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Specialism in radiography – a contemporary history of diagnostic radiography
Radiography (2009) 15, e78ee84
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journal homepage: www.elsevier.com/locate/radi
Specialism in radiography e a contemporary history of diagnostic radiography Christine Ferris* Faculty of Health & Wellbeing, Sheffield Hallam University, Robert Winston Building, Sheffield, S10 2BP, United Kingdom Received 11 July 2009; revised 24 September 2009; accepted 6 October 2009 Available online 28 October 2009
KEYWORDS Specialism; Specialisation; Career progression; History; Radiography
Abstract Aim and method: Specialism is relative comparing the unusual to a norm. Origins of radiographers’ perceptions of what is a specialism are identified. Semi-structured interviews were conducted with 21 practitioners and 10 leading voices whose combined practice span 1932e2001. Findings: Findings show that the exclusive nature of practice is influential on what is perceived as a specialism. Radiographers held career aspirations that included greater recognition, clinical involvement, autonomy and challenging work. Career aspirations were clinical rather than managerial and extended across modality boundaries. A key barrier to career progression was inequality of opportunity as local medical career requirements were dominant. Characteristics of specialism of diagnostic radiography are identified. Factors influencing the formation of specialism are also identified. Summary: Specialisation was dominant but not necessarily constructive to career progression or additional autonomy. Specialism relates to new areas of practice and is facilitated by service need, clear practice boundaries, visionary management, medical support, role development leading to increased autonomy and additional training and education. ª 2009 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Introduction Specialisation is a response to change and emphasises difference.1 As a profession, radiography has responded to changes in working conditions, technology, tasks, opportunities and structures. How radiographers specialised affected their careers. Over time, new roles and practice boundaries emerged through policy initiatives,
* Tel.: þ44 114 225 2401. E-mail address: [email protected]
technological advances, professional agenda2 and education strategy.3 Little is known about radiographers’ experiences of specialisation or the roots of specialism in diagnostic radiography. This paper on contemporary history uses interviews to explore how and why radiographers have specialised spanning the years 1932e2000. It explores what has facilitated and hindered specialisation in diagnostic radiography. ‘‘Specialism’’ relates to practice which is exclusive or exceptional.4 Radiographers see some practices, which were once considered special, to be the norm e.g. intravenous urography (IVU) and Computed Tomography (CT).
1078-8174/$ - see front matter ª 2009 The College of Radiographers. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.radi.2009.10.006
Specialism in radiography From outside the profession, the whole of radiography is considered special as it is seen to be exclusive.5e7 Identifying norms in radiographic practice and therefore, what is exceptional is problematic. Using principles of ethnography and historiography, this article discusses the origins of specialism in diagnostic radiography. The term ‘‘specialism’’ is used throughout this paper to reflect the terminology used in Stevens8 and Rosen9 on whose work this study is based. Radiography and radiology are interdependent. Radiology is a medical specialism that shapes the division of labour between radiology and radiography.10 Medical specialism is complex, divisive, and influential8 with dynamic and reactive characteristics that are linked to an increase in remuneration promoting status and recognition within and outside the medical profession.9 Given the close relationship between radiography and radiology, it may be anticipated that they could share similar value systems that identify a specialism. It is unknown to what extent specialism in diagnostic radiography emulates that of medicine.
Method A semi-structured interview was used to generate data in two phases. One researcher was involved in the generation, recording, transcription and analysis of data in both phases. The interviews were conducted in 2000 and 2001. Analysis was by hand and common themes were extracted.
Phase one Criterion-based, purposive sampling was used to identify interviewees who could offer specific, detailed accounts of their practice.11,12 Twenty-one practitioners were interviewed, their collective practice covering almost seventy years, 1932e2001. It was easier to access retired male radiographers probably due to their longer careers. Female radiographers tended to experience discontinuous work histories due to family commitments and were, therefore, more difficult to access. Particular attention was given to maintaining a gender balance in the resultant sample of 8 males and 13 females. Gender differences between radiographers had a significant impact on the radiographer’s role as masculine skills, technology and associated working conditions and practices were prioritised over patient groups and associated patient centred challenges. The impact of gender difference is overtly apparent until the 1980s. The data was analysed using a thematic approach identifying the following fields of specialism in diagnostic radiography:
Forensic Ultrasound Angiography Mammography Contrast agent studies Paediatrics Nuclear medicine Radiographer reporting Trauma
e79 Neuroradiography Dental CT
Phase two For each specialism, it was attempted to identify a leading voice with a national reputation for that area. Through communication with representatives of a range of Specialist Interest Groups (SIG) affiliated to the Society and College of Radiographers, 10 leading voices were identified. Each was interviewed using semi-structured questions. Interestingly, it was not possible to identify a national spokesperson for CT or Dental. On enquiry about neuroradiography the professional body advised contact with the SIG representing MRI. Participation in this study was voluntary with informed consent and the opportunity to withdraw at any time. Application of the key principles of credibility, transferability, dependability and conformability of the research maximised the trustworthiness of the data collection and analysis.13 This article aims to honour the stories told and give meaning to practitioners’ experiences and their lives.14 Pseudonyms are used throughout.
Findings and discussion Job satisfaction was an important feature. Interviewees gained increased job satisfaction from practice that was challenging, held professional recognition, gave increased clinical involvement and autonomy. Specifically, practice that:
expanded skills and knowledge had a patient centred approach was in a stimulating environment had an enquiry orientated approach increased responsibility had complex and demanding tasks encouraged role development had skill mix.
Opportunities to fulfil such career aspirations and challenges seemed patchy, despite Government policy to enable and empower Allied Health Professionals (AHPs)15,16 demonstrating a mismatch between local practice and national policy. Career opportunities were locally restricted, clinical career advancement was not encouraged unlike progression into managerial positions, and local, medical training needs took precedence over radiographic roles, and, subsequently, service development. Generally, specialist practice identified by imaging modality restricted career opportunities but predominates in the aspirations of the newly qualified. Career advancement was encouraged through managerial development but this was not as welcome as clinical development. ‘‘I suspect I am far better developed managerially than a lot of people at superintendent level in other places. Having said that, I don’t get the clinical specialism that they do as a pay off.’’ Stephen
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C. Ferris
Clinical development was preferable but problematic. Kathleen was employed at a large city hospital where radiology training restricted the opportunities for her progression.
or two people who were possibly superintendents, .. were incredibly specialised. Yet at another hospital I worked at we rotated through,..’’
‘‘IV injections. This is something that I know is a speciality nowadays which I’ve tried very hard to be able to, to ask to be trained but because I work in a teaching hospital we’ve got registrar radiologists who like to do all these things and we haven’t been given the option.’’ Kathleen
Radiographers who practised radiographer-led contrast agent studies such as barium work did not spend all their time performing this practice and this appeared to be a barrier to its recognition as a specialism.
