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Assistant practitioners (APs) perceptions of their developing role and practice in radiography: Results from a national survey
Radiography 17 (2011) 193e200
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Radiography journal homepage: www.elsevier.com/locate/radi
Assistant practitioners (APs) perceptions of their developing role and practice in radiography: Results from a national survey Adéle Stewart-Lord a, *, Susan M. McLaren a, Claire Ballinger b a b
Faculty of Health and Social Care, London South Bank University, 103 Borough Road, London SE1 0AA, United Kingdom NIHR Research Design Service South Central/School of Medicine, University of Southampton, Level C (805), Southampton General Hospital, Southampton SO16 6YD, United Kingdom
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 July 2010 Received in revised form 25 November 2010 Accepted 20 February 2011 Available online 16 March 2011
Introduction: In 2000, the NHS Plan set out the government’s plans for investment and reform across the NHS. Through the introduction of a new workforce at assistant practitioner (AP) level the Department of Health intended to implement new ways in which to deliver a more efficient service. At the time, little published information existed on the integration of these assistants into the contemporary radiography workforce. Publications were limited to experiences gained by various individual departments ranging in their perception of the role and education of APs. Further research was suggested to track the continuing implementation of the 4-tier structure, establish the precise nature and scope of the roles across Trusts and determine their impact on workload and patient care. Aim: To establish the number and employment locality of APs in radiography professions in England, and to explore their scope of applied practice. Method and materials: The study was conducted over three phases and employed a mixed methods design to address the aims and objectives. Phase I was a scoping exercise performed prior to data collection in which n ¼ 226 radiography sites were identified for contact across England. Phase II utilized a questionnaire as data collection tool to investigate the role of APs in radiography and explore how their roles were integrated into the radiography workforce in England. Results from phase III of the study which utilized semi-structured qualitative interviews are not included in this paper. Conclusion and discussion: Key findings depict the nature and variety of roles and responsibilities undertaken by APs in radiography. This study was the first of its kind to identify the integration of APs in radiography across a sizable geographical region. There were mixed responses to the question asking APs if they were required to perform duties outside their scope of practice. Questionnaire data revealed that a high numbers of APs were working in areas under indirect supervision. Results from this study showed that APs, in some areas at least, were performing the roles of practitioners. Therefore further investigation is needed for new roles to develop criteria to determine which new roles should be the subject of statutory regulation. Ó 2011 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Keywords: Assistant practitioner Radiography Skill mix Role development Scope of practice
Introduction In 2000, the NHS Plan1 set out the government’s plans for investment and reform across the NHS. Changing the way in which healthcare staff within the NHS work was then addressed in the Wanless Report2 commissioned to examine future health trends and explore the contribution that skill mix changes might make to the potential mismatch between supply and demand for the workforce over the next 20 years. It was identified that, in the future, healthcare assistants would take on many of the roles originally performed by qualified practitioners.
Through the introduction of a new workforce at assistant practitioner (AP) level the Department of Health3 intended to implement new ways in which to deliver a more efficient service. At the time, little published information existed on the integration of these assistants into the contemporary radiography workforce. Publications were limited to experiences gained by various individual departments ranging in their perception of the role and education of APs.4e9 The aim of this study was therefore to review the integration and role of the AP in the radiography workforce, ten years after introduction. Background
* Corresponding author. Tel.: þ44 (0)2078157931. E-mail address: [email protected] (A. Stewart-Lord).
For Allied Health Professionals (AHPs) the change in policy over the last ten years has meant a change in workforce planning
1078-8174/$ e see front matter Ó 2011 The College of Radiographers. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.radi.2011.02.006
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assumptions. Allied health professionals had to relinquish some tasks to more appropriate staff grades through the introduction of assistant and support roles.10 Role redesign as suggested by the NHS Modernization Agency11 involved the development of new and amended roles. The Changing Workforce Programme (CWP) was a national modernization programme that supported the NHS to implement and evaluate role redesign from 2001 to 2005. Key issues for AHPs were identified by the NHS Workforce Review Team.12 The aim in introducing role redesign was to deliver service improvement that would benefit both staff and patients, while focusing on key workforce priorities as outlined in the Human Resources in the NHS Plan.13 The radiography profession had already started to evolve their workforce as identified in the publication of Radiography Skill Mix3 which reported on a career progression model which encouraged new ways of working for existing staff and introduced the new role of the AP in radiography. More specifically, the new ways of working were associated with three priorities that were originally identified through the NHS Cancer Plan14 i.e. breast screening; therapeutic radiography and diagnostic radiography. A four-tier structure identified the various levels within the radiography workforce as 1) AP, 2) Practitioner, 3) Advanced Practitioner and 4) Consultant Radiographer. Clinical sites in diagnostic and therapeutic radiography were identified in which the four-tier structure was tested and tried. For radiography this meant a radical shift in the traditional role allocation amongst staff groups. The introduction of the four-tier model endorsed, encouraged and accelerated role development for radiographers.15 Radiographers were allowed to take on extended roles that were originally undertaken by radiologists.16 The cascading effect meant that APs were allowed to take on roles previously performed by radiography practitioners. The inclusion of the APs across healthcare was originally met with resistance from some professionals who believed that as assistants become better trained and experienced they would start to undertake roles that were once the sole remit of qualified professionals.17 Some radiographers refused to relinquish roles or duties to APs and preferred to protect their own practice domain.18 A number of studies explored the implementation of the fourtier model within radiography.15 Findings from these studies revealed a number of key issues that impacted on AP role development in radiography. Role extension was not implemented systematically but depended on the ease of adoption and enthusiasm of clinical departments.19 The formalization of the assistant practitioner role enabled more effective use of the radiography practitioner.15 Many publications highlighted the importance of continued evaluation of new roles and their impact on service delivery.20,21 New roles were shaped and transformed in clinical practice which emphasized the need for regular evaluation to identify advances and limitations for assistant practitioner roles. Evidence suggests that roles and responsibilities were not always shaped by guidance documentation from professional literature or the professional body, but often decisions were based on the individual practitioner’s experience and perceptions of their role.22 Therefore the perceptions of APs in radiography needed to be systematically and rigorously evaluated in relation to their role and scope of practice. The Society and College of Radiographers23e25 produced a range of publications that focused on the scope of practice and educational requirements for these new roles but no study has explored how effective these guidelines have been in informing practice and role development for the AP workforce in radiography. Further research was suggested to track the continuing implementation of the 4-tier structure, establish the precise nature and scope of the roles across Trusts and determine their impact on
workload and patient care.16 Skills for Health and the Sector Skills Council (formerly Healthwork UK) were tasked to develop transferable occupational standards and skills to underpin the new roles.3 The Core Standards for APs26 were only published in 2009, identifying the core standards that should be achieved by all APs to ensure consistency of function, level of responsibility and transferability. It is recognized that APs will have the required knowledge and skill beyond that of the traditional healthcare assistant or support worker26 but there was no suggestion that these new roles would replace radiographers.24,25 It was anticipated that APs in radiography would develop within the career progression framework23 and support service delivery by developing individuals to undertake specific tasks and activities that improve the patient flow and delivery of an effective and timely service. Even though an increased demand for radiology services and shortage of radiologist and radiography staff were considered the driving forces for skill mix and radiographer role development,15 it is unclear how future workforce changes such as an increase in the number of practitioners would impact on the AP role in radiography. Aim and objectives To establish the number and employment locality of APs in radiography professions in England, and to determine their scope of applied practice. Specific Objectives: 1. To conduct pilot fieldwork to develop and validate a questionnaire. (Phase I) 2. To determine the numbers, locations and scope of practice for APs in radiography. (Phase I) 3. To explore the roles and responsibilities of APs. (Phase II and Phase III) Method The study was conducted over three phases referred to as phase I, phase II and phase III and employed a mixed methods design27e29 to address the aims and objectives. Phase I was a scoping exercise performed over a period of three weeks prior to data collection in which n ¼ 226 radiography sites were identified for contact across England. All radiography departments across England were contacted by telephone to determine if they employed APs, how many were in post and if they were willing to take part in the study. Of the n ¼ 226 sites, n ¼ 112(49.6%) of the sites employed APs. Phase II utilized a survey to investigate the role of APs in radiography and explore how their roles were integrated into the radiography workforce in England. This phase was conducted between December 2008 and June 2009, utilizing a questionnaire as data collection tool. The researcher was responsible for designing the questionnaire, reliability testing of the data collection tool, collecting and analyzing the data from the questionnaire.30 An explanatory mixed method design enabled the analysis from the quantitative phase to be integrated in the qualitative third phase29 and facilitated this phase by identifying the participants for the qualitative investigation.28 Results from phase III of the study which utilized a qualitative approach are not included in this paper and it is anticipated the findings will be available for publication in 2011. A panel of three experts in the radiographic professions who were instrumental in the design and integration of the AP workforce in radiography were invited to review the pilot questionnaire and document the content validity.31 This was done in support of
A. Stewart-Lord et al. / Radiography 17 (2011) 193e200
the evidence found in the literature used to inform the content of the questionnaire. Three sites participated in the pilot study to establish the validity and reliability of the questionnaire, the pilot sites being excluded from the final sample. Question wording, framing, and the choice and order of response categories, were considered in the pilot responses.32,33 The self-completion questionnaire was posted to all the APs that worked within radiography professions across England identified in the scoping exercise during phase I. The use of a questionnaire allowed the researcher to gather cross sectional data from a large population in a standardized manner i.e. every respondent was asked exactly the same question in the same way. Although the effort involved in data collection was extensive, this was the most cost effective way to address the aims and reach the largest part of the population of APs working in radiography.32 The application of a mixed method design allowed the methods to be integrated into one study. The research project was described as a national project and ethical approval was requested through the National Research Ethics Service (NRES). Ethical approval was gained through an application submitted by the lead investigator to the South East Research Ethics Committee. A favorable ethical opinion was achieved from the review, and site specific assessment (SSA) exemption was granted. Results Description of the sample After the completion of phase I scoping exercise the researcher was able to send questionnaires to the n ¼ 112 sites who indicated that they employed APs of which n ¼ 85 were diagnostic departments and n ¼ 27 were therapeutic departments. During phase I the sites were asked how many APs they employed, thus allowing the researcher to send out the exact number of questionnaires to each site. Of the 112 sites who employed APs, n ¼ 83 (74.1%) responded positively to the distribution of questionnaires by making a return. The response rates for questionnaires in phase II is shown in Table 1. The sample of APs were unevenly distributed amongst the two professional fields with n ¼ 119 (71%) working within diagnostic radiography and n ¼ 48 (29%) working in therapeutic radiography as the response rate varied for each group. Of the 164 respondents there were more females n ¼ 138 (84%) than males n ¼ 26 (16%) who participated in the completion of the questionnaire as more females were employed as APs. Employment of assistant practitioners (APs) The most common employment route was through internal promotion n ¼ 48 (29.6%) as shown in Fig. 1. Internal promotion referred to APs who were previously employed as radiographer helpers and then promoted to APs where in-house training referred to APs who were employed as APs and then followed a training programme in the department to provide them with the necessary skills and knowledge. The majority of APs in both diagnostic and therapeutic radiography were employed within the NHS. There
195
Appointment Routes for APs 50 45 40 35 Number or 30 Respondents 25 20 n(%) 15 10 5 0
48 (29.6)
37 (22.8)
33 (20.4)
35 (21.6)
9 (5.6)
Internal promotion
Advert external
In house training
Recruited to follow course
Other
Figure 1. Appointment routes for assistant practitioners (APs).
