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The journey to advanced practice: An Interpretative Phenomenological Analysis of reaching destination and beyond for reporting radiographers in Scotland
Radiography xxx (xxxx) xxx
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The journey to advanced practice: An Interpretative Phenomenological Analysis of reaching destination and beyond for reporting radiographers in Scotland L.M. Cuthbertson*, Y.A. Robb, S. Blair School of Health and Life Sciences, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 0BA, UK
a r t i c l e i n f o
a b s t r a c t
Article history: Received 17 September 2019 Received in revised form 16 November 2019 Accepted 24 November 2019 Available online xxx
Introduction: Optimising radiographer and radiologist skill-mix is essential to increase efficiency and ensure quality patient care and safety in radiology services. Radiographer reporting, well established within the UK, has been legally and legitimately identified within the scope of radiographer practice for many years. Little research however has focused on perceptions and experiences of practitioners as they journey towards advanced practice in skeletal trauma reporting. Methods: A two-phase qualitative approach, utilising Interpretative Phenomenological Analysis (IPA), included a homogenous group of radiographer practitioners (n ¼ 12). Phase 1 thematically analysed personal reflective diaries. Phase 2 included oneeone, semi-structured interviews which were recorded, transcribed verbatim and reviewed using the IPA six stage thematic analysis. Results: Three super-ordinate themes emerged. This paper reflects the IPA generated from Superordinate Theme 3; Review upon and action for the role. Participants had reached destination and beyond with a focus on development of role, self and others. As reporting became firmly embedded, there was increased acceptance, educational development and positive impact on service. Reflections indicated motivation, drive, commitment, increased confidence and self-esteem Conclusion: This study provides an insight in to the participant journey towards advanced practice and skeletal trauma reporting in Scotland as participants reached destination and beyond. Implications for practice: Developments within the NHS continue to rapidly evolve and diagnostic imaging, with advancing technology, practice and changing policies, continues to remain in a constant state of change. Continued support and investment for role development, framed within a culture of effective teamworking, positive engagement and professional respect is essential. © 2019 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Keywords: Qualitative research Interpretative phenomenological analysis Advanced practice Radiographer reporting Impact and change
Introduction Radiographer reporting, well established within the UK, has been legally and legitimately identified within the scope of radiographer practice for many years.1 There is expectation that practitioners are responsible and accountable for their practice and should undertake the reporting role in the spirit of interprofessional respect and collaboration.1 Optimising radiographer and radiologist skill-mix is essential to increase efficiency and ensure quality patient care and safety in radiology services.2 Every opportunity should be taken to develop, share and maintain
* Corresponding author. E-mail address: [email protected] (L.M. Cuthbertson).
knowledge and skills in the interests of patients and referrers,1 with further suggestion however that ongoing implementation may be limited by workforce shortages.2 Background Radiographer reporting is considered the domain of advanced practice,3 and the College of Radiographers (CoR)4 produced outcome statements for demonstration by practitioners working within defined areas of specialist practice. Reporting radiographers are expected to build upon their postgraduate qualification, engage in continuing professional development (CPD) and apply for CoR accreditation which revolves around four core functions of higherlevel practice and aims to provide a framework within which CPD can be evidenced to ensure its appropriateness for advanced
https://doi.org/10.1016/j.radi.2019.11.093 1078-8174/© 2019 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Please cite this article as: Cuthbertson LM et al., The journey to advanced practice: An Interpretative Phenomenological Analysis of reaching destination and beyond for reporting radiographers in Scotland, Radiography, https://doi.org/10.1016/j.radi.2019.11.093
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practice roles.3 In addition, NHS Education for Scotland's (NES) Post-registration Career Development Framework5 was designed to provide a benchmark level focused around complexity, responsibility, experience and knowledge. Designed as an enabling tool, the purpose was to provide common language and clearly define levels of post and expected competencies to facilitate identification of transferable roles to maximise workforce flexibility. At qualification radiographers are awarded Band 5 practitioner5 status with further opportunity afforded to move to 6, 7 and 8a-c bandings. Research has focused on practitioner transition towards and within roles and recent literature was found that specifically utilised the qualitative research approach, Interpretative Phenomenological Analysis (IPA), to explore perceptions, experiences and expectations, from student to practitioner status6,7 and practitioner to advanced practice status.8,9 This paper completes the story of a journey to advanced practice in skeletal reporting and focuses on the IPA from Super-ordinate Theme 3 - Destination and Beyond: Reflection upon and Action for the Advanced Practice Role. The IPA for Superordinate themes 1&2 has been published previously.8,9 Findings identified a range of perceptions and experiences with suggestion that participants were effecting change and fulfilling high level skills associated with ‘expert clinical practice’ and ‘facilitating learning’.
has evidenced some reporting radiographers employed at Band 6 or split Band 5/6 levels.12 For Oleander when reflecting upon securing this position, she paused for thought as though considering her journey and the associated effort invested. O: I felt that it was, kind of, justifiable for our role … erm … I felt as if … that we wouldn't be getting … I felt as if it wouldn't be justifiable to get it, do it on a Band Six, because it is an expansion of our role … And I feel that after the work, that it’s deserving, in a way, erm, for the amount of work we put in, and also just to encourage other people so they can see that there's a progression in it, as well … so they don't have to do the work and then be still in the same grade … So, I really felt as if that was an important part of expanding into the role, as well, too … Oleander Transcript Lineage: 27-50 Subthemes generated for Super-ordinate Theme 3, focused upon: qualities of self, effect on service, perception of others, the educational role, the future and final thoughts. The following considers IPA for subthemes, psychological theory and extant literature with related text excerpts with transcript lineage (tl) included to support. Qualities of self
Research design and methodology Ethical approval and Research and Development Site-Specific permission were granted from Glasgow Caledonian University and four Scottish Health boards (respectively). IPA's reported ability to provide both stance and process for qualitative data analysis10 justified the selection for a two-phase study which included a homogenous group of practitioners (n ¼ 12) who had successfully completed a post graduate qualification between 2009 and 2011. Phase 1 thematically analysed reflective diaries completed during final year of study. For Phase 2 (2013), only those participants actively reporting skeletal trauma were eligible for inclusion (Table 1). Oneeone, semi-structured interviews (n ¼ 6) were recorded, transcribed and reviewed using the IPA six stage thematic analysis10 with participant anonymity protected by pseudonym. Further detail on research design, literature review, methodology, researcher reflexivity and quality assessment can be found in other papers.8,9,11 Findings All phase 2 participants had been on a professional development journey and on commencement of the reporting role, were awarded Band 7 status, concordant with CoR4 and NES framework guidance.5 The secured banding was a positive outcome as research
The terms interest, reward, determination, drive and challenge appeared frequently in the narratives, similar to findings from Ford13 and Clarke et al.14 As interviews progressed, it became obvious that the ‘field of trauma’ was where participant interests lay. Rachael succinctly emphasised this point, ‘You know, trauma is what we trained to do and that's where sort of my interest lies … ’ (tl:513e514). She also referred to liking the ‘challenge of having to think outside … the box … ’ (tl:316e318) but alluded to not realising ‘how challenging’ (tl:325) the reporting role could be. For Rebecca, she identified her long-term ‘interest in the actual x-ray image and … the need to be interested … in order to give the job everything you need to give it … (tl:114e121). In an attempt to make sense of what she was saying she then indicated that image interpretation was also something that interested her and ‘to be good at the job … it's something you either possess' [or not] … (tl:119e133). ‘Interest’ for Oleander, meant the role did not feel ‘like a chore … ’ (tl:888) and she made the association of discussing cases with her fellow reporter, to that of ‘sitting and talking over [as a]kind of release … as much as [that of] sitting having a cup of tea’ (O:895e896). In addition, Abigail referred to the feeling of ‘reward’ when she reported ‘missed fractures [that] affected the patient in a positive way … ’ (tl:674e703) which would impact upon the patient management journey. In agreement with Ford13 and Clarke et al.,14 continued review of IPA identified high levels of motivation, personal development,
Table 1 Phase 2 participant details by health board, date of commencement of reporting, context/body part for reporting, length of time reporting and availability for/date of interview. Year of post graduate Health board 1, 2 & qualification 3
Date of commencement of reporting