Stephen talks of inequality of opportunity, ‘‘..a political and geographical lottery. Some places give the people who want development and let them get there, other places it is either competitive, very restricted and resource limited.’’ Career advancement through role development was controlled locally by radiology as radiologists maintained local control of practice boundaries guiding radiographer development to aid the requirements and values of radiology. Some radiologists did not support radiographic role development and actively inhibited it whereas some encouraged clinical role development. Where there was a team of radiologists with differing opinions, this created a hostile work environment for the radiographers. Where there were medical students or trainee radiologists, their training took priority to the extent that it inhibited radiographic career opportunities.
Characteristics of specialisms Thematic analysis identified characteristics of specialism in diagnostic radiography. The greater the number of characteristics recognised, the more likely it was to be regarded as a specialism by the interviewees. The characteristics included full time commitment, the capacity of a subject to divide, practice that was challenging and gave the radiographer clinical autonomy, a need for additional training and education. Practice had to be seen as separate to what was considered routine radiographic practice and include multidisciplinary team working and service development. Some confusion about what constitutes a specialism in diagnostic radiography is apparent.
Full time commitment The amount of time committed to a field is dependent on how staff are distributed throughout the department. Staff may rotate through particular fields or each field may have dedicated staff. Where dedicated radiographers were employed, their practice was more likely to be considered a specialism. They were regarded as being knowledgeable and expert in their field. Interviewees became confused where similar practice was carried out on a part time basis and became unsure as to whether any part time practice could be considered as a specialism. Christopher, a newly qualified radiographer, had experience of CT duties being regarded as routine in one hospital and exclusive in another where there was dedicated staff. ‘‘Where I work, . people who work in CT, work there all the time and it’s kind of their empire. . the odd one
‘‘. to go into ultrasound or CT you go into that area one hundred per cent. You don’t split yourself between one or two areas whereas we are still in the position where if you want to take on this role.. then we have to do that and something else. So it’s not an area we would work in one hundred per cent. And maybe that is something that will have to come in the future in order for us to be properly recognised.’’ Where radiographers conducted additional diagnostic tests this increased their time commitment and a specialism became more easily recognisable.
Capacity to divide Some fields of practice were easily divided into other recognisable fields such as ultrasound (obstetric, abdominal, vascular etc), MRI (neurological, orthopaedic, trauma etc) and radiographer reporting (trauma, mammography, gastro-intestinal etc). Such fields were more likely to be considered as a specialism. Arthur highlights the incompatibility of anatomical divisions of conventional radiography although this remains an issue.17 ‘‘You see the path lab people, ...they separated each branch of their work but we didn’t .. you couldn’t be head of a finger X-ray.’’ Ultrasound, however, was seen as different. Ultrasound knowledge and practice grew linked to a particular medical specialism resulting in anatomical divisions such as:
obstetric and gynaecological cardiac vascular abdominal.
‘‘It would be impossible or impractical for everyone who comes out with a postgraduate diploma in medical ultrasound to be an expert or to be competent in more than two areas of ultrasound because there’s so much in each area now’’ Leading voice in ultrasound Similar anatomical divisions are identified in angiography and MRI. ‘‘..angiography has split into cardiology and vascular.’’ Leading voice in angiography ‘‘You may find that there are neuro MR radiographers’’ Leading voice in MRI Anatomical divisions reflect the historical anatomical model concept of disease that created acceptable boundaries of medical practice creating a range of discrete medical specialism.9
Specialism in radiography
The challenge and autonomy of practice The role of the radiographer was gradually reduced to be less challenging. Less complex technology encouraged an increase in the direct involvement of medicine. The problem-solving and decision-making contributions of the radiographer were reduced during image acquisition and processing. However where radiographers formally gave their opinion on image appearances, practice was seen as a welcome challenge. Where reporting occurred in the main imaging department the organisation of work became challenging requiring visionary mangement. ‘‘ We originally could not see how it would work, just having two members of staff who could report certain films, but they kept at it and we found a way around and fingers crossed we have extended that now.’’ Claire Radiographers associated autonomous practice with CT, MRI, ultrasound, mammography, forensic investigations and trauma work. Increased autonomy was attractive. Robert talks of moving into CT or MRI where, ‘‘..you can be a bit more of your own boss.’’. Radiographer autonomy improved trauma and mammography services although it became more difficult for radiographers to lead service change (leading voices e trauma and mammography). The level of autonomy relied on the local radiologists and, because of the selective offloading of their medical tasks, ‘‘..we can’t possibly be independent practitioners.’’ (Leading voice e trauma). Autonomy did not extend to role choice. As radiographer autonomy increased, medical involvement decreased and the associated field of practice was more likely to be seen as a specialism. For early practitioners radiological direction was rarely available. A number mention the importance of helping casualty officers. In the late 1930s and early ’40s, Bonnie was taught to do radiography by a surgeon who also reported the films. In the 1960s through to the early ’90s, Elizabeth would identify abnormalities to referring clinicians. Carole reflects on her experience in the 1960s. ‘‘I think in a lot of cases the radiographer can diagnose radiographs much better than the doctors, not necessarily better than the radiologists, but they can go to a radiologist if they have doubts.. Interviewees reported that their opinions of radiographers were used by referring clinicians in paediatrics and bladder pressure studies. Standardisation of radiographic technique supported radiological control over radiography. K C Clark18 was instrumental in providing the original comprehensive text showing the standard elements for each anatomical area and procedure. This technical efficiency helped to reduce radiographic practice to technical and anatomical factors and supported the reporting tasks of radiologists. Medicine valued the controlled, reproducible experiment at that time. Howell19 suggests that viewing results of experiments in the absence of the patient dehumanises the patient into
e81 ‘‘organs, symptoms or diseases’’ (p131) Interviewees identify that in radiography this approach also dehumanised the radiographer making them components in a production line. Radiographers valued their skills in patient care and put a high value on patient contact Initially, radiologists did not control what happened in the X-ray room but in the late 1970s and early ’80s, interviewees notice a change. Radiologists started to selectively reduce radiographic responsibilities. Debbie reports the reduction of radiographic duties in angiography. User friendly equipment encouraged radiologists to become more interested in developing their technical skills. Similarly, the leading voice in angiography tells of cardiologists using angiographic equipment. Interviewees report similar reductions in decision-making in IVUs encouraging them to leave conventional radiography for more autonomous work in obstetric ultrasound and angiography. The leading voice in angiography states: ‘‘.I think when I trained in the ‘60s and possibly even before in the ‘50s ...., we were in charge of it all. We did what we had been trained to do. We did the views we thought were best for the patient. We were left with examinations to complete without having to have our films checked all the way, it was our responsibility, we had much more responsibility than when I came back, I was appalled to have to go and run after a house officer.’’ Less decision-making frustrated radiographers. They felt that their competence was not used wisely and their skills were abused. Radiologists encouraged role development to enable radiographers to undertake tasks previously done by radiology, but only at times of radiological shortage. Once a full complement of radiologists was reached; ‘‘..they (radiologists) just took it (reporting) off us,’’ (Robert). Such deskilling was in direct contradiction to DoH policies and initiatives that advocate AHP role development.20e22 Rosen10 identifies that medical specialists strategically select tasks that are of value in maintaining a difference between medical specialisms. In the future, reporting skills may be of little value to radiology to maintain its own specialism as Computer Aided Diagnostics develop.23e25 Radiographic reporting skills were required to also cope with an increase in radiologists’ workloads.26 Dixon27 warned of radiographers emulating radiologists. Leading voices mention radiographers expandeding their skill repertoire to include endoscopy,28 patient assessment, biopsy29 and radiographer-led one-stop minor injury departments.30 The shortage of radiologists locally was a significant influence on Betty’s practice. Of the two radiologists, one was in favour of radiographer role expansion but the other not. Local radiological definitions inhibited the high expectations of new radiographers. According to one manager, ‘‘yes, you are an independent health care practitioner, but the radiologists are not going to let you practise like that.’’ (Debbie)