were only a small number of independent hospitals (diagnostic n ¼ 3 (1.7%), and therapeutic n ¼ 1 (2.1%) who indicated that they employed APs, therefore comparisons linked to employers were not possible. Roles and responsibilities of assistant practitioners (APs) APs working in diagnostic radiography were asked to identify what amount of time they worked in areas of/within radiography practice. Table 2 identifies the frequency in areas of/within radiographic practice as well as the total number of APs that answered the particular section (a). In diagnostic radiography the vast majority of APs were working in General x-ray units (n ¼ 77:72%) and Image Processing (n ¼ 66:61.7%). Areas where APs in diagnostic radiography worked frequently were: Accident and Emergency (n ¼ 37:35.6%), Fluoroscopy (n ¼ 34:31.8%) and Mobile x-ray units (n ¼ 21:20.2%). Reception (n ¼ 36:33.6%) was identified as the area where APs seldom worked, while Nuclear Medicine (n ¼ 69:69%) and Theaters (n ¼ 66:62.3%) were identified as the areas where most APs never worked. APs working in therapeutic radiography were asked to identify the amount of time they worked in areas of/within radiography practice. Table 4 identifies the frequency in areas of/within radiographic practice as well as the total number of APs that answered the particular section (a). In therapeutic radiography the vast majority of APs were working on Linear Accelerator treatment units (n ¼ 39:86.7%). Areas where APs in therapeutic radiography worked frequently were Pre-treatment (CTSim or Simulator) (n ¼ 13:27.7%) and general administration (n ¼ 12:25.5%). Superficial/Orthovoltage treatment units (n ¼ 18:39.1%) were identified as the area where APs seldom worked, while Pre-treatment Dosimetry (n ¼ 28:60.9%) and Brachytherapy (n ¼ 24:55.8%) were the most selected areas where APs never worked. There were mixed responses to the question asking APs if they were required to perform duties outside their scope of practice. In diagnostic radiography n ¼ 11 (9.7%) respondents felt that they were always performing duties outside their scope of practice while n ¼ 54 (47.8%) of respondents felt that they never performed duties outside their scope of practice. In therapeutic radiography n ¼ 4 (8.5%) respondents felt that they were always performing
Table 1 Response rate according to sites and questionnaires. Professional field
Sites who employed APs n (%)
Sites who responded n (%)
Sites who did not respond n (%)
Questionnaires sent out n (%)
Questionnaires returned n (%)
Diagnostic radiography Therapeutic radiography Total
85 (75.9) 27 (24.1) 112 (100)
61 (54.5) 22 (19.6) 83 (74.1)
24 (21.4) 5 (4.5) 29 (25.9)
281 (78.7) 76 (21.3) 357 (100)
119 (33.3) 48 (13.4) 167 (47)
196
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Table 2 Areas of practice diagnostic radiography. Area of work
Always (Every day) n (%)
Frequently (once a week) n (%)
Seldom (once a month) n (%)
Never n (%)
NA n (%)
Total n (%)a
Reception Image processing General administration Fluoroscopy (routine) General X-ray units Mobile X-ray units CT MRI Theaters Accident and emergency Nuclear medicine Ultrasound Mammography (breast screening)
15 66 21 7 77 10 2 3 1 23 0 2 13
18 15 18 34 20 21 8 6 12 37 0 16 2
36 (33.6) 6 (5.6) 23 (22.3) 23 (21.4) 0 20 (19.2) 14 (13.4) 9 (8.9) 11 (10.3) 12 (11.5) 2 (2) 15 (14.6) 5 (4.7)
31 9 33 32 7 43 58 63 66 20 69 52 63
7 11 8 11 3 10 21 20 16 12 29 18 24
107 107 103 107 107 104 103 101 106 104 100 103 107
a
(14) (61.7) (20.4) (6.5) (72) (9.6) (1.9) (2.9) (0.9) (22.1) (1.9) (12.1)
(16.8) (14) (17.5) (31.8) (18.7) (20.2) (7.8) (5.9) (11.3) (35.6) (15.5) (1.9)
(29) (8.4) (32) (29.9) (6.5) (41.3) (56.3) (62.4) (62.3) (19.2) (69) (50.1) (58.9)
(6.5) (10.3) (7.8) (10.3) (2.8) (9.6) (20.4) (19.8) (15.1) (11.5) (29) (17.5) (22.4)
(100) (100) (100) (100) (100) (100) (100) (100) (100) (100) (100) (100) (100)
Number and percentage of the total sample (n ¼ 119) of diagnostic assistant practitioners who responded to the question.
duties outside their scope of practice while n ¼ 15 (31.9%) of respondents felt that they never performed duties outside their scope of practice. Assistant practitioner (AP) competence and supervision Respondents were asked if they felt competent to perform all their duties. The highest responses for both diagnostic (n ¼ 94:79%) and therapeutic (n ¼ 36:75%) radiography were ‘always’ with only 1 respondent in each of the professional groups indicating ‘seldom’ or ‘never’ as demonstrated in Fig. 2. When asked if APs were involved in decision making the majority of respondents felt that they were ‘frequently’ involved as shown in Fig. 3. APs working in diagnostic radiography were asked to identify the areas where they were directly (working alongside a practitioner) or indirectly (working independently) supervised. Results are shown in Table 3. The highest number of responses for direct supervision was found in fluoroscopy in the clinical imaging department (n ¼ 39:37.5%) and acquisition of plain film radiographs for children (n ¼ 35:33.7%). The highest number of responses for indirect supervision was found in acquisition of plain film radiographs of adults (n ¼ 78:73.5%). The following indirect supervision responses were found in areas that were considered outside the scope of practice for APs in diagnostic imaging: acquisition of plain film in children (n ¼ 29:27.9%), mobile x-ray units (n ¼ 14:13.3%) and fluoroscopy outside the imaging department i.e. theater (n ¼ 11:11.2%). APs working in therapeutic radiography were asked to identify the areas where they were directly or indirectly supervised. Results are shown in Table 5. The highest number of responses for direct supervision was found in megavoltage treatment delivery (n ¼ 38:84.4%) and radical head and neck treatments (n ¼ 34:73.9%). The highest number of responses for indirect supervision was found in patient support and information (n ¼ 34:75.6%) and daily machine quality assurance (n ¼ 28:62.2%). The following indirect supervision
Figure 2. Perceptions of competence.
responses were found in areas that were considered outside the scope of practice for APs in radiotherapy: obtaining consent (n ¼ 17:37%), supply of medicines (n ¼ 11:23.9%) and on-treatment review (n ¼ 10:22.2%). APs were asked to indicate how helpful their supervisor was in informing their clinical practice. Differences in supervisory support for diagnostic and therapeutic radiography are demonstrated in Fig. 4 with the most of diagnostic radiography support being ‘very helpful’ (n ¼ 60:50.4%) and therapeutic radiography being ‘somewhat helpful’ (n ¼ 25:52.1%). Respondents were then asked to rate their daily supervision under certain headings as outlined in Table 6. Overall most responses were very positive. The highest numbers of responses were rated excellent for helpfulness (n ¼ 75:47.5%), approachability (n ¼ 76:48.4%), knowledge of practice (n ¼ 87:55.8%) and educational support (n ¼ 49:31.2%). Discussion Employment and recruitment of assistant practitioners (APs) Results showed the majority of APs were recruited from within their own departments, enabling helpers or support staff to develop and train into AP roles. It is assumed the support roles were replaced with new staff thereby creating a potential future source to recruit from. The recruitment of Agenda for Change band 2 support workers could impact on the training and development of APs at band 4 and therefore career development for support workers should be considered at interview, which in turn would enable managers to plan a future workforce considering the necessary skill mix in radiography. The scope of practice for APs identified that the role of the AP would fulfill the need to develop career progression opportunities for support workers.24,25 This assumption can only be met if APs continue to be sourced through internal promotion. It should be noted however that radiography vacancies have reduced over the last ten years16 thereby removing
Figure 3. Decision making.