Context/Body part for reporting
Length of time reporting at time of interview
Interview/Month, and Year
1 2 3
2009
September 2009 (n ¼ 1) March 2010 (n ¼ 2) January 2013 (n ¼ 2)
Trauma/Appendicular and Axial Skeleton
3 years þ 2 years þ <1 year
2
2010
August 2011 (n ¼ 2)
1 year þ
3
2011
January 2013 (n ¼ 1)
Trauma/Appendicular and Axial Skeleton Trauma/Appendicular and Axial Skeleton
Yes (April 2013) Yes (July 2013)/NA Yes (May and July 2013) Yes (July 2013)/NA
<1 year
Yes (July 2013)
Please cite this article as: Cuthbertson LM et al., The journey to advanced practice: An Interpretative Phenomenological Analysis of reaching destination and beyond for reporting radiographers in Scotland, Radiography, https://doi.org/10.1016/j.radi.2019.11.093
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commitment, self-drive and strength of character. Motivation, described generally as a dynamic process, gives behaviour energy and direction.15 Furthermore, intrinsic motivation is associated with self-determination theory (SDT),16 which can be described as the conceptualised psychological need whereby essential nutrients are essential for optimal psychological growth.17 Strong links are said to exist between intrinsic motivation and satisfaction of the needs for autonomy, competence and relatedness which also includes the pleasure one gets from a task or sense of satisfaction in completing a task.15 Concordant with SDT, individuals may only be intrinsically motivated for activities that hold intrinsic interest for them, which could be applied directly to the attitude and behaviours reflected within the descriptions of participant ‘lived experiences’ of the reporting role. Effect on service e the alternative argument As participants continued to reflect, it became obvious that not only was there positive impact on service by issue of timely reports, there was also improvement on the standard of images acquired by their diagnostic imaging colleagues. The need for optimum quality to best report skeletal trauma, emerged as a common theme, as was explanation of how sub-optimal images could impact negatively on the ability to produce a quality definitive report. Participants empathised with the potential for difficulty during imaging procedures but urged if there was a problem, some form of explanation should be provided and for Edeline, she indicated, ‘I would be [the] one … that would always write a story … ‘ (tl:660e661). Rochelle identified how she communicated with staff when an image was poor, ‘I might go to the people and say you've not documented any problem … ’ (tl:380e381) and from a legal standpoint, she indicated if there was no justification for why images were sub-optimal then how could she ‘stand up in court … if [she] had to … ’ (tl:480) to defend her report. There was an overall collective response that short training sessions had been introduced and Oleander explained they had been ‘putting up some images that … weren't great and asking … whether [the radiographers] could put a comment on … (tl:563e564). Feedback from staff had indicated ‘I don't think I could put a comment [on] … ’ (tl:569) and Oleander in response suggested ‘well, if you feel you can't put a comment on … then we can't efficiently do a good report because we can't see everything … so people are getting a wee bit better, I think erm, about knowing when to repeat things …’ (tl:569e574). When asked whether she thought the sessions were having an impact, she responded ‘I think so … I think so … ’ (tl:583e587) and although she used the word ‘think’ twice, it was interpreted that she felt more strongly and positively about the impact. Perception of others As the reporting role became more embedded and accepted, respect had been afforded from a range of stakeholders. Narratives indicated that participants believed they had earned respect which had exerted positive influence on self-confidence and self-esteem. Self-esteem, for Maslow,18 is associated with the need for recognition that all people in society have a desire for a stable, firmly based, high evaluation of themselves, for self-respect and/or selfesteem and for the esteem of others. For Rochelle, she appeared somewhat surprised as she described how people now valued her contribution and advice. Even though Accident and Emergency (A/E) doctors often came to discuss particular cases with the duty radiologist, she intimated that in their absence, ‘they [had] … asked [her] and got the answer they wanted and went away quite happy … ’ (tl:77e80). She was now seen as somebody whose opinion was also sought from A/E staff
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and radiographers, some who had been initially reluctant and resistant to acknowledge the reporting role, ‘If I'm around they'll come and ask me … and what is nice for me is the radiographers … are treating me nicer … and there is a lot more respect now … ’ (tl:365e372). Oleander also talked positively about respect from a range of colleagues which included radiographers, A/E and Minor Injury Unit (MIU) staff, ‘I think, I think there's almost a kind of respect in a way because they … understand that we know what we are talking about and they … know they can come and ask us questions … ’ (tl:387e392). Even through the early struggle with lack of management support, her determination had kept her going and she appeared to be confident about the impact the role was having on service and the health care team. In addition to inherent positivity and desire to succeed, she reflected her pride as a radiographer and the respect afforded to the reporting radiographers, ‘you can almost kind of sense a wee bit of surprise about articulate you can be about the report … (tl:405e408). Rachael also alluded to the concept of respect where people now appreciated the increased responsibility and hard work that came with the role, which she indicated was, ‘the greatest success of her whole team … because in time you see people do value what we're doing … ’ (tl:974e975). Edeline made reference to being invited to ‘discrepancy meetings … ’ (tl:801) where her opinion was sought and valued. Abigail's reflections concurred with others in relation to her opinion being sought from a broad range of professionals ‘erm particularly MIU nurses … A/E staff … and you do get a bit more respect from you peers … erm [and] I think now that I'm actively reporting … people obviously respect the qualification that you have and respect your ability … ’ (tl:240e261). The educator - bringing the people along Concordant with the higher-level core function, ‘Education, Training and Development,3 participants showed willingness and commitment to the education of a range of practitioners at varying levels of grade and expertise. When reflecting on education and learning, for self and others, Oleander stated, ‘I like to know why … ’ (tl:606), and ‘I like to tell them why … because then they'll remember … ’ (tl:597e601). Oleander was embracing her educational responsibility and she stressed she felt it an important part of her role. Regular meetings had allowed sharing of interesting cases and discussion of practice in general and although driven by the reporting radiographers, all staff were encouraged and empowered to contribute. Staff appeared to be enjoying participation which arguably was testament to the motivational attitudes of the reporting radiographers and her lengthy quote in Table 2 evidences her perceptions. Rochelle also alluded to the desire to know ‘why’ in conjunction with using the term curiosity, ‘natural curiosity, a natural curiosity, because I like to know why, why are we doing that, why are we having it this way or that way … ’ (tl:266e267). A CPD team had been formed and radiologists were now keen to support and become involved. Rochelle subsequently reflected positivity on the status afforded from staff, especially newly qualified practitioners but also mentioned ‘difficulties … with her vision to take everybody forward in education … ’ (tl:309e310). CPD is mandatory for radiographers,19 and Rochelle made reference to the difference between individuals who were ‘driven to learn more and are enthusiastic … ’ (tl:274e275), compared to those only prepared to do ‘within the hours of work … ‘(tl:272). For Rebecca, initial resistance had been experienced but ‘people [came willingly] to [the] CPD talks now … so I do think that is a bit of a success [as] we are starting to win people over … ’ (tl:1062e1069). CPD was a common theme and Abigail indicated ‘we have initiated monthly meetings where we talk about cases that have come through A/E, interesting cases and talk about technique … and how to improve service … you know … and I
Please cite this article as: Cuthbertson LM et al., The journey to advanced practice: An Interpretative Phenomenological Analysis of reaching destination and beyond for reporting radiographers in Scotland, Radiography, https://doi.org/10.1016/j.radi.2019.11.093
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Table 2 Detailed participant quotes for two subthemes relating to Superordinate Theme 3 … ‘Destination and Beyond - Review upon and action for the advanced practice reporting role.’ The Educator - Bringing the people along
The Future
