‘We don’t know what the impacts are’

“It’s become common practice in the UK in radiotherapy centres for patients to ring a bell at the end of treatment,” Keeley explains.

The practice originated in America in the 1990s, when US Navy Rear Admiral Irve Le Moyne, a patient receiving treatment for head and neck cancer, installed a brass bell in the Radiation Treatment Center at the MD Anderson Cancer Center in Texas, US. 

Adopted from the Navy's tradition of ringing a bell after completing a successful task, Keeley says it was then brought to the UK by charities – and it caught on from there. 

“I personally had mixed feelings about its use – obviously for children, it feels like a milestone and a celebration for them to ring it,” she says. 

“Evaluating its use for paediatrics wasn’t ever part of this project. It was to look at the impact on adults, because I’ve been in radiotherapy departments, working and supervising students, where patients receiving palliative care are laid on a stretcher in the corridor, often in ear shot of another patient ringing the bell. It made me think, well, they may have rung the bell months ago, years ago, and could it be a trigger for them?”

Keeley’s interest in investigating the inclusivity of the bell began after an encounter with a patient who was on continuous palliative treatment for breast cancer. Patients facing secondary disease following cancer never get to the end of treatment – they’re often not asked to ring the bell. “It’s been introduced into departments without being evidence-based. We’ve never tested it,” she explains. 

“We don’t know what the impacts on patients are. As a radiographer, I’m acutely aware of the impact it may have on people who are neurodiverse, such as those with Autism Spectrum Disorder or ADHD, or with conditions such as dementia; ringing a bell that rattles through the corridors in clinical areas where patients are being seen – how appropriate is it?”

Patient and practitioner experience 

Keeley began her investigation hoping to ask two separate focus groups about their experiences with the end of treatment bell – including patients who have both rung and not rung the bell, as well as Therapeutic Radiographers who have worked in different departments with bells. 

This was followed by a mixed group discussion, asking all participants to agree on what could replace the bell, how it could be more inclusive, and what the needs and wants of patients and staff are at the end of treatment.

The group discussions took place online – and identified anecdotal evidence that there were some unintended harms as a result of the bell. One of the patient representatives, who was in fact working in the radiotherapy department, had breast cancer herself – and despite finishing her treatment previously, the ringing sound became a trigger for post-traumatic stress disorder. 

In the end, Keeley says the representative had to take a job in a different place. She was struggling post treatment with long-term side effects and being in the department brought everything back.

‘Exploring in a more peaceful way’

Some of the key findings of these online groups were about the post-treatment experience. “There’s always a sword of Damocles hanging over a patient’s head. It feels like the wrong time to be celebrating. It’s like falling off the edge of a cliff – you finish your treatment, then your side effects peak. Two weeks later, they’re sitting at home, they don’t have any interaction with a healthcare professional,” Keeley explains. 

“And when they left the department, it was all clapping, here’s a certificate, let’s ring the bell and take a video. The patient representatives [in the focus group] wished they had some form of support network.”

Both radiographers and patients came to a consensus on a possible replacement for the end of treatment bell – a reflection stone. “The stone has a little poem on it,” says Keeley. “Patients can put their hand on it, they can feel a connection. They want to do something that someone else has done before, which the bell kind of does, but the stone explores that in a more peaceful way. They can use the stone at any time in their treatment – it doesn’t have to be at the end, because some people may not ever reach the end. It is inclusive for family members and carers; it’s a point for reflection.”

Opportunities to flourish 

Keeley has been a research assistant on multiple projects, but she says the opportunity to experience acting as principal investigator herself was “really exciting”. “I felt confident knowing the College of Radiographers was supporting me, and that I had the support of other senior members on my academic team to go to and ask questions,” says Keeley.

“Fundamentally, [filling out the funding application] was pretty straightforward. And after I got the funding, I didn’t feel any pressure – they didn’t inflict any deadlines and I found it really supportive. It was a really nice opportunity to flourish and develop my skills and my confidence as a researcher.”