A. Stewart-Lord et al. / Radiography 17 (2011) 193e200
197
Table 3 Diagnostic radiography supervision. Area of work
Direct supervision working alongside a practitioner n (%)
Indirect supervision allowed to work independently n (%)
Not applicable n (%)
Total n (%)a
Mammography CT MRI Fluoroscopy in the clinical imaging department Fluoroscopy outside the clinical imaging department (i.e. theater) Acquisition of plain film radiographs of adults Acquisition of plain film radiographs of children Mobile x-ray acquisition
7 17 13 39 14
12 0 1 26 11
85 85 85 39 73
104 102 99 104 98
a
(6.7) (16.7) (13.1) (37.5) (14.3)
17 (16) 35 (33.7) 31 (29.5)
(11.5) (1.0) (25) (11.2)
78 (73.5) 29 (27.9) 14 (13.3)
(81.7) (83.3) (85.9) (37.5) (74.5)
11 (10.4) 40 (38.5) 60 (57.1)
(100) (100) (100) (100) (100)
106 (100) 104 (100) 105 (100)
Number and percentage of the total sample (n ¼ 119) of diagnostic assistant practitioners who responded to the question.
one of the driving forces that originally introduced and developed the AP role.15,19 It is unclear whether recruitment to the AP role has been sustained over the last ten years19 or whether it has decreased in line with the decrease in radiography vacancies. The high number of recruits from external adverts identifies a potential future source for recruitment, especially at a time where people are considering a career change due to economic downturn in certain areas of the workforce market. According to the core standard 2 for APs, candidates that have the ability should be recruited to an appropriate post of employment and training programme.26 The publication however fails to elaborate on how this ability should be assessed at interview or application. Future research should evaluate and compare the two potential sources of recruitment, those within radiography services and those entering from outside healthcare to explore implications on level of practice and supervision. Assistant practitioners (APs) working in clinical imaging Results from this study support the original notion that APs predominantly undertake plain film radiography.24 When comparing the scope of practice to the findings in relation to specific imaging procedures such as CT and MRI it was noted that small numbers of APs were allowed to work in these areas supporting radiographers and providing patient support as suggested by their scope of practice.24 APs working in CT and MRI were directly supervised and therefore not taking on the role of the radiographer. Fluoroscopy work for the AP identified concerns relating to work practices. The role of the AP during fluoroscopy procedures is to support the radiographer within the clinical department whilst working under direct supervision at all times.24 Results showed that there were a number of APs that were working in fluoroscopy outside the clinical imaging department and that approximately half of them worked under indirect supervision. Education and training of the APs do not equip them for this activity and level of responsibility and practice in this area is only recommended if there is direct supervision by a radiographer who is trained in
aspects of radiation protection including justification.24 APs performing fluoroscopic procedures without direct supervision can be held accountable if exposure in the clinical area is not controlled. Mobile x-rays are frequently performed by APs and in some instances without direct supervision. The level of responsibility required to perform mobile x-rays fall outside the scope of practice for APs. During a mobile x-ray procedure imaging techniques may have to be adjusted and the operator needs to establish and maintain a temporary control area.24 The APs performing these procedures might be competent in performing these extended roles but there is no clear indication who takes responsibility for these APs once they leave the department. Any actions taken by APs with regard to children should be under the direct supervision of a radiographer24 yet results from this study demonstrated that large numbers of APs were performing x-ray procedures on children without direct supervision. The complexity of issues relating to children and possible serious consequences of any mistakes in indirect supervision whilst taking child x-rays could have serious implications for the APs as these elements are not covered in their training. Assistant practitioners (APs) working in radiotherapy Results from AP practice in radiotherapy showed that they were frequently working as part the of the treatment team on the linear accelerator. A small number of APs were still performing tasks previously associated with the support worker or radiotherapy helper. More concerning were the number of APs that were working without direct supervision in areas such complex computer planning, obtaining consent, radical head and neck treatments as well as making decisions regarding treatment complications. This could be attributed to individuals being part of a team for an extended period of time and therefore being allowed to act as radiographers as they are deemed competent by those who supervise them daily. This could also be due to confusion that continues to exist amongst the radiography profession regarding the role and responsibilities of the APs working alongside them. Even though
Table 4 Areas of practice therapeutic radiography. Area of work
Always (Every day) n (%)
Frequently (once a week) n (%)
Seldom (once a month) n (%)
Never n (%)
NA n (%)
Total n (%)a
Reception Clinics General administration (including scheduling) Pre-treatment CTSim or conventional simulation Pre-treatment dosimetry/planning Treatment units superficial/orthovoltage Treatment units cobalt Treatment units linear accelerators Brachytherapy units (HDR)
2 1 11 9 4 6 3 39 3
2 10 12 13 4 6 0 5 1
14 10 5 10 8 18 0 1 5
25 23 18 14 28 14 19 0 24
3 (6.5) 2 (4.3) 1 (2.1) 1 (2.1) 2 (4.3) 2 (4.3) 20 (47.6) 0 10 (23.3)
46 46 47 47 46 46 42 45 43
a
(4.3) (2.2) (23.4) (19.1) (8.7) (13) (7.1) (86.7) (7)
(4.3) (21.7) (25.5) (27.7) (8.7) (13) (11.1) (2.3)
(30.4) (21.7) (10.6) (21.3) (17.4) (39.1) (2.2) (11.6)
Number and percentage of the total sample (n ¼ 48) of therapeutic assistant practitioners who responded to the question.
(54.3) (50) (38.3) (29.8) (60.9) (30.5) (45.2) (55.8)
(100) (100) (100) (100) (100) (100) (100) (100) (100)
198
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Table 5 Therapeutic radiography supervision. Area of work
Direct supervision working alongside a practitioner n (%)
Indirect supervision allowed to work independently n (%)
Not applicable
Total n (%)a
Elements of pre-treatment processes; for example imaging, simple dosimetry Elements of treatment delivery; protocolized and simple megavoltage, treatments. Elements of daily machine quality assurance tasks. Elements of patient support and information within clearly defined proforma Obtaining consent for radiotherapy Complex computer treatment planning e 3D or 4D dosimetry Superficial, orthovoltage or electron treatments Radical head and neck treatments Decision making regarding treatment complications Supply of medicines (supplementary prescribing) On-treatment review/patient follow-up.
28 38 8 10 8 5 32 34 28 31 9
4 5 28 34 17 6 6 4 2 11 10
14 2 9 1 21 35 8 8 16 4 26
46 45 45 45 46 46 46 46 46 46 45
a
(60.9) (84.4) (17.8) (22.2) (17.4) (10.9) (69.6) (73.9) (60.9) (67.4) (20)
(8.7) (11.1) (62.2) (75.6) (37) (13) (13) (8.7) (4.3) (23.9) (22.2)
(30.4) (4.4) (20) (2.2) (45.7) (76.1) (17.4) (17.4) (34.8) (8.7) (57.8)
(100) (100) (100) (100) (100) (100) (100) (100) (100) (100) (100)
Number and percentage of the total sample (n ¼ 48) of therapeutic assistant practitioners who responded to the question.
small number of individuals are performing these activities, it is a matter for concern as these situations involve radiation protection, patient care, treatment planning and delivery that are considered to be outside the scope of practice for APs working in radiotherapy.25 All exposures that are part of the radiotherapy process must be undertaken by someone recognised as a practitioner under IR(ME)R 2000. In 2006 the Ionizing Radiation Medical Exposure (Amendment) Regulations confirmed that a Practitioner must be a registered healthcare professional whose profession is regulated by a body as detailed within Section 25(3) of the National Health Service Reform and HealthCare Professions Act 2002. The AP is therefore legally not allowed to take on the role of the ‘Practitioner’.25 The scope of practice for assistant practitioners (APs) Skills for Health26 proposed that APs would be able to deliver elements of health and social care and undertake clinical work in domains that have previously only been within the remit of registered professionals and even though the Scope of Practice24,25 clearly identifies these areas, APs in radiography continue to work in areas that are considered outside their scope of practice, and without direct supervision. Standard 4 of the core standards for APs declare that they should be acting at the appropriate level on the career framework which implies their role should be managed under guidance.26 Guidance is recommended through standard operating procedures and protocols. APs across England might be working according to departmental protocols and procedures but these are definitely not standardized across the country as shown by the results of this study. The Scope of Practice for APs in Clinical Imaging24 and that of Radiotherapy25 was intended as a guidance document that would underline the importance of new roles in the clinical department while assisting in service delivery; neither compromising the safety of the patient nor the quality of the care. To this end the Society and
Figure 4. Supervisors informing assistant practitioner practice.
College of Radiographers developed a voluntary register for APs. The voluntary register does not regulate the role of the APs but purely acts as a method of accreditation for education and training. The voluntary register provided the Society and College of Radiographers with anecdotal evidence that some APs were working beyond their scope of practice, and that this practice was supported if accredited by the Society and College of Radiographers. It remains unclear how the voluntary register was used to inform role development or disseminated information throughout clinical practice. This contradicts the intended purpose of the Scope of Practice which claimed that statements were published as a benchmark for safe and effective practice.24,25 Therefore the Society and College of Radiographers need to clarify the use of the register for APs. If APs are working at extended levels of practice thereby taking on roles and responsibilities that traditionally fall within the scope of the radiographer it can be argued that this might have implications for the future radiography graduate employment. There seems to be an overlap between APs and band 5 Agenda for Change radiographers, where the APs have extended their role and practice and in some cases are employed at band 5. The link between role extension and pay progression will be further explored in follow-up interviews in the third phase of this study. Assistant practitioner (AP) competence and supervision APs are accountable to themselves, their employer and more importantly the people they serve.26 The core standards for APs were published after data for this study was collected, and further research would suggest comparing the core standards with those APs who were employed prior to core standards being in place. Of particular interest would be the extent of support from managers to ensure they achieve the competencies as outlined in standard 5 of the core standards for APs.26 It is the responsibility of the APs to alert the supervising radiographer to situations where they do not have the competence or confidence to undertake the relevant task26 (GEN 63 Act within the limits of your competency and authority), yet it is the responsibility of the employer to ensure that APs are not undertaking tasks for which they have not been trained. APs need to continue to develop their knowledge and practice (HSC23).26 Results from this study demonstrate that the APs are involved in decision making as they are required to (AG2)26 contribute to care planning and review and be able to (CHS 118)26 form a professional judgment on an individual’s health condition. Supportive leadership and clinical supervision are proven elements of job satisfaction.35 There seems to be a difference in diagnostic and therapeutic radiography supervisory support as perceived by the APs. This can be attributed to the different work
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199
Table 6 Rate of supervision in every day practice. Supervision
Excel n (%)a
Good n (%)a
Fair n (%)a
Poor n (%)a
No opinion n (%)a
Total n (%)b
Helpfulness Approachability Knowledge of practice Educational support Team Involvement Their understanding of the role of the assistant practitioner. Availability of radiographers to support you
75 76 87 49 57 40 55
58 52 52 46 58 52 60
17 19 11 33 30 38 26
5 7 2 22 10 24 15
3 3 4 7 3 3 3
158 157 156 157 158 157 159
a b
(47.5) (48.4) (55.8) (31.2) (36.1) (25.5) (34.6)
(36.7) (33.1) (33.3) (29.3) (36.7) (33.1) (37.7)
(10.8) (12.1) (7.1) (21) (19) (24.2) (16.3)
(3.2) (4.5) (1.3) (14) (6.3) (15.3) (9.4)
(1.9) (1.9) (2.6) (4.5) (1.9) (1.9) (1.9)
(100) (100) (100) (100) (100) (100) (100)
Number and percentage of respondents for each option. Number and percentage of the total sample (n ¼ 167) of assistant practitioners who responded to the question.