e82 When interviewees report the introduction of new technology, radiology dictate its inclusion into practice. Robert’s experience in the late 1970s was of the introduction of ultrasonic ‘‘A’’ scope cranial study to detect head injury. This experience launched Robert into a career in obstetric ultrasound. ‘‘you used to stand at the side watching, . eventually he said do you want a go and I said I haven’t got a clue what I’m doing and he said well I’ll show you but he hadn’t got any patience you know? And I had a go at one or two and they seemed to be alright but I must admit I didn’t know how to interpret the scope.. Eventually he got fed up of doing them or he hadn’t got as much time to do them as he wanted and he used to get requests from ITU (Intensive Treatment Unit). so I never looked back from there. It went from ‘‘A’’ scope scanning right up to when the obstetric department started up...’’ The leading voice in ultrasound recalls user friendly, real-time ultrasound machines, which replaced the B scanner, a difficult machine to negotiate and time consuming to use. Radiologists became more interested in ultrasound once the equipment became user friendly. Prior to this, there was little clinical support for isolated radiographers practising ultrasound who formed their own support network, as did the radiographers in the early days of X-ray work. Radiologists governed the boundaries of radiography practice in new imaging modalities such as ultrasound and in other areas where previously radiological tasks were offloaded to radiographers. Claire recalls how radiographers in the department first undertook barium studies where she works. ‘‘They (radiologists) were very negative at first but we were fortunate in that the clinical director was for it and he laid the ground rules for it. He was a radiologist, the others would have nothing to do with it at first. I think we started with barium meals, and he was the only one who would report the. He trained the radiographers practically and it just gradually opened up.’’ Radiographers performing tasks previously undertaken by radiologists experienced difficulties when a new radiologist was appointed who did not agree on the labour boundaries. The leading voice in mammography felt that in such circumstances the radiographer’s role should discontinue, as a radiologist could make the working life of a radiographer very uncomfortable. The influence of radiology was far reaching. Jane practised in a teaching hospital where radiological registrars trained. Although previous research shows no statistically significant difference between teaching and non-teaching hospitals, Jane found securing role development difficult.31 Her work was tedious and, although not permitted to perform fluoroscopy, had to supervise registrars learning fluoroscopy. This reduced her morale and caused her to leave her job. Paradoxically the leading voice in contrast agent studies perceives a teaching hospital environment to be beneficial to role development as the large number of cases justify the deployment of dedicated staff to focused fields of practice.
C. Ferris
Change over time Interviewees identified changes in all specialisms with the exception of paediatrics and dental radiography. One gave the example of neuroradiography as a specialism which closed with the emergence of CT and MRI and subsequently re-emerged as a specialism in MRI. In A&E services a requirement for multi-modality skills and knowledge emerges. ‘‘Where you try and get an A&E Senior 1, it is very difficult, because they perceive a loss of modalities to do that. The development pathway for the A&E Superintendent and Senior 1 includes all the modalities, on the grounds that trauma patients go through those areas. Trauma does not stop at the A&E..’’ Leading voice e trauma The leading voice in paediatrics regarded CT as a specialism at one time but then reconsidered its status saying that it should be combined with trauma services. One interviewee acknowledged that forensic radiography evolved as a specialism when radiographers acquired a greater understanding of its context.
Training and education Post qualification education and training became a clear indication of specialism to radiographers. Interviewees comment on the requirement in forensic, ultrasound, angiography, mammography, radiographer-led contrast agent studies, nuclear medicine, MRI, radiographer reporting and CT but not paediatric, trauma or dental work. A range of opportunities were available from in-house courses with local credibility to postgraduate qualifications with international recognition. The leading voice in paediatrics and the leading voice in trauma talk of the difficulties of getting recognition for paediatrics and trauma as career pathways, primarily because they required multi-modality expertise. The leading voice in trauma recognised the need for an A&E radiographer to have some ultrasound skills to diagnose aneurysm and abnormal fluid collection and negotiated with ultrasound education providers to deliver elements of skills and knowledge for an A&E-focused scope of ultrasound practice.
Perceived as separate The perception of separateness is a key feature in responses. The first indication of separateness came with the professional acknowledgement of different training requirements for radiotherapy radiographers as radiotherapy services became centralised. Centralisation of services offers increased opportunity for the formation of radiography specialism as in medicine.9 In such an environment, the focus of practice is clearly articulated internally to the profession and externally to the outside world. Where practice was conducted without the backdrop of a specialist hospital, some practitioners struggled with the notion of specialism as they undertook ‘‘everything’’ autonomously from plain radiography to more complex procedures. This extended into the 1960s.
Specialism in radiography ‘‘I came from an age when most radiographers did everything anyway and there wasn’t so much specialisation.’’ (Leading voice e paediatrics). It is easy to separate fields of diagnostic radiography with physical boundaries. X-radiation and magnetic fields require clear demarcation and provide visible practice boundaries. Such boundaries impacted on the organisation of work and superseded individual, patient and service needs. Radiographers valued physical boundaries because they represented a traditional career structure that had professional and medical acknowledgement. By virtue of such physical boundaries, specialism became linked to ultrasound, angiography, mammography, radiographer-led contrast agent studies, nuclear medicine, MRI, CT and dental radiography. Staff using the separate imaging modalities became exclusively associated with them. However this detracted from patientcentred service provision. The leading voice in trauma recounts the struggle to supply ultrasound services to an A&E department. Sonographers had difficulty relating to A&E provision and equally, radiographers had difficulty with a partial association with ultrasound as such practice was not reflected in the career structure of the time. This disassociation between imaging modalities and services inhibited service and role development, and radiographer involvement in A&E services. Career development for radiographers in A&E is seen as linked to the development of reporting skills. Radiographer reporting was perceived as separate by many interviewees. The leading voice in radiographer reporting felt that it identified radiographers as a separate group which was more obvious when the radiographer followed traditional radiological behaviour using reporting facilities away from patients. Radiographer reporting can be conducted in the imaging room, a viewing area or in isolation perhaps in a private study emulating radiological practice. How work is seen to be organised is influential in identifying the physical boundaries so important to the identification of specialism. Some fields of practice, although considered special to some interviewees were not considered as such by others where the practice was perceived to be fused into everyday work. Forensic, paediatric, and trauma work is rarely considered as a specialism by interviewees as many struggled to see this practice as separate to the norm. The 24 h imaging service did not allow sufficient separation of these areas to enable their identification as specialisms. Forensic work had insufficient density. Paediatric radiography was unworkable as a specialism despite recognition that children required separate facilities. Trauma was equally difficult to separate, ‘‘It’s (trauma) such a big part of the workload you see. I think it’s very difficult to actually separate that out from a lot of the things we do.’’ Leading voice in contrast agent studies One acceptable way of separating work from what might be considered usual was to associate it with a specialist institution. The symbiotic relationship of medical specialism and specialist institution supports and emphasises separate provision to the extent that associated radiographic practice is similarly considered a specialism.9 This results in two levels of practice between specialist and general hospitals.
