographers actively involved in this; even in my own country.
Radiographers will sit back and they will say ‘They have not
done this, they always wait, it’s us…’ you know sometimes it’s
little efforts. Like in this department at least a radiographer
would say ‘Listen, I’m going to take up extra responsibility, I’m
going to do this, and this, I’m going to see that this and this is
done this way’ without necessarily thinking about money. Then
sooner or later people start to take notice of us, but we don’t do
that.”
“Things like that, fun, bring in fun, like let there be fun, the
department will change every way. It will change everybody’s
attitude. I tell you.”
“The other thing that I think about profession, working so hard
as we are doing in this department – like all the departments and
therapy – I think the well-being of the staff need to be taken into
consideration. Because we are in the process of treating these
sick patients but we tend to neglect ourselves.”
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“I mean something like now that we are faced with these very
sick patients, sometimes you go home you’re so depressed you
don’t even hope that they’ll come again for treatment. I think
things like counselling for specifically the staff, even if it’s oneon-one basis just to find out how the staff is doing.”
From birth, human beings attempt to control their environment and attain
human contact. Feelings of powerlessness, frustration and apathy develop in
early childhood if the child believes that they are unable to control some
aspects of their environment (Pender, 1982:19). A person who believes that
their life is under their own control has what is considered to be an internal
locus of control and tends to have an assertive personality which supports
personal development and self-actualisation. However, a person who believes
that what happens to them is up to fate, luck, chance or the power of others
has an external locus of control and tends to feel helpless in shaping present
or future goals (Pender, 1982:19; Ponto, 1999:176).
In a radiography context, one could argue that the medical dominance over
the profession of radiography has left radiographers feeling powerless in
shaping their own future and has resulted in feelings of apathy and
disengagement. Radiographers could therefore be expressing an external
locus of control which may be hampering their professional development. The
quotes above also indicate that the participants in this study recognised a
need to take care of their well-being but looked to an external source for the
facilitation of such care, again expressing an external locus of control.
Lewis et al. (2008:93) argue that nursing and radiography are excellent
examples of medical subordination and that this subordination has affected
the professional identity of radiographers, causing them to feel intimidated,
underappreciated and worthless. Sim and Radloff (2009:204) suggest that a
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low self-esteem is currently hampering radiographers’ confidence and
willingness to assume responsibilities beyond their prescribed roles. Colyer
(2010:4) suggests that:
“radiographers need to wake up and realise that playing a full part in achieving
the best depends on letting go of old practices and embracing the new”.
Whilst the participants in this study show an understanding that the impetus
required to drive the profession forward lies within themselves, they will need
to change their locus of control from an external to an internal locus and may
therefore need to consider models for behaviour change.
The participants in this study also expressed a need to change behaviour in
such a way that they take better care of themselves and concentrate on the
wellness of staff. Wallace, Lemaire and Ghali (2009:1714, 1716) describe
physician wellness as a physician’s physical, mental and emotional health and
well-being and believe that most physicians are not very good at managing
their wellness needs. A physician who is unwell negatively affects the health
care system as productivity, efficacy and patient care are all negatively
affected. Alacacioglu, Yavuzsen, Dirioz, Oztop and Yilmaz (2009:546) have
shown that health care workers who care for oncology patients are at risk of
developing psychological stress and burnout. Akroyd et al. (2002:820, 821)
indicate that American therapy radiographers exhibit high levels of the first
two stages of burnout (emotional exhaustion and depersonalisation) and call
for organisations to recognise burnout as a serious health care issue among
therapy radiographers.
3.5.5 Developing positive relationships with others
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There are only two ways to live your life. One is as though nothing
is a miracle. The other is as though everything is a miracle.
Albert Einstein
Teamwork is critical to the radiotherapy process and it was therefore not
surprising to hear from the participants about the importance of working well
together as a team. Participants also spoke of how important it was to have
support from team members on a personal as well as a professional level. I
was humbled to hear from participants that they were watching my career
progression with bated breath as they did not have any other role models
professionally to look up to. They spoke of watching to see if my doctoral
studies would result in career progression, almost as a test case for
themselves, to determine if further studies are indeed worthwhile. It saddened
me to think that the younger staff members were working without any real
mentoring and I felt that as therapy radiographers we are our own worst enemy
because we have not created any real mentoring for younger colleagues. The
quotes below start with participants describing the importance of teamwork
and creating a supportive environment between colleagues. They then move
to the concept of a lack of a mentor to assist with professional development.
“Ja, teamwork is very very important”
“My point being that you are usually dependent on your friend in
order to produce the best”
“…teamwork and communication. There is no way that you can
do your job without the two.”
“Ja, teamwork is also very important. Because some people I
think they just feel like they can work alone but here in
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radiotherapy it’s not like that because you’ve got to check with
one another.”
“So I think we should, instead of pointing out the negative we
should maybe, I call it intense but not necessarily, but like I said
before, bring in life. You know, take people in groups in a
weekend, take them for simple things.”
“I think what is more important is support and understanding of
each other. Like you said we must understand that we are human
first before we are therapists. Fine, therapy is our profession and
we like it but if we can understand the human side to that,
people that we are working with, they are not just workers, they
are people and they have got families and friends and boyfriends
and children and things like that. Not to be harsh you know, we
must be understanding. If you come to work and you’ve got a
problem or something, you know ok this is not a place for crying
you know we are at work, but if it happens that you cry, you
know people must have an understanding and be compassionate
to each other as staff. As much as we are compassionate to our
patients. But I feel like sometimes we ignore the human factor of
the staff and we are more concentrating on the patients.”
“Well I think basically it all falls down to respect. Considering all
the factors that you have said, it all boils down to respect. If me
and xxx are working on the same unit and we know the workload
of the unit, I mean I can’t just take a day off tomorrow because
I’m tired, you know. I must compromise and ask...if some
emergency has come up; ‘is it fine, is it ok with you? I’ll ask
somebody to cover’. You must make sure that you have some
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sort of back up before you go up and become absent. You
respect the person that you are working with; understand that
we are all stressed out sometimes.”
“You have to respect one another, you have to respect the
department, you have to respect the patient.”
“I think management has more responsibility to control the staff
to behave the way it is supposed to behave. If they’ve got a good
like management structure and a good personality, obviously
also the staff is gonna have…it’s gonna have a good effect to the
staff.”
“If I were to come in and I was a consultant and I was told ‘Here
is the department, change the group dynamic’, I will first start
working with the so-called management team, and get them to
work together and develop a model for the other people to look
up to.”
“So I think with radiography we need people like you Heather
that have a mind to study, that can end up being on top so that
they will be our ambassador between the government and us.”
“So I think we need somebody like that so that...you know, to
motivate people on the ground, then we need somebody up
there.”
“That it’s just who you are, you’re a radiographer, your studying
is not gonna give you any progression in your career. So I really
wish that I don’t know, there might be like we don’t know, that is
what we are given, there is no career path. You know going up.
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But I really wish we could see where it is gonna take you if you
do this. So we are watching you.”
Johnson (2006:2, 5) describes interpersonal skills as an ability to communicate,
disclose thoughts and feelings, build trust and inspire commitment, and
maintains that self-actualisation is not possible without effective interpersonal
skills. Interpersonal skills determine an individual’s ability to take appropriate
social initiatives, understand how people react to them and respond accordingly
(Johnson, 2006:7).
Kim et al. (2011:201–206) report on the impact of organisational culture on the
radiographers’ working environment. The authors explain that organisational
culture is formed as a result of the interactions between members of a team
and the team leaders allowing for each organisation to develop their own
organisational culture. The organisational culture that the participants in my
study seem to want to develop is one of mutual respect, teamwork, effective
communication and mentoring to facilitate career progression. Such an
organisational culture will require developing positive relationships with other
team members.
Baker, Wrubel and Rabow (2011:5) suggest that positive role modelling is
fundamental to the professional development of medical students since the
development of skills required for supporting their career is reliant on adequate
supervision through a complex process of professional development. Ravindra
and Fitzgerald (2011:706) have shown that the identification of a role model
influences the career choice of newly qualified doctors. Nisbet (2008:55) and
Trad (2009:103) argue that a newly qualified radiographer needs support and
guidance from senior colleagues to assist in the development of their clinical
competence and to help them establish a pattern of lifelong learning which
could aid in the development of a proficient workforce.
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3.6 CONCLUSION
On a personal level, spending time talking to the therapy radiographers that
participated in this research allowed me to gain valuable insight into the
professional experiences of the participants. It also allowed me to reflect on
my own experiences as a therapy radiographer and gave me an opportunity
to challenge and explore my own identity as a therapy radiographer. I was
amazed at the passion for radiotherapy and commitment for patient care
expressed by the participants during the Discovery phase of the interview
process. I was encouraged to hear from participants that they had a dream for
the profession and that they realised that they were the parties responsible for
the realisation of that dream. They were able to conceptualise what needed to
be done to realise the dream in the Design phase of the interviews but struggled
in the Delivery phase largely due to a low self-worth and poor interpersonal
skills. However, upon reflection, I could envisage the participants at a
professional crossroads that could be overcome if the positive energy and the
commitment to change voiced was harnessed and used to move past the
perceived barriers towards the dream identified by the participants. Perhaps
participants could use the words of Robert Frost for reflection and inspiration:
The Road Not Taken
TWO roads diverged in a yellow wood,
And sorry I could not travel both
And be one traveler, long I stood
And looked down one as far as I could
To where it bent in the undergrowth;
5
Then took the other, as just as fair,
And having perhaps the better claim,
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Because it was grassy and wanted wear;
Though as for that the passing there
Had worn them really about the same,
10
And both that morning equally lay
In leaves no step had trodden black.
Oh, I kept the first for another day!
Yet knowing how way leads on to way,
I doubted if I should ever come back.
15
I shall be telling this with a sigh
Somewhere ages and ages hence:
Two roads diverged in a wood, and I—
I took the one less traveled by,
And that has made all the difference.
(Frost, 1929)
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CHAPTER 4
DEVELOPMENT OF A CONCEPTUAL FRAMEWORK
FOR THE MODEL TO FACILITATE WHOLENESS
AMONG THERAPY RADIOGRAPHERS
“Do I dare
Disturb the universe?
In a minute there is time
For decisions and revisions which a minute will reverse.”
T.S. Eliot
The aim of this chapter is to present to the reader a detailed description of
how a conceptual framework for a model to facilitate wholeness among therapy
radiographers was developed. The experiences of the therapy radiographers
were explored by means of appreciative inquiry during focus group interviews.
The results of the interviews were presented in chapter 3. The themes and
categories described in chapter 3 formed the foundation for the development
of the model described in this chapter.
4.1 IDENTIFICATION OF A CENTRAL CONCEPT
Identifying the central concept for the development of the model required me
to reflect on the main themes described in chapter 3 and to reason inductively
to combine the themes from specific stories told to me into a general concept
that could be transferable to a broader radiotherapy population (Burns &
Grove, 2005:73). During this process I relied heavily on my reflective field
notes to give insight into the meaning of the stories told as I reflected on the
interview process. I was cautious that my own experiences of being a therapy
115
radiographer did not dictate the script and that I allowed myself to focus on
the stories told by participants and the underlying meaning of those stories.
The first theme that emerged from the interview data was that of life-giving
forces that promote personal and professional engagement, resulting in a
sense of purpose. Stories told in the development of this theme centred on
radiotherapy at its best. Participants described what made them feel alive and
vital at work. Recognition, appreciation, professionalism and caring were the
categories around which the stories were told. My reflective field notes
describe how I identified a strong need for validation among participants. The
participants needed to be seen and valued. Upon review of the literature, the
categories developed were well supported in both radiography and health care
literature (Bolderston et al., 2010:211; Probst & Griffiths, 2009:148; WillisShattuck et al., 2008:247).
The second theme described feelings of professional stagnation from a lack
of self-worth and interpersonal conflict. This theme saw the participants
struggling to conceptualise delivering on the dreams identified for the
profession due largely to a low sense of self-worth and poor interpersonal skills
bringing them to a personal and professional crossroads. A “just a radiographer”
syndrome has been described in the literature by Lewis et al. (2008:94) and
seemed to be an ideal fit for the stories told by the participants. Participants
also stressed that their role was very different from that of a diagnostic
radiographer and that radiotherapy is “unseen” by the community, the
government and even amongst radiographers themselves.
The final theme focused on facilitating change towards wholeness through
harnessing the positive energy and commitment to change. My reflective field
notes describe how I could feel an excited energy among participants during
the dream phase of the interview process. I was told by several participants
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after the interview that they enjoyed participating because the interview gave
them an opportunity to think “big” and allowed them to view radiotherapy in a
positive setting. The excited energy was tangible in the room and I knew that
the participants wanted change and were willing to work towards it.
Upon reflection of the above themes, I reviewed the definition of wholeness
conceptualised in this study:
Wholeness is defined as the process of becoming a physically, mentally and
spiritually whole person. Embedded in this definition is the understanding that
one cannot separate the person from their environment (Cowling, 2000:17;
Meyer, 1989:116).
Within the context of radiation therapy, becoming a mentally whole person
implies identifying the intellectual needs of therapy radiographers in order to
maintain an interest in the profession as a motivating force behind encouraging
professional development (Probst & Griffiths, 2009:151). Furthermore, a
mentally whole therapy radiographer is defined as a person who is able to
manage the emotional demands of the job while being able to maintain and
develop positive intrapersonal and interpersonal relationships both at work and
at home (Powers & Dodd, 2009:3).
A spiritually whole therapy radiographer refers to a person who has found
meaning and purpose (Baldacchino & Draper, 2001:833) in their professional
life and is a concept which transcends religion (Carr, 2000:3). A physically
whole therapy radiographer is a person who is able to prioritise their own
physical needs in terms of diet and exercise in order to maintain their own
physical health and wellbeing as an antidote to the stress encountered in the
workplace (Powers & Dodd, 2009:2).
117
While reflecting on the definition of what it means to be a whole therapy
radiographer, I realised that personal and professional wholeness could only
be achieved once therapy radiographers aligned themselves with an identity
that was unique to them as therapy radiographers. Edwards (2010:168) argues
that the inability of radiographers to develop their own identity has prevented
them from rising above medical dominance.
Ekmekci and Turley (2008:13) suggest that development of a strong
professional identity would increase awareness of the role of therapy
radiographers among other health care professionals and the general public.
Furthermore an identity would provide therapy radiographers with guidance
and direction, which would enhance their own understanding of who they are
and what they do (Ahonen, 2009:62). A superordinate identity would give
therapy radiographers a sense of belonging to a community which could aid in
developing a positive self-esteem and in building interprofessional relationships
(Johnson, 2006:351, 356; Mellin, Hunt & Nichols, 2011:141). Therefore the
facilitation of therapy radiographers’ professional identity became the central
concept for the development of a model to facilitate wholeness among therapy
radiographers.
4.2 CONCEPT DEFINITION AND CLASSIFICATION
Often, it’s not about becoming a new person, but becoming the person
you were meant to be, and already are, but don’t know how to be.
Heath L. Buckmaster, Box of Hair: A Fairy Tale
The central concepts of facilitation, professional and identity were then
defined by means of dictionary and subject literature. Copi and Cohen’s rules
(1994:192–196) for well-formulated definitions were applied. The Walker and
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Avant (2011:157–178) method of concept analysis was utilised in the concept
analysis process. The definitions therefore incorporate the attributes of the
concepts and reflect their conventional relationships.
A model case and a contrary case were then developed demonstrating the
essential attributes identified for the central concepts. In this way, I was able to
further explore the meaning and understanding of the concept of the facilitation
of a professional identity from a therapy radiographer’s perspective.
4.2.1 Dictionary definition of facilitation
The term ‘facilitation’ was searched in a variety of dictionary texts and the
resultant definitions are presented in Table 4.1 below.
TABLE 4.1: DICTIONARY DEFINITIONS OF FACILITATION
Definition of facilitation
Source
Make easy or easier
Oxford English Mini Dictionary
The act of making easy or easier
The American Heritage Dictionary
The act or process of facilitating
English Collins Dictionary
Any activity which makes tasks for
Wikipedia
others easy
The process of helping groups, or
QFinance
individuals, to learn, find a solution, or
reach a consensus, without imposing
or dictating an outcome
To make less difficult
Roget’s Thesaurus
Assist the progress of
Answers.com
The act or process of facilitating
Random House Webster’s
119
College Dictionary
The condition of being made easy (or
Princeton’s WordNet
easier) or the act of assisting or making
easier the progress or improvement of
something
The act of facilitating or making easy
Webster Dictionary
4.2.2 Subject definition of facilitation
Radiography and health care literature was searched for definitions of
facilitation. The results are presented in Table 4.2 below.
TABLE 4.2: SUBJECT DEFINITIONS OF FACILITATION
Definition
Source
All those activities that assist an individual
Henwood and Taket
radiographer to participate in an activity
(2008:209)
A nurse’s ability to create an accommodating
Cilliers and Terblanche
climate and to provide an opportunity for a
(2000:90)
patient to self-actualize
The process of making something more
Ewles and Simnett
easily achieved
(2005:335)
From the dictionary and subject definitions of facilitation, I identified what I
believed to be the essential attributes for the concept of facilitation. The
essential attributes are listed in Table 4.3 below.
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TABLE 4.3: ESSENTIAL ATTRIBUTES FOR FACILITATION
Concept
Essential attributes
Facilitation