practices where diagnostic radiographers work independently in most cases when performing an examination whilst therapeutic radiographers always treat patients within a team setting. The AP may feel more comfortable to discuss their work in a one-to-one environment. Other studies have reported that the role of the AP had a positive effect on teamworking and has enhanced the patient experience.36 Core standards for APs require them to contribute to the effectiveness of teams (HSC 241)26 and ensure they contribute to a positive and safe working culture. It is important to remember that supervision is a quality assurance framework and not a quality control process.24 APs in this study rated supervision in a very positive light with most responses rated as excellent, except for two categories. The understanding of the role of the AP and the availability of radiographers to support APs were mostly rated good rather than excellent. In many departments radiographer support is shared with radiography students and other studies have reported that although both student radiographers and trainee assistant practitioners were treated equally there was a perception that the radiographers’ time was being spread thinly to accommodate both groups of trainees.36 The role of the AP is often not fully understood by all staff working in the department as evidence suggests that AP mentors have had to deal with other staffs’ perceptions and attitudes towards the introduction of APs.36 Availability to support APs could also be reduced if APs do not have a named supervisor at all times, which means they are required to find someone to either justify the procedure or check their images. Supervision should be done by band 6 or above, and the AP should know who is supervising them at all times.24,25 Limited numbers of senior radiographers can further hinder the AP gaining the necessary supervision. However supervision is twoway process in which both the AP and the supervisor have to ensure that safe, effective practice is carried out at all times.24,25 The responsibility for ensuring the quality and standard of the ‘episode of care’ remains with the radiographer.24,25 Conclusion This study addresses the overall aim to describe the employment practices and locality of APs in England. An extensive amount of data was collected that described the scope of practice for APs in radiography. Key findings depict the nature and variety of roles and responsibilities undertaken by APs in radiography highlighting the areas where APs are working outside their scope of practice. Although the overall response rate of 47% can be considered a limitation compared to other response rates in medical literature33,34 it should be noted that n ¼ 83 (74%) of the 112 sites who employed assistant practitioners did respond to the questionnaire. Similar response rates were found in other AP studies.35 This study was the first of its kind to identify the integration of APs in radiography across a sizable geographical region. The Society and College of Radiographers24 identified limitations in the scope of practice for APs. Mobile x-ray units,
fluoroscopy and x-rays of children were areas where the responsibility related to radiation protection and patient care and were considered beyond the scope of practice of the AP. The results of this study make it evident that many APs were frequently working within these areas. Questionnaire data also revealed that high numbers of APs were working in these areas under indirect supervision, which meant that they were allowed to work independently in these areas. The Society and College of Radiographers24 expects APs to be directly supervised. The future role development of APs in radiography can only be planned when balanced against the past driving forces that originally initiated the need for this role development. Redevelopment and role redesign were the key driving forces in the healthcare service delivery model over the last ten years.1,3,10,11,14 This explanatory study has identified a number of challenges for future workforce planning in light of the anticipated future healthcare funding and a need for further evaluation. Role redesign that took place around the scope of practice for the practitioner was governed by the professional regulator, however new roles outside the practitioner scope of practice were and are not regulated by the professional regulator. The White Paper: ‘Trust, Assurance and Safety e The Regulation of Health Professionals in the 21st Century’37 stated that entry to a professional register depended on the individual being able to demonstrate fitness to practice by securing an educational qualification and level of confidence that is recognised by a responsible professional body. The government believed that previously non-regulated professions should be subject to a system of regulation that is proportionate to the risk and benefits entailed. The AP was introduced into the Career Framework at a level midway between the Healthcare Assistant and the Professional Practitioner10 therefore no regulation applied, however, results from this study showed that APs, in some areas at least, were performing the roles of practitioners thereby placing themselves and potentially service users at risk. If APs are working at similar levels to that of radiographer practitioners there should be a regulatory system in place to monitor these roles. For the APs this would mean clear guidance on regulation and a job description that explains the extended areas of practice. APs should understand how they can be held legally accountable if they were working outside these parameters. Therefore further investigation is needed to develop criteria to determine which new roles should be the subject of statutory regulation. Although the level of education and training of the AP in radiography were explored in this study results are not included in this publication, but will be addressed in future publications. Supervision in areas of limited scope of practice was followed up in phase III of the study through semi-structured interviews and qualitative analysis. The scope of practice for APs was designed to support employers and managers in the development of these roles and provide them with a safe, effective and evidence based-framework.24,25 The scope of practice for APs needs to be reviewed in light of the recent release of Core Standards for Assistant Practitioners and the
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findings of this study. As the service delivery model continues to evolve the Society and College of Radiographers advocate the review of the workforce based on research evidence to support future developments and thereby enhancing patient service.24,25 In conclusion the reader is reminded that the focus of the study was the role of the AP in radiography. Role development in radiography however, was part of a greater national strategy for change linked to policy.1 Policy is rationalized through its implementation by managers, the health care professionals who put the policy into practice, as well as the patients who remain the core focus of any policy change.38 Therefore the results of this study should further be evaluated in light of these other elements that drive change in healthcare delivery. Acknowledgements David Sines, Pro Vice Chancellor, Faulty of Society and Health, Bucks New University, Uxbridge, Middlesex. For his contribution at the start of the study. References 1. Department of Health. The NHS plan: a plan for investment, a plan for reform. London: Department of Health; July 2000. 2000a. 2. Wanless D. Securing our future health: taking a long term view. Final report. London: HM Treasury; 2002. 3. Department of Health. Radiography skills mix. A report on the four-tier service delivery model. London: Department of Health; June 2003. 2003. 4. Tuson AE, Seddon D, Hopkins CA, Maxwell AJ. Comparing of image quality between mammograms performed by an AP and by screening radiographers. Breast Cancer Research; 2002. 4;1 Symposium Mammographicum. 5. Betts EA, Sorrell M, Faulkner T. The AP in the imaging department: a practical experience. Synergy: The Society and College of Radiographers; March 2003. 6. Forsyth L, Hunt K, McGowan D. Assistant training e a local approach to a national initiative. Synergy: The Society and College of Radiographers; December 2003. 7. Hodgson D, Graham L, Abraham M. A work-based learning programme for APs in radiotherapy. Synergy: The Society and College of Radiographers; September 2005. 8. Lee L. National health service breast screening programme. Sill mix project: diagnostic and therapeutic radiography. Synergy: The Society and College of Radiographers; August 2002. 9. Ford P. The role of support workers in the department of diagnostic imaging e service managers’ perspectives. Radiography 2004;10:259e67. 10. Department of Health. Workforce matters: a guide to role redesign in cancer services. National Health Service Modernisation Agency. London: Department of Health; 2004. 11. Department of Health. Workforce themes. Introduction to role redesign. National Health Service Modernisation Agency. London: Department of Health, 2006a. 12. Department of Health. Provisional Workforce Recommendations 2007/2008 for consultation. National Health Service Workforce Review Team June 2006. London: Department of Health, 2006b. 13. Department of Health. HR in the NHS Plan. More staff working differently. London: Department of Health; July 2002. 2002.
14. Department of Health. The NHS Cancer Plan: a plan for investment, a plan for reform. London: Department of Health; September 2000. 2000b. 15. Woodford AJ. An investigation of the impact/potential impact of a four-tier profession on the practice of radiography e a literature review. Radiography 2006;12:318e26. 16. Price RC, Le Masurier SB. Longitudinal changes in extended roles in radiography: a new perspective. Radiography 2007;13:18e29. 17. McKenna H, Hasson F, Keeney S. Patient safety and quality of care: the role of the health care assistant. Journal of Advanced Nursing 2004;12:452e9. 18. White P, McKay JC. Guidelines and legal requirements which inform role expansion in radiography. Radiography 2002;8:223e34. 19. Price RC, Miller LR, Mellor F. Longitudinal changes in extended roles in radiography. Radiography 2002;8:223e34. 20. Spilsbury K, Meyer J. Use, misuse and non-use of health care assistants: understanding the work of health care assistant in hospital setting. Journal of Nursing Management 2004;12:411e8. 21. Thornley C. A question of competence? Re-evaluating the roles of the nursing auxillary and health care assistants in the NHS. Journal of Clinical Nursing 2000;9:451e8. 22. McKenna H, Hasson F. A study of skill mix in midwifery: a multimethod approach. Journal of Advanced Nursing 2002;37(1):52e61. 23. Society and College of Radiographers. A curriculum framework for radiography. London: The Society of Radiographers; 2003. 24. Society and College of Radiographers. The scope of practice of APs in clinical imaging. London: The Society of Radiographers; 2007. 25. Society and College of Radiographers. The scope of practice of APs in radiotherapy. London: The Society of Radiographers; 2007. 26. Skills for Health. Core standards for assistant practitioners. Skills for health, 2009: [Online] http://www.skillsforhealth.org.uk[Accessed 27 04.2010.]. 27. Bergman MM. Advances in mixed methods research. theories and applications. London: Sage Publications; 2008. 28. Bryman A. Social research methods. 3rd ed. Oxford: Oxford University Press; 2008. 29. Creswell JW, Plano Clark VL. Designing and conducting mixed methods research. London: Sage Publications; 2007. 30. Boynton PM, Greenhalgh T. Hands-on guide to questionnaire research. Selecting, designing and developing your questionnaire. British Medical Journal 2004;328:1312e5. 31. Presser S, Blair J. Survey pre-testing: do different methods produce different results? Sociological Methodology 1994;24:73e104. 32. Converse JM, Presser S. Survey questions: handcrafting the standardized questionnaire. Newbury Park, CA: Sage; 1986. 33. McColl E, Jacoby A, Thomas L, Soutter J, Bamford C, Steen N, et al. Design and use of questionnaires: a review of best practice applicable to surveys of health service staff and patients. Health Technology Assessment 2001;5(31). 34. Edwards PJ, Roberts I, Clarke MJ, DiGuiseppi C, Wentz R, Kwan I, et al. Methods to increase response rates in postal and electronic questionnaires (Review). The Cochrane Collaboration. London: John Wiley & Sons, Ltd; 2009. 35. Coogle CL, Parham IA, Jablonski R, Rachel JA. Enhanced care assistant training to address the workforce crisis in home care: changes related to job satisfaction and career commitment. Care Management Journals 2007; 8(2):71e81. 36. Colthart I, McBride M, Murray M. Mentoring assistant practitioners e the radiographers perspective. Radiography 2010;16:223e9. 37. Department of Health. Trust, Assurance and Safety e The Regulation of Health Professionals in the 21st Century. White Paper. February 2007. London: Department of Health; 2007. 38. Green J, Thorogood N. Analysing health policy: a sociological approach. London: Longman; 1998.