e83
Multi-disciplinary team working External recognition of specialism is powerful. Inter-professional recognition and acknowledgement of skill builds the trust and confidence required in multi-disciplinary teamwork. ‘‘.it cannot be that their expert clinical practice is because of their ability to take a chest X-ray or produce an ultrasound image. Its got to be that they can undertake the whole examination from accepting the referral to be able to undertake the imaging process but be able to provide the final step which is to provide the interpretation and then discuss it with clinical colleagues in a multi-disciplinary team meeting.’’ Leading voice e radiographer reporting Multi-disciplinary teamwork required the radiographer to move and think beyond the physical boundaries imposed by technology and the Imaging Department. Skill mix in A&E services was seen as important, with reporting radiographers able to contribute effectively to discussions on individual cases. Similarly, gastro-intestinal imaging has emerged requiring radiographers to contribute to case conferences and attracting the respect of branches of medicine other than radiology.32
Potential to grow in parallel with service provision The service contribution made by radiographers, although potentially high, was criticised as being too technologically controlled, reducing the radiographers’ input.21 The leading voice in nuclear medicine acknowledged the potential of the expansion of radiographer input into gastro-intestinal and breast care services. Where this occurred it was rapid. The leading voice in contrast agent studies acknowledged that the identification of a gastro-intestinal radiographer enabled practice to be expanded to incorporate CT colonoscopy "and become more GI specialised." Radiographers were aware that their development was being, ‘‘...driven by the needs of the service rather than the individual.’’ (Stephen). Where there was visionary management, and a justifiable service need, role development occurred paving the way for a recognised specialism. The leading voice in contrast agent studies predicted the imaging needs in the gastro-intestinal service and therefore the potential for radiographic role development. Similarly in breast care services, the role of the radiographer expanded to include reporting and biopsy techniques. The leading voice in mammography explained that as the number of clients requiring the service increased, the staff base had to reorganise their skill mix and in-house training by the radiologist supported the development of the role to include more challenging tasks giving increased autonomy.
Summary The concept of specialism is complex, relative, dynamic and dominant. It has shaped careers, controlled job satisfaction, and impacted on staff retention. The findings show
e84 that specialisation in radiography has not necessarily been constructive to career progression, patient centred care or additional autonomy. Perceptions about specialism in radiography originate in exclusive and restricted practice and change as new imaging technology and associated tasks are introduced. At the time when the interviews were conducted, there was confusion as advanced practice and expanding roles began to emerge. Advanced practice was not a clearly defined phase of a radiographer’s career structure at that time and imaging modalities provided safe career choices. Specialism is clearly linked to new areas of practice whether these are technologies, procedures or tasks. Over time, radiographers have forged new paths that attract multi-professional recognition and blur practice boundaries with other professions. This research suggests that radiographers can expand their role to include tasks previously undertaken by medicine, other health professionals and tasks in new areas of diagnosis paving the way for the formation of a specialism. In the past, this has been successful where there has been service need, clear practice boundaries, visionary management, medical support, role development leading to increased autonomy and additional training and education.
References 1. Bahm A. The specialist. Wasani: The Macmillan Company of India Ltd; 1977. 2. Cameron A, Masterson A. Role development: the drivers for change. Synergy; 2002:12e5. Jun. 3. College of Radiographers (2005) Clinical Imaging Radiotherapy and Oncology e education strategy. 4. Simpson JA, Weiner ESC. In: The Oxford English dictionary. 2nd ed., vol. XVI. Oxford: Clarendon Press; 1995. 5. Moodie I. Fifty years of history. London: The Society of Radiographers; 1970. 6. Watson A. All change for tomorrow. Radiography 1985;51(600): 289e300. Nov/Dec. 7. Carr D, Fell K. The future for radiographic practice. The British Journal of Radiology; 1997:S187e93. Special Issue November. 8. Stevens R. American medicine and the public interest e a history of specialization. London: University of California Press; 1988. 9. Rosen G. The specialization of medicine with particular reference to ophthalmology. New York: Froben Press; 1944. 10. Larkin G. Occupational monopoly and modern medicine. London: Tavistock Publications; 1983.
C. Ferris 11. Goetze J, LeCompte M. Ethnography and qualitative design in educational research. Orlando: Academic Press; 1984. 12. Coyne F. Sampling in qualitative research. Purposeful and theoretical sampling; merging or clear boundaries? Journal of Advanced Nursing 1997;26:623e30. 13. Lincoln YS, Guba EG. Naturalistic inquiry. Newbury Park: Sage; 1985. 14. Embden C. Theoretical perspectives on narrative inquiry. Collegian 1998;5(2):30e5. 15. HMSO. The NHS plan. Department of Health; 2000. 16. HMSO. Meeting the challenge: a strategy for the allied health professions. Department of Health; 2000. 17. Snaith B. General radiography e speciality status at last? Imaging and Oncology; 2005:27. 18. Clarke KC. Positioning in radiography. London: Heinemann; 1949. 19. Howell J. Technology in the hospital: transforming patient care in the early twentieth century. New York: John Hopkins University Press; 1996. 20. Department of Health. Advance letter PAM (PTA) 2/2001. Department of Health; 2001. 21. Department of Health. The role of healthcare professionals within critical care services, critical care programme. AHP and HCS Advisory Group; 2002. 22. Department of Health. A proposal to develop a national framework for assistant practitioners and advanced practitioners. Workforce Development Confederation; 2003. 23. Synergy. CAD shows promise in CT detection of early lung cancer. Synergy; 2002:5. February. 24. Flowers C. CAD in mammography. Synergy; 2001:17. December. 25. Cowen A. A tutorial on digital mammography imaging equipment part 2: developments in digital support technologies. Radiography 1998;4:239e49. 26. Price R. Radiographers meet ‘‘old’’ challenge. Radiography 1998;4:237e8. 27. Dixon AM. Letters. Synergy News; 1998. February 1998. 28. Pearson J. What is GIRSIG? Synergy News; 2003:14. February 2003. 29. Synergy News. First consultant in breast screening services. Synergy News; 2004:1. May. 30. Synergy News (2004) ‘‘Tackling the challenge of the four hour emergency wait target’’ Trauma imaging group, radiology service improvements team and the emergency services collaborative workshop 23 March 2004 in Synergy News May p16. 31. Price R, Miller L, Mellor F. Longitudinal changes in extended roles in radiography. Radiography 2002;8:223e34. 32. Nightingale J, Hogg P. GI imaging for radiographers: current practice and future possibilities. Synergy; 2000: 16e9. Dec.
