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Exploring the transition from student to practitioner in diagnostic radiography
Radiography 22 (2016) 131e136
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Radiography journal homepage: www.elsevier.com/locate/radi
Exploring the transition from student to practitioner in diagnostic radiography S. Naylor*, C. Ferris, M. Burton Sheffield Hallam University, United Kingdom
a r t i c l e i n f o
a b s t r a c t
Article history: Received 27 May 2015 Received in revised form 11 September 2015 Accepted 19 September 2015 Available online 20 October 2015
Introduction: This study explores the expectations and experiences of newly qualified diagnostic radiographers during their transition into practice. Methods: This was a longitudinal study using interpretative phenomenological analysis methodology. Data were gathered from four students who participated in a focus group. This informed semi structured interviews with a further eight students who were interviewed prior to starting work and three times over the following twelve months. Results: Themes generated from the data included; experience, fitting in, and identity. Conclusion: This study brings to light the experiences of newly qualified diagnostic radiographers. The findings are open to theoretical generalizability and raise issues that may be used by academic staff in the preparation of students and managers who support newly qualified staff members. © 2015 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Keywords: Newly qualified Transition Professional identity Clinical education
Introduction Despite changes to pre-registration education and the organisation of services, reality shock, on entering first-post practice remains an issue for healthcare professionals.1 The transition from student to practitioner is at a decisive time for diagnostic radiographers as they embark on autonomous practice in a challenging environment and continue to develop their professional identity. The working environment for newly qualified diagnostic radiographers is unpredictable with an emphasis on high pressure, target driven practice where speed and efficiency may often conflict with patient care.2 Year on year, newly qualified diagnostic radiographers have to contend with more and more as practice which was once considered “special”, is now recognised within the range of first post competencies.3 The pre-registration, undergraduate experience is a key time for the formation of healthcare students' professional identity as, during this period, they start to become socialised into their chosen profession. Professional socialisation is the process of acquiring specialist knowledge, skills, attitudes and values and through integration into a community of practice form a coherent identity of themselves as a professional within that community.4 Freidson5
* Corresponding author. E-mail address: [email protected] (S. Naylor).
saw professionalism as an occupation that has control of its own work. This raises the issue of autonomy. There is a lack of functional autonomy when legislation necessitates adherence to routine and protocols which promotes a workplace culture of conformity and discourages creativity and flair.6 This has impacted on the professional identity of diagnostic radiography. Liaschenko and Peter7 suggested that while nursing meets many of the criteria for a profession, it does not have autonomy, and never will have the ability to control its own work. The radiography profession is in a similar situation to nurses in their relationship to the medical profession who generally maintain control over the work environment.8 Diagnostic radiography is a profession with its history grounded in the use of technology, subservience to medicine and dedication to patient care, imaging service organisation and delivery.9 Diagnostic radiography is seen to be struggling to emerge as a profession10 and in many countries remains unrecognised as such.11,12 Originally, training was undertaken in hospitals using an apprenticeship format with an emphasis on practical skill.13 After considerable struggles, the move to an all graduate entry into the profession of diagnostic radiography was achieved in 1993. Although at the heart of modern medicine,14 diagnostic radiography was the last major healthcare profession to achieve all graduate entry.15 Clinical education is an essential component of pre-registration education and training16 however undergraduate clinical experience varies across higher education institutions.17 For diagnostic
http://dx.doi.org/10.1016/j.radi.2015.09.006 1078-8174/© 2015 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
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radiography students it is important for them to spend a sustained amount of time in the same clinical environment to support their professional socialisation and prepare them for autonomous practice. An aspect of professional socialisation for diagnostic radiographers is the support they get from each other by sharing experiences9 and this cultural activity creates a potential learning environment where new staff are socialised into the relevant and diverse range of communities of practice and cultures. In addition to the challenges of change, high pressure and targets, the current economic climate frequently requires newly qualified staff to “hit the ground running”.18 This paper examines the transition of student to practitioner in diagnostic radiography. Method Interpretative Phenomenological Analysis (IPA) was used as a methodology for this study. It is concerned with a detailed examination of an individual's lived experience and how they make sense of that experience.19 Researchers using IPA believe that there is a chain of connection between a person's experiences, how they talk about that experience, how they make sense of that experience and the emotional reaction to that experience.20 The source of data collection was via a focus group and in-depth, semi-structured interviews. It was a longitudinal study, which is common for research into transition.21e23 The time period included pre and post-employment which was an approach used in previous research.24 A focus group was chosen as the initial exploratory method in preference to using current literature to inform the semi-structured interviews due to the lack of literature specific to diagnostic radiography in this area. Focus groups are commonly used in qualitative research and use the interaction between participants to discover how they think or feel about a situation.25 The semi-structured interviews were undertaken over a 12 month period which resulted in some attrition, but sufficient remained for the study. Interviews are a staple method of collecting data in qualitative research and there is a general belief that words are an adequate way to access and interpret the world.26 A single trigger question of ‘How do you think you will feel during your first months working as a diagnostic radiographer?’ was used to initiate the discussion in the focus group. The emerging themes from the focus group and interviews were used to form a guide for subsequent data collection. Volunteers were recruited into the study from a single cohort of 34 final year students undertaking BSc (Hons) Diagnostic Radiography. The undergraduate course that the participants completed was a three year course with blocks of experience in a clinical environment interspersed throughout the three years with academic sessions on the university campus. The students remained attached to one hospital for a year and went to a minimum of two hospitals within the three years. Of the eight participants recruited to the longitudinal study, seven were female and one male. This imbalance reflects the demographics of the profession. The participants were all in their twenties. All of the participants recruited for the interviews had some experience of working as students in the hospitals where they were being employed. Over the past few years 80%e90% of the students from the higher education institute from which the participants were recruited obtained employment in a hospital where they were placed as students. At the request of participants, telephone interviews became the primary source of data in this study. Apart from one person telephone interviews were preferred for convenience as once employed participants were working many different shifts and extra hours, as well as having other social pressures on their time. All the interviews were recorded and professionally transcribed
