Does radiography advanced practice improve patient outcomes and health service quality? A systematic review

Assessing the barriers and enablers to the implementation of the diagnostic radiographer musculoskeletal X-ray reporting service within the NHS in England: a systematic literature review

INTRODUCTION

The United Kingdom (UK) government's healthcare policy in the early 1990s paved the way adoption of the skills mix development and implementation of diagnostic radiographers' X-ray reporting service. Current clinical practice within the public UK healthcare system reflects the same pressures of increased demand in patient imaging and limited capacity of the reporting workforce (radiographers and radiologists) as in the 1990s. This study aimed to identify, define and assess the longitudinal macro, meso, and micro barriers and enablers to the implementation of the diagnostic radiographer musculoskeletal X-ray reporting service in the National Healthcare System (NHS) in England.

METHODS

Multiple independent databases were searched, including PubMed, Ovid MEDLINE; Embase; CINAHL, and Google Scholar, as well as journal databases (Scopus, Wiley), healthcare databases (NHS Evidence Database; Cochrane Library) and grey literature databases (OpenGrey, GreyNet International, and the British Library EthOS depository) and recorded in a PRISMA flow chart. A combination of keywords, Boolean logic, truncation, parentheses and wildcards with inclusion/exclusion criteria and a time frame of 1995-2022 was applied. The literature was assessed against Joanna Briggs Institute's critical appraisal checklists. With meta-aggregation to synthesize each paper, and coded using NVivo, with context grouped into macro, meso, and micro-level sources and categorised into subgroups of enablers and barriers.

RESULTS

The wide and diverse range of data (n = 241 papers) identified barriers and enablers of implementation, which were categorised into measures of macro, meso, and micro levels, and thematic categories of context, culture, environment, and leadership.

CONCLUSION

The literature since 1995 has reframed the debates on implementation of the radiographer reporting role and has been instrumental in shaping clinical practice. There has been clear influence upon both meso (professional body) and macro-level (governmental/health service) policies and guidance, that have shaped change at micro-level NHS Trust organisations. There is evidence of a shift in culturally intrenched legacy perspectives within and between different meso-level professional bodies around skills mix acceptance and role boundaries. This has helped shape capacity building of the reporting workforce. All of which have contributed to conceptual understandings of the skills mix workforce within modern radiology services.

Exploring the role of advanced clinical practitioners (ACPs) and their contribution to health services in England: A qualitative exploratory study

BACKGROUND

An extended role being explored globally is the advanced clinical practitioner (ACP). In England this is an extended role for allied health professions, nurses and midwives in a range of settings.

OBJECTIVES

This paper focuses on three research questions: 1) What is the role of ACPs in England? 2) What are the barriers and facilitators to implementing the role? and 3) What is the contribution of ACPs to health services in England?

DESIGN/SETTING

A qualitative, exploratory study to explore perspectives on the ACP role in a range of clinical settings.

PARTICIPANTS

We recruited 63 stakeholders, including 34 nurses, working in a ACP role or ACP education. A purposive snowball sampling technique identified participants meeting inclusion criteria.

METHODS

One-to-one semi-structured interviews throughout 2020, recorded and transcribed verbatim, anonymised and thematically analysed.

RESULTS

The ACP role in England was undertaken in a broad range of clinical contexts. In England 'advanced clinical practitioner' was not a protected title. There were high levels of variability and ambiguity of understanding and deployment of the ACP role in England. Facilitators to the implementation process included training and education, clinical supervision and organisational support. Lack of protection for the role and variances in experience were barriers. Employer support facilitated development of the ACP role, however where support was limited, at either an individual or organisation level, this was a barrier. Our study highlighted the wide range of ways the ACP role benefitted patient outcomes and workforce development.

CONCLUSIONS

This study outlines the contribution that ACPs can make to health services, contributing factors and key barriers and facilitators to implementing this role. The work showed the positive contribution ACPs can make to service redesign, workforce development and patient outcomes, whilst accepting there is much work to do to ensure protected status and parity across all professions and clinical contexts.

Difficulties associated with Reporting Radiographer working practices - A narrative evidence synthesis

OBJECTIVES

This narrative synthesis of evidence identifies and explores issues that impact upon the expansion or effectiveness of Reporting Radiographers working in all diagnostic modalities within the United Kingdom (UK). The publication focuses on working practices affecting trainees and qualified Reporting Radiographers.

KEY FINDINGS

Fourteen studies informed the themes of this article, they were published between 2014 and 2021. Delays to commencement of reporting roles and variance in performance monitoring was common. Lack of formalisation, overly restrictive and out of date scopes of practice were also found. Whilst, staffing shortages contributed to underutilisation. Failure to utilise skills was most prevalent in cross sectional imaging modalities. Considerable variance in practice was also found between centres. Meanwhile, Reporting Radiographer involvement in professional development, education and research is far from universal and often dependant on individuals sacrificing their own time.

