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Are reporting radiographers fulfilling the role of advanced practitioner?
Radiography xxx (2016) 1e7
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Are reporting radiographers fulfilling the role of advanced practitioner?* R.C. Milner a, *, B. Snaith a, b a b
Mid Yorkshire Hospitals NHS Trust, Aberford Road, Wakefield, West Yorkshire, WF1 4DG, UK Faculty of Health Studies e Horton A, University of Bradford, Richmond Road, Bradford, West Yorkshire, BD7 1DP, UK
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 June 2016 Received in revised form 5 September 2016 Accepted 10 September 2016 Available online xxx
Background: Advanced practice roles are emerging in all disciplines at a rapid pace and reporting radiographers are ideally placed to work at such level. Advanced practitioners should demonstrate expert practice and show progression into three other areas of higher level practice. Most existing literature has focussed on the image interpretation aspect of the role, however there is little evidence that plain film reporting radiographers are undertaking activities beyond image interpretation and fulfilling the role of advanced practitioner. Method: Letters were posted to every acute NHS trust in the UK, inviting reporting radiographers to complete an online survey. Both quantitative and qualitative information was sought regarding demographics and roles supplementary to reporting. Results: A total of 205 responses were analysed; 83.3% of reporting radiographers describe themselves as advanced practitioner, however significantly less are showing progression into the four core functions of higher level practice. A total of 97.0% undertake expert practice, 54.7% have a leadership role, 19.8% provide expert lectures and 71.1% have roles encompassing service development or research, though most of these fall into the service development category. 34.5% felt that they were aware of the differences between extended and advanced practice though much less (9.3%) could correctly articulate the difference. Conclusion: Few individuals are aware of the difference between extended and advanced practice. Though the majority of plain film reporting radiographers identify themselves as advanced practitioners, significantly less evidence all four core functions of higher level practice. The number of individuals undertaking research and providing expert-level education is low. © 2016 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Keywords: Advanced practice Extended practice Radiographer Reporting Radiology
Introduction There are ever increasing demands on imaging services as a result of workload growth, chronic shortages in capacity and challenges to decrease waiting times for both examinations and reports.1,2 For two decades the radiology and radiography professions in the United Kingdom (UK) have increasingly collaborated to deliver services, with radiographers extending their scope of practice to support increased capacity.3 This team approach was formalised with the launch of the Imaging Skills Mix Strategy,4 and the joint Colleges statement,3 which outlined the future skill mix of
* This article was derived from work submitted as part of an MSc award at the University of Bradford. * Corresponding author. E-mail address: [email protected] (R.C. Milner).
imaging service and service delivery model. The new career framework for radiographer workforce mirrored that of nursing and other allied health professions with assistant practitioner, practitioner, advanced practitioner and the (non-medical) consultant role.4 The four-tier radiography model was designed to improve services for patients whilst optimising the use of the whole workforce and offered staff recognition for their contribution to practice. The progressive career structure allowed individuals to progress into senior positions, without having to adopt a purely management role, thereby retaining clinical excellence and experience. The role of the advanced practitioner radiographer is to develop staff, demonstrate leadership, contribute to the evidence base and strive for service improvement.4 To develop as advanced practitioners, radiographers need to evolve from the performance of discrete, task-based activities, to actively inform the patient
http://dx.doi.org/10.1016/j.radi.2016.09.001 1078-8174/© 2016 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
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pathway.5 This can make a significant contribution to service delivery and quality, ensuring effective patient care is delivered. One of the first areas to identify the opportunities afforded by the skill mix strategy was the independent reporting of radiographs, a task previously undertaken only by radiologists. Reporting radiographers are ideally placed to work at an advanced level of practice, thus releasing radiologist capacity and supporting staff and practice. Yet, there is little evidence that individuals are undertaking activities beyond image interpretation particularly contributing to improved patient outcomes or services.6,7 Advanced practice includes four core functions of higher level (advanced) practice4; expert clinical practice, professional leadership and consultancy, education training and development, and practice and service development, research and audit. The Society and College of Radiographers8 (SCoR) expects that advanced practitioners should demonstrate expert practice and show progression into the other three. Norris and Melby9 identified a lack of motivation within the nursing profession to engage in the wider expectations of advanced practice beyond direct clinical care, although little has been published relating to radiography. In an attempt to encourage the range of competencies expected of advanced practice, the radiography professional body (the SCoR) launched a voluntary accreditation scheme in 2010. The scheme provides a peer-reviewed individual benchmark against the nationally agreed standards, however to date, there is limited knowledge of the engagement, or views, of practitioners on accreditation. This article forms part of a larger study undertaken in 2015 that investigated the scope of practice and wider roles of reporting radiographers. This article provides a comparison of roles with expectations of advanced practice; other results have been published elsewhere.10 Method In April 2015 a letter was sent to every acute NHS trust in the UK; the sampling frame (hospital addresses) was developed using UK government statistics and national hospital databases and consisted of 161 trusts. The letter invited radiographers holding a qualification in ‘plain film’ reporting to participate in an online survey (Bristol Online Survey, Bristol, UK). The letter explained the purpose of the study and provided a link to an online cross-sectional questionnaire. In an attempt to improve response rate, advertisements were placed in Synergy News, a national magazine distributed to UK radiographers, and on the SCoR website. Snowball sampling via a network of colleagues, ex-colleagues, acquaintances and social media was also utilised. Inclusion was limited to radiographers in the UK, with no stipulation on whether they were currently practising. A six-week response timeframe was specified. It is recognised that the above methodology has flaws, however, a purposive approach, with invitations to all NHS trusts, supported by snowball sampling, was deemed to be the best way to reach as many respondents as possible, as there is no definitive list of the total number of reporting radiographers in the UK, or where they work. The questionnaire was designed around the core functions of advanced practice; structured questions comprised the majority of the survey, though participants were encouraged to provide additional comments. When asked about the differences between extended and advanced practice, respondent's descriptions were compared with SCoR definitions of advanced practice.8 Prior to distribution, the questionnaire was piloted on trainee and qualified reporting radiographers at a local university, resulting in minor amendments. Full research ethics committee approval was not required according to NHS Health Research Authority online checklists11 and
local research and development review, which concluded that the survey constituted service evaluation. The online data were downloaded into Excel (Microsoft Corporation, USA) where it was numerically coded, collated and analysed. Statistical analysis was undertaken using the Social Science Statistics calculator (socscistatistics.com). Free text comments were analysed using a framework approach to identify underlying themes. Results 264 responses were received within the timescale, 5 were subsequently excluded as they did not meet the inclusion criteria, leaving 259 valid responses. For the purpose of this sub-analysis the responses from 54 individuals who identified themselves as managers, consultants or lecturers have been excluded as their posts have explicitly broader functions. The remaining 205 responses from those defined (based on self-descriptions) as a reporting radiographer are described. No question was mandatory and not all participants responded to every question, therefore ‘n’ values stated differ in result reporting. Data was received from all countries within the UK however 83.9% of responses were from England, with a lower proportion from Scotland (7.3%), Wales (7.3%) and Northern Ireland (1.5%). The mean age of respondents was 42.7 years, although there was a wide range (Fig. 1). A slightly lower mean of 41.2 years was noted for males, compared to 43.4 years for females, though this was not statistically significant (t ¼ 1.569; p ¼ 0.059). The individuals had a wide range of experience (Fig. 2), with the earliest completing their initial reporting qualification in 1995. Only a small number had qualified in 2015, although this data will be incomplete due to the timing of data collection. The average age that radiographers obtained their initial reporting qualification was 34.5 years. In relation to their highest qualification, at the time of the study, the majority of respondents held a postgraduate certificate (PgC), with only 15.4% (n ¼ 31/201) having achieved a Masters degree (Table 1). There was no statistical difference between males and females when considering academic achievement (X2 ¼ 0.714; p ¼ 0.398). The majority of respondents were substantively employed at Agenda for Change (AfC) pay band 7 (88.6%; n ¼ 179/ 202), with others on band 6 and band 8a. A total of 2.0% (n ¼ 4/202) were employed on a split banding contract; band 5 or 6 with additional band 7 pay when reporting. A potential trend was identified when comparing highest qualification and pay scale; unfortunately a X2 test of independence was not possible due to the small numbers involved. There were 40 different job titles provided, subsequently grouped into 13 categories (Table 2). The three most common were; advanced practitioner radiographer (43.1% n ¼ 88/204), reporting radiographer (24.5% n ¼ 50/204) and senior radiographer (10.3% n ¼ 21/204). Two (1.0%) respondents stated that they were not sure of their official job title. Of the respondents paid at AfC band 6, 64.3% (n ¼ 9/14) had the title ‘senior radiographer’ or ‘reporting radiographer’, 14.3% (n ¼ 2/14) had the title ‘advanced practitioner’ with the remaining 21.4% (n ¼ 3/14) being designated ‘band 6’, ‘extended role’ or ‘specialist radiographer’. Of the respondents paid at band 8a, 66.7% (n ¼ 4/6) were lead radiographers; either ‘modality lead’ or ‘lead reporting radiographer’. No correlation between job title or pay scale was identified, when compared with geographical region. Almost all (96.0%; n ¼ 197/203) respondents were actively reporting, of these 94.9% (n ¼ 187/197) indicate they also provide telephone or face-to-face advice to clinicians and other service users. One third of respondents regularly attend multi-disciplinary
Please cite this article in press as: Milner RC, Snaith B, Are reporting radiographers fulfilling the role of advanced practitioner?, Radiography (2016), http://dx.doi.org/10.1016/j.radi.2016.09.001
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Number of respondents
14 12 10 8 6 4 2 0 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 64 Age Figure 1. Age spread of respondents.
