Advanced Practice

MAXIMISING THE POTENTIAL OF THE MODERN RADIOGRAPHER WORKFORCE

Successful delivery of radiology and radiotherapy ‏services is reliant upon a multiprofessional workforce ‏capable of delivering high-quality, patient-centred care ‏in a timely and cost-effective manner. In the UK, the traditional ‏relationship between the radiology and radiography ‏professions has changed, resulting in a radiographer with a ‏much-expanded scope of professional practice. Indeed the ‏radiographer role today is far removed from that promoted ‏by of the early radiography pioneers such as Furby (1944) ‏[see quotation].

While there are many professional titles in use across ‏Europe, the European Federation of Radiographer Societies ‏(EFRS ) published its definition of a ‘Radiographer’, following ‏approval by the EFRS General Assembly (EFRS 2011a).

In order to be recognised under this definition, the level of ‏knowledge, skills and competence of a radiographer should ‏be at Level 6 of the European Qualifications Framework (EQF) ‏(EFRS 2014; European Commission 2008), which is equivalent ‏to the European Higher Education Area (EHEA) Qualifications ‏Framework (2005) Bachelor level. For this purpose ‏the EFRS definition is:

Radiographers are medical imaging and radiotherapy ‏experts who are professionally accountable to the patients’ ‏physical and psychosocial well being, prior to, during and ‏following examinations or therapy; take an active role in ‏justification and optimisation of medical imaging and ‏radiotherapeutic procedures; are key-persons in radiation ‏safety of patients and third persons in accordance with ‏the “As Low As Reasonably Achievable (ALARA)” principle ‏and relevant legislation (EFRS 2011)a.

Within this document, the EFRS also identified the term ‏‘Radiographer’ as the single title at the European level, yet ‏it is clear that the scope of practice of radiographers varies ‏considerably from one country to another. Cowling (2008) ‏offered a global overview of the changing roles of radiographers, ‏suggesting that the UK is unquestionably the world ‏leader in advanced practice. She outlines four different levels ‏of role advancement (Table 1) with the UK sitting at Level 1 ‏followed by countries such as Australia, Canada, Japan, South ‏Africa and New Zealand, together with a growing number ‏of European countries (based on more recent EFRS data) ‏sitting at Level 2. Despite 90 percent of EFRS national societies ‏stating that they actively promote and support radiographer ‏role development (EFRS 2015a) there remains limited ‏evidence of the successful implementation of advanced ‏practice across many countries. The majority of European ‏countries remain at Level 3.

Analysis of a number of historical role developments ‏suggests that a range of overlapping drivers are necessary ‏to ensure widespread adoption of an extended scope of practice ‏(Table 2). Arguably, the most important driver is a significant ‏and long-standing service need. In the UK there has ‏been exponential growth in demand for radiology, alongside ‏a shortage of radiologists and increased public expectations. ‏A 2015 report showed the stark differences in the radiologist ‏workforce in the UK (7 per 100,000 population) compared ‏with the European average (11.7); indeed, the UK has less ‏than half of the radiologists/population ratio of Finland and ‏France (RCR 2015) (Figure 1). The European Society of Radiology ‏(2009) also published data indicating a European average ‏of 10.4 with national figures ranging from 0.15 to 21.5 ‏per 100,000).

From the UK data, the radiologists appear to be working ‏to capacity using a limited physical resource; the UK has ‏less than half the number of CT and MR systems and radiotherapy ‏treatment systems per million population compared ‏to many European countries (National Audit Office 2011). ‏However, they are performing more scans than these other ‏countries, with less equipment, whilst also coping with a ‏10-12% increase in CT and MRI procedures every year (NHS ‏England 2014). Maximum utilisation of limited equipment and ‏staffing resources has only been possible in the UK with the ‏routine adoption of radiographer advanced practice. That is ‏not to say that all hospitals have embraced advanced practice ‏fully; indeed many teaching hospitals have been slower ‏to embrace skills mix, probably due to higher radiologist ‏ratios. A review of the successful adoption of one particular ‏advanced role (gastrointestinal imaging) acknowledged the ‏vital role of nationally-recognised gatekeepers: in this case ‏radiologist champions, promoting radiographer role development ‏both within and beyond radiology (Nightingale and ‏Hogg 2003b). However, it is clear that for the vast majority ‏of National Health Service hospitals within the UK, radiographer ‏advanced roles are now completely embedded in service ‏delivery. Even with higher numbers of radiologists in training, it is difficult to imagine radiology departments removing ‏these posts, assuming they deliver high-quality patient care.