O: Yeah, well, erm … the other radiographers and things will actually now, if they've got some interesting things they'll keep back, erm, patient CHI numbers, and then they'll, if there are some things that they are not sure about, they'll come and ask us, as well. And we've been doing, erm, a radiography review meeting once a month as well … so we'll ask them if they've anything interesting, and if there is something that they maybe want us to look into a wee bit more, erm, and do that … So I think it's getting a wee bit more, kind of, interactive with it. Well, I feel … I feel as if it is an important part of our role, and even in everyday, you know, the kind of structured teaching … erm, you know, I kind of feel as if almost every day someone is asking us, one way or another, you know, about patients, about reports we've done, and asking us, you know like why we would say that, and how we would report it; and we've been doing … trying to encourage people into the commenting side as well, so people are getting a lot more interested … It's going well. We've, erm, we've put in a folder into A&E and asked people if there's a film they're going to red dot, could they, erm, put down a sticky label and write down what they think … And we've, kind of, given them rough guidelines as what would, maybe, be expected. Some people are going, like, really trying really hard, and trying to, like, be really descriptive, and other people are good as … you know, they will just even highlight the area … Oleander: Transcript Lineage 415-479 Ro: Yeah I guess … I think longer-term I have an idea in my head of it would be great to have more reporting radiographers in the department and I guess I am thinking myself it would be lovely if as time went on I could take a lead over the reporting radiographers and my, my ideas will, eventually I would need to learn more I would need to be more responsible and accountable and have more education behind me and I guess more research behind me to back that up and support these people and so my longer-term view of where I would go would be, …I kinda thought recently about doing Masters … I have spoken to staff at the university about how to go about doing that, how to fund it and have also spoken to my managers because I think there is a need in the hospital to have radiographers doing more than we are at the moment … I could see that the respect I have been given so far could still be extended to do more … and I have been asked to think about business cases and things ongoing so that kinda ties in with Masters … so I kind of see a bigger picture ultimately. And I don't know whether I would like to become a consultant radiographer perhaps??.. But ultimately certainly take the lead within the hospital … for educating more reporting radiographers or leading reporting radiographers to have a service that is … what's the word I am looking for?.. That maintains itself … And even more long-term I guess are the national kind of, meeting [s] with the levels of reporting that are being suggested nationally and that would be great to be part of that and I don't know whether further long-term education and educator is something I would think of beyond that and I don't know … [but] those are too far ahead to think of … Rochelle: Transcript Lineage 304-339
have a lot of people coming up and saying … how much they enjoy it … ’ (tl:758e772). Rachael also referred to CPD sessions and the ‘very good feedback … ’ (tl:390) from those engaging. The future All participants were keen to keep learning and drive self and service forward. Abigail referred to her drive to better herself but also referred to improving service and promoting the radiography profession. A: Erm, but I think I also, I do have a wee bit of a drive to kind of make myself better and to provide a better service and to promote radiographers as a whole … Erm, and I, I do find my job interesting, I think that has a big impact, rather than people who just come in and see it purely as a job. I actually do enjoy my job and I do find it interesting and I do want to find ways to improve the service that we're providing … Abigail Transcript Lineage: 736-746 Rochelle also referred to her desire to drive service forward in addition to her own job satisfaction and desire to drive others. Arguably her lengthy quote (Table 2) somewhat pulls the lived experience of the journey to advanced practice in skeletal trauma to a close. There was consideration of future and ‘beyond’ for her advanced practice journey with aspiration to meet higher-level practice expectations.4 Rachel identified her enjoyment of the role and how she saw it taking off more than she had initially thought, ‘I think it's going to expand out-with just trauma … I think given time we're going to do a GP portfolio [which] we will work up to’ (tl:506e518). This was similar to Abigail who had alluded to stronger links with ENPs, ‘in fact there have been murmurings that they would like us to play a bigger role in their service’ (tl:467e469) with potential for improvement and increased inter-professional working. For Edeline, ‘we're just growing as a team … now we've all met I think that'll make a difference’ (tl:2261e2270) with indication this may lead to greater team-working and professional
development which may impact upon sustainability of future service delivery. Consistent with the findings of Culpan et al.20 and Thom,21 participant reflections indicated opportunity to positively impact upon quality clinical imaging service provision, delivery of a cost-effective increase in diagnostic capacity, the release of radiologist time for complex clinical imaging responsibilities, benefits to patients and practitioner job satisfaction. Final thoughts At the end of the interview participants were invited to provide a sentence to sum up the discussions. As the interviewer, the aim was to put participants at ease, show support, interest and empathy which arguably was confirmed in part by the succinct quote from Rochelle, ‘erm quite relaxed, I felt it really easy to talk about things, erm quite sincere and not too difficult or challenging at all … ’ [tl:606e607]. For Abigail the interview had made her reflect upon the type of person she had thought would take on this role. She related this in context of herself and then reflected upon the type of person she had been and had now become whereby unlike other staff, she had actually manufactured herself to be where she now was now. A: I think the discussion has made me more aware of the fact that, erm, it is a certain kind of person who puts themselves forward for this and who has the dedication to go through with it …. which I hadn't really thought of before. I think I probably thought of it being more opportunistic in the past. So, I think it probably has made me think more that, erm, I, I have designed myself to be where I am now … I have made myself be where I am now, you know, whereas others haven't. Abigail Transcript Lineage: 830-844 In essence, at that moment in time she realised what she had achieved, what she was able to do and was further capable of. She alluded to never having thought of things in that particular way prior to the interview and the reflection on the ‘lived experience’ of
Please cite this article as: Cuthbertson LM et al., The journey to advanced practice: An Interpretative Phenomenological Analysis of reaching destination and beyond for reporting radiographers in Scotland, Radiography, https://doi.org/10.1016/j.radi.2019.11.093
L.M. Cuthbertson et al. / Radiography xxx (xxxx) xxx
her role appeared to have created increased self-awareness. This was also what Smith et al.10 classed as phenomenological reflection whereby through interviewer facilitation, self-conscious phenomenological reflection had occurred. Although in Rachael's account she accepted that one of the greatest successes had been her team and the effect on service, whereby ‘people do value what we are doing now … ’ (tl:974e975), she had had mixed emotions from study to uptake of the role and had often questioned whether reporting was for her. Like Abigail however her reflection indicated, ‘my personal, greatest success is learning a lot about myself … I've realised I do have the ability … in as much as I doubted myself, I've now got the self-confidence … ’ (tl:1029e1037). Reflective practice, for Brechin et al.22 and Eby,23 involved synthesis of reflection, self-awareness and critical thinking with the philosophical roots identified in phenomenology and critical theory. Rachael's final account had pulled events to a close and suggested that she had now gone through due process and found self-belief and confidence which she implied had ‘impacted on other aspects of [her] life as well … ’ (tl:1040). In concordance with Brechin et al.,22 the opportunity for reflection had enabled her to make sense of her experience through examining in context. For Edeline, the role had brought greater job satisfaction and confirmed the reality that reporting was what she wanted to do and she indicated her reporting role had given her ‘a new lease of life at work and … more focus … ’ (tl:2641e2642). Oleander explained that her advice to anyone would be to secure ‘support from your work … ’ (tl:1405) whereby her journey had not been easy and she had driven herself to achieve her goal. In spite of this, she indicated, ‘[I] just really enjoy [my reporting] role more … it shows where you can progress … it is really worthwhile, erm, and it's good for radiography in general … just to show what radiographers can do … ’ (tl:1404e1411). It was interesting and pertinent to note that Oleander's concluding thoughts focused on the profession as well as self. The conclusion of the interview for Rebecca provoked a long pause for reflection as she tried to think how to best sum up the interview. ‘Trying to think … [long pause] … If you can use an analogy of a road, it's been a road with lots of twists and turns … bits have been a bit uneven and a bit rocky … but the destination's been worth it … ’ Rebecca Transcript Lineage:1134e114. The descriptive quote clearly identified an interesting but convoluted journey. For Gallagher and Zahavi24, experience happened for the experiencing subject in an immediate way and as part of this immediacy it was implicitly marked as ‘my’ experience, which Rebecca reflected upon in an abstract way. From a phenomenological stance, this form of self-consciousness was a constant structural feature of conscious experience24 whereby the immediate and first-personal given-ness of the experiential phenomenon was accounted for in terms of a pre-reflective self-consciousness