Number of respondents
30 25 20 15 10 5 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
0
Year obtained first reporƟng qualificaƟon Figure 2. Year that respondents obtained their first reporting qualification. Table 2 Job titles grouped by category.
Table 1 Banding (pay scale) and highest qualification achieved. Highest qualification
AfC pay band
Total No. (%)
Band 6 No. (%)
Band 7 No. (%)
Band 8a No. (%)
Othera No. (%)
Postgraduate certificate Postgraduate diploma Masters degree
11 (78.6) 2 (14.3) 1 (7.1)
86 (48.9) 64 (36.4) 26 (14.8)
1 (16.7) 1 (16.7) 4 (66.7)
4 (80.0) 1 (20.0) e
102 (50.7) 68 (33.8) 31 (15.4)
Total
14
176
6
5
201
a
Other e includes split banding (5 & 7 or 6 & 7) and agency radiographers.
team (MDT) meetings (33.3% n ¼ 68/204), with the majority attending at least once a month (76.5% n ¼ 39/51), and 49.0% (n ¼ 25/51) attending at least once a week. The most common cited were; trauma (61.8% n ¼ 42/68), rheumatology (23.5% n ¼ 16/68) and radiology (11.8% n ¼ 8/68) with a smaller number attending chest, paediatric or musculoskeletal meetings. Just over half (56.0% n ¼ 112/200) of respondents described formal leadership responsibilities, with many (48.2% n ¼ 54/112) involving day-to-day management activities such as rotas, staffing
Job title
No. (%)
Advanced practitioner radiographer Band 6 radiographer Band 7 Radiographer Deputy superintendent radiographera Extended role radiographer Lead radiographer PACS administratora Practice development radiographer Reporting radiographer Senior radiographer Specialist radiographer Superintendent radiographera Trauma radiographer practitioner Not sure
88 (43.1) 2 (1.0) 4 (2.0) 2 (1.0) 2 (1.0) 14 (6.9) 1 (0.5) 1 (0.5) 50 (24.5) 21 (10.3) 12 (5.9) 4 (2.0) 1 (0.5) 2 (1.0)
Total
204
a
Identified by the authors as primarily reporting radiographers according to information provided.
or deputising for managers during their absence. Other responsibilities included staff appraisals, student liaison, health and safety, information technology, quality assurance, radiation protection and protocol development.
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A number of respondents did not believe that leadership should form part of their role and provided reasons for a lack of leadership involvement. “I'm not sure leadership is integral to advanced practitioners” [Respondent ID: 074] “Not necessary to be in a leadership role… for advanced practice” [Respondent ID: 148] “Not all advanced practitioners wish to be involved in 'management' (aka leadership)” [Respondent ID: 095] Participation in staff education is expected for the majority of respondents (73.9%;150/203), with 66.3% (n ¼ 136/205) delivering tutorials within radiology and 45.6% (n ¼ 93/204) in the wider hospital environment. Less than one fifth (19.4% n ¼ 39/201) undertake lectures at university, although the numbers are relatively small this appears to vary with academic qualification; 11.1% (11/ 99) of PgC respondents are involved in academic delivery, whilst this rises to 20.9% (14/67) of those with a postgraduate diploma (PgD) and 45.2% (14/31) of those who hold a Masters degree. In relation to broader staff development 51.2% (n ¼ 105/205) were involved in mentorship, either as a mentor or mentee (Table 3). A large proportion of respondents have been involved in the evaluation of services in the last two years (71.5%; 138/193). When reporting competency audit was excluded 58.0% (119/205) have participated in audit, whereas research activity is much lower (19.7%; 38/193). Many deemed that research was not a requirement of their role, whilst others believed it to be necessary, although time constraints and other responsibilities were a hindrance. “Research is a step further in my opinion and is more an academic pursuit. It requires a certain expertise that a practical radiographer may not relate to or enjoy particularly”
small number (25.0%; n ¼ 4/16) presenting at one or more national or international conferences. Only 12.2% (n ¼ 25/205) of respondents had published in the two-year timeframe, with the majority authoring a single article (76.0%; n ¼ 19/25). Peer review publications were the most common (64.0%; n ¼ 16/25), followed by a non-peer review, such as in a professional magazine (52.0%; n ¼ 13/25); one respondent had contributed to a textbook chapter (4.0%; n ¼ 1/25). Although 34.5% (n ¼ 70/203) indicated awareness of the difference between extended and advanced practice, few were able to correctly articulate this (9.3%; n ¼ 19/205). Commonly, respondents perceived the difference to relate to levels of education and qualification. “Advanced practice requires further study and qualifications. Extended practice requires on the job training but no study” [Respondent ID: 165] “Extended practice has no formal qualification. Advanced practice requires post graduate training” [Respondent ID: 050] “Extended practice takes on less formal roles whereas advanced practice requires formal higher education qualifications” [Respondent ID: 243] “Extended is 'in-house' training on procedures with a local agreement… Advanced is formal training in a specific field with qualification” [Respondent ID: 237] “Extended practice refers to in house courses for things such as cannulation. Advanced practice refers to roles which require additional training and qualifications in a formal learning environment such as university” [Respondent ID: 215]
[Respondent ID: 071] “Research, although useful, is not necessarily advantageous in an acute clinical setting” [Respondent ID: 130] “Time for research is non-existent when attempting to maintain a clinical service. I am still an advanced practitioner even though I am not involved in research” [Respondent ID: 076] Within the two years preceding the survey, 8.8% (n ¼ 18/205) of respondents had presented at a conference. Although there was limited information about the specific presentations, the majority (75.0%; n ¼ 12/16) were at UK special interest groups, with only a
Table 3 Mentorship roles undertaken by respondents. Mentorship role
No. (%)
Mentee Mentor Mentee and mentor Involved in mentorship but none of the above Not involved in mentorship
9 (4.4) 87 (42.4) 9 (4.4) 15 (7.3) 85 (41.5)
Total
205
When asked to identify their self-perceived role level (extended, advanced, or consultant practitioner), 83.3% (n ¼ 170/204) described themselves as advanced practitioners (Table 4). Of those describing themselves as extended role practitioners, 92.3% (24/26) are employed at AfC band 7 or above. Just over half (54.4%; n ¼ 111/ 204) felt that the four core functions are necessary for advanced practice, whereas 89.2% (n ¼ 181/203) believe them necessary for consultant practice. Although 56.0% (n ¼ 108/193) stated they are undertaking all four core functions (Table 4), the number undertaking individual elements varied and was as low as 19.8%. Interestingly, just 40.0% (n ¼ 2/5) of those describing themselves as consultant practitioners, were undertaking all four core functions. No geographical variation in engagement with the four core functions was identified. A small number (n ¼ 3) of respondents selected ‘other’ when asked about their self-perceived role title describing themselves as ‘radiographer’ or ‘reporting radiographer.’ Although 55.4% (113/204) of respondents have heard of the SCoR accreditation scheme, only 2.9% (6/205) had been accredited, a further 43.9% (90/205) plan to become accredited in the future. When age was compared to willingness to become accredited, a statistically significant negative response came from older respondents (mean 45.1 vs 39.8 years; X2 ¼ 3.738; p < 0.05). A number of reasons were offered to explain their intention not to apply for accreditation. Two specific themes emerged from analysis of the free text comments; a lack of perceived benefit to the individual, and a lack of time to complete the tasks associated with accreditation.