process

helping

creating an opportunity
4.2.3 Dictionary definitions of professional
The term ‘professional’ was searched in a variety of dictionary texts and the
resultant definitions are presented in Table 4.4 below.
TABLE 4.4: DICTIONARY DEFINITIONS OF PROFESSIONAL
Definition of professional
Source

Of or belonging to a profession
Oxford English Mini

Doing something as a job rather than a hobby
Dictionary

Competent

Following an occupation as a means of Dictionary.com
livelihood or for gain

Of,
pertaining
to,
or
connected
with
a
profession

Appropriate to a profession

Engaged in one of the learned professions

Following
as
a
business
an
occupation
ordinarily engaged in as a pastime

A
person
who
belongs to one of
the
professions

A person who is expert at his or her work
121

Of or pertaining to a profession, or calling,
Brainy Quote
conforming to the rules or standards of a
profession

A person who prosecutes anything
professionally, or for a livelihood, and not in
the character of an amateur

Person formally certified by a professional
Business dictionary
body of belonging to a specific profession by
virtue of having completed a required course
of studies and/or practice and whose
competence can usually be measured against
an established set of standards

Person who has achieved an acclaimed level
of proficiency in a calling or trade

A member of a vocation founded upon
Wikipedia
specialised educational training

Participating for gain or livelihood in an activity
Merriam-Webster
or field of endeavour often engaged in by
Dictionary
amateurs

Engaged in one of the learned professions

Of, relating to, engaged in, or suitable for a
The free online
profession
dictionary

Conforming to the standards of a profession

Engaging in an activity as a source of
livelihood or as a career

Performed by persons receiving pay

Having or showing great skill, expert

A skilled practitioner, an expert
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
Any employee engaged in work predominantly
Lectric Law Library
intellectual and varied in character as opposed
to routine mental, manual, mechanical, or
physical work; involving the consistent
exercise of discretion and judgment in its
performance; of such a character that the
output produced or the result accomplished
cannot be standardized in relation to a given
period of time; requiring knowledge of an
advanced type in a field of science or learning
customarily acquired by a prolonged course of
specialized intellectual instruction and study in
an institution of higher learning or a hospital,
as distinguished from a general academic
education or from an apprenticeship or from
training in the performance of routine mental,
manual or physical processes
4.2.4 Subject definitions of professional
Radiography literature was reviewed to identify what the term ‘professional’
means to radiographers. The results are presented in Table 4.5 below.
TABLE 4.5: SUBJECT DEFINITIONS OF PROFESSIONAL
Definition
Source
Expert clinical practice; professional leadership and
Forsyth and Maehle
consultancy; education, training and development;
(2010:280)
practice and service development, research and
evaluation
123
Possession of specialist knowledge which can be
Sim and Radloff
acquired only through higher education,
(2009:204)
representation via a professional organization, a
distinctive code of professional conduct; autonomy
and altruism
A body of specialist knowledge and skills; a
Yielder and Davis
commitment to high standards of service; varying
(2009:346)
degrees of self-regulation and autonomy; moral and
ethical standards of behaviour
Knowledge base; research skills; responsibility;
Nixon (2001:31–34)
sophisticated processes of debate, argument and
persuasion
A mastery of a specialized knowledge base,
Marshall & Sykes
autonomy, membership in a professional body, an
(2011:158)
ethical code of conduct, accreditation
Altruism, compassion and ethical practice
Wright, Jolly,
Schneider-Kolsky &
Baird (2011:7)
Empathy, well-developed cognitive processes, moral Sparks (2000:599)
reasoning ability and interpersonal effectiveness
A person who has completed 4 years of study at an
Kowalczyk and
accredited Higher Education Institution that has led
Leggett (2005:24)
to the award of a minimum of a baccalaureate degree
To be perceived as being a professional, three
Donnelly and Strife
attributes are essential. They are clinical competence,
(2006:775)
effective communication and the ability to carry out
an ethical decision making process prioritizing the
needs of the patient
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From the above dictionary and subject definitions, I developed a list of essential
attributes for the concept of professional as shown in Table 4.6 below.
TABLE 4.6: ESSENTIAL ATTRIBUTES FOR PROFESSIONAL
Concept
Professional
Essential attributes

autonomy

self-directed
4.2.5 Dictionary definitions of identity
The term ‘identity’ was searched in a variety of dictionary texts and the resultant
definitions are presented in Table 4.7 below.
TABLE 4.7: DICTIONARY DEFINITIONS OF IDENTITY
Definition of identity

Source
The fact of being who or what a person or thing
Oxford English
is
Mini Dictionary