CoRIPS offers funding to enable research radiographers who have a burning question to carry out their investigation without fear of losing time, money and energy that might be needed to ensure their own stability. The Industry Partnership Scheme Research Grant funds projects related to any aspect of the science and practice of radiography. Applications for this grant are considered on a first come, first served basis, with a maximum of 10 applications being assessed per round. Interested parties can make bids for small projects up to £5,000 and of up to £10,000 for one larger project.  

Keeley’s application earned her a grant of £5,030 and, despite challenges caused by the onset of the Covid-19 pandemic, the research identified a need for more inclusive and supportive practices post treatment. Funding through the College of Radiographers Industry Partnership Scheme arrived in April 2020 – during lockdown. 

Then, Keeley went on maternity leave early, after her son was born in October 2020. “There’s been some challenges,” she admits. “It was all locked down and online, still in the aftermath of Covid. That’s why it’s taken four years to get published!”

Not only did Keeley get the chance to develop her own abilities with research, she says, but the Industry Partnership Scheme also served as a platform for her to make connections with people interested in the topic. After delivering her presentation at the UK Imaging and Oncology Conference, Keeley explains she talked to radiographers who had read the research after it had been published in the SoR Radiography journal. “They came up to me and said ‘so glad you’ve written this’ or ‘I’ve been thinking about the impact it has and why we do it’ and ‘it was really brave of you to put your neck out’.

“There’s always going to be a challenge with changing people’s minds, but an alternative would be good for everybody.”

The opportunities that have come through these networks, she says, are giving her the chance to continue her research – Keeley wants to take what she’s done so far to a bigger survey of radiographers to get their thoughts and feelings on the treatment bell. “I’ve forged connections through the UKIO presentation with radiographers who work in Scotland,” she explains. “They’re really interested in the study.”

Together, they’re hoping to pull a research proposal together to do a wider questionnaire about Therapeutic Radiographers and the practice of ringing the bell. This will get them a larger sample size, and access to a wider community of radiographers.

Keeley’s journey 

Keeley’s journey into radiography started at school, where she’d always been good at maths and science, but wasn’t really sure what to do when she finished her A-levels. She ended up taking sports science and physiology for a year at the University of Leeds – before realising it wasn’t for her. “I didn’t like the biomechanics side, I just liked the physiology and the anatomy,” she says. “So I changed courses and studied medical science for three years. After that I worked for a year with West Yorkshire Police as an intelligence analyst, and I just found that I did not want to have a desk job. I wanted to use the knowledge I’d gained. I wanted to work with people.”

Keeley spotted an opportunity for a postgraduate diploma in radiotherapy and oncology at Sheffield Hallam University, a two-year course that allowed her to qualify as a Therapeutic Radiographer in 2008. From there Keeley worked at the Leeds Teaching Hospital NHS Foundation Trust in pre-treatment, as a basic-grade radiographer, and then on the treatment machines as a senior. 

While working at Leeds, Keeley began doing guest lecturing, which sparked her interest in research. While working clinically, Keeley completed her Master’s degree as well, topping up her postgraduate diploma in radiotherapy and oncology. 

When an opportunity for a lecturing post arose, Keeley seized it – initially just for the experience. But when she saw the chance to get involved in projects as a research assistant alongside researchers such as Professor Heidi Probst, Keeley jumped at the chance to develop those skills. “I do miss clinical. I miss the patients,” she admits. “But in my role, I still mentor and visit the students at the Royal Derby Hospital, so I still go into the department and hear the bell ringing. I’m also now leading the therapeutic radiography apprenticeship at Sheffield Hallam University. I’m working with lots of different employers and apprentices nationally.

“Academia has given me the opportunity to explore different avenues in radiotherapy that I wouldn’t have gotten to do in clinical. I definitely miss the patients, but that’s why it’s nice to undertake research with service user involvement. We all want to make things better for the patients.”

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