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Table 4 Self-perceived role and evidence of role function. Self -perceived role
No. (%) who identify as this role
Practice domain undertaken Expert practice no. (%)
Leadership no. (%)
Education no. (%)
Research & service development no. (%)
Extended role practitioner Advanced practitioner Consultant practitioner
26 (12.7) 170 (83.3) 5 (2.5)
25/25 (100) 163/169 (96.4) 5/5 (100)
12/26 (46.2) 96/170 (56.5) 2/5 (40.0)
3/24 (12.6) 33/168 (19.6) 3/5 (60.0)
13/21 (61.9) 118/164 (72.0) 4/5 (80.0)
Total
201
193/199 (97.0)
110/201 (54.7)
39/197 (19.8)
135/190 (71.1)
“The time needed to complete this is eluding me at the moment as I have too many other responsibilities“ [Respondent ID: 239] “It doesn't affect my pay or role in practice. Purely an admin exercise” [Respondent ID: 140] “More work for little or no benefit?” [Respondent ID: 133]
Discussion Based on a recent estimate of the population,12 the response rate of 259 likely represents approximately one-third of reporting radiographers in the UK. As responses were at an individual level it is not possible to state how many separate NHS Trusts are represented. The respondents provided details of their geographic region rather than employer. The results of this survey suggest a year on year increase in radiographers independently reporting radiographs with evidence of greater utilisation.10,12 It therefore appears that opportunities associated with such roles are being recognised by imaging services. An abundance of articles have explored the role of the reporting radiographer,12,13 however, these have focussed on ability rather than the influence of their role in practice. In particular there is a dearth of knowledge related to the delivery of the core functions of higher level practice. The results parallel the nursing14 and physiotherapy15 professions, with a lack of standardisation of educational expectations, instead placing a significant emphasis on clinical experience. Australia and the United States define a Masters degree as the academic baseline for advanced practice.16,17 The SCoR have reinforced the expectation that the UK should also expect all advanced practitioners to have completed a full Masters qualification. This aspiration was included in their strategy to increase research capability and capacity which also suggests that those aiming for consultant roles should be engaging in doctoral education.18 Harris and Paterson19 found that a number of those in consultant roles had yet to achieve a Masters degree and disappointingly, this study demonstrates that the majority of radiographers employed to report radiographs hold only a PgC, the minimum academic achievement for their role. As only 15.4% have achieved the SCoR expectation of a Masters degree, their advanced practice status may be challenged if national standards are enforced. Snaith et al.12 suggested that variation in awards offered by universities may explain the difference between academic achievement, with qualifications varying dependent on anatomical structures studied and university attended. Although it is not known how many are currently pursuing further study, these findings correlate with previous literature5 which suggest that many radiographers undertake postgraduate modules, but few
complete the full award. It is important that radiographers recognise the educational expectations of higher level practice to enable personal and professional development. Although the majority of radiographers are paid at AfC band 7; as expected when compared with national job profiles.20 Smaller numbers were employed at higher and lower grades, showing similarities to the nursing profession.14,21 There are several factors which could contribute to this trend, one of which is radiographers who possess only a PgC reporting qualification may be practising as extended scope practitioners (at AfC band 6), rather than advanced practitioners. Further research is required to identify whether radiographer career progression, as evidenced by pay level, is associated with academic achievement. A small number of respondents indicated they are paid on a split banding scheme, at a higher rate when reporting and a lower rate when not; a strategy supposedly curtailed with the national pay system.22 The number and range of different job titles was unforeseen. One of the key concepts supporting accreditation is to maintain consistency in the use of ‘advanced practitioner’ title.23 It is clear from both nursing and radiography literature that there are numerous perceptions of advanced practice and that many confuse this with extended scope, thereby exacerbating the confusion between the two titles.14,15,23e25 The longstanding confusion surrounding terminology such as role extension, role expansion, role development, advanced practice and expert practice has been acknowledged by the Department of Health.26 The lack of consistency makes it difficult to compare potential advanced roles and remains problematic and confusing,24,26 both for patients and health professionals; as evidenced by the lack of awareness of the survey respondents. Advanced roles are developing rapidly in all disciplines, bridging gaps in the existing medical workforce and providing holistic care to patients27; it is therefore imperative that the correct use of such terms is widely promoted, understood and accepted. The external profile of radiographers can assist in improving the recognition of the advanced practice role, however the number of individuals regularly attending MDT meetings is disappointing. Literature has highlighted the importance of this practice, and has illustrated the benefits to reporting practice and radiographer development.3,28 Reporting radiographers should have the opportunity to liaise with others, both radiographers and radiologists, discussing interesting or complex cases.29 Such attendance is extremely valuable and encouraged by professional bodies to provide important learning opportunities and promote interprofessional collaboration.3 Just over half of reporting radiographers considered leadership to be part of their role, contradicting previous literature which confirms leadership as a key quality for advanced practitioners.30,31 Its importance has been highlighted in imaging service delivery, suggesting that it is essential to continually improve the service.3 One respondent clearly confused leadership with management, a common error.31 A problem with specifying leadership as a core function is the difficulty in defining or measuring it. Until now, little
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has been published concerning what leadership roles are undertaken by reporting radiographers. Encouragingly, over three quarters of respondents have taken part in service evaluation in the last two years, providing some assurance that these roles are involved in measuring and improving practice. Nonetheless, it remains evident that advanced practitioners are responsible for promoting best practice and should ultimately become responsible leaders; these individuals are fundamental in leading the radiography profession and their own speciality, gaining both local and international recognition for the opportunities associated with the role.32,33 Over half of respondents from the current study have taken part in audit in the past two years. The Health and Care Professions Council, standards of proficiency, state that radiographers at all levels should be able to assure the quality of their practice, participate in audit, and be able to engage in research appropriate to their role.34 It is suggested that few reporting radiographers are research active given the low level of dissemination through conferences (8.8%) and publication (12.2%) in the preceding two years. This is perhaps unsurprising when only one-third of consultant radiographers have undertaken such activities.19 It is of some comfort that almost a quarter of those who have been published in the last two years have multiple publications, however this raises further concerns that the evidence base may be populated by the same authors. The education of self and others is an expectation of advanced practice.8 Although almost three-quarters of respondents are contributing