verbatim in preparation for analysis. There is no one prescribed approach to the analysis of IPA. For this study the set of guidelines provided by Smith27 were adopted and used by the first author. In order to establish the credibility of this study different strategies have been utilised including member checking, peer-review, reflexivity and by providing a rich description of the participants' accounts. Before the final interview undertaken at 12 months the participants were presented with a provisional interpretation. A list containing a summary of themes was emailed to participants for their consideration prior to interview. Peer reviewers, who were colleagues or supervisors familiar with the research or phenomena being explored, were presented with highlights of the analysis. This process challenged the analysis, prompted discussion and provided a sounding board for ideas. This ensured that there was robustness to the emerging themes. Reflexivity was used in this study as a continual process of self-reflection on personal biases, preconceived notions and assumptions.28 Using reflexivity as a thoughtful self-awareness during the research process can transform the problem of inter-subjectivity between the researcher and the researched into an opportunity to challenge and examine aspects of the research process.29 It allows the researcher to examine the effects they have on the research process.30 The higher education institute granted ethical approval for this study. Informed consent was obtained and documented prior to data collection. Maintaining anonymity can be problematic. All names have been changed in order to preserve anonymity. However, it could be rightly assumed that the researcher will use their own academic establishment and hospitals which are conveniently located.31 Thus consideration has been given to preserving anonymity during the writing of this paper which has influenced the amount of contextual detail provided about the hospitals and the participants. The following results, which are illustrated by the participants' own words, have been obtained through voluntary participation. They are an integration of the findings of the focus group and interviews. Whilst the researcher being immersed in the data could have potentially influenced the findings this has been carefully managed and it is the lived experience of the participants which is illuminated in the following results. The study used a small, purposively selected group of participants. As such there is no intention of making broad generalisations from the findings of this research. Any claims made are bound within a relatively homogenous sample. However, theoretical generalizability can be applied. The reader, using their existing professional and experiential knowledge, can consider the value of the research and its relevancy to their situation. Results Analysis of the data produced themes of experience, fitting in, and identity which are presented below. A fourth theme, supporting the transition, was also generated. In order to present a comprehensive account of this extensive topic it is discussed in a separate article.32 A schematic diagram of the themes can be seen in Fig. 1. As is common with IPA, the results are presented without reference to existing literature and separate to the discussion.33 Experience There was a general feeling of concern about working in areas where they lacked experience and a ‘fear of the unknown’ similar to that experienced by the participants of the focus group. This was particularly highlighted with regard to working out of normal working hours.
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“I think when you qualify and you do it on your own you do gain that confidence.” (Mary 2nd interviews) Although they found that doing things on their own increased their confidence, they also recognised the need for support and appeared to find no problem on asking for support when required. They were happy to seek clarification if they were unsure, either from written protocols or from the person requesting the procedure. “They were wanting me to ……… I've not done this for ages, and I said just do one with me and then I'll be fine after that, and I just, I seem to pick it up really quickly.” (Claire 3rd interviews)
Figure 1. A schematic diagram of the themes.
“I've got another on-call next week as well, so, I still worry the night before, still get a little bit worried, but no, it's going well.” (Mary 3rd interviews) Another area that caused concern initially was working in the operating theatre. “I think that that theatre was a big thing for me, I was scared about it.” (Heather 2nd interviews) With experience their confidence grew “I think being left on my own to do it I realized I can actually do it.” (Heather 2nd interviews) When they first start work newly qualified radiographers are tired and consider the imaging department to be busy. This appeared to be unexpected and something that they were unprepared for. It was interesting that three of the radiographers described the situation as ‘crazy’ and this term was used over the 12 month period. “You think you're tired as a student, but, this is crazy”. (Heather 2nd interviews) When the participants started in employment they found that they are working shift patterns that resulted in them working extra hours in a week and several weekends. Although most students gain some experience of working outside the normal working day these are not additional hours. They thus went from working 28 h a week primarily 9 am to 5 pm, to working more than a standard 37.5 h a week and covering any time during the 24 h day. “I normally get about 4 on-calls a month, but I've been working Christmas and New Year, so it's all added up, we do do quite a lot.” (Kathy 2nd interviews) The participants highlighted the need to do things on their own. They found that managing on their own increased their confidence when they had to figure things out for themselves. “I think it was just being let loose on my own and just now it's like I've no idea what I was worried about.” (Claire 2nd interviews)
There was a general concern about taking on responsibility for both them and for students once they were qualified. The most prominent additional responsibility the radiographers encountered was checking their images for technical acceptability and justifying the request cards. The case of Claire below illustrates how, although the ultimate responsibility was not hers at the time she was a student, she had practised the decision-making process and thus felt confident in taking on these additional responsibilities. Those who were concerned soon found that taking responsibility gave them job satisfaction. “It doesn't worry me actually, checking my images; I know it's a responsibility …… I feel confident enough to know now, if I don't know now I'm not really gonna know am I? … If you if you've already practised I suppose, yeah, made your own mind up before you check with them …” (Claire 1st interviews). Some imaging departments had a policy that restricted newly qualified staff from supervising students. However, in reality all the participants were supervising students after a few weeks and there was a general concern about taking responsibility for students, particularly in taking responsibility for their images. “I think they're trying their best to get them to work with seniors rather than every other radiographer, but I have been supervising them this week, it's a bit weird actually ……” (Kathy 2nd interviews) Once they had grown in confidence in checking their own images, they felt more comfortable supervising the students. “I think, once I got over checking my own films now I'm more confident checking theirs, it's just the same really.” (Kathy 3rd interviews) Assessing students was found to be difficult, particularly finding the right words to give negative feedback. This indicated that there was a development need in this area which should have possibly been fulfilled while they were still students. “I think I may be a little bit lenient. ……I try and put one or two things but it is easy to fall into the trap of just being very positive and not wanting to be so negative.” (Sam 4th interviews)
Fitting in At the focus group, where participants had not yet found employment, concerns were raised about joining a ‘cliquey’ imaging department and the need to join an established group.