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Radiography journal homepage: www.elsevier.com/locate/radi
Assistant practitioners (APs) perceptions of their developing role and practice in radiography: Results from a national survey Adéle Stewart-Lord a, *, Susan M. McLaren a, Claire Ballinger b a b
Faculty of Health and Social Care, London South Bank University, 103 Borough Road, London SE1 0AA, United Kingdom NIHR Research Design Service South Central/School of Medicine, University of Southampton, Level C (805), Southampton General Hospital, Southampton SO16 6YD, United Kingdom
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 July 2010 Received in revised form 25 November 2010 Accepted 20 February 2011 Available online 16 March 2011
Introduction: In 2000, the NHS Plan set out the government’s plans for investment and reform across the NHS. Through the introduction of a new workforce at assistant practitioner (AP) level the Department of Health intended to implement new ways in which to deliver a more efficient service. At the time, little published information existed on the integration of these assistants into the contemporary radiography workforce. Publications were limited to experiences gained by various individual departments ranging in their perception of the role and education of APs. Further research was suggested to track the continuing implementation of the 4-tier structure, establish the precise nature and scope of the roles across Trusts and determine their impact on workload and patient care. Aim: To establish the number and employment locality of APs in radiography professions in England, and to explore their scope of applied practice. Method and materials: The study was conducted over three phases and employed a mixed methods design to address the aims and objectives. Phase I was a scoping exercise performed prior to data collection in which n ¼ 226 radiography sites were identified for contact across England. Phase II utilized a questionnaire as data collection tool to investigate the role of APs in radiography and explore how their roles were integrated into the radiography workforce in England. Results from phase III of the study which utilized semi-structured qualitative interviews are not included in this paper. Conclusion and discussion: Key findings depict the nature and variety of roles and responsibilities undertaken by APs in radiography. This study was the first of its kind to identify the integration of APs in radiography across a sizable geographical region. There were mixed responses to the question asking APs if they were required to perform duties outside their scope of practice. Questionnaire data revealed that a high numbers of APs were working in areas under indirect supervision. Results from this study showed that APs, in some areas at least, were performing the roles of practitioners. Therefore further investigation is needed for new roles to develop criteria to determine which new roles should be the subject of statutory regulation. Ó 2011 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Keywords: Assistant practitioner Radiography Skill mix Role development Scope of practice
Introduction In 2000, the NHS Plan1 set out the government’s plans for investment and reform across the NHS. Changing the way in which healthcare staff within the NHS work was then addressed in the Wanless Report2 commissioned to examine future health trends and explore the contribution that skill mix changes might make to the potential mismatch between supply and demand for the workforce over the next 20 years. It was identified that, in the future, healthcare assistants would take on many of the roles originally performed by qualified practitioners.
Through the introduction of a new workforce at assistant practitioner (AP) level the Department of Health3 intended to implement new ways in which to deliver a more efficient service. At the time, little published information existed on the integration of these assistants into the contemporary radiography workforce. Publications were limited to experiences gained by various individual departments ranging in their perception of the role and education of APs.4e9 The aim of this study was therefore to review the integration and role of the AP in the radiography workforce, ten years after introduction. Background
* Corresponding author. Tel.: þ44 (0)2078157931. E-mail address: [email protected] (A. Stewart-Lord).
For Allied Health Professionals (AHPs) the change in policy over the last ten years has meant a change in workforce planning
1078-8174/$ e see front matter Ó 2011 The College of Radiographers. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.radi.2011.02.006
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assumptions. Allied health professionals had to relinquish some tasks to more appropriate staff grades through the introduction of assistant and support roles.10 Role redesign as suggested by the NHS Modernization Agency11 involved the development of new and amended roles. The Changing Workforce Programme (CWP) was a national modernization programme that supported the NHS to implement and evaluate role redesign from 2001 to 2005. Key issues for AHPs were identified by the NHS Workforce Review Team.12 The aim in introducing role redesign was to deliver service improvement that would benefit both staff and patients, while focusing on key workforce priorities as outlined in the Human Resources in the NHS Plan.13 The radiography profession had already started to evolve their workforce as identified in the publication of Radiography Skill Mix3 which reported on a career progression model which encouraged new ways of working for existing staff and introduced the new role of the AP in radiography. More specifically, the new ways of working were associated with three priorities that were originally identified through the NHS Cancer Plan14 i.e. breast screening; therapeutic radiography and diagnostic radiography. A four-tier structure identified the various levels within the radiography workforce as 1) AP, 2) Practitioner, 3) Advanced Practitioner and 4) Consultant Radiographer. Clinical sites in diagnostic and therapeutic radiography were identified in which the four-tier structure was tested and tried. For radiography this meant a radical shift in the traditional role allocation amongst staff groups. The introduction of the four-tier model endorsed, encouraged and accelerated role development for radiographers.15 Radiographers were allowed to take on extended roles that were originally undertaken by radiologists.16 The cascading effect meant that APs were allowed to take on roles previously performed by radiography practitioners. The inclusion of the APs across healthcare was originally met with resistance from some professionals who believed that as assistants become better trained and experienced they would start to undertake roles that were once the sole remit of qualified professionals.17 Some radiographers refused to relinquish roles or duties to APs and preferred to protect their own practice domain.18 A number of studies explored the implementation of the fourtier model within radiography.15 Findings from these studies revealed a number of key issues that impacted on AP role development in radiography. Role extension was not implemented systematically but depended on the ease of adoption and enthusiasm of clinical departments.19 The formalization of the assistant practitioner role enabled more effective use of the radiography practitioner.15 Many publications highlighted the importance of continued evaluation of new roles and their impact on service delivery.20,21 New roles were shaped and transformed in clinical practice which emphasized the need for regular evaluation to identify advances and limitations for assistant practitioner roles. Evidence suggests that roles and responsibilities were not always shaped by guidance documentation from professional literature or the professional body, but often decisions were based on the individual practitioner’s experience and perceptions of their role.22 Therefore the perceptions of APs in radiography needed to be systematically and rigorously evaluated in relation to their role and scope of practice. The Society and College of Radiographers23e25 produced a range of publications that focused on the scope of practice and educational requirements for these new roles but no study has explored how effective these guidelines have been in informing practice and role development for the AP workforce in radiography. Further research was suggested to track the continuing implementation of the 4-tier structure, establish the precise nature and scope of the roles across Trusts and determine their impact on
workload and patient care.16 Skills for Health and the Sector Skills Council (formerly Healthwork UK) were tasked to develop transferable occupational standards and skills to underpin the new roles.3 The Core Standards for APs26 were only published in 2009, identifying the core standards that should be achieved by all APs to ensure consistency of function, level of responsibility and transferability. It is recognized that APs will have the required knowledge and skill beyond that of the traditional healthcare assistant or support worker26 but there was no suggestion that these new roles would replace radiographers.24,25 It was anticipated that APs in radiography would develop within the career progression framework23 and support service delivery by developing individuals to undertake specific tasks and activities that improve the patient flow and delivery of an effective and timely service. Even though an increased demand for radiology services and shortage of radiologist and radiography staff were considered the driving forces for skill mix and radiographer role development,15 it is unclear how future workforce changes such as an increase in the number of practitioners would impact on the AP role in radiography. Aim and objectives To establish the number and employment locality of APs in radiography professions in England, and to determine their scope of applied practice. Specific Objectives: 1. To conduct pilot fieldwork to develop and validate a questionnaire. (Phase I) 2. To determine the numbers, locations and scope of practice for APs in radiography. (Phase I) 3. To explore the roles and responsibilities of APs. (Phase II and Phase III) Method The study was conducted over three phases referred to as phase I, phase II and phase III and employed a mixed methods design27e29 to address the aims and objectives. Phase I was a scoping exercise performed over a period of three weeks prior to data collection in which n ¼ 226 radiography sites were identified for contact across England. All radiography departments across England were contacted by telephone to determine if they employed APs, how many were in post and if they were willing to take part in the study. Of the n ¼ 226 sites, n ¼ 112(49.6%) of the sites employed APs. Phase II utilized a survey to investigate the role of APs in radiography and explore how their roles were integrated into the radiography workforce in England. This phase was conducted between December 2008 and June 2009, utilizing a questionnaire as data collection tool. The researcher was responsible for designing the questionnaire, reliability testing of the data collection tool, collecting and analyzing the data from the questionnaire.30 An explanatory mixed method design enabled the analysis from the quantitative phase to be integrated in the qualitative third phase29 and facilitated this phase by identifying the participants for the qualitative investigation.28 Results from phase III of the study which utilized a qualitative approach are not included in this paper and it is anticipated the findings will be available for publication in 2011. A panel of three experts in the radiographic professions who were instrumental in the design and integration of the AP workforce in radiography were invited to review the pilot questionnaire and document the content validity.31 This was done in support of
A. Stewart-Lord et al. / Radiography 17 (2011) 193e200
the evidence found in the literature used to inform the content of the questionnaire. Three sites participated in the pilot study to establish the validity and reliability of the questionnaire, the pilot sites being excluded from the final sample. Question wording, framing, and the choice and order of response categories, were considered in the pilot responses.32,33 The self-completion questionnaire was posted to all the APs that worked within radiography professions across England identified in the scoping exercise during phase I. The use of a questionnaire allowed the researcher to gather cross sectional data from a large population in a standardized manner i.e. every respondent was asked exactly the same question in the same way. Although the effort involved in data collection was extensive, this was the most cost effective way to address the aims and reach the largest part of the population of APs working in radiography.32 The application of a mixed method design allowed the methods to be integrated into one study. The research project was described as a national project and ethical approval was requested through the National Research Ethics Service (NRES). Ethical approval was gained through an application submitted by the lead investigator to the South East Research Ethics Committee. A favorable ethical opinion was achieved from the review, and site specific assessment (SSA) exemption was granted. Results Description of the sample After the completion of phase I scoping exercise the researcher was able to send questionnaires to the n ¼ 112 sites who indicated that they employed APs of which n ¼ 85 were diagnostic departments and n ¼ 27 were therapeutic departments. During phase I the sites were asked how many APs they employed, thus allowing the researcher to send out the exact number of questionnaires to each site. Of the 112 sites who employed APs, n ¼ 83 (74.1%) responded positively to the distribution of questionnaires by making a return. The response rates for questionnaires in phase II is shown in Table 1. The sample of APs were unevenly distributed amongst the two professional fields with n ¼ 119 (71%) working within diagnostic radiography and n ¼ 48 (29%) working in therapeutic radiography as the response rate varied for each group. Of the 164 respondents there were more females n ¼ 138 (84%) than males n ¼ 26 (16%) who participated in the completion of the questionnaire as more females were employed as APs. Employment of assistant practitioners (APs) The most common employment route was through internal promotion n ¼ 48 (29.6%) as shown in Fig. 1. Internal promotion referred to APs who were previously employed as radiographer helpers and then promoted to APs where in-house training referred to APs who were employed as APs and then followed a training programme in the department to provide them with the necessary skills and knowledge. The majority of APs in both diagnostic and therapeutic radiography were employed within the NHS. There
195
Appointment Routes for APs 50 45 40 35 Number or 30 Respondents 25 20 n(%) 15 10 5 0
48 (29.6)
37 (22.8)
33 (20.4)
35 (21.6)
9 (5.6)
Internal promotion
Advert external
In house training
Recruited to follow course
Other
Figure 1. Appointment routes for assistant practitioners (APs).