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/radi
Specialism in radiography e a contemporary history of diagnostic radiography Christine Ferris* Faculty of Health & Wellbeing, Sheffield Hallam University, Robert Winston Building, Sheffield, S10 2BP, United Kingdom Received 11 July 2009; revised 24 September 2009; accepted 6 October 2009 Available online 28 October 2009
KEYWORDS Specialism; Specialisation; Career progression; History; Radiography
Abstract Aim and method: Specialism is relative comparing the unusual to a norm. Origins of radiographers’ perceptions of what is a specialism are identified. Semi-structured interviews were conducted with 21 practitioners and 10 leading voices whose combined practice span 1932e2001. Findings: Findings show that the exclusive nature of practice is influential on what is perceived as a specialism. Radiographers held career aspirations that included greater recognition, clinical involvement, autonomy and challenging work. Career aspirations were clinical rather than managerial and extended across modality boundaries. A key barrier to career progression was inequality of opportunity as local medical career requirements were dominant. Characteristics of specialism of diagnostic radiography are identified. Factors influencing the formation of specialism are also identified. Summary: Specialisation was dominant but not necessarily constructive to career progression or additional autonomy. Specialism relates to new areas of practice and is facilitated by service need, clear practice boundaries, visionary management, medical support, role development leading to increased autonomy and additional training and education. ª 2009 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Introduction Specialisation is a response to change and emphasises difference.1 As a profession, radiography has responded to changes in working conditions, technology, tasks, opportunities and structures. How radiographers specialised affected their careers. Over time, new roles and practice boundaries emerged through policy initiatives,
* Tel.: þ44 114 225 2401. E-mail address: [email protected]
technological advances, professional agenda2 and education strategy.3 Little is known about radiographers’ experiences of specialisation or the roots of specialism in diagnostic radiography. This paper on contemporary history uses interviews to explore how and why radiographers have specialised spanning the years 1932e2000. It explores what has facilitated and hindered specialisation in diagnostic radiography. ‘‘Specialism’’ relates to practice which is exclusive or exceptional.4 Radiographers see some practices, which were once considered special, to be the norm e.g. intravenous urography (IVU) and Computed Tomography (CT).
1078-8174/$ - see front matter ª 2009 The College of Radiographers. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.radi.2009.10.006
Specialism in radiography From outside the profession, the whole of radiography is considered special as it is seen to be exclusive.5e7 Identifying norms in radiographic practice and therefore, what is exceptional is problematic. Using principles of ethnography and historiography, this article discusses the origins of specialism in diagnostic radiography. The term ‘‘specialism’’ is used throughout this paper to reflect the terminology used in Stevens8 and Rosen9 on whose work this study is based. Radiography and radiology are interdependent. Radiology is a medical specialism that shapes the division of labour between radiology and radiography.10 Medical specialism is complex, divisive, and influential8 with dynamic and reactive characteristics that are linked to an increase in remuneration promoting status and recognition within and outside the medical profession.9 Given the close relationship between radiography and radiology, it may be anticipated that they could share similar value systems that identify a specialism. It is unknown to what extent specialism in diagnostic radiography emulates that of medicine.
Method A semi-structured interview was used to generate data in two phases. One researcher was involved in the generation, recording, transcription and analysis of data in both phases. The interviews were conducted in 2000 and 2001. Analysis was by hand and common themes were extracted.
Phase one Criterion-based, purposive sampling was used to identify interviewees who could offer specific, detailed accounts of their practice.11,12 Twenty-one practitioners were interviewed, their collective practice covering almost seventy years, 1932e2001. It was easier to access retired male radiographers probably due to their longer careers. Female radiographers tended to experience discontinuous work histories due to family commitments and were, therefore, more difficult to access. Particular attention was given to maintaining a gender balance in the resultant sample of 8 males and 13 females. Gender differences between radiographers had a significant impact on the radiographer’s role as masculine skills, technology and associated working conditions and practices were prioritised over patient groups and associated patient centred challenges. The impact of gender difference is overtly apparent until the 1980s. The data was analysed using a thematic approach identifying the following fields of specialism in diagnostic radiography:
Forensic Ultrasound Angiography Mammography Contrast agent studies Paediatrics Nuclear medicine Radiographer reporting Trauma
e79 Neuroradiography Dental CT
Phase two For each specialism, it was attempted to identify a leading voice with a national reputation for that area. Through communication with representatives of a range of Specialist Interest Groups (SIG) affiliated to the Society and College of Radiographers, 10 leading voices were identified. Each was interviewed using semi-structured questions. Interestingly, it was not possible to identify a national spokesperson for CT or Dental. On enquiry about neuroradiography the professional body advised contact with the SIG representing MRI. Participation in this study was voluntary with informed consent and the opportunity to withdraw at any time. Application of the key principles of credibility, transferability, dependability and conformability of the research maximised the trustworthiness of the data collection and analysis.13 This article aims to honour the stories told and give meaning to practitioners’ experiences and their lives.14 Pseudonyms are used throughout.
Findings and discussion Job satisfaction was an important feature. Interviewees gained increased job satisfaction from practice that was challenging, held professional recognition, gave increased clinical involvement and autonomy. Specifically, practice that:
expanded skills and knowledge had a patient centred approach was in a stimulating environment had an enquiry orientated approach increased responsibility had complex and demanding tasks encouraged role development had skill mix.
Opportunities to fulfil such career aspirations and challenges seemed patchy, despite Government policy to enable and empower Allied Health Professionals (AHPs)15,16 demonstrating a mismatch between local practice and national policy. Career opportunities were locally restricted, clinical career advancement was not encouraged unlike progression into managerial positions, and local, medical training needs took precedence over radiographic roles, and, subsequently, service development. Generally, specialist practice identified by imaging modality restricted career opportunities but predominates in the aspirations of the newly qualified. Career advancement was encouraged through managerial development but this was not as welcome as clinical development. ‘‘I suspect I am far better developed managerially than a lot of people at superintendent level in other places. Having said that, I don’t get the clinical specialism that they do as a pay off.’’ Stephen
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Clinical development was preferable but problematic. Kathleen was employed at a large city hospital where radiology training restricted the opportunities for her progression.
or two people who were possibly superintendents, .. were incredibly specialised. Yet at another hospital I worked at we rotated through,..’’
‘‘IV injections. This is something that I know is a speciality nowadays which I’ve tried very hard to be able to, to ask to be trained but because I work in a teaching hospital we’ve got registrar radiologists who like to do all these things and we haven’t been given the option.’’ Kathleen
Radiographers who practised radiographer-led contrast agent studies such as barium work did not spend all their time performing this practice and this appeared to be a barrier to its recognition as a specialism.
Stephen talks of inequality of opportunity, ‘‘..a political and geographical lottery. Some places give the people who want development and let them get there, other places it is either competitive, very restricted and resource limited.’’ Career advancement through role development was controlled locally by radiology as radiologists maintained local control of practice boundaries guiding radiographer development to aid the requirements and values of radiology. Some radiologists did not support radiographic role development and actively inhibited it whereas some encouraged clinical role development. Where there was a team of radiologists with differing opinions, this created a hostile work environment for the radiographers. Where there were medical students or trainee radiologists, their training took priority to the extent that it inhibited radiographic career opportunities.