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“You want to make sure you fit in and you want people to think nicely of you” (focus group) Students who were familiar with the hospital where they were being employed were much less concerned about fitting in. “They're all really nice, I think, and ‘cos I've been there for 2 years that, I do know everyone, so it's ……” (Louise 1st interviews) Some were already starting their transition while they were still students. “Since I got the job, it feels like it's totally different, …… and it's like we're part of the team when we go out with them, it doesn't really feel like I'm a student anymore.” (Claire 1st interviews) Looking back at the twelve month interview Kathy saw a drawback to such swift integration. “I think because they have integrated me into the team so well no one's really asked if I'd any problems or anything, but I haven't so …” (Kathy 4th interviews) During the transition all the participants interviewed became gradually more aware of, and involved in, departmental politics. “As a student you just think I'll leave it I know that I suppose it's not really your Department to meddle with.” (Sam 4th interviews)
Claire described a situation where she was surprised when a consultant approached her for advice about a difficult procedure. She expected the doctor to be telling her what to do rather than viewing herself as an equal professional. “The specialist who bleeped me said I'm ringing you for advice because I want to know what you want to do about where to do it.” (Claire 4th interviews) In contrast to this Emma experienced a more hierarchical attitude in a situation where a doctor refused to speak to her because she was new. “There are certain doctors, that if someone else is around who can question them, I'll get them to go, rather than me. Because I've been round to see them before and he refused to speak to me because I am new.” (Emma 3rd interviews) In addition to the transition into practice, with the exception of Mary and Louise who remained at home, the participants had other major life events occurring during the transition such as moving house, getting married and having an operation. The impact that this had on the transition has not been noted or explored and could be a topic for further research. “I've got to sort all that kind of thing out I'll be moving out with my girlfriend now so we've got to sort that out and get a house and stuff and that's … That is going to be quite difficult in a way, just choosing somewhere really.” (Sam 1st interviews)
The newly qualified diagnostic radiographers realised that they needed to get involved in issues that affected them. “There's quite a lot going off at the minute, ……I get involved really because things that they are talking about are gonna affect me for 40 e 50 years.” (Kathy 4th interviews) Identity The newly qualified diagnostic radiographers had a desire to cast off the student identity as they moved into practice. Some were concerned that they would still be treated like a student for a while once they were qualified but this was not experienced. “I will be interested to see what it is like if the people will treat you a bit studenty because you have always been a student here.” (Sam 1st interviews) After twelve months, some of them were looking to their future. “I want to do something … I either want to do MRI or I want to do something reporting to start with. I looked into it a little bit ……” (Sam 4th interviews) When the newly qualified diagnostic radiographers interacted with doctors they had different experiences. Sam had a shift in selfperception and as he gradually grew in confidence he found that he could speak to the doctors as fellow professionals. “When it's just you, and you're like, I'm not sure about this, you go and speak to a doctor and they'll convince you it's right.” (Sam 2nd interviews) “ … now, because you've had the experience of someone coming up to you and saying. “I want skull X-ray” and you are going to have to say ‘no we don't do them’ and eventually you have a list of reasons why. So that satisfies them a bit more.” (Sam 4th interviews)
Discussion The diagnostic radiographers in this study, as others have found, were well prepared for most clinical practice.34 O'Kane35 suggested that effective student placements eased transition and reduced reality shock. The lack of reality shock within diagnostic radiography could be attributed to the pattern of workplace learning undertaken as students. The participants, as students, stayed at one placement for a year before moving to another, thus they were more likely to be integrated into a community of practice through sustained engagement in that practice.17,36 This reflects the survey of new graduates undertaken by the Society of Radiographers37 who cited clinical placement as contributing to their preparedness for practice. However, due to the supernumerary status and need for supervision, clinical education cannot fully prepare the students for the reality of practice. One area that exemplified this was working in an operating theatre. As students they must always be directly supervised whilst working in theatre. With this as a contributing factor, the readiness of diagnostic radiography students for undertaking imaging procedures in theatre has been questioned.38 Once qualified, working in theatre involves entering a different community of practice as the only diagnostic radiographer. In this area they are working with other professionals and lack the immediate support of other radiographers. It was frequently mentioned about how tired the participants were. This issue was never raised prior to starting work and was possibly unexpected. Even after six months they were working extra hours and feeling tired. As mentioned earlier, due to the need for supervision and their supernumerary status, clinical education cannot fully prepare students for the reality of practice. There were many reports from the participants of being busy and this was often described as ‘crazy’. The term can mean mad or insane, and can also be used to describe a very intense situation, or feeling that