were only a small number of independent hospitals (diagnostic n ¼ 3 (1.7%), and therapeutic n ¼ 1 (2.1%) who indicated that they employed APs, therefore comparisons linked to employers were not possible. Roles and responsibilities of assistant practitioners (APs) APs working in diagnostic radiography were asked to identify what amount of time they worked in areas of/within radiography practice. Table 2 identifies the frequency in areas of/within radiographic practice as well as the total number of APs that answered the particular section (a). In diagnostic radiography the vast majority of APs were working in General x-ray units (n ¼ 77:72%) and Image Processing (n ¼ 66:61.7%). Areas where APs in diagnostic radiography worked frequently were: Accident and Emergency (n ¼ 37:35.6%), Fluoroscopy (n ¼ 34:31.8%) and Mobile x-ray units (n ¼ 21:20.2%). Reception (n ¼ 36:33.6%) was identified as the area where APs seldom worked, while Nuclear Medicine (n ¼ 69:69%) and Theaters (n ¼ 66:62.3%) were identified as the areas where most APs never worked. APs working in therapeutic radiography were asked to identify the amount of time they worked in areas of/within radiography practice. Table 4 identifies the frequency in areas of/within radiographic practice as well as the total number of APs that answered the particular section (a). In therapeutic radiography the vast majority of APs were working on Linear Accelerator treatment units (n ¼ 39:86.7%). Areas where APs in therapeutic radiography worked frequently were Pre-treatment (CTSim or Simulator) (n ¼ 13:27.7%) and general administration (n ¼ 12:25.5%). Superficial/Orthovoltage treatment units (n ¼ 18:39.1%) were identified as the area where APs seldom worked, while Pre-treatment Dosimetry (n ¼ 28:60.9%) and Brachytherapy (n ¼ 24:55.8%) were the most selected areas where APs never worked. There were mixed responses to the question asking APs if they were required to perform duties outside their scope of practice. In diagnostic radiography n ¼ 11 (9.7%) respondents felt that they were always performing duties outside their scope of practice while n ¼ 54 (47.8%) of respondents felt that they never performed duties outside their scope of practice. In therapeutic radiography n ¼ 4 (8.5%) respondents felt that they were always performing
Table 1 Response rate according to sites and questionnaires. Professional field
Sites who employed APs n (%)
Sites who responded n (%)
Sites who did not respond n (%)
Questionnaires sent out n (%)
Questionnaires returned n (%)
Diagnostic radiography Therapeutic radiography Total
85 (75.9) 27 (24.1) 112 (100)
61 (54.5) 22 (19.6) 83 (74.1)
24 (21.4) 5 (4.5) 29 (25.9)
281 (78.7) 76 (21.3) 357 (100)
119 (33.3) 48 (13.4) 167 (47)
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Table 2 Areas of practice diagnostic radiography. Area of work
Always (Every day) n (%)
Frequently (once a week) n (%)
Seldom (once a month) n (%)
Never n (%)
NA n (%)
Total n (%)a
Reception Image processing General administration Fluoroscopy (routine) General X-ray units Mobile X-ray units CT MRI Theaters Accident and emergency Nuclear medicine Ultrasound Mammography (breast screening)
15 66 21 7 77 10 2 3 1 23 0 2 13
18 15 18 34 20 21 8 6 12 37 0 16 2
36 (33.6) 6 (5.6) 23 (22.3) 23 (21.4) 0 20 (19.2) 14 (13.4) 9 (8.9) 11 (10.3) 12 (11.5) 2 (2) 15 (14.6) 5 (4.7)
31 9 33 32 7 43 58 63 66 20 69 52 63
7 11 8 11 3 10 21 20 16 12 29 18 24
107 107 103 107 107 104 103 101 106 104 100 103 107
a
(14) (61.7) (20.4) (6.5) (72) (9.6) (1.9) (2.9) (0.9) (22.1) (1.9) (12.1)
(16.8) (14) (17.5) (31.8) (18.7) (20.2) (7.8) (5.9) (11.3) (35.6) (15.5) (1.9)
(29) (8.4) (32) (29.9) (6.5) (41.3) (56.3) (62.4) (62.3) (19.2) (69) (50.1) (58.9)
(6.5) (10.3) (7.8) (10.3) (2.8) (9.6) (20.4) (19.8) (15.1) (11.5) (29) (17.5) (22.4)
(100) (100) (100) (100) (100) (100) (100) (100) (100) (100) (100) (100) (100)
Number and percentage of the total sample (n ¼ 119) of diagnostic assistant practitioners who responded to the question.
duties outside their scope of practice while n ¼ 15 (31.9%) of respondents felt that they never performed duties outside their scope of practice. Assistant practitioner (AP) competence and supervision Respondents were asked if they felt competent to perform all their duties. The highest responses for both diagnostic (n ¼ 94:79%) and therapeutic (n ¼ 36:75%) radiography were ‘always’ with only 1 respondent in each of the professional groups indicating ‘seldom’ or ‘never’ as demonstrated in Fig. 2. When asked if APs were involved in decision making the majority of respondents felt that they were ‘frequently’ involved as shown in Fig. 3. APs working in diagnostic radiography were asked to identify the areas where they were directly (working alongside a practitioner) or indirectly (working independently) supervised. Results are shown in Table 3. The highest number of responses for direct supervision was found in fluoroscopy in the clinical imaging department (n ¼ 39:37.5%) and acquisition of plain film radiographs for children (n ¼ 35:33.7%). The highest number of responses for indirect supervision was found in acquisition of plain film radiographs of adults (n ¼ 78:73.5%). The following indirect supervision responses were found in areas that were considered outside the scope of practice for APs in diagnostic imaging: acquisition of plain film in children (n ¼ 29:27.9%), mobile x-ray units (n ¼ 14:13.3%) and fluoroscopy outside the imaging department i.e. theater (n ¼ 11:11.2%). APs working in therapeutic radiography were asked to identify the areas where they were directly or indirectly supervised. Results are shown in Table 5. The highest number of responses for direct supervision was found in megavoltage treatment delivery (n ¼ 38:84.4%) and radical head and neck treatments (n ¼ 34:73.9%). The highest number of responses for indirect supervision was found in patient support and information (n ¼ 34:75.6%) and daily machine quality assurance (n ¼ 28:62.2%). The following indirect supervision
Figure 2. Perceptions of competence.
responses were found in areas that were considered outside the scope of practice for APs in radiotherapy: obtaining consent (n ¼ 17:37%), supply of medicines (n ¼ 11:23.9%) and on-treatment review (n ¼ 10:22.2%). APs were asked to indicate how helpful their supervisor was in informing their clinical practice. Differences in supervisory support for diagnostic and therapeutic radiography are demonstrated in Fig. 4 with the most of diagnostic radiography support being ‘very helpful’ (n ¼ 60:50.4%) and therapeutic radiography being ‘somewhat helpful’ (n ¼ 25:52.1%). Respondents were then asked to rate their daily supervision under certain headings as outlined in Table 6. Overall most responses were very positive. The highest numbers of responses were rated excellent for helpfulness (n ¼ 75:47.5%), approachability (n ¼ 76:48.4%), knowledge of practice (n ¼ 87:55.8%) and educational support (n ¼ 49:31.2%). Discussion Employment and recruitment of assistant practitioners (APs) Results showed the majority of APs were recruited from within their own departments, enabling helpers or support staff to develop and train into AP roles. It is assumed the support roles were replaced with new staff thereby creating a potential future source to recruit from. The recruitment of Agenda for Change band 2 support workers could impact on the training and development of APs at band 4 and therefore career development for support workers should be considered at interview, which in turn would enable managers to plan a future workforce considering the necessary skill mix in radiography. The scope of practice for APs identified that the role of the AP would fulfill the need to develop career progression opportunities for support workers.24,25 This assumption can only be met if APs continue to be sourced through internal promotion. It should be noted however that radiography vacancies have reduced over the last ten years16 thereby removing
Figure 3. Decision making.