Characteristics of specialisms Thematic analysis identified characteristics of specialism in diagnostic radiography. The greater the number of characteristics recognised, the more likely it was to be regarded as a specialism by the interviewees. The characteristics included full time commitment, the capacity of a subject to divide, practice that was challenging and gave the radiographer clinical autonomy, a need for additional training and education. Practice had to be seen as separate to what was considered routine radiographic practice and include multidisciplinary team working and service development. Some confusion about what constitutes a specialism in diagnostic radiography is apparent.
Full time commitment The amount of time committed to a field is dependent on how staff are distributed throughout the department. Staff may rotate through particular fields or each field may have dedicated staff. Where dedicated radiographers were employed, their practice was more likely to be considered a specialism. They were regarded as being knowledgeable and expert in their field. Interviewees became confused where similar practice was carried out on a part time basis and became unsure as to whether any part time practice could be considered as a specialism. Christopher, a newly qualified radiographer, had experience of CT duties being regarded as routine in one hospital and exclusive in another where there was dedicated staff. ‘‘Where I work, . people who work in CT, work there all the time and it’s kind of their empire. . the odd one
‘‘. to go into ultrasound or CT you go into that area one hundred per cent. You don’t split yourself between one or two areas whereas we are still in the position where if you want to take on this role.. then we have to do that and something else. So it’s not an area we would work in one hundred per cent. And maybe that is something that will have to come in the future in order for us to be properly recognised.’’ Where radiographers conducted additional diagnostic tests this increased their time commitment and a specialism became more easily recognisable.
Capacity to divide Some fields of practice were easily divided into other recognisable fields such as ultrasound (obstetric, abdominal, vascular etc), MRI (neurological, orthopaedic, trauma etc) and radiographer reporting (trauma, mammography, gastro-intestinal etc). Such fields were more likely to be considered as a specialism. Arthur highlights the incompatibility of anatomical divisions of conventional radiography although this remains an issue.17 ‘‘You see the path lab people, ...they separated each branch of their work but we didn’t .. you couldn’t be head of a finger X-ray.’’ Ultrasound, however, was seen as different. Ultrasound knowledge and practice grew linked to a particular medical specialism resulting in anatomical divisions such as:
obstetric and gynaecological cardiac vascular abdominal.
‘‘It would be impossible or impractical for everyone who comes out with a postgraduate diploma in medical ultrasound to be an expert or to be competent in more than two areas of ultrasound because there’s so much in each area now’’ Leading voice in ultrasound Similar anatomical divisions are identified in angiography and MRI. ‘‘..angiography has split into cardiology and vascular.’’ Leading voice in angiography ‘‘You may find that there are neuro MR radiographers’’ Leading voice in MRI Anatomical divisions reflect the historical anatomical model concept of disease that created acceptable boundaries of medical practice creating a range of discrete medical specialism.9
Specialism in radiography
The challenge and autonomy of practice The role of the radiographer was gradually reduced to be less challenging. Less complex technology encouraged an increase in the direct involvement of medicine. The problem-solving and decision-making contributions of the radiographer were reduced during image acquisition and processing. However where radiographers formally gave their opinion on image appearances, practice was seen as a welcome challenge. Where reporting occurred in the main imaging department the organisation of work became challenging requiring visionary mangement. ‘‘ We originally could not see how it would work, just having two members of staff who could report certain films, but they kept at it and we found a way around and fingers crossed we have extended that now.’’ Claire Radiographers associated autonomous practice with CT, MRI, ultrasound, mammography, forensic investigations and trauma work. Increased autonomy was attractive. Robert talks of moving into CT or MRI where, ‘‘..you can be a bit more of your own boss.’’. Radiographer autonomy improved trauma and mammography services although it became more difficult for radiographers to lead service change (leading voices e trauma and mammography). The level of autonomy relied on the local radiologists and, because of the selective offloading of their medical tasks, ‘‘..we can’t possibly be independent practitioners.’’ (Leading voice e trauma). Autonomy did not extend to role choice. As radiographer autonomy increased, medical involvement decreased and the associated field of practice was more likely to be seen as a specialism. For early practitioners radiological direction was rarely available. A number mention the importance of helping casualty officers. In the late 1930s and early ’40s, Bonnie was taught to do radiography by a surgeon who also reported the films. In the 1960s through to the early ’90s, Elizabeth would identify abnormalities to referring clinicians. Carole reflects on her experience in the 1960s. ‘‘I think in a lot of cases the radiographer can diagnose radiographs much better than the doctors, not necessarily better than the radiologists, but they can go to a radiologist if they have doubts.. Interviewees reported that their opinions of radiographers were used by referring clinicians in paediatrics and bladder pressure studies. Standardisation of radiographic technique supported radiological control over radiography. K C Clark18 was instrumental in providing the original comprehensive text showing the standard elements for each anatomical area and procedure. This technical efficiency helped to reduce radiographic practice to technical and anatomical factors and supported the reporting tasks of radiologists. Medicine valued the controlled, reproducible experiment at that time. Howell19 suggests that viewing results of experiments in the absence of the patient dehumanises the patient into
e81 ‘‘organs, symptoms or diseases’’ (p131) Interviewees identify that in radiography this approach also dehumanised the radiographer making them components in a production line. Radiographers valued their skills in patient care and put a high value on patient contact Initially, radiologists did not control what happened in the X-ray room but in the late 1970s and early ’80s, interviewees notice a change. Radiologists started to selectively reduce radiographic responsibilities. Debbie reports the reduction of radiographic duties in angiography. User friendly equipment encouraged radiologists to become more interested in developing their technical skills. Similarly, the leading voice in angiography tells of cardiologists using angiographic equipment. Interviewees report similar reductions in decision-making in IVUs encouraging them to leave conventional radiography for more autonomous work in obstetric ultrasound and angiography. The leading voice in angiography states: ‘‘.I think when I trained in the ‘60s and possibly even before in the ‘50s ...., we were in charge of it all. We did what we had been trained to do. We did the views we thought were best for the patient. We were left with examinations to complete without having to have our films checked all the way, it was our responsibility, we had much more responsibility than when I came back, I was appalled to have to go and run after a house officer.’’ Less decision-making frustrated radiographers. They felt that their competence was not used wisely and their skills were abused. Radiologists encouraged role development to enable radiographers to undertake tasks previously done by radiology, but only at times of radiological shortage. Once a full complement of radiologists was reached; ‘‘..they (radiologists) just took it (reporting) off us,’’ (Robert). Such deskilling was in direct contradiction to DoH policies and initiatives that advocate AHP role development.20e22 Rosen10 identifies that medical specialists strategically select tasks that are of value in maintaining a difference between medical specialisms. In the future, reporting skills may be of little value to radiology to maintain its own specialism as Computer Aided Diagnostics develop.23e25 Radiographic reporting skills were required to also cope with an increase in radiologists’ workloads.26 Dixon27 warned of radiographers emulating radiologists. Leading voices mention radiographers expandeding their skill repertoire to include endoscopy,28 patient assessment, biopsy29 and radiographer-led one-stop minor injury departments.30 The shortage of radiologists locally was a significant influence on Betty’s practice. Of the two radiologists, one was in favour of radiographer role expansion but the other not. Local radiological definitions inhibited the high expectations of new radiographers. According to one manager, ‘‘yes, you are an independent health care practitioner, but the radiologists are not going to let you practise like that.’’ (Debbie)