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they had more work than they can handle.39 This may have been in reality due to imaging departments being understaffed or the increased demand for imaging and radiography being a profession under pressure.17,40 However, being crazy-busy was associated with time management.41 Therefore the crazy situation might have been their perception due to being new to the reality of work and the need to develop coping strategies for busy periods, as in the study by Toal-Sullivan.42 Eraut43 suggested a different reason for feeling busy, and that the survival of newly qualified staff was dependent upon them being able to reduce their cognitive load by being able to progress quickly from deliberative modes of cognition to instant reflex modes. This was similar to the notion of Dreyfus and Dreyfus44 and Benner45 that professionals will move through a scale from novice to expert and that there is a need to develop routinized behaviour in order to reduce the pressure of work from the individual. Being familiar with a hospital, and the staff, alleviated some of the stress of starting work as a professional. The higher education institute where the participants trained has several clinical placements that work in partnership to train students. A high proportion of students found employment in a hospital where they had trained. Williams and Berry46 suggested that the timescale for full competency following qualification will be shorter for newly qualified staff members who are familiar with an imaging department. In this situation the trajectory towards full integration commences as a student. This meant that if a student towards their third year would like to find employment in a particular geographical area it would be beneficial to both students and the imaging department for them to spend some of their final year in that hospital if it can be facilitated. The participants in this study felt comfortable in taking responsibility for themselves but struggled taking responsibility for students. Supervising students takes more effort, because a practice that has become a seamless task needs to be unpicked into description and explanation to pass on to the learner.47 Some imaging departments have policies aimed at restricting the exposure of new staff to students, but in practice all participants were supervising students after only a few weeks. Studies with nurses also found that their participants felt stress at supervising students or other members of staff.48e50 Although the participants quickly became confident in supervising students, they found that, even after 12 months, there was still some anxiety at assessing students. Getting on with the people that they worked with was very important to the participants. Newton and McKenna22 identified the need to gain knowledge of social hierarchy and where a newcomer fits in. This knowledge is gained tacitly through a series of encounters which are generally set up for other purposes.51,52 The staffroom has been identified by Solomon, Boud and Rooney53 as a place where informal ‘talk’ can occur in a safe environment where hierarchy is suspended. Diagnostic radiographers readily talk to each other and share experiences which will assist with the development of cultural knowledge.54 Where a clan type culture is found it is thought to be a friendly place to work, and where some colleagues are likely to be classed as friends. It affected their enjoyment of work. There were illustrations given of ‘fitting in’ such as when others sought their opinion. A clan culture is held together by loyalty, tradition and collaboration, all of which can be seen in an imaging department where radiographers readily work together and support each other.54 Towards the end of the longitudinal study the newly qualified diagnostic radiographers were showing signs of becoming more aware of the organisation and politics within an imaging department. Most of them found that decisions were made which directly affected them and therefore they could not avoid becoming involved. As students, the
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participants were on the periphery of practice, thus shielded from the full impact of organisational culture and politics. Professional identity is a key issue in the transition from student to practitioner.55 While education is an important period in developing professional identity, graduation is not the end of the process.55 It was important to the participants of this study that they would be able to cast off the label of ‘student’ once working as a qualified member of staff. The indications from the results are that newly qualified diagnostic radiographers have some sense of professional identity on graduation but that it develops further over time. Initially they felt unsure and lacked confidence, particularly when entering different areas such as an operating theatre. The amount of self-confidence that graduates have will impact on professional identity.55 Eventually, by twelve months all participants in this study had developed enough to be able to discuss requests for imaging with doctors as a fellow professional. Professional identity could be considered a relationship between professional and personal aspects of life, which is dynamic and changeable.56 The participants in this study were developing their personal identities throughout their first year in practice. Some experienced becoming a wife, a home owner and a patient which all impacted on their identity. Conclusion This research was undertaken to explore the expectations and experiences of newly qualified diagnostic radiographers during their transition from student to practitioner. This is a short period of time in a professional's career, but one which is important, as it is during this period that they move from being a supervised student to an autonomous practitioner. It has been recognised as a difficult, stressful, but exciting period. In this current climate of a competitive market and high patient expectations it is important that this transition is swift, and effectively managed. The findings of the research will be of interest to both academic and clinical staff. It can be used to inform the development of undergraduate educational courses and support mechanisms, as it brings to light some of the issues that newly qualified staff have found problematic, such as supervising students. This qualitative study is open to theoretical generalizability, which allows the reader, using their existing professional and experiential knowledge, to consider the value of the research and its relevancy to their situation. The study indicates that experiential, situated learning is important, and a high quality hands-on clinical experience with a balance of theoretical input from a higher education institute develops autonomous, reflective practitioners. The culture of the organisation into which the newly qualified practitioners enter affects their transition. Newly qualified staff members that enter a supportive environment feel able to ask for help and advice, thus have a smoother transition than if entering a hierarchical environment where power is exercised over them. The professional identity of the diagnostic radiographers starts as a student and further develops during the transition into practice. The initial lack of confidence quickly reduces as they became more integrated into the community of practice. Further research is recommended in the following areas: As the culture of the organisation impacts on transition, exploring further the culture of imaging departments using the framework of communities of practice would be valuable. This research was undertaken on students who had been employed by one of their placement sites. Therefore, it would be useful to replicate the study with participants who are employed in different departments, and those moving directly into specialities.
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Working in an operating theatre stands out as a difficult area for some newly qualified diagnostic radiographers. Research into how best to prepare students for this experience would benefit the students and their future employer.