to the education of others it is likely that most do not meet the ‘expert level’ criteria. It is encouraging that so many provide tutorials within radiology; passing on knowledge and skills is vital to encourage and develop junior staff and students. Mentorship is an effective method of developing an individual's potential; and it is suggested that every radiographer should be part of such programme.35 There is no previous research exploring the mentorship roles of reporting radiographers, but this study provides a benchmark with almost half of responding reporting radiographers supporting the development of others. It is disappointing that less than 10% have a personal mentor, this lack of support for personal development may continue to hamper progression towards non-medical consultant roles. Just over half identified their role to include all the core functions of higher level practice, despite most describing themselves as an advanced practitioner. Interestingly, 12.7% describe themselves as extended role practitioners with most paid at AfC band 7 or above, suggesting employers may not expect, or want, all core functions undertaken. This theme is evident amongst other health professions9,14 and questions whether the pay level can be justified if the role is not undertaking broader advanced practitioner activities. Whereas most respondents believe all four core functions to be necessary for consultant practitioners, fewer consider these necessary for advanced practice. A small number of respondents perceive themselves to be working as consultant practitioners, but did not appear to be consistently undertaking all four core functions. Expert practice, as expected, is the most widely undertaken, whilst practice and service development, research and evaluation is the least, in common with consultant practice.19 These findings suggest a disparity between individuals' perceptions of what an advanced or consultant practitioner role should encompass, and the guidance. This may be exacerbated by the SCoR expectation that individuals working at an advanced level would progress in the non-clinical areas, although accreditation expects evidence of all. Only a small number of respondents have been accredited as advanced practitioners with the professional body, despite over half being aware of the SCoR scheme. The theme of ‘more work for little benefit’ was common, suggesting that reporting radiographers
felt there was little incentive to undertake accreditation, particularly at the later stages of their careers. This appears to be less of a challenge for younger respondents who seem more likely to embrace accreditation. The SCoR will need to emphasise the benefits of accreditation, to ensure that this is not a hollow achievement. In the absence of a differential registration with the regulatory body, this is the only peer-reviewed evidence of role activities. Limitations The results may be more generalisable to English practice, where 83.9% of responses were generated. The fact there were fewer responses from Scotland, Wales and Northern Ireland is acknowledged, however it has previously been suggested that these countries have slower uptake of reporting radiographer and advanced practice initiatives, than England.10,12,25 The study was open to self-selection and social desirability bias; however the anonymity of the online questionnaire should negate this to some extent. This remains one of the largest in-depth studies of UK reporting radiographers, at individual level, to date. The assessment of whether individuals were undertaking the core functions of higher level practice was based on responses to questions on education provision, dissemination, service evaluation and leadership. The figure must be interpreted with caution as respondents were not asked to provide evidence of how core functions were undertaken. Conclusion A chronic shortage in imaging capacity, coupled with increased demands for radiology services and a drive to reduce report turnaround times suggests that skill mix is more relevant than ever. The current study concludes that 83% of reporting radiographers describe themselves as advanced practitioners, but few have evidence of all four core functions of higher level practice. Employers may focus on clinical competence to provide the reporting capacity required, however it would be foolish for radiographers to disregard the breadth of practice expected at this level. It is imperative that these individuals strive to develop into advanced, and further consultant, practitioner roles. Funding None. Conflict of interest statement None. References 1. NHS England. Diagnostic imaging dataset: annual statistical release 2014-15. Leeds: NHS England. Available from: https://www.england.nhs.uk/statistics/ wp-content/uploads/sites/2/2014/11/Annual-Statistical-Release-2014-15-DIDPDF-1.1MB.pdf. [Accessed 19 June 2016]. 2. Royal College of Radiologists. Unreported X-rays, computed tomography (CT) and magnetic resonance imaging (MRI) examinations: results of the September 2015 snapshot survey of English NHS acute trusts. 2015. Available from: https://www. rcr.ac.uk/sites/default/files/rcr_reporting_survey_sept15.pdf [Accessed 18 February 2016]. 3. Royal College of Radiologists and the Society and College of Radiographers. Team working in clinical imaging. London: The Royal College of Radiologists; 2012. 4. Department of Health. Radiography skills mix e a report on the four-tier service delivery model. London: Department of Health; 2003. 5. Hardy M, Snaith B. How to achieve advanced practitioner status: a discussion paper. Radiography 2007;13:142e6.
Please cite this article in press as: Milner RC, Snaith B, Are reporting radiographers fulfilling the role of advanced practitioner?, Radiography (2016), http://dx.doi.org/10.1016/j.radi.2016.09.001
R.C. Milner, B. Snaith / Radiography xxx (2016) 1e7 6. Society and College of Radiographers. Role development revisited, the research evidence. London: College of Radiographers; 2003. 7. Hardy M, Johnson L, Sharples R, Boynes S, Irving D. Does radiographer advanced practice improve patient outcomes and health service quality? A systematic review. British J Radiol. http://dx.doi.org/10.1259/bjr.20151066. 8. Society and College of Radiographers. Advanced practitioner accreditation. London: Deeson; 2015. Available from: http://www.sor.org/careerprogression/advanced-practitioners/advanced-practitioner-accreditation [Accessed 25 September 2015]. 9. Norris T, Melby V. The acute care nurse practitioner: challenging existing boundaries of emergency nurses in the United Kingdom. J Clin Nurs 2006;15: 253e63. 10. Milner RC, Culpan G, Snaith B. [Under Review] Radiographer reporting in the UK: is the current scope of practice limiting reporting capacity? Br J Radiol 2016. http://dx.doi.org/10.1259/bjr.20160228. 11. Health Research Authority. HRA decision tool. Available at: http://www.hradecisiontools.org.uk/ethics/. [Accessed 3 May 2016]. 12. Snaith BA, Lewis EF, Hardy M. Radiographer reporting in the UK: a longitudinal analysis. Radiography 2015;21(2):119e23. 13. Brealey S, Scally A, Hahn S, Thomas N, Godfrey C, Coomarasamy A. Accuracy of radiographer plain radiograph reporting in clinical practice: a meta-analysis. Clin Radiol 2005;60:232e41. 14. McConnell D, Slevin OD, McIlfatrick SJ. Emergency nurse practitioners' perceptions of their role and scope of practice: is it advanced practice? Int Emerg Nurs 2013;21:76e83. 15. Grimmer K, Morris J, Kim S, Milanese S, Fletcher W. Physiotherapy practice: opportunities for international collaboration on workforce reforms, policy and research. Physiother Res Int 2016. http://dx.doi.org/10.1002/pri.1661. 16. Hoskins R. Evaluating new role within emergency care: a literature review. Int Emerg Nurs 2011;19:125e40. 17. Smith T, Harris J, Woznitza N, Maresse S, Sale C. Conceptualisation of the characteristics of advanced practitioners in the medical radiation professions. J Med Radiat Sci 2015;62:204e11. 18. Society and College of Radiographers. 2016-2021 society and college of radiographers research strategy. London: College of Radiographers; 2015. 19. Harris R, Paterson A. Exploring the research domain of consultant practice: perceptions and opinions of consultant radiographers. Radiography 2016;22: 12e20.