e82 When interviewees report the introduction of new technology, radiology dictate its inclusion into practice. Robert’s experience in the late 1970s was of the introduction of ultrasonic ‘‘A’’ scope cranial study to detect head injury. This experience launched Robert into a career in obstetric ultrasound. ‘‘you used to stand at the side watching, . eventually he said do you want a go and I said I haven’t got a clue what I’m doing and he said well I’ll show you but he hadn’t got any patience you know? And I had a go at one or two and they seemed to be alright but I must admit I didn’t know how to interpret the scope.. Eventually he got fed up of doing them or he hadn’t got as much time to do them as he wanted and he used to get requests from ITU (Intensive Treatment Unit). so I never looked back from there. It went from ‘‘A’’ scope scanning right up to when the obstetric department started up...’’ The leading voice in ultrasound recalls user friendly, real-time ultrasound machines, which replaced the B scanner, a difficult machine to negotiate and time consuming to use. Radiologists became more interested in ultrasound once the equipment became user friendly. Prior to this, there was little clinical support for isolated radiographers practising ultrasound who formed their own support network, as did the radiographers in the early days of X-ray work. Radiologists governed the boundaries of radiography practice in new imaging modalities such as ultrasound and in other areas where previously radiological tasks were offloaded to radiographers. Claire recalls how radiographers in the department first undertook barium studies where she works. ‘‘They (radiologists) were very negative at first but we were fortunate in that the clinical director was for it and he laid the ground rules for it. He was a radiologist, the others would have nothing to do with it at first. I think we started with barium meals, and he was the only one who would report the. He trained the radiographers practically and it just gradually opened up.’’ Radiographers performing tasks previously undertaken by radiologists experienced difficulties when a new radiologist was appointed who did not agree on the labour boundaries. The leading voice in mammography felt that in such circumstances the radiographer’s role should discontinue, as a radiologist could make the working life of a radiographer very uncomfortable. The influence of radiology was far reaching. Jane practised in a teaching hospital where radiological registrars trained. Although previous research shows no statistically significant difference between teaching and non-teaching hospitals, Jane found securing role development difficult.31 Her work was tedious and, although not permitted to perform fluoroscopy, had to supervise registrars learning fluoroscopy. This reduced her morale and caused her to leave her job. Paradoxically the leading voice in contrast agent studies perceives a teaching hospital environment to be beneficial to role development as the large number of cases justify the deployment of dedicated staff to focused fields of practice.
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Change over time Interviewees identified changes in all specialisms with the exception of paediatrics and dental radiography. One gave the example of neuroradiography as a specialism which closed with the emergence of CT and MRI and subsequently re-emerged as a specialism in MRI. In A&E services a requirement for multi-modality skills and knowledge emerges. ‘‘Where you try and get an A&E Senior 1, it is very difficult, because they perceive a loss of modalities to do that. The development pathway for the A&E Superintendent and Senior 1 includes all the modalities, on the grounds that trauma patients go through those areas. Trauma does not stop at the A&E..’’ Leading voice e trauma The leading voice in paediatrics regarded CT as a specialism at one time but then reconsidered its status saying that it should be combined with trauma services. One interviewee acknowledged that forensic radiography evolved as a specialism when radiographers acquired a greater understanding of its context.
Training and education Post qualification education and training became a clear indication of specialism to radiographers. Interviewees comment on the requirement in forensic, ultrasound, angiography, mammography, radiographer-led contrast agent studies, nuclear medicine, MRI, radiographer reporting and CT but not paediatric, trauma or dental work. A range of opportunities were available from in-house courses with local credibility to postgraduate qualifications with international recognition. The leading voice in paediatrics and the leading voice in trauma talk of the difficulties of getting recognition for paediatrics and trauma as career pathways, primarily because they required multi-modality expertise. The leading voice in trauma recognised the need for an A&E radiographer to have some ultrasound skills to diagnose aneurysm and abnormal fluid collection and negotiated with ultrasound education providers to deliver elements of skills and knowledge for an A&E-focused scope of ultrasound practice.
Perceived as separate The perception of separateness is a key feature in responses. The first indication of separateness came with the professional acknowledgement of different training requirements for radiotherapy radiographers as radiotherapy services became centralised. Centralisation of services offers increased opportunity for the formation of radiography specialism as in medicine.9 In such an environment, the focus of practice is clearly articulated internally to the profession and externally to the outside world. Where practice was conducted without the backdrop of a specialist hospital, some practitioners struggled with the notion of specialism as they undertook ‘‘everything’’ autonomously from plain radiography to more complex procedures. This extended into the 1960s.
Specialism in radiography ‘‘I came from an age when most radiographers did everything anyway and there wasn’t so much specialisation.’’ (Leading voice e paediatrics). It is easy to separate fields of diagnostic radiography with physical boundaries. X-radiation and magnetic fields require clear demarcation and provide visible practice boundaries. Such boundaries impacted on the organisation of work and superseded individual, patient and service needs. Radiographers valued physical boundaries because they represented a traditional career structure that had professional and medical acknowledgement. By virtue of such physical boundaries, specialism became linked to ultrasound, angiography, mammography, radiographer-led contrast agent studies, nuclear medicine, MRI, CT and dental radiography. Staff using the separate imaging modalities became exclusively associated with them. However this detracted from patientcentred service provision. The leading voice in trauma recounts the struggle to supply ultrasound services to an A&E department. Sonographers had difficulty relating to A&E provision and equally, radiographers had difficulty with a partial association with ultrasound as such practice was not reflected in the career structure of the time. This disassociation between imaging modalities and services inhibited service and role development, and radiographer involvement in A&E services. Career development for radiographers in A&E is seen as linked to the development of reporting skills. Radiographer reporting was perceived as separate by many interviewees. The leading voice in radiographer reporting felt that it identified radiographers as a separate group which was more obvious when the radiographer followed traditional radiological behaviour using reporting facilities away from patients. Radiographer reporting can be conducted in the imaging room, a viewing area or in isolation perhaps in a private study emulating radiological practice. How work is seen to be organised is influential in identifying the physical boundaries so important to the identification of specialism. Some fields of practice, although considered special to some interviewees were not considered as such by others where the practice was perceived to be fused into everyday work. Forensic, paediatric, and trauma work is rarely considered as a specialism by interviewees as many struggled to see this practice as separate to the norm. The 24 h imaging service did not allow sufficient separation of these areas to enable their identification as specialisms. Forensic work had insufficient density. Paediatric radiography was unworkable as a specialism despite recognition that children required separate facilities. Trauma was equally difficult to separate, ‘‘It’s (trauma) such a big part of the workload you see. I think it’s very difficult to actually separate that out from a lot of the things we do.’’ Leading voice in contrast agent studies One acceptable way of separating work from what might be considered usual was to associate it with a specialist institution. The symbiotic relationship of medical specialism and specialist institution supports and emphasises separate provision to the extent that associated radiographic practice is similarly considered a specialism.9 This results in two levels of practice between specialist and general hospitals.