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Contents lists available at ScienceDirect
Radiography journal homepage: www.elsevier.com/locate/radi
Exploring the transition from student to practitioner in diagnostic radiography S. Naylor*, C. Ferris, M. Burton Sheffield Hallam University, United Kingdom
a r t i c l e i n f o
a b s t r a c t
Article history: Received 27 May 2015 Received in revised form 11 September 2015 Accepted 19 September 2015 Available online 20 October 2015
Introduction: This study explores the expectations and experiences of newly qualified diagnostic radiographers during their transition into practice. Methods: This was a longitudinal study using interpretative phenomenological analysis methodology. Data were gathered from four students who participated in a focus group. This informed semi structured interviews with a further eight students who were interviewed prior to starting work and three times over the following twelve months. Results: Themes generated from the data included; experience, fitting in, and identity. Conclusion: This study brings to light the experiences of newly qualified diagnostic radiographers. The findings are open to theoretical generalizability and raise issues that may be used by academic staff in the preparation of students and managers who support newly qualified staff members. © 2015 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Keywords: Newly qualified Transition Professional identity Clinical education
Introduction Despite changes to pre-registration education and the organisation of services, reality shock, on entering first-post practice remains an issue for healthcare professionals.1 The transition from student to practitioner is at a decisive time for diagnostic radiographers as they embark on autonomous practice in a challenging environment and continue to develop their professional identity. The working environment for newly qualified diagnostic radiographers is unpredictable with an emphasis on high pressure, target driven practice where speed and efficiency may often conflict with patient care.2 Year on year, newly qualified diagnostic radiographers have to contend with more and more as practice which was once considered “special”, is now recognised within the range of first post competencies.3 The pre-registration, undergraduate experience is a key time for the formation of healthcare students' professional identity as, during this period, they start to become socialised into their chosen profession. Professional socialisation is the process of acquiring specialist knowledge, skills, attitudes and values and through integration into a community of practice form a coherent identity of themselves as a professional within that community.4 Freidson5
* Corresponding author. E-mail address: [email protected] (S. Naylor).
saw professionalism as an occupation that has control of its own work. This raises the issue of autonomy. There is a lack of functional autonomy when legislation necessitates adherence to routine and protocols which promotes a workplace culture of conformity and discourages creativity and flair.6 This has impacted on the professional identity of diagnostic radiography. Liaschenko and Peter7 suggested that while nursing meets many of the criteria for a profession, it does not have autonomy, and never will have the ability to control its own work. The radiography profession is in a similar situation to nurses in their relationship to the medical profession who generally maintain control over the work environment.8 Diagnostic radiography is a profession with its history grounded in the use of technology, subservience to medicine and dedication to patient care, imaging service organisation and delivery.9 Diagnostic radiography is seen to be struggling to emerge as a profession10 and in many countries remains unrecognised as such.11,12 Originally, training was undertaken in hospitals using an apprenticeship format with an emphasis on practical skill.13 After considerable struggles, the move to an all graduate entry into the profession of diagnostic radiography was achieved in 1993. Although at the heart of modern medicine,14 diagnostic radiography was the last major healthcare profession to achieve all graduate entry.15 Clinical education is an essential component of pre-registration education and training16 however undergraduate clinical experience varies across higher education institutions.17 For diagnostic
http://dx.doi.org/10.1016/j.radi.2015.09.006 1078-8174/© 2015 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
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radiography students it is important for them to spend a sustained amount of time in the same clinical environment to support their professional socialisation and prepare them for autonomous practice. An aspect of professional socialisation for diagnostic radiographers is the support they get from each other by sharing experiences9 and this cultural activity creates a potential learning environment where new staff are socialised into the relevant and diverse range of communities of practice and cultures. In addition to the challenges of change, high pressure and targets, the current economic climate frequently requires newly qualified staff to “hit the ground running”.18 This paper examines the transition of student to practitioner in diagnostic radiography. Method Interpretative Phenomenological Analysis (IPA) was used as a methodology for this study. It is concerned with a detailed examination of an individual's lived experience and how they make sense of that experience.19 Researchers using IPA believe that there is a chain of connection between a person's experiences, how they talk about that experience, how they make sense of that experience and the emotional reaction to that experience.20 The source of data collection was via a focus group and in-depth, semi-structured interviews. It was a longitudinal study, which is common for research into transition.21e23 The time period included pre and post-employment which was an approach used in previous research.24 A focus group was chosen as the initial exploratory method in preference to using current literature to inform the semi-structured interviews due to the lack of literature specific to diagnostic radiography in this area. Focus groups are commonly used in qualitative research and use the interaction between participants to discover how they think or feel about a situation.25 The semi-structured interviews were undertaken over a 12 month period which resulted in some attrition, but sufficient remained for the study. Interviews are a staple method of collecting data in qualitative research and there is a general belief that words are an adequate way to access and interpret the world.26 A single trigger question of ‘How do you think you will feel during your first months working as a diagnostic radiographer?’ was used to initiate the discussion in the focus group. The emerging themes from the focus group and interviews were used to form a guide for subsequent data collection. Volunteers were recruited into the study from a single cohort of 34 final year students undertaking BSc (Hons) Diagnostic Radiography. The undergraduate course that the participants completed was a three year course with blocks of experience in a clinical environment interspersed throughout the three years with academic sessions on the university campus. The students remained attached to one hospital for a year and went to a minimum of two hospitals within the three years. Of the eight participants recruited to the longitudinal study, seven were female and one male. This imbalance reflects the demographics of the profession. The participants were all in their twenties. All of the participants recruited for the interviews had some experience of working as students in the hospitals where they were being employed. Over the past few years 80%e90% of the students from the higher education institute from which the participants were recruited obtained employment in a hospital where they were placed as students. At the request of participants, telephone interviews became the primary source of data in this study. Apart from one person telephone interviews were preferred for convenience as once employed participants were working many different shifts and extra hours, as well as having other social pressures on their time. All the interviews were recorded and professionally transcribed