A close similarity

What identifies somebody or something

Essential self

Sameness

The state or fact of remaining the same one or
Encarta
Dictionary.com
ones, as under varying aspects or conditions

The condition of being oneself or itself, and not
another

Condition or character as to who a person or
what a thing is

The state or fact as being the same one as
125
described

The sense of self, providing sameness and
continuity in personality over time

Exact likeness in nature or qualities

The collective aspect of the set of
Answers.com
characteristics by which a thing is definitively
recognizable or known

The set of behavioural or personality
characteristics by which an individual is
recognizable as a member of a group

The quality or condition of being the same as
something else

The distinct personality of an individual regarded
as a persisting entity, individuality


Sameness of essential or generic character in
Merriam-Webster
different instances
Dictionary
Sameness in all that constitutes the objective
reality of a thing: oneness

The distinguishing character or personality of an
individual: individuality

The condition of being the same with something
described or asserted

The distinct personality of an individual regarded The free online
as a persisting entity
dictionary
126

The condition or fact of being the same or
Your Dictionary
exactly alike, sameness, oneness

The condition or fact of being a specific person
or thing; individuality

The characteristics and qualities of a person,
considered collectively and regarded as
essential to that person’s self-awareness

The condition of being the same as a person or
thing described or claimed

The state or quality of being identical, or the
BrainyQuote
same; sameness

The condition of being the same with something
described or asserted, or of possessing a
character claimed
4.2.6 Subject definitions of identity
Radiography and health care literature was reviewed to establish the subject
definition of identity. The results are presented in Table 4.8 below.
TABLE 4.8: SUBJECT DEFINITIONS OF IDENTITY
Definition
Source
The radiographer’s conception of what it means to
Niemi and
be and act as a radiographer representing one’s
Paasivaara
philosophy of radiography. Professional identity also
(2007:259)
defines values and beliefs that guide the
radiographer’s thinking, actions and interaction with
the patient.
127
The commonality of the nursing profession and the
Ohlen and Segesten
special way the nurse utilises this commonality. The
(1998:721–722)
nurse’s perception of himself or herself in the
context of nursing practice.
Therapy radiographer: Blending highly technical
Ekmekci and Turley
skills with the ability to provide emotional support
(2008:11)
and psychosocial support to cancer patients and
their families.
A subjective sense as well as an observable quality
Erickson (1970)
of personal sameness and continuity, paired with
some belief in the sameness and continuity of some
shared world image. As a quality of unself-conscious
living, this can be gloriously obvious in a young
person who has found himself as he has found his
communality. In him we see emerge a unique
unification of what is irreversibly given--that is, body
type and temperament, giftedness and vulnerability,
infantile models and acquired ideals--with the open
choices provided in available roles, occupational
possibilities, values offered, mentors met, friendships
made, and first sexual encounters.
The essential attributes for the concept of identity were then taken from the
definitions presented above and are listed in Table 4.9 below.
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TABLE 4.9: ESSENTIAL ATTRIBUTES FOR IDENTITY
Concept
Identity
Essential attributes

recognisable

commonality

shared world image
Upon reflection of the dictionary and subject definitions and on the essential
attributes for the central concept a conceptual definition was developed.
Therefore the facilitation of a professional identity of therapy radiographers as
an integral part of wholeness refers to creating an opportunity for therapy
radiographers to develop a shared world image for their profession that is
recognisable in that it conceptualises the professional attributes that define
the profession and provides a commonality with which therapy radiographers
can identify. It is a process that involves helping therapy radiographers to
create a perception of themselves as skilled professionals who are
autonomous, self-directed and able to achieve personal and professional
wholeness.
4.3 CREATING CONCEPTUAL MEANING FOR THE CONCEPT
OF FACILITATION OF A PROFESSIONAL IDENTITY
It isn't what you have or who you are or where you are or what you are
doing that makes you happy or unhappy. It is what you think about it.
Dale Carnegie, How to Win Friends & Influence People
A model case has been constructed below to represent the experience of the
central concept that is facilitating a professional identity as an integral part of
wholeness for therapy radiographers. A contrary case is also presented to
129
obtain clarity about what is not reflected in the central concept (Chinn &
Kramer, 2011:166–170).
The model case has been developed from my own personal journey in clinical
radiotherapy practice, and the contrary case has been developed from stories
told by the participants in the focus group interviews.
4.3.1 A model case
On completion of my National Higher Diploma in Radiography (Therapy), I
started working at Hillbrow Hospital in the radiation oncology department. I
was filled with excitement and proud to be joining the department. To me the
therapy radiographers emulated the professional attributes that I aspired to.
They were empathetic towards their patients and professional in their conduct
and it was this shared world image that attracted me to the profession in the
first place. Therapy radiographers were recognisable as radiographers who
cared about the patients they were responsible for and who were accountable
for their actions. This gave therapy radiographers a commonality which was
identifiable and which distinguished them from their diagnostic radiography
colleagues. I was ready to join this group of professionals and was proud to
be part of their team.
As I had done very well in my studies, I was selected by the director of the
radiation oncology service to undergo additional training in treatment planning
and high dose rate brachytherapy treatment planning, which was something
usually reserved for medical physicists. I was very excited and realised that
an opportunity had been created for me to develop myself and my profession.
The director really took me under his wing and began helping me to develop
myself professionally. Under his guidance, I also took part in a treatment
planning study which resulted in a presentation at an oncology congress. I
started gaining confidence in my own ability and enjoyed the process of
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learning new skills and presenting work at a congress usually reserved for
oncologists. I began to see my future in radiation oncology differently than I
had done before. I was able to see myself aspiring to break through the barriers
perceived by radiographers. I saw a future where I could be autonomous and
self-directed, a future where I could achieve my personal and professional
dreams. I started devising a plan and a time frame to achieve my dreams and
have consistently been at work to get there. The best part is that I am thoroughly
enjoying the journey.
4.3.2 A contrary case
Susan is a 42-year-old therapy radiographer. She is a single mother to two
children. She has worked in the same oncology department since graduation.
This is her story.
I work in the treatment planning department which is the centre of any oncology
department. This is the place where all new patients start their radiotherapy
journey. When I took up a position in treatment planning I was excited. With
treatment planning comes a huge responsibility as you are responsible for
producing the best possible plan for the delivery of the radiotherapy treatment.
It involves working closely with the oncologists and medical physicists and
was always viewed as a position reserved for the best therapy radiographers.
Unfortunately the job has not lived up to my expectations.
I am still just the radiographer. Sure, the plan is my responsibility to produce,
and that part of my job I enjoy, it’s the rest I don’t really like. For example,
once I have completed a plan the oncologist needs to come and view the plan
on the treatment planning computer and approve the plan if he is satisfied
with it. I dread asking the oncologists to come and look at treatment plans.
First, I have to beg them to come and it’s like I am asking them a personal
favour. Then when they do get around to coming they behave as if they are
131
God that has just entered the building. They expect me to drop what I am
doing and rush over to assist them because they don’t have the faintest idea
of how to pull up a plan on the computer. They are usually rude and
disrespectful but I just have to be polite because they are the oncologists
and I am just the radiographer.
My worst is when they are not happy with the plan. More often than not they
call the physicist to come and take a look because I am not good enough to
fix the plan myself. Then the physicist marches in and makes it out like they
will just have to take over because the radiographer just won’t get it right.
What the oncologist does not realise is that the moment they leave the room
so does the physicist and it’s me that spends hours on the computer to try
and get a better plan. It’s no good complaining to our head of department.
She knows just as well as I do that we are not on the same footing as the
oncologists and the medical physicists. They don’t take her seriously.
Then there are the radiographers on the treatment units. There is this wall
between us as they are resentful that I have the “better” job in the department,
I work in treatment planning and that is supposed to be higher up in the
perceived hierarchy. I don’t really fit in with them as they believe I fit in with
the treatment planning staff. It’s funny really, how divided we are as a staff
grouping. I know better, I don’t fit in with the treatment planning staff, I am not
worthy of the oncologists or the physicists, I am just the radiographer!
I am always on the lookout for another job. Maybe private practice will be
better? The problem is that when you tell people that you hate your job and
they ask what you do they have no idea what you are talking about. It’s as if
the world does not know we exist. I might as well accept that I am stuck in
radiotherapy, there is no way out. I have nothing left in me for this job. I have
to drag myself out of bed every morning. My job has just become a pay
132
cheque, it leaves me feeling empty inside. Maybe someone somewhere will
help me find a job I enjoy!
4.4 CLASSIFICATION OF THE CONCEPTS
Dickoff et al. (1968:422–435) make use of a survey list as a means to classify
concepts as part of creating a conceptual framework required in theory
generation. The survey list has been described as “an organized, empirically
grounded guide to achieving a purpose” by Chinn and Kramer (1995:69). A
purpose or goal is required so that a path to achieving the goal (wholeness
among therapy radiographers) can be developed. For this reason the survey
list described by Dickoff et al. was used to classify the concepts that were
then utilised in the development of the model to facilitate wholeness as part of
a professional identity among therapy radiographers as individuals and as a
professional group. The concepts to be classified are the agent, the recipient,
the context, the dynamics, the process and the terminus.

The agent in this model is a senior therapy radiographer who can
facilitate the journey towards personal and professional wholeness for
therapy radiographers.

The recipient in this model is a therapy radiographer who is unable to
achieve wholeness as an individual or as a professional.

The context of this model is an academic radiation oncology
department in Gauteng, South Africa.

The dynamics or the catalyst responsible for the initiation of the
process of change was voiced eloquently by the participants in the
study. Participants spoke of being “stuck”, largely due to a devalued
sense of self, interpersonal conflict and a medical dominance that left
participants feeling as though the profession could not grow or move
133
forward. A lack of a clear professional identity made it difficult for
participants to envisage ways in which to overcome the perceived
barriers in the quest for personal and professional wholeness.

The process involves giving therapy radiographers an opportunity to
reinvent themselves as individuals and as professionals. It is a process
that will help therapy radiographers to create a professional identity
that provides a commonality which binds them together as a group and
develops a shared world image that defines the profession. An internal
locus of control, the facilitation of positive self-esteem and creating an
enabling environment for professional development will help therapy
radiographers to create a perception of themselves as skilled
professionals who are autonomous, self-directed and able to achieve
personal and professional wholeness.