whenever individuals lived through or underwent an experience, which for Rebecca, was the journey her advanced practice reporting role. Discussion All participants had embarked upon their similar but idiographic journeys, they had travelled along, reached destination and were now considering the future and beyond. Narratives showed a range of similarities and differences in perceptions and experiences which can be expected for the nuances of IPA.10 Arguably, different responses may actually in part reflect the personalities, preferences and learning styles within and across interviews during the data collection and analysis phases. Just as Smith et al.10 suggested, IPA looked for the convergence and divergence of opinion from participants, which arguably could be considered analogous with the potential for concordance and discordance associated with the interpretation of radiographer reports. As the participants recounted the perceptions and experiences of their lived experience, qualities of self-drive, motivation, determination, desire to motivate, enthuse and drive others emerged, which consistent with Johnston and Johnston25 reflected the efforts they had committed to, which they perceived as meaningful and worthwhile. Motivation was aimed at achieving goals, fuelled by emotion and social origins and what was particularly important and apparent was the inherent drive from all for improvement for self, service and others. Although there was more acceptance as the reporting role became embedded, some scepticism and resistance had remained. The initial aversion to change controverted government, professional body and service directives and needed constant address. Developments within the NHS continue to rapidly evolve and diagnostic imaging with constant advancing technologies, roles and changing policies, continues to remain in a constant state of change. Achieving useful service evolution is a complex process with multi-factorial challenges26 and for rapidly changing organisations, management require to create a culture able to embrace the potential for perpetual change.27 Henderson et al.,26 reported that strategic service managers in Scotland identified various possibilities where change could be beneficial but this had been hampered by systems and attitudes that did not welcome or facilitate change. One major strategy focused on the setting up of a national Scottish National Radiology Reporting Service and the pilot (March 2019) was due to run until August 2019, which following subsequent review would evaluate future potential.28 By 2021 there is an expectation that all advanced radiographer practitioners should hold a minimum of a full Master's degree29 therefore for anyone embarking upon education and professional development, support, time, finance, management and mentor support should be afforded to allow individuals to achieve their goals. For Lewin,30 successful change can only be achieved by either strengthening the driving forces or weakening the FORCES HINDERING CHANGE (RESISTORS)
FORCES SUPPORTING CHANGE (ENABLERS) • • • • • • •
Initiatives from government bodies, professional bodies, education Supportive radiologists, managers, peers, colleagues, ENPs, medical staff NHS, Service improvement, need to increase efficiency and effectiveness, waiting time targets, role developments, advanced practice Increased knowledge, skills and competencies through education and practice Peer and mentor support New ways of working, best use of staff skills, increased job satisfaction Inter-professional working, team building, professional respect, increased esteem
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• • • • • • •
Lack of support for new initiatives Un-supportive radiologists, managers, colleagues Effect of radiologist training, decrease in skill set for radiologists, lack of time for education of SPRs, lack of understanding of role from colleagues Effect on work/life balance, lack of time, lack of support Lack of time for peer and mentor support Established work patterns, culture, resistance to change Effect of perception of others on self and role
Figure 1. Forcefield analysis; driving forces and restraining forces. Adapted from Lewin.30
Please cite this article as: Cuthbertson LM et al., The journey to advanced practice: An Interpretative Phenomenological Analysis of reaching destination and beyond for reporting radiographers in Scotland, Radiography, https://doi.org/10.1016/j.radi.2019.11.093
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restraining forces as depicted within a Forcefield Analysis. Fig. 1 reflects the potential driving forces responsible for the initiation and direction of change and those restraining forces that had potential to influence participant journeys. Arguably, as the practitioners continue to embed their role and evidence increased skill and competency, the balance of the force-field will remain in a constant state of flux. Conclusion This paper concludes the story of the journey to advanced practice in skeletal trauma reporting. Inevitably, as patterns of care continue to change to a patient focused approach, multidisciplinary involvement is required to strengthen the core function of working across professional boundaries with capacity to influence service improvement. Participants had reached destination and were contemplating and planning for future with a focus on development of role and self. Following the initial difficulties and challenges, reflections indicated increased acceptance which arguably was testament to participant motivation and commitment. This said, culture and resistance had potential to thwart personal and professional success and subsequent fulfilment of government and professional body objectives. Continued role development initiatives are therefore essential to ensure service quality and patient benefit, framed within a culture of effective teamworking, positive engagement and professional respect. Funding This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors. Conflict of interest statement None Acknowledgements This paper was derived from a larger Professional Doctorate thesis submitted to Glasgow Caledonian University in April 2015. Many thanks are due to the advanced practitioners who willingly gave their permission and time to participate in the research. Many thanks also go to my doctoral supervisors whose expertise and support was invaluable and motivated me to succeed. References 1. The Society and College of Radiographers. Reporting. Retrieved from: https:// www.sor.org/practice/reporting. 2. The Royal College of Radiologists. Clinical radiology UK workforce census 2018 report. London: The Royal College of Radiologists; 2019. Retrieved from: https://www.rcr.ac.uk/system/files/publication/field_publication_files/clinicalradiology-uk-workforce-census-report-2018.pdf. 3. The Society of Radiographers. Advanced practitioner. Retrieved from, https:// www.sor.org/learning/document-library/education-and-professionaldevelopment-strategy-new-directions/advanced-practitioner.
4. The College of Radiographers. Education and career framework for the radiography workforce. London: The College of Radiographers; 2013. 5. NHS Education for Scotland Post-registration Career Development Framework draws together a Career Framework for Health. Level attributes, qualifications and scottish credit and qualifications framework (SCQF) level for each pillar of practice. Retrieved from, http://www.careerframework.nes.scot.nhs.uk/. 6. Naylor S, Ferris C, Burton M. Exploring the transition from student to practitioner in diagnostic radiography. Radiography 2016;22(2):131e6. https:// doi.org/10.1016/j.radi.2015.09.006. 7. Harvey-Lloyd JM, Morris J, Stew G. Being a newly qualified diagnostic radiographer: learning to fly in the face of reality. Radiography 2019;25(3):e63e7. https://doi.org/10.1016/j.radi.2019.01.007. 8. Cuthbertson LM. The journey to advanced practice and skeletal trauma reporting; an Interpretative Phenomenological Analysis of preparation for the role. Radiography 2019;25(1):s40e7. https://doi.org/10.1016/j.radi.2019.02.013. 9. Cuthbertson L M. Skeletal trauma reporting; perceptions and experiences of radiographer practitioners exposed to the reporting role. Radiography https:// doi.org/10.1016/j.radi.2019.06.010 (in press). 10. Smith JA, Flowers P, Larkin M. Interpretative phenomenological analysis theory method and research. London: Sage; 2009. 11. Cuthbertson L M. The journey to radiographer advanced practice: a methodological reflection on the use of interpretative phenomenological analysis to explore perceptions and experiences. J Radiother Pract https://doi.org/10.1017/ S1460396919000621 (in press). 12. Milner RC, Snaith B. Are radiographers fulfilling the role of advanced practitioner? Radiography 2017;23(1):48e54. https://doi.org/10.1016/j.radi.2016.09.001. 13. Ford P. The role of the consultant radiographer - experience of appointees. Radiography 2010;6(3):189e97. https://doi.org/10.1016/j.radi.2010.03.001. 14. Clarke R, Allen D, Arnold P, Snaith B. Implementing radiographic CT head reporting: the experiences of students and managers. Radiography 2014;20(2): 117e20. https://doi.org/10.1016/j.radi.2013.12.008. 15. Reeve JM. Understanding motivation and emotion. 5th ed. USA: John Wiley & Sons; 2009. 16. Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol 2000;55(1): 68e78. 17. Deci EL, Ryan RM. The “what” and “why” of goal pursuits: human needs and the self-determination of behaviour. Psychol Inq 2000;11(4):227e68. 18. Maslow AH. A theory of human motivation. Psychological Review 1943;50(4): 370e96. 19. Health and Care Professions Council. Standards of proficiency for radiographers london. Health and Care Professions Council; 2013. 20. Culpan G, Culpan A-M, Docherty P, Denton E. Radiographer reporting: a literature review to support cancer workforce planning in England. Radiography 2019;25(2):155e63. https://doi.org/10.1016/j.radi.2019.02.010. 21. Thom SE. Does advanced practice in radiography benefit the healthcare system? A literature review. Radiography 2018;24(1):84e9. https://doi.org/ 10.1016/j.radi.2017.08.002. 22. Brechin A, Brown H, Eby MA. Critical practice in health and social care. London: Sage; 2000. 23. Eby MA. Understanding professional development. In: Brechin A, Brown H, Eby MA, editors. Critical practice in health and social care. London: Sage; 2000. 24. Gallagher S, Zahavi D. The phenomenological mind. London: Routledge; 2012. 25. Johnson DW, Johnson R. Training for cooperative group work. In: West M, Tjosvold D, Smith K, editors. International handbook of organizational teamwork and cooperative working. London: Wiley; 2003. 26. Henderson I, Mathers SA, McConnell J. Advanced and extended scope practice of diagnostic radiographers in Scotland: exploring strategic imaging service imperatives. Radiography 2017;23(3):181e6. https://doi.org/10.1016/ j.radi.2017.02.009. 27. Ogden S, Wersun A. Strategic management MGTM310. Glasgow Caledonian University, London, Thomson Learning; 2006. 28. Scottish Radiology Transformation Programme. Retrieved from: https://www. sharedservices.scot.nhs.uk/media/1568/srtp-bulletin-march-2019-v10.pdf. 29. The Society and College of Radiographers. Research Strategy 2016-2021. Retrieved from: https://www.sor.org/learning/document-library/researchstrategy-2016-2021. 30. Lewin K. Field theory in social science. New York: Harper and Row; 1951.