verbatim in preparation for analysis. There is no one prescribed approach to the analysis of IPA. For this study the set of guidelines provided by Smith27 were adopted and used by the first author. In order to establish the credibility of this study different strategies have been utilised including member checking, peer-review, reflexivity and by providing a rich description of the participants' accounts. Before the final interview undertaken at 12 months the participants were presented with a provisional interpretation. A list containing a summary of themes was emailed to participants for their consideration prior to interview. Peer reviewers, who were colleagues or supervisors familiar with the research or phenomena being explored, were presented with highlights of the analysis. This process challenged the analysis, prompted discussion and provided a sounding board for ideas. This ensured that there was robustness to the emerging themes. Reflexivity was used in this study as a continual process of self-reflection on personal biases, preconceived notions and assumptions.28 Using reflexivity as a thoughtful self-awareness during the research process can transform the problem of inter-subjectivity between the researcher and the researched into an opportunity to challenge and examine aspects of the research process.29 It allows the researcher to examine the effects they have on the research process.30 The higher education institute granted ethical approval for this study. Informed consent was obtained and documented prior to data collection. Maintaining anonymity can be problematic. All names have been changed in order to preserve anonymity. However, it could be rightly assumed that the researcher will use their own academic establishment and hospitals which are conveniently located.31 Thus consideration has been given to preserving anonymity during the writing of this paper which has influenced the amount of contextual detail provided about the hospitals and the participants. The following results, which are illustrated by the participants' own words, have been obtained through voluntary participation. They are an integration of the findings of the focus group and interviews. Whilst the researcher being immersed in the data could have potentially influenced the findings this has been carefully managed and it is the lived experience of the participants which is illuminated in the following results. The study used a small, purposively selected group of participants. As such there is no intention of making broad generalisations from the findings of this research. Any claims made are bound within a relatively homogenous sample. However, theoretical generalizability can be applied. The reader, using their existing professional and experiential knowledge, can consider the value of the research and its relevancy to their situation. Results Analysis of the data produced themes of experience, fitting in, and identity which are presented below. A fourth theme, supporting the transition, was also generated. In order to present a comprehensive account of this extensive topic it is discussed in a separate article.32 A schematic diagram of the themes can be seen in Fig. 1. As is common with IPA, the results are presented without reference to existing literature and separate to the discussion.33 Experience There was a general feeling of concern about working in areas where they lacked experience and a ‘fear of the unknown’ similar to that experienced by the participants of the focus group. This was particularly highlighted with regard to working out of normal working hours.
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“I think when you qualify and you do it on your own you do gain that confidence.” (Mary 2nd interviews) Although they found that doing things on their own increased their confidence, they also recognised the need for support and appeared to find no problem on asking for support when required. They were happy to seek clarification if they were unsure, either from written protocols or from the person requesting the procedure. “They were wanting me to ……… I've not done this for ages, and I said just do one with me and then I'll be fine after that, and I just, I seem to pick it up really quickly.” (Claire 3rd interviews)
Figure 1. A schematic diagram of the themes.
“I've got another on-call next week as well, so, I still worry the night before, still get a little bit worried, but no, it's going well.” (Mary 3rd interviews) Another area that caused concern initially was working in the operating theatre. “I think that that theatre was a big thing for me, I was scared about it.” (Heather 2nd interviews) With experience their confidence grew “I think being left on my own to do it I realized I can actually do it.” (Heather 2nd interviews) When they first start work newly qualified radiographers are tired and consider the imaging department to be busy. This appeared to be unexpected and something that they were unprepared for. It was interesting that three of the radiographers described the situation as ‘crazy’ and this term was used over the 12 month period. “You think you're tired as a student, but, this is crazy”. (Heather 2nd interviews) When the participants started in employment they found that they are working shift patterns that resulted in them working extra hours in a week and several weekends. Although most students gain some experience of working outside the normal working day these are not additional hours. They thus went from working 28 h a week primarily 9 am to 5 pm, to working more than a standard 37.5 h a week and covering any time during the 24 h day. “I normally get about 4 on-calls a month, but I've been working Christmas and New Year, so it's all added up, we do do quite a lot.” (Kathy 2nd interviews) The participants highlighted the need to do things on their own. They found that managing on their own increased their confidence when they had to figure things out for themselves. “I think it was just being let loose on my own and just now it's like I've no idea what I was worried about.” (Claire 2nd interviews)
There was a general concern about taking on responsibility for both them and for students once they were qualified. The most prominent additional responsibility the radiographers encountered was checking their images for technical acceptability and justifying the request cards. The case of Claire below illustrates how, although the ultimate responsibility was not hers at the time she was a student, she had practised the decision-making process and thus felt confident in taking on these additional responsibilities. Those who were concerned soon found that taking responsibility gave them job satisfaction. “It doesn't worry me actually, checking my images; I know it's a responsibility …… I feel confident enough to know now, if I don't know now I'm not really gonna know am I? … If you if you've already practised I suppose, yeah, made your own mind up before you check with them …” (Claire 1st interviews). Some imaging departments had a policy that restricted newly qualified staff from supervising students. However, in reality all the participants were supervising students after a few weeks and there was a general concern about taking responsibility for students, particularly in taking responsibility for their images. “I think they're trying their best to get them to work with seniors rather than every other radiographer, but I have been supervising them this week, it's a bit weird actually ……” (Kathy 2nd interviews) Once they had grown in confidence in checking their own images, they felt more comfortable supervising the students. “I think, once I got over checking my own films now I'm more confident checking theirs, it's just the same really.” (Kathy 3rd interviews) Assessing students was found to be difficult, particularly finding the right words to give negative feedback. This indicated that there was a development need in this area which should have possibly been fulfilled while they were still students. “I think I may be a little bit lenient. ……I try and put one or two things but it is easy to fall into the trap of just being very positive and not wanting to be so negative.” (Sam 4th interviews)
Fitting in At the focus group, where participants had not yet found employment, concerns were raised about joining a ‘cliquey’ imaging department and the need to join an established group.