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20. NHS Employers. National profiles for diagnostic & therapeutic radiography. London: NHS Employers; 2005. 21. Fotheringham D, Dickie S, Cooper M. The evolution of the role of the Emergency Nurse Practitioner in Scotland: a longitudinal study. J Clin Nurs 2011;20:2958e67. 22. University of Hertfordshire. Effect of agenda for change on career progression of the radiographic workforce 2009. Available from: https://www.sor.org/system/ files/document-library/public/sor_2009.06.24_Effect_of_AfC_report_no_exec_ summ_Herts_v1.0%282%29.pdf. [Accessed 24 June 2016]. 23. Hardy M, Legg J, Smith T, Ween B, Williams I, Motto J. The concept of advanced radiographic practice: an international perspective. Radiography 2008;14:e15e9. 24. Eddy A. Advanced practice for therapy radiographers e a discussion paper. Radiography 2008;14:24e31. 25. Henderson I, Mathers SA, McConnell J, Minnoch D. Advanced and extended scope practice of radiographers: the Scottish perspective. Radiography 2016;22:185e93. 26. Department of Health. Extending the practice of allied health professionals in the NHS. London: Department of Health; 2006. 27. Imison C, Castle-Clarke S, Watson R. Reshaping the workforce to deliver the care patients need. Br J Radiol 2016 Sep;89(1065). 20160228. http://dx.doi.org/ 10.1259/bjr.20160228. [Epub 2016 Jul 4]. 28. Hardy M, Snaith B. How to achieve consultant practitioner status: a discussion paper. Radiography 2007;13:265e70. 29. Paterson AM, Price RC, Thomas A, Nuttall L. Reporting by radiographers: a policy and practice guide. Radiography 2004;10:205e12. 30. Yielder J. Leadership and power in medical imaging. Radiography 2006;12: 305e13. 31. Tootell A, Hogg P. Advance practice e concepts, definitions and education. Eur Assoc Nucl Med Annu Conf Eur J Nucl Med Mol Imaging 2010;37:S23. Available from: http://www.eanm.org/education_esnm/cme_cte/cte_2010/pdf/cte2a_ tootell.pdf [Accessed 25 September 2015]. 32. Kelly J, Hogg P, Henwood S. The role of a consultant breast radiographer: a description and a reflection. Radiography 2008;14:e2e10. 33. White P, McKay JC. The specialist radiographer e does the role justify the title? Radiography 2004;10:217e27. 34. Health and Care Professions Council. Standards of proficiency: radiographers. 2013. London. 35. Society and College of Radiographers. Clinical supervision framework. London: College of Radiographers; 2003.
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Contents lists available at ScienceDirect
Radiography journal homepage: www.elsevier.com/locate/radi
Are reporting radiographers fulfilling the role of advanced practitioner?* R.C. Milner a, *, B. Snaith a, b a b
Mid Yorkshire Hospitals NHS Trust, Aberford Road, Wakefield, West Yorkshire, WF1 4DG, UK Faculty of Health Studies e Horton A, University of Bradford, Richmond Road, Bradford, West Yorkshire, BD7 1DP, UK
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 June 2016 Received in revised form 5 September 2016 Accepted 10 September 2016 Available online xxx
Background: Advanced practice roles are emerging in all disciplines at a rapid pace and reporting radiographers are ideally placed to work at such level. Advanced practitioners should demonstrate expert practice and show progression into three other areas of higher level practice. Most existing literature has focussed on the image interpretation aspect of the role, however there is little evidence that plain film reporting radiographers are undertaking activities beyond image interpretation and fulfilling the role of advanced practitioner. Method: Letters were posted to every acute NHS trust in the UK, inviting reporting radiographers to complete an online survey. Both quantitative and qualitative information was sought regarding demographics and roles supplementary to reporting. Results: A total of 205 responses were analysed; 83.3% of reporting radiographers describe themselves as advanced practitioner, however significantly less are showing progression into the four core functions of higher level practice. A total of 97.0% undertake expert practice, 54.7% have a leadership role, 19.8% provide expert lectures and 71.1% have roles encompassing service development or research, though most of these fall into the service development category. 34.5% felt that they were aware of the differences between extended and advanced practice though much less (9.3%) could correctly articulate the difference. Conclusion: Few individuals are aware of the difference between extended and advanced practice. Though the majority of plain film reporting radiographers identify themselves as advanced practitioners, significantly less evidence all four core functions of higher level practice. The number of individuals undertaking research and providing expert-level education is low. © 2016 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Keywords: Advanced practice Extended practice Radiographer Reporting Radiology
Introduction There are ever increasing demands on imaging services as a result of workload growth, chronic shortages in capacity and challenges to decrease waiting times for both examinations and reports.1,2 For two decades the radiology and radiography professions in the United Kingdom (UK) have increasingly collaborated to deliver services, with radiographers extending their scope of practice to support increased capacity.3 This team approach was formalised with the launch of the Imaging Skills Mix Strategy,4 and the joint Colleges statement,3 which outlined the future skill mix of
* This article was derived from work submitted as part of an MSc award at the University of Bradford. * Corresponding author. E-mail address: [email protected] (R.C. Milner).
imaging service and service delivery model. The new career framework for radiographer workforce mirrored that of nursing and other allied health professions with assistant practitioner, practitioner, advanced practitioner and the (non-medical) consultant role.4 The four-tier radiography model was designed to improve services for patients whilst optimising the use of the whole workforce and offered staff recognition for their contribution to practice. The progressive career structure allowed individuals to progress into senior positions, without having to adopt a purely management role, thereby retaining clinical excellence and experience. The role of the advanced practitioner radiographer is to develop staff, demonstrate leadership, contribute to the evidence base and strive for service improvement.4 To develop as advanced practitioners, radiographers need to evolve from the performance of discrete, task-based activities, to actively inform the patient
http://dx.doi.org/10.1016/j.radi.2016.09.001 1078-8174/© 2016 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
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pathway.5 This can make a significant contribution to service delivery and quality, ensuring effective patient care is delivered. One of the first areas to identify the opportunities afforded by the skill mix strategy was the independent reporting of radiographs, a task previously undertaken only by radiologists. Reporting radiographers are ideally placed to work at an advanced level of practice, thus releasing radiologist capacity and supporting staff and practice. Yet, there is little evidence that individuals are undertaking activities beyond image interpretation particularly contributing to improved patient outcomes or services.6,7 Advanced practice includes four core functions of higher level (advanced) practice4; expert clinical practice, professional leadership and consultancy, education training and development, and practice and service development, research and audit. The Society and College of Radiographers8 (SCoR) expects that advanced practitioners should demonstrate expert practice and show progression into the other three. Norris and Melby9 identified a lack of motivation within the nursing profession to engage in the wider expectations of advanced practice beyond direct clinical care, although little has been published relating to radiography. In an attempt to encourage the range of competencies expected of advanced practice, the radiography professional body (the SCoR) launched a voluntary accreditation scheme in 2010. The scheme provides a peer-reviewed