Please cite this article as: Cuthbertson LM et al., The journey to advanced practice: An Interpretative Phenomenological Analysis of reaching destination and beyond for reporting radiographers in Scotland, Radiography, https://doi.org/10.1016/j.radi.2019.11.093
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Radiography journal homepage: www.elsevier.com/locate/radi
The journey to advanced practice: An Interpretative Phenomenological Analysis of reaching destination and beyond for reporting radiographers in Scotland L.M. Cuthbertson*, Y.A. Robb, S. Blair School of Health and Life Sciences, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 0BA, UK
a r t i c l e i n f o
a b s t r a c t
Article history: Received 17 September 2019 Received in revised form 16 November 2019 Accepted 24 November 2019 Available online xxx
Introduction: Optimising radiographer and radiologist skill-mix is essential to increase efficiency and ensure quality patient care and safety in radiology services. Radiographer reporting, well established within the UK, has been legally and legitimately identified within the scope of radiographer practice for many years. Little research however has focused on perceptions and experiences of practitioners as they journey towards advanced practice in skeletal trauma reporting. Methods: A two-phase qualitative approach, utilising Interpretative Phenomenological Analysis (IPA), included a homogenous group of radiographer practitioners (n ¼ 12). Phase 1 thematically analysed personal reflective diaries. Phase 2 included oneeone, semi-structured interviews which were recorded, transcribed verbatim and reviewed using the IPA six stage thematic analysis. Results: Three super-ordinate themes emerged. This paper reflects the IPA generated from Superordinate Theme 3; Review upon and action for the role. Participants had reached destination and beyond with a focus on development of role, self and others. As reporting became firmly embedded, there was increased acceptance, educational development and positive impact on service. Reflections indicated motivation, drive, commitment, increased confidence and self-esteem Conclusion: This study provides an insight in to the participant journey towards advanced practice and skeletal trauma reporting in Scotland as participants reached destination and beyond. Implications for practice: Developments within the NHS continue to rapidly evolve and diagnostic imaging, with advancing technology, practice and changing policies, continues to remain in a constant state of change. Continued support and investment for role development, framed within a culture of effective teamworking, positive engagement and professional respect is essential. © 2019 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Keywords: Qualitative research Interpretative phenomenological analysis Advanced practice Radiographer reporting Impact and change
Introduction Radiographer reporting, well established within the UK, has been legally and legitimately identified within the scope of radiographer practice for many years.1 There is expectation that practitioners are responsible and accountable for their practice and should undertake the reporting role in the spirit of interprofessional respect and collaboration.1 Optimising radiographer and radiologist skill-mix is essential to increase efficiency and ensure quality patient care and safety in radiology services.2 Every opportunity should be taken to develop, share and maintain
* Corresponding author. E-mail address: [email protected] (L.M. Cuthbertson).
knowledge and skills in the interests of patients and referrers,1 with further suggestion however that ongoing implementation may be limited by workforce shortages.2 Background Radiographer reporting is considered the domain of advanced practice,3 and the College of Radiographers (CoR)4 produced outcome statements for demonstration by practitioners working within defined areas of specialist practice. Reporting radiographers are expected to build upon their postgraduate qualification, engage in continuing professional development (CPD) and apply for CoR accreditation which revolves around four core functions of higherlevel practice and aims to provide a framework within which CPD can be evidenced to ensure its appropriateness for advanced
https://doi.org/10.1016/j.radi.2019.11.093 1078-8174/© 2019 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Please cite this article as: Cuthbertson LM et al., The journey to advanced practice: An Interpretative Phenomenological Analysis of reaching destination and beyond for reporting radiographers in Scotland, Radiography, https://doi.org/10.1016/j.radi.2019.11.093
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practice roles.3 In addition, NHS Education for Scotland's (NES) Post-registration Career Development Framework5 was designed to provide a benchmark level focused around complexity, responsibility, experience and knowledge. Designed as an enabling tool, the purpose was to provide common language and clearly define levels of post and expected competencies to facilitate identification of transferable roles to maximise workforce flexibility. At qualification radiographers are awarded Band 5 practitioner5 status with further opportunity afforded to move to 6, 7 and 8a-c bandings. Research has focused on practitioner transition towards and within roles and recent literature was found that specifically utilised the qualitative research approach, Interpretative Phenomenological Analysis (IPA), to explore perceptions, experiences and expectations, from student to practitioner status6,7 and practitioner to advanced practice status.8,9 This paper completes the story of a journey to advanced practice in skeletal reporting and focuses on the IPA from Super-ordinate Theme 3 - Destination and Beyond: Reflection upon and Action for the Advanced Practice Role. The IPA for Superordinate themes 1&2 has been published previously.8,9 Findings identified a range of perceptions and experiences with suggestion that participants were effecting change and fulfilling high level skills associated with ‘expert clinical practice’ and ‘facilitating learning’.