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“You want to make sure you fit in and you want people to think nicely of you” (focus group) Students who were familiar with the hospital where they were being employed were much less concerned about fitting in. “They're all really nice, I think, and ‘cos I've been there for 2 years that, I do know everyone, so it's ……” (Louise 1st interviews) Some were already starting their transition while they were still students. “Since I got the job, it feels like it's totally different, …… and it's like we're part of the team when we go out with them, it doesn't really feel like I'm a student anymore.” (Claire 1st interviews) Looking back at the twelve month interview Kathy saw a drawback to such swift integration. “I think because they have integrated me into the team so well no one's really asked if I'd any problems or anything, but I haven't so …” (Kathy 4th interviews) During the transition all the participants interviewed became gradually more aware of, and involved in, departmental politics. “As a student you just think I'll leave it I know that I suppose it's not really your Department to meddle with.” (Sam 4th interviews)
Claire described a situation where she was surprised when a consultant approached her for advice about a difficult procedure. She expected the doctor to be telling her what to do rather than viewing herself as an equal professional. “The specialist who bleeped me said I'm ringing you for advice because I want to know what you want to do about where to do it.” (Claire 4th interviews) In contrast to this Emma experienced a more hierarchical attitude in a situation where a doctor refused to speak to her because she was new. “There are certain doctors, that if someone else is around who can question them, I'll get them to go, rather than me. Because I've been round to see them before and he refused to speak to me because I am new.” (Emma 3rd interviews) In addition to the transition into practice, with the exception of Mary and Louise who remained at home, the participants had other major life events occurring during the transition such as moving house, getting married and having an operation. The impact that this had on the transition has not been noted or explored and could be a topic for further research. “I've got to sort all that kind of thing out I'll be moving out with my girlfriend now so we've got to sort that out and get a house and stuff and that's … That is going to be quite difficult in a way, just choosing somewhere really.” (Sam 1st interviews)
The newly qualified diagnostic radiographers realised that they needed to get involved in issues that affected them. “There's quite a lot going off at the minute, ……I get involved really because things that they are talking about are gonna affect me for 40 e 50 years.” (Kathy 4th interviews) Identity The newly qualified diagnostic radiographers had a desire to cast off the student identity as they moved into practice. Some were concerned that they would still be treated like a student for a while once they were qualified but this was not experienced. “I will be interested to see what it is like if the people will treat you a bit studenty because you have always been a student here.” (Sam 1st interviews) After twelve months, some of them were looking to their future. “I want to do something … I either want to do MRI or I want to do something reporting to start with. I looked into it a little bit ……” (Sam 4th interviews) When the newly qualified diagnostic radiographers interacted with doctors they had different experiences. Sam had a shift in selfperception and as he gradually grew in confidence he found that he could speak to the doctors as fellow professionals. “When it's just you, and you're like, I'm not sure about this, you go and speak to a doctor and they'll convince you it's right.” (Sam 2nd interviews) “ … now, because you've had the experience of someone coming up to you and saying. “I want skull X-ray” and you are going to have to say ‘no we don't do them’ and eventually you have a list of reasons why. So that satisfies them a bit more.” (Sam 4th interviews)
Discussion The diagnostic radiographers in this study, as others have found, were well prepared for most clinical practice.34 O'Kane35 suggested that effective student placements eased transition and reduced reality shock. The lack of reality shock within diagnostic radiography could be attributed to the pattern of workplace learning undertaken as students. The participants, as students, stayed at one placement for a year before moving to another, thus they were more likely to be integrated into a community of practice through sustained engagement in that practice.17,36 This reflects the survey of new graduates undertaken by the Society of Radiographers37 who cited clinical placement as contributing to their preparedness for practice. However, due to the supernumerary status and need for supervision, clinical education cannot fully prepare the students for the reality of practice. One area that exemplified this was working in an operating theatre. As students they must always be directly supervised whilst working in theatre. With this as a contributing factor, the readiness of diagnostic radiography students for undertaking imaging procedures in theatre has been questioned.38 Once qualified, working in theatre involves entering a different community of practice as the only diagnostic radiographer. In this area they are working with other professionals and lack the immediate support of other radiographers. It was frequently mentioned about how tired the participants were. This issue was never raised prior to starting work and was possibly unexpected. Even after six months they were working extra hours and feeling tired. As mentioned earlier, due to the need for supervision and their supernumerary status, clinical education cannot fully prepare students for the reality of practice. There were many reports from the participants of being busy and this was often described as ‘crazy’. The term can mean mad or insane, and can also be used to describe a very intense situation, or feeling that