individual benchmark against the nationally agreed standards, however to date, there is limited knowledge of the engagement, or views, of practitioners on accreditation. This article forms part of a larger study undertaken in 2015 that investigated the scope of practice and wider roles of reporting radiographers. This article provides a comparison of roles with expectations of advanced practice; other results have been published elsewhere.10 Method In April 2015 a letter was sent to every acute NHS trust in the UK; the sampling frame (hospital addresses) was developed using UK government statistics and national hospital databases and consisted of 161 trusts. The letter invited radiographers holding a qualification in ‘plain film’ reporting to participate in an online survey (Bristol Online Survey, Bristol, UK). The letter explained the purpose of the study and provided a link to an online cross-sectional questionnaire. In an attempt to improve response rate, advertisements were placed in Synergy News, a national magazine distributed to UK radiographers, and on the SCoR website. Snowball sampling via a network of colleagues, ex-colleagues, acquaintances and social media was also utilised. Inclusion was limited to radiographers in the UK, with no stipulation on whether they were currently practising. A six-week response timeframe was specified. It is recognised that the above methodology has flaws, however, a purposive approach, with invitations to all NHS trusts, supported by snowball sampling, was deemed to be the best way to reach as many respondents as possible, as there is no definitive list of the total number of reporting radiographers in the UK, or where they work. The questionnaire was designed around the core functions of advanced practice; structured questions comprised the majority of the survey, though participants were encouraged to provide additional comments. When asked about the differences between extended and advanced practice, respondent's descriptions were compared with SCoR definitions of advanced practice.8 Prior to distribution, the questionnaire was piloted on trainee and qualified reporting radiographers at a local university, resulting in minor amendments. Full research ethics committee approval was not required according to NHS Health Research Authority online checklists11 and
local research and development review, which concluded that the survey constituted service evaluation. The online data were downloaded into Excel (Microsoft Corporation, USA) where it was numerically coded, collated and analysed. Statistical analysis was undertaken using the Social Science Statistics calculator (socscistatistics.com). Free text comments were analysed using a framework approach to identify underlying themes. Results 264 responses were received within the timescale, 5 were subsequently excluded as they did not meet the inclusion criteria, leaving 259 valid responses. For the purpose of this sub-analysis the responses from 54 individuals who identified themselves as managers, consultants or lecturers have been excluded as their posts have explicitly broader functions. The remaining 205 responses from those defined (based on self-descriptions) as a reporting radiographer are described. No question was mandatory and not all participants responded to every question, therefore ‘n’ values stated differ in result reporting. Data was received from all countries within the UK however 83.9% of responses were from England, with a lower proportion from Scotland (7.3%), Wales (7.3%) and Northern Ireland (1.5%). The mean age of respondents was 42.7 years, although there was a wide range (Fig. 1). A slightly lower mean of 41.2 years was noted for males, compared to 43.4 years for females, though this was not statistically significant (t ¼ 1.569; p ¼ 0.059). The individuals had a wide range of experience (Fig. 2), with the earliest completing their initial reporting qualification in 1995. Only a small number had qualified in 2015, although this data will be incomplete due to the timing of data collection. The average age that radiographers obtained their initial reporting qualification was 34.5 years. In relation to their highest qualification, at the time of the study, the majority of respondents held a postgraduate certificate (PgC), with only 15.4% (n ¼ 31/201) having achieved a Masters degree (Table 1). There was no statistical difference between males and females when considering academic achievement (X2 ¼ 0.714; p ¼ 0.398). The majority of respondents were substantively employed at Agenda for Change (AfC) pay band 7 (88.6%; n ¼ 179/ 202), with others on band 6 and band 8a. A total of 2.0% (n ¼ 4/202) were employed on a split banding contract; band 5 or 6 with additional band 7 pay when reporting. A potential trend was identified when comparing highest qualification and pay scale; unfortunately a X2 test of independence was not possible due to the small numbers involved. There were 40 different job titles provided, subsequently grouped into 13 categories (Table 2). The three most common were; advanced practitioner radiographer (43.1% n ¼ 88/204), reporting radiographer (24.5% n ¼ 50/204) and senior radiographer (10.3% n ¼ 21/204). Two (1.0%) respondents stated that they were not sure of their official job title. Of the respondents paid at AfC band 6, 64.3% (n ¼ 9/14) had the title ‘senior radiographer’ or ‘reporting radiographer’, 14.3% (n ¼ 2/14) had the title ‘advanced practitioner’ with the remaining 21.4% (n ¼ 3/14) being designated ‘band 6’, ‘extended role’ or ‘specialist radiographer’. Of the respondents paid at band 8a, 66.7% (n ¼ 4/6) were lead radiographers; either ‘modality lead’ or ‘lead reporting radiographer’. No correlation between job title or pay scale was identified, when compared with geographical region. Almost all (96.0%; n ¼ 197/203) respondents were actively reporting, of these 94.9% (n ¼ 187/197) indicate they also provide telephone or face-to-face advice to clinicians and other service users. One third of respondents regularly attend multi-disciplinary
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3
Number of respondents
14 12 10 8 6 4 2 0 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 64 Age Figure 1. Age spread of respondents.
Number of respondents
30 25 20 15 10 5 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
0
Year obtained first reporƟng qualificaƟon Figure 2. Year that respondents obtained their first reporting qualification. Table 2 Job titles grouped by category.
Table 1 Banding (pay scale) and highest qualification achieved. Highest qualification
AfC pay band
Total No. (%)
Band 6 No. (%)
Band 7 No. (%)
Band 8a No. (%)
Othera No. (%)
Postgraduate certificate Postgraduate diploma Masters degree
11 (78.6) 2 (14.3) 1 (7.1)
86 (48.9) 64 (36.4) 26 (14.8)
1 (16.7) 1 (16.7) 4 (66.7)
4 (80.0) 1 (20.0) e
102 (50.7) 68 (33.8) 31 (15.4)
Total
14
176
6
5
201
a
Other e includes split banding (5 & 7 or 6 & 7) and agency radiographers.
team (MDT) meetings (33.3% n ¼ 68/204), with the majority attending at least once a month (76.5% n ¼ 39/51), and 49.0% (n ¼ 25/51) attending at least once a week. The most common cited were; trauma (61.8% n ¼ 42/68), rheumatology (23.5% n ¼ 16/68) and radiology (11.8% n ¼ 8/68) with a smaller number attending chest, paediatric or musculoskeletal meetings. Just over half (56.0% n ¼ 112/200) of respondents described formal leadership responsibilities, with many (48.2% n ¼ 54/112) involving day-to-day management activities such as rotas, staffing
Job title
No. (%)
Advanced practitioner radiographer Band 6 radiographer Band 7 Radiographer Deputy superintendent radiographera Extended role radiographer Lead radiographer PACS administratora Practice development radiographer Reporting radiographer Senior radiographer Specialist radiographer Superintendent radiographera Trauma radiographer practitioner Not sure
88 (43.1) 2 (1.0) 4 (2.0) 2 (1.0) 2 (1.0) 14 (6.9) 1 (0.5) 1 (0.5) 50 (24.5) 21 (10.3) 12 (5.9) 4 (2.0) 1 (0.5) 2 (1.0)
Total
204
a
Identified by the authors as primarily reporting radiographers according to information provided.
or deputising for managers during their absence. Other responsibilities included staff appraisals, student liaison, health and safety, information technology, quality assurance, radiation protection and protocol development.