has evidenced some reporting radiographers employed at Band 6 or split Band 5/6 levels.12 For Oleander when reflecting upon securing this position, she paused for thought as though considering her journey and the associated effort invested. O: I felt that it was, kind of, justifiable for our role … erm … I felt as if … that we wouldn't be getting … I felt as if it wouldn't be justifiable to get it, do it on a Band Six, because it is an expansion of our role … And I feel that after the work, that it’s deserving, in a way, erm, for the amount of work we put in, and also just to encourage other people so they can see that there's a progression in it, as well … so they don't have to do the work and then be still in the same grade … So, I really felt as if that was an important part of expanding into the role, as well, too … Oleander Transcript Lineage: 27-50 Subthemes generated for Super-ordinate Theme 3, focused upon: qualities of self, effect on service, perception of others, the educational role, the future and final thoughts. The following considers IPA for subthemes, psychological theory and extant literature with related text excerpts with transcript lineage (tl) included to support. Qualities of self
Research design and methodology Ethical approval and Research and Development Site-Specific permission were granted from Glasgow Caledonian University and four Scottish Health boards (respectively). IPA's reported ability to provide both stance and process for qualitative data analysis10 justified the selection for a two-phase study which included a homogenous group of practitioners (n ¼ 12) who had successfully completed a post graduate qualification between 2009 and 2011. Phase 1 thematically analysed reflective diaries completed during final year of study. For Phase 2 (2013), only those participants actively reporting skeletal trauma were eligible for inclusion (Table 1). Oneeone, semi-structured interviews (n ¼ 6) were recorded, transcribed and reviewed using the IPA six stage thematic analysis10 with participant anonymity protected by pseudonym. Further detail on research design, literature review, methodology, researcher reflexivity and quality assessment can be found in other papers.8,9,11 Findings All phase 2 participants had been on a professional development journey and on commencement of the reporting role, were awarded Band 7 status, concordant with CoR4 and NES framework guidance.5 The secured banding was a positive outcome as research
The terms interest, reward, determination, drive and challenge appeared frequently in the narratives, similar to findings from Ford13 and Clarke et al.14 As interviews progressed, it became obvious that the ‘field of trauma’ was where participant interests lay. Rachael succinctly emphasised this point, ‘You know, trauma is what we trained to do and that's where sort of my interest lies … ’ (tl:513e514). She also referred to liking the ‘challenge of having to think outside … the box … ’ (tl:316e318) but alluded to not realising ‘how challenging’ (tl:325) the reporting role could be. For Rebecca, she identified her long-term ‘interest in the actual x-ray image and … the need to be interested … in order to give the job everything you need to give it … (tl:114e121). In an attempt to make sense of what she was saying she then indicated that image interpretation was also something that interested her and ‘to be good at the job … it's something you either possess' [or not] … (tl:119e133). ‘Interest’ for Oleander, meant the role did not feel ‘like a chore … ’ (tl:888) and she made the association of discussing cases with her fellow reporter, to that of ‘sitting and talking over [as a]kind of release … as much as [that of] sitting having a cup of tea’ (O:895e896). In addition, Abigail referred to the feeling of ‘reward’ when she reported ‘missed fractures [that] affected the patient in a positive way … ’ (tl:674e703) which would impact upon the patient management journey. In agreement with Ford13 and Clarke et al.,14 continued review of IPA identified high levels of motivation, personal development,
Table 1 Phase 2 participant details by health board, date of commencement of reporting, context/body part for reporting, length of time reporting and availability for/date of interview. Year of post graduate Health board 1, 2 & qualification 3
Date of commencement of reporting
Context/Body part for reporting
Length of time reporting at time of interview
Interview/Month, and Year
1 2 3
2009
September 2009 (n ¼ 1) March 2010 (n ¼ 2) January 2013 (n ¼ 2)
Trauma/Appendicular and Axial Skeleton
3 years þ 2 years þ <1 year
2
2010
August 2011 (n ¼ 2)
1 year þ
3
2011
January 2013 (n ¼ 1)
Trauma/Appendicular and Axial Skeleton Trauma/Appendicular and Axial Skeleton
Yes (April 2013) Yes (July 2013)/NA Yes (May and July 2013) Yes (July 2013)/NA
<1 year
Yes (July 2013)
Please cite this article as: Cuthbertson LM et al., The journey to advanced practice: An Interpretative Phenomenological Analysis of reaching destination and beyond for reporting radiographers in Scotland, Radiography, https://doi.org/10.1016/j.radi.2019.11.093
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commitment, self-drive and strength of character. Motivation, described generally as a dynamic process, gives behaviour energy and direction.15 Furthermore, intrinsic motivation is associated with self-determination theory (SDT),16 which can be described as the conceptualised psychological need whereby essential nutrients are essential for optimal psychological growth.17 Strong links are said to exist between intrinsic motivation and satisfaction of the needs for autonomy, competence and relatedness which also includes the pleasure one gets from a task or sense of satisfaction in completing a task.15 Concordant with SDT, individuals may only be intrinsically motivated for activities that hold intrinsic interest for them, which could be applied directly to the attitude and behaviours reflected within the descriptions of participant ‘lived experiences’ of the reporting role. Effect on service e the alternative argument As participants continued to reflect, it became obvious that not only was there positive impact on service by issue of timely reports, there was also improvement on the standard of images acquired by their diagnostic imaging colleagues. The need for optimum quality to best report skeletal trauma, emerged as a common theme, as was explanation of how sub-optimal images could impact negatively on the ability to produce a quality definitive report. Participants empathised with the potential for difficulty during imaging procedures but urged if there was a problem, some form of explanation should be provided and for Edeline, she indicated, ‘I would be [the] one … that would always write a story … ‘ (tl:660e661). Rochelle identified how she communicated with staff when an image was poor, ‘I might go to the people and say you've not documented any problem … ’ (tl:380e381) and from a legal standpoint, she indicated if there was no justification for why images were sub-optimal then how could she ‘stand up in court … if [she] had to … ’ (tl:480) to defend her report. There was an overall collective response that short training sessions had been introduced and Oleander explained they had been ‘putting up some images that … weren't great and asking … whether [the radiographers] could put a comment on … (tl:563e564). Feedback from staff had indicated ‘I don't think I could put a comment [on] … ’ (tl:569) and Oleander in response suggested ‘well, if you feel you can't put a comment on … then we can't efficiently do a good report because we can't see everything … so people are getting a wee bit better, I think erm, about knowing when to repeat things …’ (tl:569e574). When asked whether she thought the sessions were having an impact, she responded ‘I think so … I think so … ’ (tl:583e587) and although she used the word ‘think’ twice, it was interpreted that she felt more strongly and positively about the impact. Perception of others As the reporting role became more embedded and accepted, respect had been afforded from a range of stakeholders. Narratives indicated that participants believed they had earned respect which had exerted positive influence on self-confidence and self-esteem. Self-esteem, for Maslow,18 is associated with the need for recognition that all people in society have a desire for a stable, firmly based, high evaluation of themselves, for self-respect and/or selfesteem and for the esteem of others. For Rochelle, she appeared somewhat surprised as she described how people now valued her contribution and advice. Even though Accident and Emergency (A/E) doctors often came to discuss particular cases with the duty radiologist, she intimated that in their absence, ‘they [had] … asked [her] and got the answer they wanted and went away quite happy … ’ (tl:77e80). She was now seen as somebody whose opinion was also sought from A/E staff
3