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they had more work than they can handle.39 This may have been in reality due to imaging departments being understaffed or the increased demand for imaging and radiography being a profession under pressure.17,40 However, being crazy-busy was associated with time management.41 Therefore the crazy situation might have been their perception due to being new to the reality of work and the need to develop coping strategies for busy periods, as in the study by Toal-Sullivan.42 Eraut43 suggested a different reason for feeling busy, and that the survival of newly qualified staff was dependent upon them being able to reduce their cognitive load by being able to progress quickly from deliberative modes of cognition to instant reflex modes. This was similar to the notion of Dreyfus and Dreyfus44 and Benner45 that professionals will move through a scale from novice to expert and that there is a need to develop routinized behaviour in order to reduce the pressure of work from the individual. Being familiar with a hospital, and the staff, alleviated some of the stress of starting work as a professional. The higher education institute where the participants trained has several clinical placements that work in partnership to train students. A high proportion of students found employment in a hospital where they had trained. Williams and Berry46 suggested that the timescale for full competency following qualification will be shorter for newly qualified staff members who are familiar with an imaging department. In this situation the trajectory towards full integration commences as a student. This meant that if a student towards their third year would like to find employment in a particular geographical area it would be beneficial to both students and the imaging department for them to spend some of their final year in that hospital if it can be facilitated. The participants in this study felt comfortable in taking responsibility for themselves but struggled taking responsibility for students. Supervising students takes more effort, because a practice that has become a seamless task needs to be unpicked into description and explanation to pass on to the learner.47 Some imaging departments have policies aimed at restricting the exposure of new staff to students, but in practice all participants were supervising students after only a few weeks. Studies with nurses also found that their participants felt stress at supervising students or other members of staff.48e50 Although the participants quickly became confident in supervising students, they found that, even after 12 months, there was still some anxiety at assessing students. Getting on with the people that they worked with was very important to the participants. Newton and McKenna22 identified the need to gain knowledge of social hierarchy and where a newcomer fits in. This knowledge is gained tacitly through a series of encounters which are generally set up for other purposes.51,52 The staffroom has been identified by Solomon, Boud and Rooney53 as a place where informal ‘talk’ can occur in a safe environment where hierarchy is suspended. Diagnostic radiographers readily talk to each other and share experiences which will assist with the development of cultural knowledge.54 Where a clan type culture is found it is thought to be a friendly place to work, and where some colleagues are likely to be classed as friends. It affected their enjoyment of work. There were illustrations given of ‘fitting in’ such as when others sought their opinion. A clan culture is held together by loyalty, tradition and collaboration, all of which can be seen in an imaging department where radiographers readily work together and support each other.54 Towards the end of the longitudinal study the newly qualified diagnostic radiographers were showing signs of becoming more aware of the organisation and politics within an imaging department. Most of them found that decisions were made which directly affected them and therefore they could not avoid becoming involved. As students, the
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participants were on the periphery of practice, thus shielded from the full impact of organisational culture and politics. Professional identity is a key issue in the transition from student to practitioner.55 While education is an important period in developing professional identity, graduation is not the end of the process.55 It was important to the participants of this study that they would be able to cast off the label of ‘student’ once working as a qualified member of staff. The indications from the results are that newly qualified diagnostic radiographers have some sense of professional identity on graduation but that it develops further over time. Initially they felt unsure and lacked confidence, particularly when entering different areas such as an operating theatre. The amount of self-confidence that graduates have will impact on professional identity.55 Eventually, by twelve months all participants in this study had developed enough to be able to discuss requests for imaging with doctors as a fellow professional. Professional identity could be considered a relationship between professional and personal aspects of life, which is dynamic and changeable.56 The participants in this study were developing their personal identities throughout their first year in practice. Some experienced becoming a wife, a home owner and a patient which all impacted on their identity. Conclusion This research was undertaken to explore the expectations and experiences of newly qualified diagnostic radiographers during their transition from student to practitioner. This is a short period of time in a professional's career, but one which is important, as it is during this period that they move from being a supervised student to an autonomous practitioner. It has been recognised as a difficult, stressful, but exciting period. In this current climate of a competitive market and high patient expectations it is important that this transition is swift, and effectively managed. The findings of the research will be of interest to both academic and clinical staff. It can be used to inform the development of undergraduate educational courses and support mechanisms, as it brings to light some of the issues that newly qualified staff have found problematic, such as supervising students. This qualitative study is open to theoretical generalizability, which allows the reader, using their existing professional and experiential knowledge, to consider the value of the research and its relevancy to their situation. The study indicates that experiential, situated learning is important, and a high quality hands-on clinical experience with a balance of theoretical input from a higher education institute develops autonomous, reflective practitioners. The culture of the organisation into which the newly qualified practitioners enter affects their transition. Newly qualified staff members that enter a supportive environment feel able to ask for help and advice, thus have a smoother transition than if entering a hierarchical environment where power is exercised over them. The professional identity of the diagnostic radiographers starts as a student and further develops during the transition into practice. The initial lack of confidence quickly reduces as they became more integrated into the community of practice. Further research is recommended in the following areas: As the culture of the organisation impacts on transition, exploring further the culture of imaging departments using the framework of communities of practice would be valuable. This research was undertaken on students who had been employed by one of their placement sites. Therefore, it would be useful to replicate the study with participants who are employed in different departments, and those moving directly into specialities.
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Working in an operating theatre stands out as a difficult area for some newly qualified diagnostic radiographers. Research into how best to prepare students for this experience would benefit the students and their future employer.
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