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A number of respondents did not believe that leadership should form part of their role and provided reasons for a lack of leadership involvement. “I'm not sure leadership is integral to advanced practitioners” [Respondent ID: 074] “Not necessary to be in a leadership role… for advanced practice” [Respondent ID: 148] “Not all advanced practitioners wish to be involved in 'management' (aka leadership)” [Respondent ID: 095] Participation in staff education is expected for the majority of respondents (73.9%;150/203), with 66.3% (n ¼ 136/205) delivering tutorials within radiology and 45.6% (n ¼ 93/204) in the wider hospital environment. Less than one fifth (19.4% n ¼ 39/201) undertake lectures at university, although the numbers are relatively small this appears to vary with academic qualification; 11.1% (11/ 99) of PgC respondents are involved in academic delivery, whilst this rises to 20.9% (14/67) of those with a postgraduate diploma (PgD) and 45.2% (14/31) of those who hold a Masters degree. In relation to broader staff development 51.2% (n ¼ 105/205) were involved in mentorship, either as a mentor or mentee (Table 3). A large proportion of respondents have been involved in the evaluation of services in the last two years (71.5%; 138/193). When reporting competency audit was excluded 58.0% (119/205) have participated in audit, whereas research activity is much lower (19.7%; 38/193). Many deemed that research was not a requirement of their role, whilst others believed it to be necessary, although time constraints and other responsibilities were a hindrance. “Research is a step further in my opinion and is more an academic pursuit. It requires a certain expertise that a practical radiographer may not relate to or enjoy particularly”
small number (25.0%; n ¼ 4/16) presenting at one or more national or international conferences. Only 12.2% (n ¼ 25/205) of respondents had published in the two-year timeframe, with the majority authoring a single article (76.0%; n ¼ 19/25). Peer review publications were the most common (64.0%; n ¼ 16/25), followed by a non-peer review, such as in a professional magazine (52.0%; n ¼ 13/25); one respondent had contributed to a textbook chapter (4.0%; n ¼ 1/25). Although 34.5% (n ¼ 70/203) indicated awareness of the difference between extended and advanced practice, few were able to correctly articulate this (9.3%; n ¼ 19/205). Commonly, respondents perceived the difference to relate to levels of education and qualification. “Advanced practice requires further study and qualifications. Extended practice requires on the job training but no study” [Respondent ID: 165] “Extended practice has no formal qualification. Advanced practice requires post graduate training” [Respondent ID: 050] “Extended practice takes on less formal roles whereas advanced practice requires formal higher education qualifications” [Respondent ID: 243] “Extended is 'in-house' training on procedures with a local agreement… Advanced is formal training in a specific field with qualification” [Respondent ID: 237] “Extended practice refers to in house courses for things such as cannulation. Advanced practice refers to roles which require additional training and qualifications in a formal learning environment such as university” [Respondent ID: 215]
[Respondent ID: 071] “Research, although useful, is not necessarily advantageous in an acute clinical setting” [Respondent ID: 130] “Time for research is non-existent when attempting to maintain a clinical service. I am still an advanced practitioner even though I am not involved in research” [Respondent ID: 076] Within the two years preceding the survey, 8.8% (n ¼ 18/205) of respondents had presented at a conference. Although there was limited information about the specific presentations, the majority (75.0%; n ¼ 12/16) were at UK special interest groups, with only a
Table 3 Mentorship roles undertaken by respondents. Mentorship role
No. (%)
Mentee Mentor Mentee and mentor Involved in mentorship but none of the above Not involved in mentorship
9 (4.4) 87 (42.4) 9 (4.4) 15 (7.3) 85 (41.5)
Total
205
When asked to identify their self-perceived role level (extended, advanced, or consultant practitioner), 83.3% (n ¼ 170/204) described themselves as advanced practitioners (Table 4). Of those describing themselves as extended role practitioners, 92.3% (24/26) are employed at AfC band 7 or above. Just over half (54.4%; n ¼ 111/ 204) felt that the four core functions are necessary for advanced practice, whereas 89.2% (n ¼ 181/203) believe them necessary for consultant practice. Although 56.0% (n ¼ 108/193) stated they are undertaking all four core functions (Table 4), the number undertaking individual elements varied and was as low as 19.8%. Interestingly, just 40.0% (n ¼ 2/5) of those describing themselves as consultant practitioners, were undertaking all four core functions. No geographical variation in engagement with the four core functions was identified. A small number (n ¼ 3) of respondents selected ‘other’ when asked about their self-perceived role title describing themselves as ‘radiographer’ or ‘reporting radiographer.’ Although 55.4% (113/204) of respondents have heard of the SCoR accreditation scheme, only 2.9% (6/205) had been accredited, a further 43.9% (90/205) plan to become accredited in the future. When age was compared to willingness to become accredited, a statistically significant negative response came from older respondents (mean 45.1 vs 39.8 years; X2 ¼ 3.738; p < 0.05). A number of reasons were offered to explain their intention not to apply for accreditation. Two specific themes emerged from analysis of the free text comments; a lack of perceived benefit to the individual, and a lack of time to complete the tasks associated with accreditation.
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Table 4 Self-perceived role and evidence of role function. Self -perceived role
No. (%) who identify as this role
Practice domain undertaken Expert practice no. (%)
Leadership no. (%)
Education no. (%)
Research & service development no. (%)
Extended role practitioner Advanced practitioner Consultant practitioner
26 (12.7) 170 (83.3) 5 (2.5)
25/25 (100) 163/169 (96.4) 5/5 (100)
12/26 (46.2) 96/170 (56.5) 2/5 (40.0)
3/24 (12.6) 33/168 (19.6) 3/5 (60.0)
13/21 (61.9) 118/164 (72.0) 4/5 (80.0)
Total
201
193/199 (97.0)
110/201 (54.7)
39/197 (19.8)
135/190 (71.1)
“The time needed to complete this is eluding me at the moment as I have too many other responsibilities“ [Respondent ID: 239] “It doesn't affect my pay or role in practice. Purely an admin exercise” [Respondent ID: 140] “More work for little or no benefit?” [Respondent ID: 133]
Discussion Based on a recent estimate of the population,12 the response rate of 259 likely represents approximately one-third of reporting radiographers in the UK. As responses were at an individual level it is not possible to state how many separate NHS Trusts are represented. The respondents provided details of their geographic region rather than employer. The results of this survey suggest a year on year increase in radiographers independently reporting radiographs with evidence of greater utilisation.10,12 It therefore appears that opportunities associated with such roles are being recognised by imaging services. An abundance of articles have explored the role of the reporting radiographer,12,13 however, these have focussed on ability rather than the influence of their role in practice. In particular there is a dearth of knowledge related to the delivery of the core functions of higher level practice. The results parallel the nursing14 and physiotherapy15 professions, with a lack of standardisation of educational expectations, instead placing a significant emphasis on clinical experience. Australia and the United States define a Masters degree as the academic baseline for advanced practice.16,17 The SCoR have reinforced the expectation that the UK should also expect all advanced practitioners to have completed a full Masters qualification. This aspiration was included in their strategy to increase research capability and capacity which also suggests that those aiming for consultant roles should be engaging in doctoral education.18 Harris and Paterson19 found that a number of those in consultant roles had yet to achieve a Masters degree and disappointingly, this study demonstrates that the majority of radiographers employed to report radiographs hold only a PgC, the minimum academic achievement for their role. As only 15.4% have achieved the SCoR expectation of a Masters degree, their advanced practice status may be challenged if national standards are enforced. Snaith et al.12 suggested that variation in awards offered by universities may explain the difference between academic achievement, with qualifications varying dependent on anatomical structures studied and university attended. Although it is not known how many are currently pursuing further study, these findings correlate with previous literature5 which suggest that many radiographers undertake postgraduate modules, but few