The terminus in this model is that therapy radiographers will develop a
professional identity as a part of achieving personal and professional
wholeness.
4.5 THE DEVELOPMENT OF RELATIONSHIP STATEMENTS
The concepts classified in 4.4 above were then written into the relationship
statements below.
1.
The dream of a therapy radiographer is to be recognised as a skilled
professional within the oncology environment who has opportunities for
professional growth and development.
2.
A lack of self-worth, professional stagnation and interpersonal conflict
are the barriers hampering the growth and development of the therapy
radiographer.
134
3.
Facilitation provides a therapy radiographer with an opportunity for selfdevelopment and exploration by making use of their own potential and
by taking responsibility for their own goals.
4.
A strong professional identity would provide therapy radiographers with
guidance and direction, which would enhance their own understanding
of who they are and what they do, thereby reinventing themselves as
individuals and as professionals.
5.
A professional identity could give therapy radiographers a sense of
belonging and could create a shared world image and a commonality
with which therapy radiographers could identify.
6.
The development of a professional identity would empower the therapy
radiographer and would make the development of an internal locus of
control and positive self-esteem possible.
7.
The articulation of a clear professional identity is essential for the
development of a therapy radiographer who is an autonomous, selfdirected professional.
8.
The therapy radiographer who reinvents themselves as an autonomous,
self-directed professional will be able to experience personal and
professional wholeness.
Linking the concepts resulted in the conceptual map based on the 4-D model
of appreciative inquiry utilised in the focus group interviews. The conceptual
map is presented in Figure 4.1 below.
135
FIGURE 4.1: CONCEPTUAL MAP
136
4.6 CONCLUSION
The chapter outlined the conceptual framework model developed in this
research and reported on in chapter 5. The central concepts for the model
were identified, defined and classified. Relationship statements were
developed and a conceptual map formed. When creating a conceptual
framework, I was mindful that I was developing new theory that would
hopefully have a positive impact on the profession of radiotherapy. The
words in the poem below reflected my experiences at the time and helped
me to be respectful of the therapy radiographers’ dreams as told to me in
the interview process.
I sit beside the fire and think
Of all that I have seen
Of meadow flowers and butterflies
In summers that have been
Of yellow leaves and gossamer
In autumns that there were
With morning mist and silver sun
And wind upon my hair
I sit beside the fire and think
Of how the world will be
When winter comes without a spring
That I shall ever see
For still there are so many things
That I have never seen
In every wood in every spring
There is a different green
134
I sit beside the fire and think
Of people long ago
And people that will see a world
That I shall never know
But all the while I sit and think
Of times there were before
I listen for returning feet
And voices at the door
J.R.R. Tolkien
135
CHAPTER 5
DESCRIPTION OF THE MODEL TO FACILITATE
WHOLENESS AS PART OF A PROFESSIONAL
IDENTITY FOR THERAPY RADIOGRAPHERS
It is right it should be so;
Man was made for Joy & Woe;
And when this we rightly know
Thro’ the World we safely go.
Joy & Woe are woven fine,
A Clothing for the Soul divine;
Under every grief & pine
Runs a joy with silken twine.
William Blake (1757–1827),
in Auguries of Innocence
5.1 INTRODUCTION
In this chapter the model is described for the facilitation of wholeness as
part of a professional identity for therapy radiographers. In chapter 4, the
central concept, the facilitation of a professional identity, was identified and
conceptually defined. The essential attributes for the defined concepts were
identified and will be defined as part of the description of the model in this
chapter.
The description of the model will consist of a visual representation of the
model, an overview of the model, and the purpose, assumptions and
structure of the model. The description of the model will be based on Chinn
and Kramer’s process (2011:154–205) for empiric knowledge development.
Guidelines to operationalise the model and an evaluation of the model will
also be provided.
136
5.2 AN OVERVIEW OF THE MODEL
The overview of the model provides the reader with a brief introduction to
the model illustrated in Figure 5.1. The model incorporates the conceptual
map presented in Figure 4.1 into its structure.
137
FIGURE 5.1: A MODEL TO FACILITATE WHOLENESS AS PART OF A
PROFESSIONAL IDENTITY FOR THERAPY RADIOGRAPHERS
138
The need for a model to address wholeness as part of a professional
identity for therapy radiographers arose as a result of a growing body of
radiography literature highlighting the plight of therapy radiographers
nationally and internationally. The negativity which plagues the literature
acted as the catalyst for me to undertake a research project which focused
on the positive aspects of radiation oncology and the therapy radiographers
themselves.
The results of the appreciative inquiry interviews described in chapter 3
support a growing body of radiography literature which suggests that
therapy radiographers lack a clear professional identity and are therefore
experiencing feelings demonstrating a lack of self-worth and inferiority
within the oncology team setting. However, a positive energy and
commitment to change was also evident among participants. The model
therefore incorporates this positive energy into its structure to create an
opportunity for therapy radiographers to reinvent themselves and develop
a shared world image that is recognisable and that brings commonality to
the group as a whole. Therapy radiographers should then emerge as selfdirected autonomous individuals who are able to deliver on their dream of
experiencing personal and professional wholeness. The model includes in
its structure the context of an academic radiation oncology department.
The process of the model will be described in the three stages of planning,
implementation and evaluation. In-depth discussions of all the definitions
and strategies to be used during the implementation of the model will be
given.
5.3 THE DESCRIPTION OF THE MODEL
The model will be described according to the following concepts:

The purpose of the model

The theoretical assumptions of the model
139

The context of the model

Theoretical definitions of the model concepts

Relationship statements

The structure of the model

The model process
5.3.1 The purpose of the model
Alone we can do so little; together we can do so much.
Helen Keller
The purpose of this model is to provide a framework for therapy
radiographers to begin a journey that will see the development of a
professional identity for therapy radiography, leading to professional
wholeness. In this way, therapy radiographers can begin to realise the
dream that they have for the profession, making their work fulfilling and
giving them a sense of purpose and a clear idea of what they do and who
they are. By facilitating wholeness as part of a professional identity, the
model creates a context in which the concept of wholeness becomes
meaningful for the profession of radiotherapy.
Therapy radiographers who feel fulfilled and who have found their way
towards professional wholeness should also be more effective at providing
a professional service to oncology patients. Staff who are emotionally
exhausted respond to patients in a depersonalised way and appear callous
and cynical instead of expressing genuine empathetic concern (Bakker,
Killmer, Siegrist & Schaufeli, 2000:884–885). One could therefore assume
that a therapy radiographer that has found wholeness as part of a
professional identity would be equipped emotionally to provide optimal
patient care.
140
In conclusion, the purpose of this model is to provide the theoretical
framework for the facilitation of wholeness as part of a professional identity
for therapy radiographers. In this way, the model hopes to be the start of
the process of realising the dream that the participants in this study
verbalised for the profession and for themselves. Therefore the purpose of
this model is designed to bring about a change in therapy radiography to
achieve a goal.
5.3.2 The theoretical assumptions of the model
The purpose of life is to live it, to taste experience to the utmost, to
reach out eagerly and without fear for newer and richer experience.
Eleanor Roosevelt
The theory of health promotion in nursing (University of Johannesburg,
2009:4) was used as a guide on which the assumptions of the model are
based. The assumptions are stated below.
The first assumption in the theory is that a person is seen holistically in
interaction with the environment in an integrated manner. This assumption
is congruent with the ontological assumptions embedded in the qualitative
research paradigm employed in this research study. It is an assumption that
therefore holds true for the research study. Therefore the first assumption
of the model is:
The therapy radiographer is seen wholistically and interacts with their
internal and external environment in an integrated manner. In this way, the
assumption is made that the therapy radiographer cannot be separated
from their environment.
The theory next assumes that a person’s environment consists of an
internal and external environment. The internal environment consists of
141
body, mind and spiritual dimensions. The external environment consists of
physical, social and spiritual dimensions.
For this model the internal environment of the therapy radiographer consists
of body (physical wholeness), mind (mental wholeness) and spiritual
dimensions (spiritual wholeness). The external environment consists of
physical (the oncology department and the profession of radiotherapy),
social (interpersonal relationships in a multidisciplinary, patient care centred
setting) and spiritual dimensions (self-directed professional group).
Therefore the second assumption of the model is:
By achieving wholeness as part of a professional identity, the therapy
radiographer will achieve an integrated rediscovery of self which will
transform her internal environment. The external environment will then be
influenced by the internal transformation, enabling the therapy radiographer
to function as an integrated individual.
The theory of health promotion in nursing (University of Johannesburg,
2009:4) also assumes that “the nurse is a sensitive therapeutic professional
who demonstrates knowledge, skills and values to facilitate the promotion
of health”. As the senior therapy radiographer is an agent in the model who
will be fundamental to the facilitation of wholeness as part of a professional
identity, the model assumes that:
The senior therapy radiographer is a professional who demonstrates the
knowledge, skills and values required to facilitate wholeness as part of a
professional identity among therapy radiographers.
The assumption that “health is an interactive dynamic process in the
patient’s environment” stated in the theory (University of Johannesburg,
2009:4) is the basis for the next assumption of the model. Since the
facilitation of wholeness as part of a professional identity requires the
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therapy radiographers to be actively involved in the process, the assumption
made is that:
Therapy radiographers are ready and willing to become part of an
interactive, dynamic process that will lead to the achievement of wholeness
as part of a professional identity.
Finally, the last assumption made is taken from the theory (University of
Johannesburg, 2009:4) that the “promotion of health implicates the
mobilization of resources”. The assumption for the model is that:
The therapy radiographers and the management of the academic radiation
oncology department which provides the context for the model are willing
and able to commit the time and energy to allow for the model process to
be implemented.
5.3.3 The context of the model
Chinn and Kramer (2011:176) believe that for theory to be useful in practice,
the context in which the theoretical relationships have been placed must
be defined. The context for this model is an academic radiation oncology
department situated in a provincial hospital in Gauteng. The context of the
model is meaningful, as the fieldwork for the model development was also
conducted there.
5.3.4 Theoretical definitions of the model concepts
The definitions of the central and related concepts for the model provide a
conceptual framework for the development of relationship statements.
Within the context of radiation therapy, becoming a mentally whole person
implies identifying the intellectual needs of therapy radiographers in order
to maintain an interest in the profession as a motivating force behind
encouraging professional development.
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The central concept of the model is the facilitation of a professional identity
of therapy radiographers. For the purpose of this model, the central concept
is defined as follows:
The facilitation of a professional identity of therapy radiographers as an
integral part of wholeness refers to creating an opportunity for therapy
radiographers to develop a shared world image for their profession that is
recognisable in that it conceptualises the professional attributes that define
the profession and provides a commonality with which therapy
radiographers can identify. It is a process that involves helping therapy
radiographers to create a perception of themselves as skilled professionals
who are autonomous, self-directed and able to achieve personal and
professional wholeness.
The related concepts of facilitation, professional identity, therapy
radiographer and wholeness are defined for the purpose of this model as
follows:

Facilitation
Facilitation, in this model, refers to a process whereby therapy
radiographers are helped to create an opportunity to reinvent
themselves and are allowed to discover what it means to be a therapy
radiographer. Facilitation provides the structure and guidance required
in this process so that the dream of experiencing personal and
professional wholeness can be achieved. Facilitation allows the
therapy radiographers to make use of their own potential and to take
responsibility for their own goals.

Professional identity
For the purpose of this model a professional identity is defined as an
identity conceptualised by the therapy radiographers themselves that
incorporates how they wish to view themselves as individuals and as a
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professional group. It is in essence the formulating of a shared world
image that will unite the therapy radiographers to allow for a professional
group that is self-directed as they can appreciate who they are and
where they want to go. Furthermore, a professional identity will empower
the therapy radiographers to develop personally and professionally so
that they may become autonomous and self-directed.