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197
Table 3 Diagnostic radiography supervision. Area of work
Direct supervision working alongside a practitioner n (%)
Indirect supervision allowed to work independently n (%)
Not applicable n (%)
Total n (%)a
Mammography CT MRI Fluoroscopy in the clinical imaging department Fluoroscopy outside the clinical imaging department (i.e. theater) Acquisition of plain film radiographs of adults Acquisition of plain film radiographs of children Mobile x-ray acquisition
7 17 13 39 14
12 0 1 26 11
85 85 85 39 73
104 102 99 104 98
a
(6.7) (16.7) (13.1) (37.5) (14.3)
17 (16) 35 (33.7) 31 (29.5)
(11.5) (1.0) (25) (11.2)
78 (73.5) 29 (27.9) 14 (13.3)
(81.7) (83.3) (85.9) (37.5) (74.5)
11 (10.4) 40 (38.5) 60 (57.1)
(100) (100) (100) (100) (100)
106 (100) 104 (100) 105 (100)
Number and percentage of the total sample (n ¼ 119) of diagnostic assistant practitioners who responded to the question.
one of the driving forces that originally introduced and developed the AP role.15,19 It is unclear whether recruitment to the AP role has been sustained over the last ten years19 or whether it has decreased in line with the decrease in radiography vacancies. The high number of recruits from external adverts identifies a potential future source for recruitment, especially at a time where people are considering a career change due to economic downturn in certain areas of the workforce market. According to the core standard 2 for APs, candidates that have the ability should be recruited to an appropriate post of employment and training programme.26 The publication however fails to elaborate on how this ability should be assessed at interview or application. Future research should evaluate and compare the two potential sources of recruitment, those within radiography services and those entering from outside healthcare to explore implications on level of practice and supervision. Assistant practitioners (APs) working in clinical imaging Results from this study support the original notion that APs predominantly undertake plain film radiography.24 When comparing the scope of practice to the findings in relation to specific imaging procedures such as CT and MRI it was noted that small numbers of APs were allowed to work in these areas supporting radiographers and providing patient support as suggested by their scope of practice.24 APs working in CT and MRI were directly supervised and therefore not taking on the role of the radiographer. Fluoroscopy work for the AP identified concerns relating to work practices. The role of the AP during fluoroscopy procedures is to support the radiographer within the clinical department whilst working under direct supervision at all times.24 Results showed that there were a number of APs that were working in fluoroscopy outside the clinical imaging department and that approximately half of them worked under indirect supervision. Education and training of the APs do not equip them for this activity and level of responsibility and practice in this area is only recommended if there is direct supervision by a radiographer who is trained in
aspects of radiation protection including justification.24 APs performing fluoroscopic procedures without direct supervision can be held accountable if exposure in the clinical area is not controlled. Mobile x-rays are frequently performed by APs and in some instances without direct supervision. The level of responsibility required to perform mobile x-rays fall outside the scope of practice for APs. During a mobile x-ray procedure imaging techniques may have to be adjusted and the operator needs to establish and maintain a temporary control area.24 The APs performing these procedures might be competent in performing these extended roles but there is no clear indication who takes responsibility for these APs once they leave the department. Any actions taken by APs with regard to children should be under the direct supervision of a radiographer24 yet results from this study demonstrated that large numbers of APs were performing x-ray procedures on children without direct supervision. The complexity of issues relating to children and possible serious consequences of any mistakes in indirect supervision whilst taking child x-rays could have serious implications for the APs as these elements are not covered in their training. Assistant practitioners (APs) working in radiotherapy Results from AP practice in radiotherapy showed that they were frequently working as part the of the treatment team on the linear accelerator. A small number of APs were still performing tasks previously associated with the support worker or radiotherapy helper. More concerning were the number of APs that were working without direct supervision in areas such complex computer planning, obtaining consent, radical head and neck treatments as well as making decisions regarding treatment complications. This could be attributed to individuals being part of a team for an extended period of time and therefore being allowed to act as radiographers as they are deemed competent by those who supervise them daily. This could also be due to confusion that continues to exist amongst the radiography profession regarding the role and responsibilities of the APs working alongside them. Even though
Table 4 Areas of practice therapeutic radiography. Area of work
Always (Every day) n (%)
Frequently (once a week) n (%)
Seldom (once a month) n (%)
Never n (%)
NA n (%)
Total n (%)a
Reception Clinics General administration (including scheduling) Pre-treatment CTSim or conventional simulation Pre-treatment dosimetry/planning Treatment units superficial/orthovoltage Treatment units cobalt Treatment units linear accelerators Brachytherapy units (HDR)
2 1 11 9 4 6 3 39 3
2 10 12 13 4 6 0 5 1
14 10 5 10 8 18 0 1 5
25 23 18 14 28 14 19 0 24
3 (6.5) 2 (4.3) 1 (2.1) 1 (2.1) 2 (4.3) 2 (4.3) 20 (47.6) 0 10 (23.3)
46 46 47 47 46 46 42 45 43
a
(4.3) (2.2) (23.4) (19.1) (8.7) (13) (7.1) (86.7) (7)
(4.3) (21.7) (25.5) (27.7) (8.7) (13) (11.1) (2.3)
(30.4) (21.7) (10.6) (21.3) (17.4) (39.1) (2.2) (11.6)
Number and percentage of the total sample (n ¼ 48) of therapeutic assistant practitioners who responded to the question.
(54.3) (50) (38.3) (29.8) (60.9) (30.5) (45.2) (55.8)
(100) (100) (100) (100) (100) (100) (100) (100) (100)
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Table 5 Therapeutic radiography supervision. Area of work
Direct supervision working alongside a practitioner n (%)
Indirect supervision allowed to work independently n (%)
Not applicable
Total n (%)a
Elements of pre-treatment processes; for example imaging, simple dosimetry Elements of treatment delivery; protocolized and simple megavoltage, treatments. Elements of daily machine quality assurance tasks. Elements of patient support and information within clearly defined proforma Obtaining consent for radiotherapy Complex computer treatment planning e 3D or 4D dosimetry Superficial, orthovoltage or electron treatments Radical head and neck treatments Decision making regarding treatment complications Supply of medicines (supplementary prescribing) On-treatment review/patient follow-up.
28 38 8 10 8 5 32 34 28 31 9
4 5 28 34 17 6 6 4 2 11 10
14 2 9 1 21 35 8 8 16 4 26
46 45 45 45 46 46 46 46 46 46 45
a
(60.9) (84.4) (17.8) (22.2) (17.4) (10.9) (69.6) (73.9) (60.9) (67.4) (20)
(8.7) (11.1) (62.2) (75.6) (37) (13) (13) (8.7) (4.3) (23.9) (22.2)
(30.4) (4.4) (20) (2.2) (45.7) (76.1) (17.4) (17.4) (34.8) (8.7) (57.8)
(100) (100) (100) (100) (100) (100) (100) (100) (100) (100) (100)
Number and percentage of the total sample (n ¼ 48) of therapeutic assistant practitioners who responded to the question.
small number of individuals are performing these activities, it is a matter for concern as these situations involve radiation protection, patient care, treatment planning and delivery that are considered to be outside the scope of practice for APs working in radiotherapy.25 All exposures that are part of the radiotherapy process must be undertaken by someone recognised as a practitioner under IR(ME)R 2000. In 2006 the Ionizing Radiation Medical Exposure (Amendment) Regulations confirmed that a Practitioner must be a registered healthcare professional whose profession is regulated by a body as detailed within Section 25(3) of the National Health Service Reform and HealthCare Professions Act 2002. The AP is therefore legally not allowed to take on the role of the ‘Practitioner’.25 The scope of practice for assistant practitioners (APs) Skills for Health26 proposed that APs would be able to deliver elements of health and social care and undertake clinical work in domains that have previously only been within the remit of registered professionals and even though the Scope of Practice24,25 clearly identifies these areas, APs in radiography continue to work in areas that are considered outside their scope of practice, and without direct supervision. Standard 4 of the core standards for APs declare that they should be acting at the appropriate level on the career framework which implies their role should be managed under guidance.26 Guidance is recommended through standard operating procedures and protocols. APs across England might be working according to departmental protocols and procedures but these are definitely not standardized across the country as shown by the results of this study. The Scope of Practice for APs in Clinical Imaging24 and that of Radiotherapy25 was intended as a guidance document that would underline the importance of new roles in the clinical department while assisting in service delivery; neither compromising the safety of the patient nor the quality of the care. To this end the Society and
Figure 4. Supervisors informing assistant practitioner practice.
College of Radiographers developed a voluntary register for APs. The voluntary register does not regulate the role of the APs but purely acts as a method of accreditation for education and training. The voluntary register provided the Society and College of Radiographers with anecdotal evidence that some APs were working beyond their scope of practice, and that this practice was supported if accredited by the Society and College of Radiographers. It remains unclear how the voluntary register was used to inform role development or disseminated information throughout clinical practice. This contradicts the intended purpose of the Scope of Practice which claimed that statements were published as a benchmark for safe and effective practice.24,25 Therefore the Society and College of Radiographers need to clarify the use of the register for APs. If APs are working at extended levels of practice thereby taking on roles and responsibilities that traditionally fall within the scope of the radiographer it can be argued that this might have implications for the future radiography graduate employment. There seems to be an overlap between APs and band 5 Agenda for Change radiographers, where the APs have extended their role and practice and in some cases are employed at band 5. The link between role extension and pay progression will be further explored in follow-up interviews in the third phase of this study. Assistant practitioner (AP) competence and supervision APs are accountable to themselves, their employer and more importantly the people they serve.26 The core standards for APs were published after data for this study was collected, and further research would suggest comparing the core standards with those APs who were employed prior to core standards being in place. Of particular interest would be the extent of support from managers to ensure they achieve the competencies as outlined in standard 5 of the core standards for APs.26 It is the responsibility of the APs to alert the supervising radiographer to situations where they do not have the competence or confidence to undertake the relevant task26 (GEN 63 Act within the limits of your competency and authority), yet it is the responsibility of the employer to ensure that APs are not undertaking tasks for which they have not been trained. APs need to continue to develop their knowledge and practice (HSC23).26 Results from this study demonstrate that the APs are involved in decision making as they are required to (AG2)26 contribute to care planning and review and be able to (CHS 118)26 form a professional judgment on an individual’s health condition. Supportive leadership and clinical supervision are proven elements of job satisfaction.35 There seems to be a difference in diagnostic and therapeutic radiography supervisory support as perceived by the APs. This can be attributed to the different work
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Table 6 Rate of supervision in every day practice. Supervision
Excel n (%)a
Good n (%)a
Fair n (%)a
Poor n (%)a
No opinion n (%)a
Total n (%)b
Helpfulness Approachability Knowledge of practice Educational support Team Involvement Their understanding of the role of the assistant practitioner. Availability of radiographers to support you
75 76 87 49 57 40 55
58 52 52 46 58 52 60
17 19 11 33 30 38 26
5 7 2 22 10 24 15
3 3 4 7 3 3 3
158 157 156 157 158 157 159
a b
(47.5) (48.4) (55.8) (31.2) (36.1) (25.5) (34.6)
(36.7) (33.1) (33.3) (29.3) (36.7) (33.1) (37.7)
(10.8) (12.1) (7.1) (21) (19) (24.2) (16.3)
(3.2) (4.5) (1.3) (14) (6.3) (15.3) (9.4)
(1.9) (1.9) (2.6) (4.5) (1.9) (1.9) (1.9)
(100) (100) (100) (100) (100) (100) (100)
Number and percentage of respondents for each option. Number and percentage of the total sample (n ¼ 167) of assistant practitioners who responded to the question.