complete the full award. It is important that radiographers recognise the educational expectations of higher level practice to enable personal and professional development. Although the majority of radiographers are paid at AfC band 7; as expected when compared with national job profiles.20 Smaller numbers were employed at higher and lower grades, showing similarities to the nursing profession.14,21 There are several factors which could contribute to this trend, one of which is radiographers who possess only a PgC reporting qualification may be practising as extended scope practitioners (at AfC band 6), rather than advanced practitioners. Further research is required to identify whether radiographer career progression, as evidenced by pay level, is associated with academic achievement. A small number of respondents indicated they are paid on a split banding scheme, at a higher rate when reporting and a lower rate when not; a strategy supposedly curtailed with the national pay system.22 The number and range of different job titles was unforeseen. One of the key concepts supporting accreditation is to maintain consistency in the use of ‘advanced practitioner’ title.23 It is clear from both nursing and radiography literature that there are numerous perceptions of advanced practice and that many confuse this with extended scope, thereby exacerbating the confusion between the two titles.14,15,23e25 The longstanding confusion surrounding terminology such as role extension, role expansion, role development, advanced practice and expert practice has been acknowledged by the Department of Health.26 The lack of consistency makes it difficult to compare potential advanced roles and remains problematic and confusing,24,26 both for patients and health professionals; as evidenced by the lack of awareness of the survey respondents. Advanced roles are developing rapidly in all disciplines, bridging gaps in the existing medical workforce and providing holistic care to patients27; it is therefore imperative that the correct use of such terms is widely promoted, understood and accepted. The external profile of radiographers can assist in improving the recognition of the advanced practice role, however the number of individuals regularly attending MDT meetings is disappointing. Literature has highlighted the importance of this practice, and has illustrated the benefits to reporting practice and radiographer development.3,28 Reporting radiographers should have the opportunity to liaise with others, both radiographers and radiologists, discussing interesting or complex cases.29 Such attendance is extremely valuable and encouraged by professional bodies to provide important learning opportunities and promote interprofessional collaboration.3 Just over half of reporting radiographers considered leadership to be part of their role, contradicting previous literature which confirms leadership as a key quality for advanced practitioners.30,31 Its importance has been highlighted in imaging service delivery, suggesting that it is essential to continually improve the service.3 One respondent clearly confused leadership with management, a common error.31 A problem with specifying leadership as a core function is the difficulty in defining or measuring it. Until now, little
Please cite this article in press as: Milner RC, Snaith B, Are reporting radiographers fulfilling the role of advanced practitioner?, Radiography (2016), http://dx.doi.org/10.1016/j.radi.2016.09.001
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has been published concerning what leadership roles are undertaken by reporting radiographers. Encouragingly, over three quarters of respondents have taken part in service evaluation in the last two years, providing some assurance that these roles are involved in measuring and improving practice. Nonetheless, it remains evident that advanced practitioners are responsible for promoting best practice and should ultimately become responsible leaders; these individuals are fundamental in leading the radiography profession and their own speciality, gaining both local and international recognition for the opportunities associated with the role.32,33 Over half of respondents from the current study have taken part in audit in the past two years. The Health and Care Professions Council, standards of proficiency, state that radiographers at all levels should be able to assure the quality of their practice, participate in audit, and be able to engage in research appropriate to their role.34 It is suggested that few reporting radiographers are research active given the low level of dissemination through conferences (8.8%) and publication (12.2%) in the preceding two years. This is perhaps unsurprising when only one-third of consultant radiographers have undertaken such activities.19 It is of some comfort that almost a quarter of those who have been published in the last two years have multiple publications, however this raises further concerns that the evidence base may be populated by the same authors. The education of self and others is an expectation of advanced practice.8 Although almost three-quarters of respondents are contributing to the education of others it is likely that most do not meet the ‘expert level’ criteria. It is encouraging that so many provide tutorials within radiology; passing on knowledge and skills is vital to encourage and develop junior staff and students. Mentorship is an effective method of developing an individual's potential; and it is suggested that every radiographer should be part of such programme.35 There is no previous research exploring the mentorship roles of reporting radiographers, but this study provides a benchmark with almost half of responding reporting radiographers supporting the development of others. It is disappointing that less than 10% have a personal mentor, this lack of support for personal development may continue to hamper progression towards non-medical consultant roles. Just over half identified their role to include all the core functions of higher level practice, despite most describing themselves as an advanced practitioner. Interestingly, 12.7% describe themselves as extended role practitioners with most paid at AfC band 7 or above, suggesting employers may not expect, or want, all core functions undertaken. This theme is evident amongst other health professions9,14 and questions whether the pay level can be justified if the role is not undertaking broader advanced practitioner activities. Whereas most respondents believe all four core functions to be necessary for consultant practitioners, fewer consider these necessary for advanced practice. A small number of respondents perceive themselves to be working as consultant practitioners, but did not appear to be consistently undertaking all four core functions. Expert practice, as expected, is the most widely undertaken, whilst practice and service development, research and evaluation is the least, in common with consultant practice.19 These findings suggest a disparity between individuals' perceptions of what an advanced or consultant practitioner role should encompass, and the guidance. This may be exacerbated by the SCoR expectation that individuals working at an advanced level would progress in the non-clinical areas, although accreditation expects evidence of all. Only a small number of respondents have been accredited as advanced practitioners with the professional body, despite over half being aware of the SCoR scheme. The theme of ‘more work for little benefit’ was common, suggesting that reporting radiographers
felt there was little incentive to undertake accreditation, particularly at the later stages of their careers. This appears to be less of a challenge for younger respondents who seem more likely to embrace accreditation. The SCoR will need to emphasise the benefits of accreditation, to ensure that this is not a hollow achievement. In the absence of a differential registration with the regulatory body, this is the only peer-reviewed evidence of role activities. Limitations The results may be more generalisable to English practice, where 83.9% of responses were generated. The fact there were fewer responses from Scotland, Wales and Northern Ireland is acknowledged, however it has previously been suggested that these countries have slower uptake of reporting radiographer and advanced practice initiatives, than England.10,12,25 The study was open to self-selection and social desirability bias; however the anonymity of the online questionnaire should negate this to some extent. This remains one of the largest in-depth studies of UK reporting radiographers, at individual level, to date. The assessment of whether individuals were undertaking the core functions of higher level practice was based on responses to questions on education provision, dissemination, service evaluation and leadership. The figure must be interpreted with caution as respondents were not asked to provide evidence of how core functions were undertaken. Conclusion A chronic shortage in imaging capacity, coupled with increased demands for radiology services and a drive to reduce report turnaround times suggests that skill mix is more relevant than ever. The current study concludes that 83% of reporting radiographers describe themselves as advanced practitioners, but few have evidence of all four core functions of higher level practice. Employers may focus on clinical competence to provide the reporting capacity required, however it would be foolish for radiographers to disregard the breadth of practice expected at this level. It is imperative that these individuals strive to develop into advanced, and further consultant, practitioner roles. Funding None. Conflict of interest statement None. References 1. NHS England. Diagnostic imaging dataset: annual statistical release 2014-15. Leeds: NHS England. Available from: https://www.england.nhs.uk/statistics/ wp-content/uploads/sites/2/2014/11/Annual-Statistical-Release-2014-15-DIDPDF-1.1MB.pdf. [Accessed 19 June 2016]. 2. Royal College of Radiologists. Unreported X-rays, computed tomography (CT) and magnetic resonance imaging (MRI) examinations: results of the September 2015 snapshot survey of English NHS acute trusts. 2015. Available from: https://www. rcr.ac.uk/sites/default/files/rcr_reporting_survey_sept15.pdf [Accessed 18 February 2016]. 3. Royal College of Radiologists and the Society and College of Radiographers. Team working in clinical imaging. London: The Royal College of Radiologists; 2012. 4. Department of Health. Radiography skills mix e a report on the four-tier service delivery model. London: Department of Health; 2003. 5. Hardy M, Snaith B. How to achieve advanced practitioner status: a discussion paper. Radiography 2007;13:142e6.
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Please cite this article in press as: Milner RC, Snaith B, Are reporting radiographers fulfilling the role of advanced practitioner?, Radiography (2016), http://dx.doi.org/10.1016/j.radi.2016.09.001