Therapy radiographer
A therapy radiographer is also referred to as a radiotherapist or as a
radiation therapist. For the purpose of this model, a therapy radiographer
is a person employed by the academic radiation oncology department,
for whom this model has been developed, as a therapy radiographer.
It is assumed for this model that a therapy radiographer is a person
who lacks a clear professional identity and is not experiencing personal
or professional wholeness. The therapy radiographer in this model is
therefore experiencing a lack of self-worth, feelings of professional
stagnation and interpersonal conflict.

Wholeness
For the purpose of this study, wholeness is defined as the process of
becoming a physically, mentally and spiritually whole person. Within
the context of radiation therapy, becoming a mentally whole person
implies identifying the intellectual needs of therapy radiographers in
order to maintain their interest in the profession as a motivating force
behind encouraging professional development. Furthermore, a mentally
whole therapy radiographer is defined as a person who is able to
manage the emotional demands of the job while being able to maintain
and develop positive intrapersonal and interpersonal relationships both
at work and at home. A spiritually whole therapy radiographer refers to
a person who has found meaning and purpose in their professional life
and is a concept which transcends religion. Physical wholeness implies
being able to make conscious decisions about healthy lifestyle choices.
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5.3.5 Relationship statements
1.
The dream of a therapy radiographer is to be recognised as a skilled
professional within the oncology environment who has opportunities
for professional growth and development.
2.
A lack of self-worth, professional stagnation and interpersonal conflict
are the barriers hampering the growth and development of the therapy
radiographer.
3.
Facilitation provides a therapy radiographer with an opportunity for
self-development and exploration by making use of their own potential
and by taking responsibility for their own goals.
4.
A strong professional identity would provide therapy radiographers
with guidance and direction, which would enhance their own
understanding of who they are and what they do, thereby reinventing
themselves as individuals and as professionals.
5.
A professional identity could give therapy radiographers a sense of
belonging and could create a shared world image and a commonality
with which therapy radiographers could identify.
6.
The development of a professional identity would empower the therapy
radiographer and would make the development of autonomy and a
positive self-esteem possible.
7.
The articulation of a clear professional identity is essential for the
development of a therapy radiographer who is an autonomous, selfdirected professional.
8.
A
therapy
radiographer
who
reinvents
themselves
as
an
autonomous, self-directed professional will be able to experience
personal and professional wholeness.
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5.3.6 The structure of the model
Never doubt that a small group of thoughtful, committed, citizens
can change the world. Indeed, it is the only thing that ever has.
Margaret Mead
The model is visually represented in Figure 5.1. The border surrounding the
model represents the context in which the model is to be operationalised,
that is, an academic radiation oncology department situated in a tertiary
hospital in Gauteng. I selected orange because the colour symbolises to
me a warm comfortable environment which is conducive to allowing the
therapy radiographers to rediscover themselves in a setting which is
welcoming and safe.
The lower third of the model (Figure 5.2) is represented as a banner that
wraps around the journey of discovery and pulls through the middle and
top third of the model. The left end of the banner is the facilitator, a senior
therapy radiographer, who can facilitate the journey towards personal and
professional wholeness for therapy radiographers. I chose to represent the
facilitator in lilac as this colour represents a person who is calm, centred
and is experiencing wholeness themselves. The right end of the banner is
the therapy radiographer who is about to embark on a journey towards
personal and professional wholeness.
I selected the colour light blue to represent the therapy radiographer as this
colour symbolises a person who has not yet stood in the sun of wholeness
and still needs to develop and grow.
The centre of the banner is a puzzle piece that is joining the two ends
together by creating an opportunity for the therapy radiographer to develop
a shared world image by allowing the facilitator and the therapy radiographer
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to work together in a journey of discovery. I mixed the colours of lilac and
light blue to represent this section of the model.
FIGURE 5.2: THE BOTTOM THIRD OF THE MODEL
The middle third of the model (Figure 5.3) has been drawn as a box
representing the dream and design phase of the journey towards personal
and professional wholeness. The large triangle pointing up towards
wholeness represents the process of developing a shared world image. I
used a darker blue for this section as the colour symbolises water which is
fluid but crystal clear. The world image therefore that is developed by the
therapy radiographers is amenable to change as the profession and the
therapy radiographers grow and develop; however, it is a shared world
image that is clear in its definition.
The triangles which hinge on the large blue triangle represent the concepts
of recognition and commonality. The shared world image must provide the
therapy radiographers with a commonality with which they can identify. I
selected the colour green for this concept to symbolise the growth of the
therapy radiographer. The triangle representing the concept of recognition
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has been drawn in red. Red symbolises a shared world image which
stands out and clearly identifies the professional attributes which unite the
profession.
The rectangle forming the top of the box represents the therapy radiographer
who is an autonomous self-directed professional and this has been drawn
in yellow. To me, yellow symbolises a new beginning and is therefore an
ideal colour to represent a reinvented therapy radiographer.
Leaving the box is an arrow pointing to the concept of wholeness, labelled
‘Deliver’. I once again used lilac to represent the delivery stage of the journey
towards personal and professional wholeness. At this point in the journey
the therapy radiographer has reinvented themselves and is ready to
experience personal and professional wholeness, just as the facilitator was
at the start of the journey.
FIGURE 5.3: THE MIDDLE THIRD OF THE MODEL
The top third of the model (Figure 5.4) represents the therapy radiographer
experiencing personal and professional wholeness. I selected a deep orange
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for this section of the journey as orange is warm and inspirational. Orange
also fits well within the colour chosen for the outer border of the model, as
ultimately the therapy radiographer must identify with her context or
environment.
FIGURE 5.4: THE TOP THIRD OF THE MODEL
5.3.7 The model process
The model process will be described in the three steps listed below.

Planning

Implementation

Evaluation
5.3.7.1 Planning
The planning of the model process began with contextualising the concepts
found in the model with literature to support the implementation of the model.
This process ensured that the theory developed could be implemented so
that the purpose of the model could be achieved. Planning therefore started
with me looking at each phase of the model, namely discover, dream, design
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and deliver, in order to develop a strategy to implement the model that was
based on sound reasoning and supported by literature.
5.3.7.2 Implementation
The model will be implemented in the phases of discover, dream and design
and deliver, in keeping with the theme of appreciative inquiry. The model will
be operationalised in the form of a workshop described in the next section.
The theory guiding the implementation of the model will now be explored
to provide a theoretical framework to guide the operationalisation of the
model.
a) Discover
The model begins with a journey of discovery. It assumes that a therapy
radiographer that is experiencing personal and professional wholeness,
such as myself, creates an opportunity for other therapy radiographers to
discover who they are and what they want to be.
Key to this process of discovery is the ability to be self-aware and to be
reflective and reflexive. Being self-aware will allow the therapy
radiographers to control their behaviour and therefore adapt their
behaviour to changing circumstances. Self-awareness will also assist
therapy radiographers to solve their own problems, cope with stress and
communicate more effectively with other people (Johnson, 2006:52, 53).
The Johari window (www.businessballs.com/johariwindowmodel.htm) is
arguably one of the most well-known and utilised tools used by managers
to develop self-awareness skills among staff members and is therefore a
tool to develop self-awareness among therapy radiographers. The Johari
window was developed by American psychologists by the names of
Joseph Luft and Harry Ingham in 1955 while conducting research on
group development. A combination of self-disclosure and receiving
feedback is said to improve self-awareness.
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Creating an opportunity for the therapy radiographer to be reflective and
reflexive would allow the therapy radiographer to reflect on past experiences
and to be aware of the role that they played in forming those experiences
(reflexive). Therapy radiographers should then be able to reinvent themselves
as individuals and as professionals. Reflective journaling has been shown
to be an effective tool in promoting practice in a radiotherapy context and
is therefore utilised in the operationalisation of the model.
b) Dream and design
The model then moves to a dream and design process. Here therapy
radiographers are encouraged to dream and then brainstorm ideas about
an ideal professional identity that can unite them as a professional group
and that provides them with a commonality, allowing them to emerge as
autonomous, self-directed professionals. This stage of the journey will require
the therapy radiographers to be equipped with effective interpersonal skills
and to develop an internal locus of control and an achievable professional
development plan.
The interpersonal skills identified to be problematic in the focus group
interviews were those of communication and conflict management. The
operationalisation of the model therefore requires communication skills
and conflict management skills to be taught.
Constructive communication skills pave the way for therapy radiographers
to learn how to express their feelings in a constructive way and how to
communicate effectively with other team members. Back, Arnold, Tulsky,
Baile and Fryer-Edwards (2003:2433–2434) suggest that a communication
retreat that allows participants to practise the skills learnt and reinforces
the learning process is critical to the facilitation of good communication
skills. However, if such an ideal is not available to a facilitator, teaching
basic requirements for effective communication is possible. Teaching
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therapy radiographers the 7 C’s of communication, for example, may be a
helpful start. The 7 C’s suggest that communication needs to be:

Clear

Concise

Concrete

Correct

Coherent

Complete

Courteous (www.mindtools.com/pages/article/newCs_85.htm)
Johnson (2006:132–161) explains that anyone wishing to improve their
communication skills needs to be taught how to send and receive messages
effectively. Sending messages effectively includes the following skills:
1. Taking ownership of the message by using personal pronouns such as
I, me and my
2. Describing the behaviour rather than the person
3. Making statements that describe how the relationship is unfolding
4. Understanding the other person’s perspective
5. Obtaining feedback on how the message is being received by the other
person
6. Making sure that verbal and non-verbal messages are congruent
When receiving a message, says Johnson (2006:148), a person must be
guided how to paraphrase what has been said to them, negotiate the
meaning of the message being sent and consider the sender’s perspective
when interpreting the message. Therapy radiographers should be taught the
above communication strategies during the operationalisation of the model.
Role play is then used to give the therapy radiographers an opportunity to
implement the theory taught.
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Effective conflict management skills will be facilitated by teaching five
basic strategies that can be used when managing conflict. The strategies
are illustrated in Figure 5.5 below. A person can select the turtle approach
and withdraw from the conflict when neither the goal nor the relationship
with that person is important. The shark approach is used when the goal
is important, but the relationship with the other person is not. In this
approach the person uses force to achieve their goal without consideration
of the other person involved. The teddy bear approach is used when the
goal is of little importance but the relationship is of high importance. In this
approach the person gives in and does not attempt to achieve their goal.
The fox is a compromising approach used when both the goal and the
relationship are of moderate importance and a person is willing to give up
a little of both. The owl advocates negotiation and is the approach best
used when both the goal and the relationship are equally important. An
agreement is negotiated that maximises joint benefits whilst maintaining
the integrity of the relationship.
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FIGURE 5.5: CONFLICT STRATEGIES (Johnson, 2006:256)
Furthermore, Johnson (2006:259) sets out six rules to consider when
engaged in conflict with a person with whom an ongoing relationship exists.
The rules are easily transferred to a radiotherapy setting and are as follows:
1. Do not withdraw or ignore conflict. Brinkert (2010:152) supports this
idea and suggests that managers openly discuss the central role of
conflict in a hospital setting.
2. Do not engage in win-lose negotiations. In this situation interpersonal
relationships will be negatively impacted upon.
3. Assess for smoothing. Placing the needs of a colleague above the
individual may be beneficial in the long term as the person may
reciprocate when the situation is reversed. Jordan and Troth (2002:94)
155
suggest that nurses with a high emotional intelligence score are better
equipped to manage interpersonal conflict at work.
4. Compromise when time is short.
5. Initiate problem solving negotiations. Being able to engage in problem
solving negotiations is the most difficult but most important conflict
resolution strategy. Seren and Ustun (2008:393) found that the conflict
resolution skills of nursing students was significantly higher in students
who had been educated using a problem-based learning approach
than those who were taught using a conventional curriculum.
6. Use your sense of humour.
An internal locus of control is developed by improving self-esteem and
self-concept in a supportive environment. This can be achieved in a
workshop setting by facilitating a professional identity and improving staff
cohesiveness by giving therapy radiographers an identity which brings about
a commonality with which they can align. The design of the workshop to
operationalise the model therefore takes into account the health action
model (Ewles & Simnett, 2005:272). Self-esteem and self-concept can also
be facilitated by promoting the concept that therapy radiographers need to
take care of their physical health.
Physical fitness and nutritional planning are important aspects of promoting
optimal well-being as described by Pender (1982:83, 91). Powers and
Dodd (2009:3) assert that maintaining a good physical health profile can
assist in improving a person’s quality of life. They recommend that the FIT
principle (frequency, intensity and duration or time) be applied when
designing a personal exercise programme. Applying this principle would
involve exercising 3–5 times per week at a moderate intensity for about 30
minutes per session. Good nutrition is defined by Powers and Dodd
(2009:196) as a diet that incorporates all the nutrients required to maintain
156
a healthy body. The United States Department of Agriculture (USDA) has
developed a MyPyramid food guidance system to encourage consumers
to eat a nutrient-rich varied diet and to incorporate physical activity into
daily schedules. The pyramid is presented in Figure 5.6 below:
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FIGURE 5.6: MYPYRAMID (www.mypyramid.gov)
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Goal setting is an important aspect of the workshop to realise the dream of
professional development. Probst and Griffiths (2009:155) have shown
that therapy radiographers achieve job satisfaction when they are given
opportunities to engage in professional development opportunities and are
enthusiastic about learning new competencies that allow them to take on
additional responsibility and prevent the work from becoming monotonous.
Therapy radiographers will be assisted to develop realistic and achievable
goals by using a force field approach developed by Kurt Lewin (1951).
This approach encourages the therapy radiographer to break goals up into
workable units and to be realistic by listing the restraining and facilitating
forces present that may impact on the attainment of the goal.
c) Deliver
The model then requires the therapy radiographers to deliver on their
dream of developing a professional identity and experiencing personal and
professional wholeness. In order to do that, it is worth consulting the
literature on how to deliver sustained change in behaviour. The stages of
change model (Figure 5.7) developed by Prochaska and DiClemente show
how people naturally change their behaviour (Ewles & Simnett, 2005:272).
The model describes a cycle of change that can be thought of as a revolving
door as people usually go around more than once before the change
becomes permanent. The pre-contemplation stage describes a stage at
which a person is unaware that change must occur. The contemplation
stage is where the participants in this study could arguably be at. This is
the stage where people are motivated to seriously consider changing habits.
The commitment stage requires that people be committed to making a
change, and the action stage requires that a person actively begin to
change behaviour. A variety of coping strategies are required in the
maintenance phase as people struggle to maintain the changed behaviour.
At the relapse stage satisfaction from a changed behaviour dominates but
the majority of people relapse and move back into the pre-contemplation
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stage. The exit stage occurs when a person has settled into a changed
behaviour.
FIGURE 5.7: THE STAGES OF CHANGE MODEL (Ewles & Simnett, 2005:273)
Based on the concepts detailed in the Ewles and Simnett (2005:272) model,
therapy radiographers will be encouraged to keep a reflective journal after
the conclusion of the workshop so that they can reflect on their progress
and make changes should the goal of experiencing wholeness become
difficult.
5.3.7.3 Evaluation
The model terminus is when therapy radiographers experience personal
and professional wholeness. The model must therefore be able to deliver a
therapy radiographer who is physically, mentally and spiritually a whole
person. The model facilitates the development of a mentally whole person
by encouraging professional development and facilitation of effective
160
interpersonal skills. A spiritually whole therapy radiographer is facilitated
through the model process by providing a superordinate identity to give
therapy radiographers a commonality and a sense of belonging. Physical
wholeness is facilitated by motivating therapy radiographers to make
conscious decisions about healthy lifestyle choices.
5.4 GUIDELINES TO OPERATIONALISE THE MODEL
The ability to convert ideas to things is the secret to outward success.
Henry Ward Beecher
The process described in 5.3 above will now be described so that it can be
deliberately applied in practice. Therefore guidelines to operationalise the
model in an oncology setting are described below.
5.4.1 Planning
Planning the workshop will need to be done with close cooperation of the
assistant director of the oncology department concerned. The workshop is
designed to be offered over four days, which will need to be planned in
such a way as not to compromise service delivery in the department. A
suggestion may be to plan the workshop to be held over a scheduled
major service for a linear accelerator.
Each participant will also be required to have a copy of the workbook to
assist the workshop process. The books would need to be printed ahead
of time. Each participant will need to be given a diary in which reflective
journaling after completion of the workshop can be undertaken.
A venue suitable for group discussions and role play activities will need to
be selected. A flip chart for charting ideas generated by participants must
be available.
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As the workshop is scheduled to be offered over four full days, refreshments
at the tea break and lunch will need to be provided for each participant.
5.4.2 Implementation
The model will be implemented in the form of a four-day workshop. The
agenda for the workshop can be found in the workshop manual (Appendix
7). The workshop will be implemented by taking participants through the
three stages of the model, namely discover, dream and design, and deliver.
In order to achieve a lasting change in behaviour, however, participants
will be encouraged to develop the habit of reflective journaling.
5.4.2.1 Workshop, day 1 – Discover
At the start of the workshop, the participants will be welcomed and the
purpose of the model, the facilitation of a professional identity as part of
achieving personal and professional wholeness will be explained to them.
Participants will also be encouraged to agree on ground rules for participating
in group discussions and role play activities. Anticipated rules will be, for
example, allowing all participants to contribute to discussions, respecting
the ideas and opinions of all participants, offering constructive rather than
destructive critique and punctuality at the start of the day and when returning
from tea and lunch breaks.
Participants will then be given an opportunity to begin a journey of selfdiscovery.
The facilitator will start the process by explaining to participants why selfdiscovery is an important skill. He or she will then explain the concept of a
Johari window to participants. Participants would then be given time to sit
and reflect on what their personal Johari window looks like and to complete
the blank Johari window found in the workbook. A half-hour tea break
would then take place.
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After tea, participants will be asked to take turns to share their Johari
window with the group. Each participant’s Johari window can be commented
on by the group members to allow the presenter to gain some feedback on
how they are perceived by the group. Careful facilitation of the session will
be required to allow for the comments made to be constructive, giving the
participant an opportunity to receive feedback in a supportive, enabling
environment. A lunch break would follow.
The session after lunch is designed to foster reflective writing and aims to
encourage participants to become both reflective and reflexive. Participants
will be given a journal in which they will be encouraged to write reflective
reports at least weekly and then to become reflexive by recognising their
role in the incident reflected upon. Reflective journaling will become a tool
that will also be used to help develop and monitor the attainment of goals
once the workshop is complete.
The reflective writing session will be based on the model proposed by
Hamilton and Druva (2010:342) and will be facilitated as follows:

A 40-minute mini lecture will be given covering the following
content:

A definition of reflective practice

Reflective journaling as a reflective practice tool

Using reflective journaling in goal setting

Barriers to reflection

Facilitators for reflection

Challenges and common pitfalls

A 60-minute activity and group discussion will follow. Here
participants will be asked to complete a reflective writing task. A
group discussion will follow where participants will be asked to
discuss:

Topics appropriate for reflective journaling
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
How reflection can lead to action and change

Reflection and self-awareness
The day will come to an end with participants having an opportunity to
share their reflections of the day’s proceedings.
5.4.2.2 Workshop, day 2 – Dream and design
Day 2 of the workshop will be facilitated by giving participants an opportunity
to reinvent themselves and their professional identity. They will then be
asked to design how they could envisage turning the dream into a workable
reality.
At the start of the day, participants will be asked to tell the group what their
dream for the profession is and how they would like to see themselves in
the future. Careful facilitation of this discussion will be required. Quieter
group members will need to be encouraged to share their dream and
dominant group members should be gently encouraged to give all members
an opportunity to share their ideas. Participants will also need to be
encouraged to think outside of known barriers, such as scope of practice,
as this session is a dreaming session and the realities will be faced when
the time comes in the workshop to formulate (design) a plan to turn the
dreams into possibilities.
A tea break will then take place to allow participants to reflect on the dreams
discussed.
Participants will then move into a brainstorming session in which they will
be asked to brainstorm an ideal professional identity based on their dreams
of the earlier session. Attributes, values and descriptive terms suggested
by participants will be written on a flip chart by the facilitator. Participants
will be encouraged to not to reject any ideas at this stage but rather to
suggest any idea that comes to mind.
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Then, the facilitator will begin to help participants start to combine and
categorise ideas and to find associations between categories. This will be
done by linking ideas on the flip chart and developing a mind map as
categories emerge. A lunch break will be taken at the end of this session.
Once the participants are happy that the mind map conceptualises the
concepts that are most important to their identity, an identity statement will
be developed from the concepts captured on the mind map. Participants
will be given an opportunity to write the newly developed identity statement
into their own personal workbook.
The final session of the day will involve the design phase of the workshop.
Participants will be asked to reflect on the newly developed identity
statement and to discuss how they as a professional group will work
towards becoming the professionals described in the identity statement.
The day will close with participants sharing their thoughts of the day’s
proceedings.
5.4.2.3 Workshop, day 3 – Improving interpersonal skills
Day 3 focuses on developing effective interpersonal skills so that the
participants are able to work effectively as members of a multidisciplinary
oncology team. It will aid in the development of an internal locus of control
and assist in the development of an achievable professional development
plan.
Day 3 begins with a session on improving communication skills. A 60-minute
lecture will start the day and will cover the following topics:

What is communication?