and radiographers, some who had been initially reluctant and resistant to acknowledge the reporting role, ‘If I'm around they'll come and ask me … and what is nice for me is the radiographers … are treating me nicer … and there is a lot more respect now … ’ (tl:365e372). Oleander also talked positively about respect from a range of colleagues which included radiographers, A/E and Minor Injury Unit (MIU) staff, ‘I think, I think there's almost a kind of respect in a way because they … understand that we know what we are talking about and they … know they can come and ask us questions … ’ (tl:387e392). Even through the early struggle with lack of management support, her determination had kept her going and she appeared to be confident about the impact the role was having on service and the health care team. In addition to inherent positivity and desire to succeed, she reflected her pride as a radiographer and the respect afforded to the reporting radiographers, ‘you can almost kind of sense a wee bit of surprise about articulate you can be about the report … (tl:405e408). Rachael also alluded to the concept of respect where people now appreciated the increased responsibility and hard work that came with the role, which she indicated was, ‘the greatest success of her whole team … because in time you see people do value what we're doing … ’ (tl:974e975). Edeline made reference to being invited to ‘discrepancy meetings … ’ (tl:801) where her opinion was sought and valued. Abigail's reflections concurred with others in relation to her opinion being sought from a broad range of professionals ‘erm particularly MIU nurses … A/E staff … and you do get a bit more respect from you peers … erm [and] I think now that I'm actively reporting … people obviously respect the qualification that you have and respect your ability … ’ (tl:240e261). The educator - bringing the people along Concordant with the higher-level core function, ‘Education, Training and Development,3 participants showed willingness and commitment to the education of a range of practitioners at varying levels of grade and expertise. When reflecting on education and learning, for self and others, Oleander stated, ‘I like to know why … ’ (tl:606), and ‘I like to tell them why … because then they'll remember … ’ (tl:597e601). Oleander was embracing her educational responsibility and she stressed she felt it an important part of her role. Regular meetings had allowed sharing of interesting cases and discussion of practice in general and although driven by the reporting radiographers, all staff were encouraged and empowered to contribute. Staff appeared to be enjoying participation which arguably was testament to the motivational attitudes of the reporting radiographers and her lengthy quote in Table 2 evidences her perceptions. Rochelle also alluded to the desire to know ‘why’ in conjunction with using the term curiosity, ‘natural curiosity, a natural curiosity, because I like to know why, why are we doing that, why are we having it this way or that way … ’ (tl:266e267). A CPD team had been formed and radiologists were now keen to support and become involved. Rochelle subsequently reflected positivity on the status afforded from staff, especially newly qualified practitioners but also mentioned ‘difficulties … with her vision to take everybody forward in education … ’ (tl:309e310). CPD is mandatory for radiographers,19 and Rochelle made reference to the difference between individuals who were ‘driven to learn more and are enthusiastic … ’ (tl:274e275), compared to those only prepared to do ‘within the hours of work … ‘(tl:272). For Rebecca, initial resistance had been experienced but ‘people [came willingly] to [the] CPD talks now … so I do think that is a bit of a success [as] we are starting to win people over … ’ (tl:1062e1069). CPD was a common theme and Abigail indicated ‘we have initiated monthly meetings where we talk about cases that have come through A/E, interesting cases and talk about technique … and how to improve service … you know … and I
Please cite this article as: Cuthbertson LM et al., The journey to advanced practice: An Interpretative Phenomenological Analysis of reaching destination and beyond for reporting radiographers in Scotland, Radiography, https://doi.org/10.1016/j.radi.2019.11.093
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Table 2 Detailed participant quotes for two subthemes relating to Superordinate Theme 3 … ‘Destination and Beyond - Review upon and action for the advanced practice reporting role.’ The Educator - Bringing the people along
The Future
O: Yeah, well, erm … the other radiographers and things will actually now, if they've got some interesting things they'll keep back, erm, patient CHI numbers, and then they'll, if there are some things that they are not sure about, they'll come and ask us, as well. And we've been doing, erm, a radiography review meeting once a month as well … so we'll ask them if they've anything interesting, and if there is something that they maybe want us to look into a wee bit more, erm, and do that … So I think it's getting a wee bit more, kind of, interactive with it. Well, I feel … I feel as if it is an important part of our role, and even in everyday, you know, the kind of structured teaching … erm, you know, I kind of feel as if almost every day someone is asking us, one way or another, you know, about patients, about reports we've done, and asking us, you know like why we would say that, and how we would report it; and we've been doing … trying to encourage people into the commenting side as well, so people are getting a lot more interested … It's going well. We've, erm, we've put in a folder into A&E and asked people if there's a film they're going to red dot, could they, erm, put down a sticky label and write down what they think … And we've, kind of, given them rough guidelines as what would, maybe, be expected. Some people are going, like, really trying really hard, and trying to, like, be really descriptive, and other people are good as … you know, they will just even highlight the area … Oleander: Transcript Lineage 415-479 Ro: Yeah I guess … I think longer-term I have an idea in my head of it would be great to have more reporting radiographers in the department and I guess I am thinking myself it would be lovely if as time went on I could take a lead over the reporting radiographers and my, my ideas will, eventually I would need to learn more I would need to be more responsible and accountable and have more education behind me and I guess more research behind me to back that up and support these people and so my longer-term view of where I would go would be, …I kinda thought recently about doing Masters … I have spoken to staff at the university about how to go about doing that, how to fund it and have also spoken to my managers because I think there is a need in the hospital to have radiographers doing more than we are at the moment … I could see that the respect I have been given so far could still be extended to do more … and I have been asked to think about business cases and things ongoing so that kinda ties in with Masters … so I kind of see a bigger picture ultimately. And I don't know whether I would like to become a consultant radiographer perhaps??.. But ultimately certainly take the lead within the hospital … for educating more reporting radiographers or leading reporting radiographers to have a service that is … what's the word I am looking for?.. That maintains itself … And even more long-term I guess are the national kind of, meeting [s] with the levels of reporting that are being suggested nationally and that would be great to be part of that and I don't know whether further long-term education and educator is something I would think of beyond that and I don't know … [but] those are too far ahead to think of … Rochelle: Transcript Lineage 304-339
have a lot of people coming up and saying … how much they enjoy it … ’ (tl:758e772). Rachael also referred to CPD sessions and the ‘very good feedback … ’ (tl:390) from those engaging. The future All participants were keen to keep learning and drive self and service forward. Abigail referred to her drive to better herself but also referred to improving service and promoting the radiography profession. A: Erm, but I think I also, I do have a wee bit of a drive to kind of make myself better and to provide a better service and to promote radiographers as a whole … Erm, and I, I do find my job interesting, I think that has a big impact, rather than people who just come in and see it purely as a job. I actually do enjoy my job and I do find it interesting and I do want to find ways to improve the service that we're providing … Abigail Transcript Lineage: 736-746 Rochelle also referred to her desire to drive service forward in addition to her own job satisfaction and desire to drive others. Arguably her lengthy quote (Table 2) somewhat pulls the lived experience of the journey to advanced practice in skeletal trauma to a close. There was consideration of future and ‘beyond’ for her advanced practice journey with aspiration to meet higher-level practice expectations.4 Rachel identified her enjoyment of the role and how she saw it taking off more than she had initially thought, ‘I think it's going to expand out-with just trauma … I think given time we're going to do a GP portfolio [which] we will work up to’ (tl:506e518). This was similar to Abigail who had alluded to stronger links with ENPs, ‘in fact there have been murmurings that they would like us to play a bigger role in their service’ (tl:467e469) with potential for improvement and increased inter-professional working. For Edeline, ‘we're just growing as a team … now we've all met I think that'll make a difference’ (tl:2261e2270) with indication this may lead to greater team-working and professional
development which may impact upon sustainability of future service delivery. Consistent with the findings of Culpan et al.20 and Thom,21 participant reflections indicated opportunity to positively impact upon quality clinical imaging service provision, delivery of a cost-effective increase in diagnostic capacity, the release of radiologist time for complex clinical imaging responsibilities, benefits to patients and practitioner job satisfaction. Final thoughts At the end of the interview participants were invited to provide a sentence to sum up the discussions. As the interviewer, the aim was to put participants at ease, show support, interest and empathy which arguably was confirmed in part by the succinct quote from Rochelle, ‘erm quite relaxed, I felt it really easy to talk about things, erm quite sincere and not too difficult or challenging at all … ’ [tl:606e607]. For Abigail the interview had made her reflect upon the type of person she had thought would take on this role. She related this in context of herself and then reflected upon the type of person she had been and had now become whereby unlike other staff, she had actually manufactured herself to be where she now was now. A: I think the discussion has made me more aware of the fact that, erm, it is a certain kind of person who puts themselves forward for this and who has the dedication to go through with it …. which I hadn't really thought of before. I think I probably thought of it being more opportunistic in the past. So, I think it probably has made me think more that, erm, I, I have designed myself to be where I am now … I have made myself be where I am now, you know, whereas others haven't. Abigail Transcript Lineage: 830-844 In essence, at that moment in time she realised what she had achieved, what she was able to do and was further capable of. She alluded to never having thought of things in that particular way prior to the interview and the reflection on the ‘lived experience’ of
Please cite this article as: Cuthbertson LM et al., The journey to advanced practice: An Interpretative Phenomenological Analysis of reaching destination and beyond for reporting radiographers in Scotland, Radiography, https://doi.org/10.1016/j.radi.2019.11.093