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Multi-disciplinary team working External recognition of specialism is powerful. Inter-professional recognition and acknowledgement of skill builds the trust and confidence required in multi-disciplinary teamwork. ‘‘.it cannot be that their expert clinical practice is because of their ability to take a chest X-ray or produce an ultrasound image. Its got to be that they can undertake the whole examination from accepting the referral to be able to undertake the imaging process but be able to provide the final step which is to provide the interpretation and then discuss it with clinical colleagues in a multi-disciplinary team meeting.’’ Leading voice e radiographer reporting Multi-disciplinary teamwork required the radiographer to move and think beyond the physical boundaries imposed by technology and the Imaging Department. Skill mix in A&E services was seen as important, with reporting radiographers able to contribute effectively to discussions on individual cases. Similarly, gastro-intestinal imaging has emerged requiring radiographers to contribute to case conferences and attracting the respect of branches of medicine other than radiology.32
Potential to grow in parallel with service provision The service contribution made by radiographers, although potentially high, was criticised as being too technologically controlled, reducing the radiographers’ input.21 The leading voice in nuclear medicine acknowledged the potential of the expansion of radiographer input into gastro-intestinal and breast care services. Where this occurred it was rapid. The leading voice in contrast agent studies acknowledged that the identification of a gastro-intestinal radiographer enabled practice to be expanded to incorporate CT colonoscopy "and become more GI specialised." Radiographers were aware that their development was being, ‘‘...driven by the needs of the service rather than the individual.’’ (Stephen). Where there was visionary management, and a justifiable service need, role development occurred paving the way for a recognised specialism. The leading voice in contrast agent studies predicted the imaging needs in the gastro-intestinal service and therefore the potential for radiographic role development. Similarly in breast care services, the role of the radiographer expanded to include reporting and biopsy techniques. The leading voice in mammography explained that as the number of clients requiring the service increased, the staff base had to reorganise their skill mix and in-house training by the radiologist supported the development of the role to include more challenging tasks giving increased autonomy.
Summary The concept of specialism is complex, relative, dynamic and dominant. It has shaped careers, controlled job satisfaction, and impacted on staff retention. The findings show
e84 that specialisation in radiography has not necessarily been constructive to career progression, patient centred care or additional autonomy. Perceptions about specialism in radiography originate in exclusive and restricted practice and change as new imaging technology and associated tasks are introduced. At the time when the interviews were conducted, there was confusion as advanced practice and expanding roles began to emerge. Advanced practice was not a clearly defined phase of a radiographer’s career structure at that time and imaging modalities provided safe career choices. Specialism is clearly linked to new areas of practice whether these are technologies, procedures or tasks. Over time, radiographers have forged new paths that attract multi-professional recognition and blur practice boundaries with other professions. This research suggests that radiographers can expand their role to include tasks previously undertaken by medicine, other health professionals and tasks in new areas of diagnosis paving the way for the formation of a specialism. In the past, this has been successful where there has been service need, clear practice boundaries, visionary management, medical support, role development leading to increased autonomy and additional training and education.
References 1. Bahm A. The specialist. Wasani: The Macmillan Company of India Ltd; 1977. 2. Cameron A, Masterson A. Role development: the drivers for change. Synergy; 2002:12e5. Jun. 3. College of Radiographers (2005) Clinical Imaging Radiotherapy and Oncology e education strategy. 4. Simpson JA, Weiner ESC. In: The Oxford English dictionary. 2nd ed., vol. XVI. Oxford: Clarendon Press; 1995. 5. Moodie I. Fifty years of history. London: The Society of Radiographers; 1970. 6. Watson A. All change for tomorrow. Radiography 1985;51(600): 289e300. Nov/Dec. 7. Carr D, Fell K. The future for radiographic practice. The British Journal of Radiology; 1997:S187e93. Special Issue November. 8. Stevens R. American medicine and the public interest e a history of specialization. London: University of California Press; 1988. 9. Rosen G. The specialization of medicine with particular reference to ophthalmology. New York: Froben Press; 1944. 10. Larkin G. Occupational monopoly and modern medicine. London: Tavistock Publications; 1983.
C. Ferris 11. Goetze J, LeCompte M. Ethnography and qualitative design in educational research. Orlando: Academic Press; 1984. 12. Coyne F. Sampling in qualitative research. Purposeful and theoretical sampling; merging or clear boundaries? Journal of Advanced Nursing 1997;26:623e30. 13. Lincoln YS, Guba EG. Naturalistic inquiry. Newbury Park: Sage; 1985. 14. Embden C. Theoretical perspectives on narrative inquiry. Collegian 1998;5(2):30e5. 15. HMSO. The NHS plan. Department of Health; 2000. 16. HMSO. Meeting the challenge: a strategy for the allied health professions. Department of Health; 2000. 17. Snaith B. General radiography e speciality status at last? Imaging and Oncology; 2005:27. 18. Clarke KC. Positioning in radiography. London: Heinemann; 1949. 19. Howell J. Technology in the hospital: transforming patient care in the early twentieth century. New York: John Hopkins University Press; 1996. 20. Department of Health. Advance letter PAM (PTA) 2/2001. Department of Health; 2001. 21. Department of Health. The role of healthcare professionals within critical care services, critical care programme. AHP and HCS Advisory Group; 2002. 22. Department of Health. A proposal to develop a national framework for assistant practitioners and advanced practitioners. Workforce Development Confederation; 2003. 23. Synergy. CAD shows promise in CT detection of early lung cancer. Synergy; 2002:5. February. 24. Flowers C. CAD in mammography. Synergy; 2001:17. December. 25. Cowen A. A tutorial on digital mammography imaging equipment part 2: developments in digital support technologies. Radiography 1998;4:239e49. 26. Price R. Radiographers meet ‘‘old’’ challenge. Radiography 1998;4:237e8. 27. Dixon AM. Letters. Synergy News; 1998. February 1998. 28. Pearson J. What is GIRSIG? Synergy News; 2003:14. February 2003. 29. Synergy News. First consultant in breast screening services. Synergy News; 2004:1. May. 30. Synergy News (2004) ‘‘Tackling the challenge of the four hour emergency wait target’’ Trauma imaging group, radiology service improvements team and the emergency services collaborative workshop 23 March 2004 in Synergy News May p16. 31. Price R, Miller L, Mellor F. Longitudinal changes in extended roles in radiography. Radiography 2002;8:223e34. 32. Nightingale J, Hogg P. GI imaging for radiographers: current practice and future possibilities. Synergy; 2000: 16e9. Dec.