The 7 C’s of communication

How to send effective messages

How to receive messages effectively
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The participants will then be divided into groups of three to complete the
role play activity outlined in the workbook. A tea break will follow the activity.
After tea, the focus of the workshop will turn to the development of effective
conflict resolution skills. Once again, the session will be facilitated by
equipping the participants with the theory on effective conflict resolution
skills in the form of a lecture and then giving participants an opportunity to
discuss the concepts taught in the lecture session. The topics to be covered
in the lecture will be:

Understanding conflicts of interest

Conflict resolution strategies

Assertive behaviour strategies
Participants would then be divided into groups of three to complete the
group work exercise outlined in the workbook. Lunch would follow the role
play activity.
After the lunch break, participants will return for a session to discuss physical
fitness and nutritional planning. A healthy eating plan and the importance
of regular exercise will be discussed with participants.
The day’s session will be brought to a close by giving participants an
opportunity to reflect on the day’s proceedings.
5.4.2.4 Workshop, day 4 – Goal setting and delivery
Day 4 of the workshop will begin by explaining the force field approach to
goal setting to participants. Participants will be taken through the following
steps:

Breaking goals down into steps that appear achievable

Brainstorming driving forces that may help to facilitate goal
achievement
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
Brainstorming restraining forces that may hamper the achievement
of the goal

Deciding how to minimise the restraining forces and maximise the
facilitating forces

Setting a plan into action

Deciding how to evaluate the success of the plan
A tea break would follow the session. Participants will then return from the
tea break to spend time working on their own personal development plan
using the force field approach and the worksheet in their workbook. Once
the session is complete the participants will be given a lunch break.
The session after lunch focuses on sustaining a change in behaviour by
encouraging participants to continue a process of reflection and action on
a continuum. The participants will be encouraged to keep a reflective journal
and to consistently reflect on their journey towards wholeness using a
discover, dream, design and deliver cycle in the following manner:

Discover: Participants will be encouraged to regularly reflect on
how content they are at home and at work. They will be encouraged
to document their reflections in their journal.

Dream: Participants will then reflect on what they would like to see
change in their personal and professional lives.

Design:
Participants will enter into a process of goal setting to
achieve the changes that they have identified.

Deliver: Participants will reflect on their progress in achieving the
stated goal.
167
The process continues as participants will be encouraged to once again
take time to discover, dream, design and deliver on their own vision of
personal and professional wholeness.
In addition to the process outlined above, participants will also be
encouraged to write in their reflective journal about incidents or events at
work or at home and recognise the role that they played in those events.
Encouraging participants to be both reflective and reflexive will assist in
sustaining positive behaviour change.
5.4.3 Workshop evaluation
At the close of the workshop, participants will be asked to complete the
workshop evaluation document found in their workbooks. The evaluation
document aims to assess how useful participants found the workshop. The
participants will also be given an opportunity in the document to comment
on changes to the workshop that they think may improve their experience.
5.5 EVALUATION OF THE MODEL
He that will not reflect is a ruined man.
Asian Proverb
Evaluating a theoretical model requires the researcher to reflect critically
on whether or not the model could function in a clinical setting and on the
purpose that the model serves (Chinn & Kramer, 2011:197). The model
developed in this study was evaluated using Chinn and Kramer’s questions
for critical reflection (2011:197–205). Chinn and Kramer propose that
researchers reflect critically on five questions and discuss their reflections
with colleagues who can challenge the assumptions made and contribute
to the insights made by the researcher.
168
For this study, the researcher presented the model to the research
supervisors who had the experience required at evaluating theoretical
models and who were in a position to critically reflect on the model and
challenge assumptions made. The model was also presented at a national
congress in May 2012 (Lawrence et al., 2012). The audience at the
congress included research methodology experts who were asked to
evaluate and provide critique on the model as it was presented. The
feedback received was positive and no changes were made to the model
structure or design from the feedback received.
5.5.1 Clarity of the model
Here Chinn and Kramer (2011:198–210) suggest that the question, “how
clear is this theory?” be posed. This question is essentially asking how well
the theory can be understood and how consistently the concepts are
conceptualised. Upon critical reflection, it was decided that the model was
clear. The concepts were defined using dictionary and subject literature.
They were defined generally and were then given meaning specifically
within the professional context into which the model is placed. The
relationships between the concepts were explained and the explanations
were further enhanced using diagrams. The concepts were used
consistently with the proposed definitions.
The basic assumptions upon which the model was based were consistent
with one another and served a purpose which was made clear when each
assumption was posed. I described a therapy radiographer as a person
with an internal and external environment. The view of the person and the
external environment were compatible and fitted within the assumptions
made.
The overall structure of the model was diagrammatically represented and
was clear to follow. The concepts fit within the theory and build a picture
169
and a sequence which is clear to follow both in the written description of
the theory and on the diagram presented.
The concepts used in the 4-D model of appreciative inquiry were deliberately
pulled through the research process from the interviews into the model
development and implementation to ensure consistency in the concepts
used. The thread of the 4D design pulled through the research process
made, in my mind, the understanding of the model clearer and provided a
consistent trail of evidence through the research process and the model
development.
Chinn and Kramer (2011:198–199) further explain that semantic clarity is
important in ensuring that the meaning of concepts contained in a theory
are clear. They caution that excessive narrative and the use of excessive
examples obscure clarity, making concepts difficult to understand. Concepts
should therefore be consistent with common meanings, and definitions
given should be short and simple. The definitions of the concepts given in
this model have been kept short and consistent with common meanings in
the context of radiation oncology.
Semantic consistency is the second feature of Chinn and Kramer’s
description of clarity (2011:19). Here concepts should be used consistently
with their definitions. Definitions provided must therefore be consistent with
one another and should fit with the assumptions made. Upon reflection of
this aspect of my model, I am satisfied that semantic consistency has been
met as the model was relatively simple to operationalise and the concepts
fit well within the assumptions described.
5.5.2 Simplicity of the model
Here Chinn and Kramer (2011:201– 202) suggest that the question, “how
simple is this theory?” be posed. For a theory to meet the criteria for
simplicity there should not be too many theoretical relationships between
and among numerous concepts. A central concept was identified for the
170
development of my model and the relationships between the concepts
were frequently reassessed and rewritten until only simpler relationships
between concepts were described.
Furthermore, the relationships described in the model are organised into a
logical format that is simple to understand. The model is intended to be
operationalised in a clinical radiotherapy setting and therefore needs to be
detailed enough to be operationalised but simple enough to be
understandable. Whilst the concept of wholeness can become complex,
the model has been developed in such a way that it meets the criteria for
simplicity.
5.5.3 Generalisability of the model
Here Chinn and Kramer (2011:202) suggest that the question, “how general
is this theory?” be posed. The model proposed in this study is intended to
guide therapy radiographers towards the concept of wholeness. It addresses
a specific phenomenon and is therefore limited in its scope of application.
The concepts used in the theory are simple but can be applied across a
broad range of experiences, as the model interrelates the therapy
radiographer as an individual into the environment of oncology.
The generality of the theory posed in this model can therefore be assessed
by answering two questions, namely “to whom does this theory apply?”
and “when does it apply?”. The model presented in this study applies to
therapy radiographers working in a specific radiation oncology department
in a South African setting. It is applicable when therapy radiographers find
themselves questioning their professional identity and struggling to find
wholeness within their professional and personal experiences. The scope
of application of the model is therefore limited and the theory hence may
not be generalised.
171
Chinn and Kramer (2011:203) believe that the desirability of a theory that
is generalisable depends on the purpose of the theory. The purpose of my
model was not to address a general phenomenon, but rather to address
the concept of achieving personal and professional wholeness in a very
specific setting. I believe, therefore, that generalisability in this case is not
essential as the model needs to address a specific population in a specified
context.
5.5.4 Accessibility of the model
Here Chinn and Kramer (2011:203–204) suggest that the question, “how
accessible is this theory?” be posed. A theory that is accessible is one in
which empiric indicators can be identified for each concept and the
outcomes can be achieved.
The concepts described in this model are simple; however, empiric indicators
are not quantifiable as achieving a sense of wholeness is based on
individual perceptions. One cannot measure the extent to which a person
has experienced the concept of wholeness. However, the definitions of the
concepts presented adequately reflect the meaning of the concept, making
the concepts empirically observable as behaviours change within the
individual therapy radiographer. Expected observable behaviour changes
may be a reduction in absenteeism, improved organisational commitment,
an increase in the desire to learn new skills or improve qualifications and
improved patient care. The operationalisation of the model encourages
sustained behaviour change and requires that the therapy radiographers
reflect regularly on the concept of achieving wholeness.
The intended outcome of the model can be achieved because clear
guidelines to operationalise the model into a clinical oncology setting have
been described and are easy to understand and realistic to implement.
The model is therefore accessible and can be implemented to bring about
change to an individual therapy radiographer.
172
5.5.5 The importance of the model
Here Chinn and Kramer (2011:204) suggest that the question, “how
important is this theory?” be posed. They state that an important theory is
“forward looking; usable in practice, education, and research; and valuable
for creating a desired future”.
The model proposed in this study creates a new professional identity for
therapy radiographers that could impact on their professional fulfilment,
and this in turn may impact on staff retention, recruitment and patient care.
The model is grounded in practice, is clinically relevant to the needs of
today’s therapy radiographer and is supported by radiography and health
care literature. The model has the potential to influence a therapy
radiographer as an individual and as a professional group. It has relevance
to radiotherapy education and could encourage radiotherapy research. In
a context of extreme staff shortages and increasing patient numbers, the
model is important to the future of oncology and to the quality of care
received by radiotherapy patients.
Chinn and Kramer (2011:204) propose that a researcher ask the questions,
“do I like this theory?” and “why do I like it or not like it?” when considering
the importance of a theory. I asked myself the questions and reflected on
the answers.
I do like the model developed in this research. I like it because it gives me
hope for a group of professionals and a profession that I am passionate
about. It fills me with excitement as I talk to therapy radiographers about it.
I recently spoke with and then received an e-mail from the assistant director
at the department in which the data collection for the model development
was conducted. She told me of her excitement about my research and her
enthusiasm to have me come and present my model to her staff. Her
comments motivated me to push through the writing of the thesis so that I
may turn my attention to finding ways to operationalise the model and share
173
my work with therapy radiographers. In my mind, the theory developed in
this research is important and should make a difference to clinical
radiotherapy.
5.6 CONCLUSION
Chapter 5 saw the description of the model developed as a result of
appreciative inquiry interviews held with therapy radiographers at a tertiary
hospital. The model is based on the therapy radiographers’ discovery that
there is something good about being a therapy radiographer and that they
do in fact have dreams for the profession. The model aims to assist
therapy radiographers to design and deliver on the dreams identified.
A wise person once told me that the difference between a dream and a
goal is focus and a time line. The model described in this chapter provides
the therapy radiographers with a focus; the time line is up to the individual
and the profession. My dream for the profession is that therapy radiographers
will implement the guidelines to operationalise the model described in this
chapter and that their dreams become reality.
174
CHAPTER 6
CONCLUSION, CHALLENGES, RECOMMENDATIONS
AND ORIGINAL CONTRIBUTION
“No road is too long for him who advances slowly and does
not hurry, and no attainment is beyond his reach who
equips himself with patience to achieve it.”
Jean de la Bruyère
6.1 INTRODUCTION
The aim of this study was to develop new theory on the process of being a
therapy radiographer in order to develop a model to facilitate wholeness
among therapy radiographers and to develop guidelines to operationalise
such a model. This chapter reflects upon whether or not the research aim
was met and considers the challenges faced during the research process.
Recommendations for further research in radiography are outlined and the
research is evaluated for its contribution of knowledge to the profession.
6.2 OVERVIEW OF THE RESEARCH PROCESS
The study utilised a qualitative theory-generating research design, using
appreciative inquiry to identify a central concept onto which a model to
facilitate wholeness among therapy radiographers was developed. This
process was achieved in four steps.
Step 1 was achieved in two phases. Phase 1 saw the identification of a
central concept by conducting fieldwork. The experiences of the therapy
radiographers were explored by means of appreciative inquiry incorporating
focus group interviews. Participants were asked to share stories of being a
therapy radiographer using a 4-D model of conducting appreciative inquiry
175
interviews (Watkins & Mohr, 2001:43). Fourteen therapy radiographers
participated in the interviews. The interviews were audiotaped and later
transcribed verbatim. During the interviews field notes were taken and
were incorporated into the data analysis. Data analysis was conducted by
means of open coding as described by Creswell (2003:190–195). An
independent coder was given a copy of the uncoded verbatim transcripts
and a meeting was arranged in order to reach consensus on the themes
and categories developed from the coded data. Three themes were
identified:
life-giving forces that promote personal and professional
engagement resulting in a sense of purpose, professional stagnation from
a lack of self-worth and interpersonal conflict, and facilitating change
towards wholeness by harnessing the positive energy and commitment to
change.
Identifying the central concept for the development of the model required
me to reflect on the main themes described above and to reason inductively
to combine the themes from specific stories told to me into a general
concept that could be transferable to a broader radiotherapy population
(Burns & Grove, 2005:73). The facilitation of the therapy radiographers’
professional identity became the central concept for the development of a
model to facilitate wholeness among therapy radiographers.
Phase 2 saw the central concept defined and classified. The central concept
was defined by means of identifying central criteria using dictionary and
subject literature. The defined concepts were classified by means of the
survey list of Dickoff et al. (1968:422–435).
In step 2 concepts identified in step 1 were written into relationship
statements in order to develop a preliminary conceptual model as the
framework for the research.
Step 3 consisted of the description of the model to facilitate wholeness as
part of a professional identity among therapy radiographers. The central
176
and related concepts found in the model were defined and relationship
statements were developed between the central and related concepts.
The structure of the model was developed and presented both in a written
and a visual format.
Step 4 entailed the development of guidelines to operationalise the model
in order to assist in the clinical application of the model in a radiotherapy
setting. A workshop was developed and described in enough detail to be
operationalised but simple enough to be understandable. The workshop
aimed to:

facilitate self-awareness

promote self-esteem and self-concept

develop an internal locus of control

develop effective interpersonal skills

facilitate the development of a professional identity

facilitate the journey towards achieving a sense of personal and
professional wholeness
The model was then evaluated using Chinn and Kramer’s questions for
critical reflection (Chinn & Kramer, 2011:197–205). Upon reflection, I consider
the model to have met the criteria for being adequate for its purpose.
It can be concluded that the aim of the research was achieved as a model
to facilitate wholeness among therapy radiographers was successfully
developed and guidelines to operationalise the model were presented.
The evaluation of the model concluded that the model met the criteria
described by Chinn and Kramer (2011:197–205) and was suitable for
application in a clinical radiotherapy context. The model, if successfully
implemented into a clinical setting, has the potential to improve the
professional fulfilment of therapy radiographers, uplift the profession of
radiotherapy and could impact positively on patient care and staff retention
and recruitment.
177
6.3 CHALLENGES
Nothing is predestined: The obstacles of your past can
become the gateways that lead to new beginnings.
Ralph Blum
As is true of most academic research projects, challenges were faced which
impacted on the data collection and subsequent results presented in this
report. The challenges faced are described below and their impact on the
quality of this report is reflected upon.
6.3.1 Sample size
As a qualitative research design was employed in this research study, it
was decided to limit the data collection site to one academic hospital, making
the data collected contextual in nature. Collecting data from participants at
one site, rather than including participants from a variety of oncology
departments, limits the generalisability of the findings, which can be
considered to be a limitation in the design of the research.
However, the participants had a wide range of radiotherapy experiences
and had experience working in more than one oncology setting. The
participants were also told not to limit their storytelling to experiences at
their current place of work, but rather to feel free to share stories about their
radiotherapy experiences in any setting which they had found themselves
in. In order to assist in the transferability of the results from this setting to
another, a dense description of the data collected was provided. The
literature review also assisted in the transferability of the findings as it was
evidenced in the literature that similar themes are reported by researchers
in a wide range of research settings across multiple countries.
178
Of course, including participants from multiple oncology settings would have
had an impact on the time and resources available to me as the research
was for qualification purposes and therefore had time and resources
restrictions. As much as the sample size poses a potential limitation of the
study, the participants in my study were an asset to the study. They gave
up their time to participate freely and were enthusiastic about participating
in the interview process. The participants were information rich and provided
enough data to reach the point of saturation, thereby negating the necessity
for the inclusion of additional participants in the study. In a qualitative
study, the concept of data saturation is considered to be more important
than sample size. I was content that I had reached data saturation when
the focus group interviews ended, and the research supervisors, who had
access to the verbatim transcripts were also satisfied that data saturation
had been reached.
6.3.2 Time
As is typical of most radiotherapy departments, the department at which
the interviews were conducted was short staffed and overloaded with
patients. The staff were working long hours to prevent waiting lists from
becoming unmanageable and were dealing with high patient to therapy
radiographer ratios. Furthermore, since research is fairly new to radiography,
radiographers generally have little or no experience with research and are
therefore not willing to participate in research activities that require time
outside of working hours. Therefore, I had little choice but to conduct the
interviews during a normal working day. This had its own set of challenges,
as I had limited time with the participants. Although the participants
appeared relaxed during the interviews, I cannot help but wonder if they
would have shared more stories with me if the interviews were conducted
outside of working hours when participants were not mindful of the patients
still waiting to be treated.
179
Of course, on the other hand, more than half of the staff complement
participated in the interviews, which may not have been the case had they
been required to volunteer their free time to research participation. With
the implementation of CPD by the Health Professions Council of South
Africa, therapy radiographers are reluctant to spend free time on “work”
activities that do not equate with points towards their CPD portfolio.
6.3.3 Audio recorder
In order to allow for an accurate verbatim transcription of the interview
data, the interviews were audiotaped. The first interview was conducted
with the audio recorder placed in the middle of the group which resulted in
some audio missing from the transcription of the interview. From my
perspective, this did not pose too great a problem as I could recall the
interview in detail. However, it did impact on the independent coder who
was not present at the interview and did not have the luxury of recall that I
had. However, the themes and categories generated by the independent
coder and I were similar and consensus was easily reached.
6.4 RECOMMENDATIONS FOR RADIOGRAPHY PRACTICE,
EDUCATION AND RESEARCH
Recommendations made as a result of developing the model and my
personal reflections on the process will be discussed in relation to
radiography practice, education and research.
6.4.1 Recommendations for radiography practice
It is recommended that:

The model be operationalised into clinical radiotherapy practice.
180

Radiotherapy managers who wish to operationalise the model in
their own department do so using small groups of individuals and
gradually encourage the participation of the department as a whole.

Therapy radiographers be encouraged to identify possible role
extension and role advancement opportunities in clinical practice
and feed that information to higher education institutions.

Employers of therapy radiographers encourage their staff to further
develop their professional qualifications by introducing incentives to
study further.
6.4.2 Recommendations for radiography education

Higher education institutions need to become proactive and start
developing formal qualifications to facilitate the implementation of
role advancement in a South African setting.

Higher education institutions need to develop an ethos of research
participation in undergraduate students in order to support the
concept of radiographers becoming active generators of new ideas
instead of passive users of new knowledge generated by allied
professionals.
6.4.3 Recommendations for radiography research
It is recommended that:

The model be operationalised in a clinical radiotherapy setting and
evaluated accordingly. This may be considered as a potential topic
for a candidate in the MTech: Radiography programme.

The model be considered for its transferability possibilities to other
radiography disciplines (diagnostic radiography, nuclear medicine
181
and ultrasound) which are presumably finding similar professional
challenges.
6.5 ORIGINAL CONTRIBUTION OF KNOWLEDGE TO THE
PROFESSION OF RADIOTHERAPY
Upon reflection, I feel that the research has made the following contributions
to the profession of radiotherapy and to health care research in general:

The model itself is a unique contribution to the topic of the mental,
physical and spiritual health of therapy radiographers. Previous
research has focused on reporting problematic areas and has not
made any significant attempt to address the issues faced by
therapy radiographers.

The research methodology employed makes a unique contribution
to health care research in general. I have not come across a
research article that employed the use of appreciative inquiry to
identify a central concept for model development. This novel use of
appreciative inquiry may inspire other researchers to consider the
methodology in further studies.
6.6 CONCLUSION
In conclusion it can be said that the aim of the research, namely to develop
a model to facilitate wholeness among therapy radiographers, has been
met. It is now up to the profession to take up the challenge and embrace
the future of the profession by letting go of what they do now and moving
towards the concept of achieving wholeness. Therapy radiographers have
a dream that can be achieved through a focused drive towards personal and
professional change. It is hoped that the model developed in this study
can become an effective tool through which the change can be initiated. I
would like to leave the reader with a poem which I feel eloquently captures
the journey that I encourage all therapy radiographers to begin.
182
If
If you can keep your head when all about you
Are losing theirs and blaming it on you;
If you can trust yourself when all men doubt you,
But make allowance for their doubting too;
If you can wait and not be tired by waiting,
Or, being lied about, don't deal in lies,
Or, being hated, don't give way to hating,
And yet don't look too good, nor talk too wise;
If you can dream – and not make dreams your master;
If you can think – and not make thoughts your aim;
If you can meet with triumph and disaster
And treat those two imposters just the same;
If you can bear to hear the truth you've spoken
Twisted by knaves to make a trap for fools,
Or watch the things you gave your life to broken,
And stoop and build 'em up with wornout tools;
If you can make one heap of all your winnings
And risk it on one turn of pitch-and-toss,
And lose, and start again at your beginnings
And never breath a word about your loss;
If you can force your heart and nerve and sinew
To serve your turn long after they are gone,
And so hold on when there is nothing in you
Except the Will which says to them: "Hold on";
If you can talk with crowds and keep your virtue,
Or walk with kings – nor lose the common touch;
If neither foes nor loving friends can hurt you;
If all men count with you, but none too much;
If you can fill the unforgiving minute
183
With sixty seconds' worth of distance run –
Yours is the Earth and everything that's in it,
And – which is more – you'll be a Man my son!
Rudyard Kipling
(http://www.everypoet.com/archive/poetry/Rudyard_Kipling/kipling_if.htm)
184
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