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her role appeared to have created increased self-awareness. This was also what Smith et al.10 classed as phenomenological reflection whereby through interviewer facilitation, self-conscious phenomenological reflection had occurred. Although in Rachael's account she accepted that one of the greatest successes had been her team and the effect on service, whereby ‘people do value what we are doing now … ’ (tl:974e975), she had had mixed emotions from study to uptake of the role and had often questioned whether reporting was for her. Like Abigail however her reflection indicated, ‘my personal, greatest success is learning a lot about myself … I've realised I do have the ability … in as much as I doubted myself, I've now got the self-confidence … ’ (tl:1029e1037). Reflective practice, for Brechin et al.22 and Eby,23 involved synthesis of reflection, self-awareness and critical thinking with the philosophical roots identified in phenomenology and critical theory. Rachael's final account had pulled events to a close and suggested that she had now gone through due process and found self-belief and confidence which she implied had ‘impacted on other aspects of [her] life as well … ’ (tl:1040). In concordance with Brechin et al.,22 the opportunity for reflection had enabled her to make sense of her experience through examining in context. For Edeline, the role had brought greater job satisfaction and confirmed the reality that reporting was what she wanted to do and she indicated her reporting role had given her ‘a new lease of life at work and … more focus … ’ (tl:2641e2642). Oleander explained that her advice to anyone would be to secure ‘support from your work … ’ (tl:1405) whereby her journey had not been easy and she had driven herself to achieve her goal. In spite of this, she indicated, ‘[I] just really enjoy [my reporting] role more … it shows where you can progress … it is really worthwhile, erm, and it's good for radiography in general … just to show what radiographers can do … ’ (tl:1404e1411). It was interesting and pertinent to note that Oleander's concluding thoughts focused on the profession as well as self. The conclusion of the interview for Rebecca provoked a long pause for reflection as she tried to think how to best sum up the interview. ‘Trying to think … [long pause] … If you can use an analogy of a road, it's been a road with lots of twists and turns … bits have been a bit uneven and a bit rocky … but the destination's been worth it … ’ Rebecca Transcript Lineage:1134e114. The descriptive quote clearly identified an interesting but convoluted journey. For Gallagher and Zahavi24, experience happened for the experiencing subject in an immediate way and as part of this immediacy it was implicitly marked as ‘my’ experience, which Rebecca reflected upon in an abstract way. From a phenomenological stance, this form of self-consciousness was a constant structural feature of conscious experience24 whereby the immediate and first-personal given-ness of the experiential phenomenon was accounted for in terms of a pre-reflective self-consciousness
whenever individuals lived through or underwent an experience, which for Rebecca, was the journey her advanced practice reporting role. Discussion All participants had embarked upon their similar but idiographic journeys, they had travelled along, reached destination and were now considering the future and beyond. Narratives showed a range of similarities and differences in perceptions and experiences which can be expected for the nuances of IPA.10 Arguably, different responses may actually in part reflect the personalities, preferences and learning styles within and across interviews during the data collection and analysis phases. Just as Smith et al.10 suggested, IPA looked for the convergence and divergence of opinion from participants, which arguably could be considered analogous with the potential for concordance and discordance associated with the interpretation of radiographer reports. As the participants recounted the perceptions and experiences of their lived experience, qualities of self-drive, motivation, determination, desire to motivate, enthuse and drive others emerged, which consistent with Johnston and Johnston25 reflected the efforts they had committed to, which they perceived as meaningful and worthwhile. Motivation was aimed at achieving goals, fuelled by emotion and social origins and what was particularly important and apparent was the inherent drive from all for improvement for self, service and others. Although there was more acceptance as the reporting role became embedded, some scepticism and resistance had remained. The initial aversion to change controverted government, professional body and service directives and needed constant address. Developments within the NHS continue to rapidly evolve and diagnostic imaging with constant advancing technologies, roles and changing policies, continues to remain in a constant state of change. Achieving useful service evolution is a complex process with multi-factorial challenges26 and for rapidly changing organisations, management require to create a culture able to embrace the potential for perpetual change.27 Henderson et al.,26 reported that strategic service managers in Scotland identified various possibilities where change could be beneficial but this had been hampered by systems and attitudes that did not welcome or facilitate change. One major strategy focused on the setting up of a national Scottish National Radiology Reporting Service and the pilot (March 2019) was due to run until August 2019, which following subsequent review would evaluate future potential.28 By 2021 there is an expectation that all advanced radiographer practitioners should hold a minimum of a full Master's degree29 therefore for anyone embarking upon education and professional development, support, time, finance, management and mentor support should be afforded to allow individuals to achieve their goals. For Lewin,30 successful change can only be achieved by either strengthening the driving forces or weakening the FORCES HINDERING CHANGE (RESISTORS)
FORCES SUPPORTING CHANGE (ENABLERS) • • • • • • •
Initiatives from government bodies, professional bodies, education Supportive radiologists, managers, peers, colleagues, ENPs, medical staff NHS, Service improvement, need to increase efficiency and effectiveness, waiting time targets, role developments, advanced practice Increased knowledge, skills and competencies through education and practice Peer and mentor support New ways of working, best use of staff skills, increased job satisfaction Inter-professional working, team building, professional respect, increased esteem
5
• • • • • • •
Lack of support for new initiatives Un-supportive radiologists, managers, colleagues Effect of radiologist training, decrease in skill set for radiologists, lack of time for education of SPRs, lack of understanding of role from colleagues Effect on work/life balance, lack of time, lack of support Lack of time for peer and mentor support Established work patterns, culture, resistance to change Effect of perception of others on self and role
Figure 1. Forcefield analysis; driving forces and restraining forces. Adapted from Lewin.30
Please cite this article as: Cuthbertson LM et al., The journey to advanced practice: An Interpretative Phenomenological Analysis of reaching destination and beyond for reporting radiographers in Scotland, Radiography, https://doi.org/10.1016/j.radi.2019.11.093
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restraining forces as depicted within a Forcefield Analysis. Fig. 1 reflects the potential driving forces responsible for the initiation and direction of change and those restraining forces that had potential to influence participant journeys. Arguably, as the practitioners continue to embed their role and evidence increased skill and competency, the balance of the force-field will remain in a constant state of flux. Conclusion This paper concludes the story of the journey to advanced practice in skeletal trauma reporting. Inevitably, as patterns of care continue to change to a patient focused approach, multidisciplinary involvement is required to strengthen the core function of working across professional boundaries with capacity to influence service improvement. Participants had reached destination and were contemplating and planning for future with a focus on development of role and self. Following the initial difficulties and challenges, reflections indicated increased acceptance which arguably was testament to participant motivation and commitment. This said, culture and resistance had potential to thwart personal and professional success and subsequent fulfilment of government and professional body objectives. Continued role development initiatives are therefore essential to ensure service quality and patient benefit, framed within a culture of effective teamworking, positive engagement and professional respect. Funding This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors. Conflict of interest statement None Acknowledgements This paper was derived from a larger Professional Doctorate thesis submitted to Glasgow Caledonian University in April 2015. Many thanks are due to the advanced practitioners who willingly gave their permission and time to participate in the research. Many thanks also go to my doctoral supervisors whose expertise and support was invaluable and motivated me to succeed. References 1. The Society and College of Radiographers. Reporting. Retrieved from: https:// www.sor.org/practice/reporting. 2. The Royal College of Radiologists. Clinical radiology UK workforce census 2018 report. London: The Royal College of Radiologists; 2019. Retrieved from: https://www.rcr.ac.uk/system/files/publication/field_publication_files/clinicalradiology-uk-workforce-census-report-2018.pdf. 3. The Society of Radiographers. Advanced practitioner. Retrieved from, https:// www.sor.org/learning/document-library/education-and-professionaldevelopment-strategy-new-directions/advanced-practitioner.
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Please cite this article as: Cuthbertson LM et al., The journey to advanced practice: An Interpretative Phenomenological Analysis of reaching destination and beyond for reporting radiographers in Scotland, Radiography, https://doi.org/10.1016/j.radi.2019.11.093