practices where diagnostic radiographers work independently in most cases when performing an examination whilst therapeutic radiographers always treat patients within a team setting. The AP may feel more comfortable to discuss their work in a one-to-one environment. Other studies have reported that the role of the AP had a positive effect on teamworking and has enhanced the patient experience.36 Core standards for APs require them to contribute to the effectiveness of teams (HSC 241)26 and ensure they contribute to a positive and safe working culture. It is important to remember that supervision is a quality assurance framework and not a quality control process.24 APs in this study rated supervision in a very positive light with most responses rated as excellent, except for two categories. The understanding of the role of the AP and the availability of radiographers to support APs were mostly rated good rather than excellent. In many departments radiographer support is shared with radiography students and other studies have reported that although both student radiographers and trainee assistant practitioners were treated equally there was a perception that the radiographers’ time was being spread thinly to accommodate both groups of trainees.36 The role of the AP is often not fully understood by all staff working in the department as evidence suggests that AP mentors have had to deal with other staffs’ perceptions and attitudes towards the introduction of APs.36 Availability to support APs could also be reduced if APs do not have a named supervisor at all times, which means they are required to find someone to either justify the procedure or check their images. Supervision should be done by band 6 or above, and the AP should know who is supervising them at all times.24,25 Limited numbers of senior radiographers can further hinder the AP gaining the necessary supervision. However supervision is twoway process in which both the AP and the supervisor have to ensure that safe, effective practice is carried out at all times.24,25 The responsibility for ensuring the quality and standard of the ‘episode of care’ remains with the radiographer.24,25 Conclusion This study addresses the overall aim to describe the employment practices and locality of APs in England. An extensive amount of data was collected that described the scope of practice for APs in radiography. Key findings depict the nature and variety of roles and responsibilities undertaken by APs in radiography highlighting the areas where APs are working outside their scope of practice. Although the overall response rate of 47% can be considered a limitation compared to other response rates in medical literature33,34 it should be noted that n ¼ 83 (74%) of the 112 sites who employed assistant practitioners did respond to the questionnaire. Similar response rates were found in other AP studies.35 This study was the first of its kind to identify the integration of APs in radiography across a sizable geographical region. The Society and College of Radiographers24 identified limitations in the scope of practice for APs. Mobile x-ray units,
fluoroscopy and x-rays of children were areas where the responsibility related to radiation protection and patient care and were considered beyond the scope of practice of the AP. The results of this study make it evident that many APs were frequently working within these areas. Questionnaire data also revealed that high numbers of APs were working in these areas under indirect supervision, which meant that they were allowed to work independently in these areas. The Society and College of Radiographers24 expects APs to be directly supervised. The future role development of APs in radiography can only be planned when balanced against the past driving forces that originally initiated the need for this role development. Redevelopment and role redesign were the key driving forces in the healthcare service delivery model over the last ten years.1,3,10,11,14 This explanatory study has identified a number of challenges for future workforce planning in light of the anticipated future healthcare funding and a need for further evaluation. Role redesign that took place around the scope of practice for the practitioner was governed by the professional regulator, however new roles outside the practitioner scope of practice were and are not regulated by the professional regulator. The White Paper: ‘Trust, Assurance and Safety e The Regulation of Health Professionals in the 21st Century’37 stated that entry to a professional register depended on the individual being able to demonstrate fitness to practice by securing an educational qualification and level of confidence that is recognised by a responsible professional body. The government believed that previously non-regulated professions should be subject to a system of regulation that is proportionate to the risk and benefits entailed. The AP was introduced into the Career Framework at a level midway between the Healthcare Assistant and the Professional Practitioner10 therefore no regulation applied, however, results from this study showed that APs, in some areas at least, were performing the roles of practitioners thereby placing themselves and potentially service users at risk. If APs are working at similar levels to that of radiographer practitioners there should be a regulatory system in place to monitor these roles. For the APs this would mean clear guidance on regulation and a job description that explains the extended areas of practice. APs should understand how they can be held legally accountable if they were working outside these parameters. Therefore further investigation is needed to develop criteria to determine which new roles should be the subject of statutory regulation. Although the level of education and training of the AP in radiography were explored in this study results are not included in this publication, but will be addressed in future publications. Supervision in areas of limited scope of practice was followed up in phase III of the study through semi-structured interviews and qualitative analysis. The scope of practice for APs was designed to support employers and managers in the development of these roles and provide them with a safe, effective and evidence based-framework.24,25 The scope of practice for APs needs to be reviewed in light of the recent release of Core Standards for Assistant Practitioners and the
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findings of this study. As the service delivery model continues to evolve the Society and College of Radiographers advocate the review of the workforce based on research evidence to support future developments and thereby enhancing patient service.24,25 In conclusion the reader is reminded that the focus of the study was the role of the AP in radiography. Role development in radiography however, was part of a greater national strategy for change linked to policy.1 Policy is rationalized through its implementation by managers, the health care professionals who put the policy into practice, as well as the patients who remain the core focus of any policy change.38 Therefore the results of this study should further be evaluated in light of these other elements that drive change in healthcare delivery. Acknowledgements David Sines, Pro Vice Chancellor, Faulty of Society and Health, Bucks New University, Uxbridge, Middlesex. For his contribution at the start of the study. References 1. Department of Health. The NHS plan: a plan for investment, a plan for reform. London: Department of Health; July 2000. 2000a. 2. Wanless D. Securing our future health: taking a long term view. Final report. London: HM Treasury; 2002. 3. Department of Health. Radiography skills mix. A report on the four-tier service delivery model. London: Department of Health; June 2003. 2003. 4. Tuson AE, Seddon D, Hopkins CA, Maxwell AJ. Comparing of image quality between mammograms performed by an AP and by screening radiographers. Breast Cancer Research; 2002. 4;1 Symposium Mammographicum. 5. Betts EA, Sorrell M, Faulkner T. The AP in the imaging department: a practical experience. Synergy: The Society and College of Radiographers; March 2003. 6. Forsyth L, Hunt K, McGowan D. Assistant training e a local approach to a national initiative. Synergy: The Society and College of Radiographers; December 2003. 7. Hodgson D, Graham L, Abraham M. A work-based learning programme for APs in radiotherapy. Synergy: The Society and College of Radiographers; September 2005. 8. Lee L. National health service breast screening programme. Sill mix project: diagnostic and therapeutic radiography. Synergy: The Society and College of Radiographers; August 2002. 9. Ford P. The role of support workers in the department of diagnostic imaging e service managers’ perspectives. Radiography 2004;10:259e67. 10. Department of Health. Workforce matters: a guide to role redesign in cancer services. National Health Service Modernisation Agency. London: Department of Health; 2004. 11. Department of Health. Workforce themes. Introduction to role redesign. National Health Service Modernisation Agency. London: Department of Health, 2006a. 12. Department of Health. Provisional Workforce Recommendations 2007/2008 for consultation. National Health Service Workforce Review Team June 2006. London: Department of Health, 2006b. 13. Department of Health. HR in the NHS Plan. More staff working differently. London: Department of Health; July 2002. 2002.
14. Department of Health. The NHS Cancer Plan: a plan for investment, a plan for reform. London: Department of Health; September 2000. 2000b. 15. Woodford AJ. An investigation of the impact/potential impact of a four-tier profession on the practice of radiography e a literature review. Radiography 2006;12:318e26. 16. Price RC, Le Masurier SB. Longitudinal changes in extended roles in radiography: a new perspective. Radiography 2007;13:18e29. 17. McKenna H, Hasson F, Keeney S. Patient safety and quality of care: the role of the health care assistant. Journal of Advanced Nursing 2004;12:452e9. 18. White P, McKay JC. Guidelines and legal requirements which inform role expansion in radiography. Radiography 2002;8:223e34. 19. Price RC, Miller LR, Mellor F. Longitudinal changes in extended roles in radiography. Radiography 2002;8:223e34. 20. Spilsbury K, Meyer J. Use, misuse and non-use of health care assistants: understanding the work of health care assistant in hospital setting. Journal of Nursing Management 2004;12:411e8. 21. Thornley C. A question of competence? Re-evaluating the roles of the nursing auxillary and health care assistants in the NHS. Journal of Clinical Nursing 2000;9:451e8. 22. McKenna H, Hasson F. A study of skill mix in midwifery: a multimethod approach. Journal of Advanced Nursing 2002;37(1):52e61. 23. Society and College of Radiographers. A curriculum framework for radiography. London: The Society of Radiographers; 2003. 24. Society and College of Radiographers. The scope of practice of APs in clinical imaging. London: The Society of Radiographers; 2007. 25. Society and College of Radiographers. The scope of practice of APs in radiotherapy. London: The Society of Radiographers; 2007. 26. Skills for Health. Core standards for assistant practitioners. Skills for health, 2009: [Online] http://www.skillsforhealth.org.uk[Accessed 27 04.2010.]. 27. Bergman MM. Advances in mixed methods research. theories and applications. London: Sage Publications; 2008. 28. Bryman A. Social research methods. 3rd ed. Oxford: Oxford University Press; 2008. 29. Creswell JW, Plano Clark VL. Designing and conducting mixed methods research. London: Sage Publications; 2007. 30. Boynton PM, Greenhalgh T. Hands-on guide to questionnaire research. Selecting, designing and developing your questionnaire. British Medical Journal 2004;328:1312e5. 31. Presser S, Blair J. Survey pre-testing: do different methods produce different results? Sociological Methodology 1994;24:73e104. 32. Converse JM, Presser S. Survey questions: handcrafting the standardized questionnaire. Newbury Park, CA: Sage; 1986. 33. McColl E, Jacoby A, Thomas L, Soutter J, Bamford C, Steen N, et al. Design and use of questionnaires: a review of best practice applicable to surveys of health service staff and patients. Health Technology Assessment 2001;5(31). 34. Edwards PJ, Roberts I, Clarke MJ, DiGuiseppi C, Wentz R, Kwan I, et al. Methods to increase response rates in postal and electronic questionnaires (Review). The Cochrane Collaboration. London: John Wiley & Sons, Ltd; 2009. 35. Coogle CL, Parham IA, Jablonski R, Rachel JA. Enhanced care assistant training to address the workforce crisis in home care: changes related to job satisfaction and career commitment. Care Management Journals 2007; 8(2):71e81. 36. Colthart I, McBride M, Murray M. Mentoring assistant practitioners e the radiographers perspective. Radiography 2010;16:223e9. 37. Department of Health. Trust, Assurance and Safety e The Regulation of Health Professionals in the 21st Century. White Paper. February 2007. London: Department of Health; 2007. 38. Green J, Thorogood N. Analysing health policy: a sociological approach. London: Longman; 1998.