Confusing Range of Terminology

One of the difficulties in interpreting the success or otherwise ‏of the advancing role of the radiographer is the range of ‏terminology that is used, often interchangeably, which may ‏have created confusion (Hardy and Snaith 2006). Role developments ‏can be an expansion of practice, whereby radiographers ‏take on new duties that confer the same level of practice ‏and responsibility; these role developments can become ‏part of the normal scope of practice of radiographers over ‏time. Role extension refers to roles which were traditionally ‏undertaken by other professionals, usually radiologists. Such ‏roles may result in a higher level of practice and increased ‏responsibility and autonomy. Hardy and Snaith (2006) argue ‏that the extended role is a natural development for a professional ‏radiographer.

Until recently, a lack of clarity has persisted around a definition ‏of advanced role in the radiography context. Early attempts ‏to define radiographer advanced practice roles were made by ‏Nightingale and Hogg (2003a; 2003b) and Hardy and Snaith ‏in 2006. These authors suggest that ‘advancement’ does ‏not purely indicate an increase in the nature or complexity ‏of skills; a radiographer who performs an extended role, ‏whist having increased responsibilities, will not necessarily ‏be working at an advanced practice level.

T o perform at this higher level (as expected of an advanced ‏practitioner) would require them to be actively developing ‏practice for the benefit of their patients. While expert clinical ‏practice in a clearly defined area is a key component of ‏their role, advanced practitioners should also demonstrate:

• Delivery of specialist care to patients;
  
• Contribution to, and evaluation of, the evidence base to ‏develop practice ;
  
• Education and training of other staff;
  
• Recognition of knowledge and expertise – expert resource;
  
• Team leadership, including service management and planning. (EFRS 2011b; Hardy and Snaith 2006; Kelly et al 2008; Snaith and Hardy 2007)
  

Working Across Traditional Healthcare Boundaries

Advanced practitioners often work across traditional healthcare ‏boundaries, being fully integrated into new care pathways ‏and the multidisciplinary team. This clearly delineates ‏the advanced practitioner from the largely uniprofessional ‏focus of the radiographer practitioner grade. The transition ‏from practitioner to advanced practitioner requires significant ‏investment at the individual, service and organisational ‏level if it is to succeed and become firmly embedded within ‏healthcare practice. To achieve this status requires additional ‏knowledge, skills and expertise, and this is most compatible ‏with Masters level (EQF Level 7) study (SCoR 2005), with ‏evidence of successful integration of advanced clinical competences ‏within a postgraduate framework (Piper et al 2010; ‏2014; 2015). Lack of formal education has several potential ‏consequences, including lack of transferability between ‏hospitals, reduced recognition, and lack of opportunity for ‏career advancement. Radiographers should be encouraged ‏to see postgraduate study as an essential component of ‏advanced practice (EFRS 2011b), though currently only 39% ‏of educational institutions with a pre-registration radiography ‏programme currently offer Masters programmes for ‏radiographers while only 14.6% offer doctoral programmes ‏(McNulty et al. 2016).

In summary, an advanced practitioner is:

An individual who has significantly developed their role ‏and who consequently has additional clinical expertise in ‏a defined area of practice, accompanied by deep underpinning, ‏evidence-based knowledge related to that expertise. ‏They make appropriate clinical decisions related to ‏their enhanced level of practice, directly impacting on the ‏patient care pathway (EFRS 2011)b.

and is:

...autonomous in clinical practice, defines the scope of practice ‏of others and continuously develops clinical practice ‏within a defined field (College of Radiographers 2005).

and:

... has an essential role in enabling the advancement of innovative ‏practice where this can contribute to improvements ‏in service delivery and quality patient care (EFRS 2012a).

 
Benefits and Limitations of Advanced Practice

As the interest in adopting radiographer advanced roles grows ‏in many European countries, a clearer picture has emerged ‏about the benefits and limitations of advanced practice in ‏countries which have embraced it (Kelly et al. 2008). There ‏is empirical evidence to demonstrate that radiographers ‏are competent to perform advanced roles, with many studies ‏comparing radiographer performance directly to that of ‏radiologists (Judson and Nightingale 2009; Woznitza et al. ‏2014; Torres-Mejía et al. 2015; Reid et al. 2016; Moran and ‏Warren-Forward 2016). Evidence of the wider impacts of ‏advanced practice is growing, but more is required (Law et al. ‏2008; Hardy et al. 2013; Lockwood 2016; Snaith et al. 2015; ‏Clarke et al. 2014). There is also evidence to demonstrate the ‏successful uptake of advanced roles (Price and Le Masurier ‏2007; SCoR 2012), but few articles consider why advanced ‏practice may have failed to be fully adopted in some regions.

