1. BACKGROUND In 2009 two advanced practice radiation therapy positions were piloted at the Juravinski Cancer Centre, the Bone Metastases Clinical Specialist and the Head and Neck Clinical Specialist. These roles were part of the Clinical Specialist Radiation Therapist Demonstration Project funded by the Ministry of Health and Long Term Care (MOHLTC) in Ontario, implemented to address wait times, increase access to care, and improve health of Ontarians. Centres funded to pilot Clinical Specialist Radiation Therapist (CSRT) positions were selected based on successful applications demonstrating site readiness, position clarity, and alignment of potential outcomes. PURPOSE A toolkit was used to help Managers in radiation therapy departments to assess the need for advanced radiation therapist practitioners, to design and implement the positions within a specific delivery model, and to evaluate the success and/or failure of the positions. This is an overview of the implementation of advanced practitioners using this toolkit. METHOD The quality framework "Plan, Do, Study, Act" (PDSA) provided the basis for the implementation, assessment and evolution of the positions to meet the changing needs of the Centre and its patients. Plan Plan - The initial Plan phase involved defining the patient population, identifying and engaging key stakeholders, and conducting a needs assessment to determine the issues and gaps in service delivery. The CSRT positions were then defined and key outcomes were identified, along with appropriate measurement tools. Special consideration was given to defining the competency requirements for the CSRT positions. Do Do - The Do phase involved the recruitment and selection of CSRTs. Candidates completed a rigorous application and interview process. Since there was no established formal preparation for the CSRTs at the time, interested radiation therapists submitted a Prior Learning Assessment and Recognition (PLAR) portfolio. The PLAR documented knowledge and skills related to professional practice and competencies, to demonstrate each candidate’s ability to perform as a CSRT. The CSRTs and their respective positions were introduced to the health care teams and received orientation and on-going support. Goals, responsibilities and timelines were identified and closely monitored. Barriers were identified and ongoing support was provided to help facilitate positive partnerships and collaboration to ensure successful implementation of the positions and outcomes. Study Study - The Study phase utilized a standard set of data collection tools and methods adopted from the previous CSRT Project to measure wait times, skill concordance, access to care, competency and satisfaction of patients, radiation therapists, and stakeholders. The CSRT Demonstration Project also worked with Centres to establish alternate methods to measure unique aspects of CSRT positions and related outcomes. Act Act - The Act phase implemented the positions based on the “toolkit” descriptions. The positions were evaluated to assess how well they fulfilled the needs of the Centre and its patients and the goals to address wait times, increase access to care, and improve health of Ontarians. Adaptations were made to meet the needs of the patients and the Radiation Treatment Program. A-Tale-of-Two Advanced Practice Radiation Therapy Positions at the Juravinski Cancer Centre in Hamilton, Ontario, Canada M. Smoke, J. Blain, L. Doerwald-Munoz N. Harnett, L. Zychla PlanDoStudy Act

2. FINDINGS The Bone Metastases Clinical Specialist Role Description matched the “toolkit” description and currently has expanded the practice to include brain metastases patients. With this new position, Standards of Practice for the palliative population have been reviewed and subsequently, new policies and procedures have been developed and implemented. The advanced skills of this CSRT have resulted in considerable time savings for the radiation oncologists in treatment planning and simulation. The Head and Neck Clinical Specialist The Head and Neck Clinical Specialist position was implemented based on the “toolkit” role and required adaptations to meet emerging technical challenges and incorporates a greater emphasis on research and quality assurance than the original “toolkit” description. A-Tale-of-Two Advanced Practice Radiation Therapy Positions at the Juravinski Cancer Centre in Hamilton, Ontario, Canada M. Smoke, J. Blain, L. Doerwald-Munoz N. Harnett, L. Zychla

3. REFERENCES 1.Clinical Specialist Radiation Therapist Demonstration Project: Implementation Tool Kit, Phase II, Cancer Care Ontario, 2008. 2.Clinical Specialist Radiation Therapist Demonstration Project: Prior Learning Assessment and Recognition, Cancer Care Ontario, 2007. 3.Bryant-Lukosius, D. (2008). Oncology Advanced Practice Nurse Role Implementation Toolkit. Toronto: Cancer Care Ontario. 4.Bryant-Lukosius, D., & DiCenso, A. (2004). A framework for the introduction and evaluation of advanced practice nursing roles. Journal of Advanced Nursing, 48(5), 530-540. 5.Bryant-Lukosius, D., DiCenso, A., Browne, G., & Pinelli, J. (2004). Advanced practice nursing roles: development, implementation, and evaluation. Journal of Advanced Nursing, 48(5), 519-529. 6.Bryant-Lukosius, D., Green, E., Fitch, M., Macartney, G., Robb-Blenderman, L., McFarlane, S., Bosompra, K., DiCenso, A., Matthews, S., & Milne, H. (2007). A survey of oncology advanced practice nurses in Ontario: Profile and predictors of job satisfaction. Canadian Journal of Nursing Leadership, 20(2), 50-68. 7.Deming, W.E. (1986). Out of the Crisis. MIT Center for Advanced Engineering Study. 8.Roberts, S., Kennedy, D., MacLeod, A.M., Findlay, H., & Gollish, J. (2008). A framework for the development and implementation of an advanced practice role for physiotherapists that improves access and quality of care for patients. Healthcare Quarterly, 11(2), 67-75. 9.Bryant-Lukosius, D. (2002-2008). Interactive Workshops on Advanced Practice Nurse Role: Development, Implementation, and Evaluation. 10.The PEPPA Project Team. (2007-2009). The Development and Evaluation of Oncology Advanced Practice Nursing Roles for Underserviced Populations. Funding by: The Change Foundation, Cancer Care Ontario and Ontario Regional Cancer Programs. Principal Investigator: D. Bryant-Lukosius. Co- Investigators: B. Ballantyne, D. Bakker, P. Baxter, J. Bowen, N. Carter, M. Conlon, E. Green, J. Darrall, A. DiCenso, A. Knight, T. MacKenzie, T. Parks, B. Paulse, A. Snider, J. Wiernikowski, R. Wong, K. Willison. A-Tale-of-Two Advanced Practice Radiation Therapy Positions at the Juravinski Cancer Centre in Hamilton, Ontario, Canada M. Smoke, J. Blain, L. Doerwald-Munoz N. Harnett, L. Zychla CONCLUSIONS CONCLUSIONS The Bone Metastases CSRT position closely matched the “toolkit” role and was successfully integrated into the program. The Head and Neck CSRT position was implemented and required adaptations to meet the emerging technical challenges and incorporates emphasis on research and quality assurance. Both CSRT positions were deemed successful in fulfilling the goals of the project. Further evaluation of these and other potential CSRT positions will be undertaken using the same tools and methods utilized in the toolkit with appropriate modifications. The authors recognize the Ministry of Health and Long Term Care for their generous funding of this project.