One exception is a recent article by Henderson et al. (2016) ‏that highlights the current status of advanced practice of ‏radiographers in Scotland, which did not compare favourably ‏to the adoption of such roles in the rest of the UK.

Boundaries Between the Professions Begin to Blur ‏and Reposition

As radiographers adopt new advanced roles, the boundaries ‏between the professions begin to blur and reposition. For ‏example, a decade ago there was a clear demarcation between ‏the role of the radiographer in trauma imaging (producing the ‏images) and that of the radiologist (reporting the images), ‏whereas this distinction is now less clear, with 41 percent of ‏UK imaging departments in 2012 employing radiographers ‏to report trauma images (SCoR 2012).

Similarly, radiographers in many centres in the UK are now ‏performing and reporting a range of contrast gastrointestinal ‏procedures (SCoR 2012), yet for some examinations such as ‏CT colonography there is still considerable debate amongst ‏the radiologist community about whether radiographers should ‏be involved in reporting (Boellaard 2012). While radiologists ‏may be concerned that radiographers are encroaching upon ‏their domain, radiographers may have similar concerns about ‏assistant practitioners (non-registered healthcare workers) ‏encroaching on the radiographer scope of practice. One of ‏the concerns regularly expressed is that as roles are delegated ‏by one professional group to another, reduced exposure ‏to practice will lead to a change in the baseline skills of the ‏delegating profession. The ‘expert’ will shift from one profession ‏to another: radiologists will need to be prepared to ‘let ‏go’ of some professional expertise, and radiographers must ‏be prepared to shoulder this increased expectation.

The Radiography journal, which is the official journal of ‏the EFRS and the Society and College of Radiographers, has ‏been the main conduit for dissemination of evidence related ‏to advanced practice, and it continues to engage with the ‏European radiographer community to encourage evidencebased ‏practice and radiographer research and to develop ‏publishing and dissemination skills. Published articles within ‏this and other journals have shown tangible benefits of ‏radiographer advanced practice, including improvements to ‏examination waiting times and report turnaround times with ‏no adverse effects in terms of patient safety and outcomes. ‏Radiographers in the UK have embraced these new opportunities ‏to utilise their skills and expertise—the most highly ‏skilled radiographers are now being retained via a lifelong ‏career pathway, rather than them moving to management or ‏education posts due to a lack of challenging opportunities in ‏clinical practice. While other countries are working towards ‏the adoption of advanced roles, they do not all have the critical ‏drivers that have been apparent in the UK.

Immense Benefits Through Implementation of ‏Advanced Practice

Nevertheless, the benefits to radiographers and their patients ‏could be immense through the implementation of advanced practice across a wide range of areas such as musculoskeletal ‏(MSK) reporting, breast imaging, gastrointestinal imaging, ‏interventional procedures and radiotherapy. For this to ‏happen on a large scale there needs to be a clear professional ‏steer. In the UK, by stating that the modern scope of radiographer ‏practice is “that which the radiographer is educated ‏and competent to perform”, the Society and College of Radiographers ‏(2009) is making it clear that it sees no boundaries ‏to the practice of a radiographer. Similarly, the EFRS as the ‏umbrella organisation for 39 national radiographer societies ‏and 55 educational institutions, representing over 100,000 ‏radiographers and over 8,000 radiography students across ‏Europe, has a role in guiding member organisations. Through ‏its Statements on Education (2012b) and ongoing work on ‏establishing EQF Level 6 (2014) and Level 7 benchmarking ‏documents for radiographers, the EFRS continue to highlight ‏the need for the wider consideration of role development, ‏role extension and advanced practice. Raising the profile of ‏the radiography profession and of radiography education, ‏together with the continued development of its relationship ‏with the European Society of Radiology, are some of the ‏essential ingredients to facilitate this at the European level. ‏However, national and local opportunities to improve patient ‏care and outcomes will always remain the critical driver for ‏the development of the radiographer scope of practice.

Key Points

• As radiographers adopt new advanced roles, boundaries between the professions begin to blur and reposition.
  
• A range of overlapping drivers is necessary to ensure widespread adoption of an extended scope of practice.