CONCLUSION

Governance in many centres would benefit from renewal and standardisation, particularly relating to scopes of practice and performance monitoring audits. Measures are also required to encourage compliance with guidance, address staffing issues and reduce variation between centres. Failure to address these issues has the potential to impair collaboration, delay patient care and increase economic inefficiencies whilst negatively impacting satisfaction for service users and staff. Lack of involvement in professional development, education and research suggests Reporting Radiographers are not accomplishing their full potential, educating the next generation of the reporting workforce and driving evidence-based change for further development of the specialism.

IMPLICATIONS FOR PRACTICE

Better use of the existing workforce is essential to increase productivity, value, and security of Reporting Radiographer services, which are essential to improve patient outcomes and efficiency.

Radiographers' self-perceived competencies after attending postgraduate courses in CT and MRI

INTRODUCTION

Postgraduate education in computed tomography (CT) and magnetic resonance imaging (MRI) varies globally. Multiple factors affect the development of associated core skills and competencies for these specialist roles. Previous research has highlighted that different teaching standards and methods may influence radiographers' confidence and competencies. Nonetheless, there is limited knowledge of skill development and capabilities in post-registration roles. Hence, the aim of this research was to explore radiographers' self-perceived competencies before, during and after successful completion of postgraduate study.

METHODS

Radiographers enrolled on the CT and MRI courses voluntarily completed questionnaires at three time points. As part of the last survey, questions were added to evaluate their perceptions of the courses' impact on their clinical and professional practice. Descriptive statistics, Wilcoxon matched pairs signed rank and Friedman tests, were performed to analyse results across the different time points.

RESULTS

53 students completed the baseline survey, with initial perceived areas of weakness being lack of knowledge relating to CT or MR technology, cross-sectional anatomy and pathology. Follow up surveys, highlighted a significant increase in self-described competence in technical knowledge, literature appraisal and image viewing skills. As a result of completing the course, students described favourable changes to their departmental practices and their own continuing professional development (CPD). Challenges detailed included but not limited to lack of study time provided by employers, and the demands of balancing studies and work commitments.

CONCLUSION

Postgraduate education has value and positively impacts radiographers and their clinical departments. The courses enabled the radiographers, including those experienced in CT and or MRI to develop skills they could translate into clinical practice, thereby contributing towards service delivery.

IMPLICATIONS FOR PRACTICE

Post graduate education has the potential to enhance self-perceived competency in aspects of CT and MRI practice.

Advanced practice roles of therapeutic radiographers/radiation therapists: A systematic literature review

INTRODUCTION

Advances in Radiotherapy (RT) technology and increase of complexity in cancer care have enabled the implementation of new treatment techniques. Subsequently, a greater level of autonomy, responsibility, and accountability in the practice of Therapeutic Radiographers/Radiation Therapists (TR/RTTs) has led to Advanced Practice (AP) roles. The published evidence of this role is scattered with confusing terminology and divergence regarding the perception of whether a specific role represents AP internationally. This study aims to establish an international baseline of evidence on AP roles in RT to identify roles and activities performed by TR/RTTs at advanced level practice and to summarise the impact.

METHODS

A systematic PRISMA review of the literature was undertaken. Thematic analysis was used to synthesise the roles and associated activities. Six RT external experts validated the list. The impact was scrutinised in terms of clinical, organisational, and professional outcomes.

RESULTS

Studies (n = 87) were included and categorised into four groups. AP roles were listed by clinical area, site-specific, and scope of practice, and advanced activities were organised into seven dimensions and 27 sub-dimensions. Three most-reported outcomes were: enhanced service capacity, higher patient satisfaction, and safety maintenance.

CONCLUSION

Evidence-based AP amongst TR/RTTs show how AP roles were conceptualised, implemented, and evaluated. Congruence studies have shown that TR/RTTs are at par with the gold-standard across the various AP roles.

IMPLICATIONS FOR PRACTICE

This is the first systematic literature review synthetisising AP roles and activities of TR/RTTs. This study also identified the main areas of AP that can be used to develop professional frameworks and education guiding policy by professional bodies, educators and other stakeholders.

Optimizing integrated imaging service delivery by tier in low-resource health systems

Access to imaging diagnostics has been shown to result in accurate treatment, management, and optimal outcomes. Particularly in low-income and low-middle-income countries (LICs, LMICs), access is limited due to a lack of adequate resources. To achieve Sustainable Development Goal (SDG) 3, access to imaging services is critical at every tier of the health system. Optimizing imaging services in low-resource settings is best accomplished by prescriptive, integrated, and coordinated tiered service delivery that takes contextual factors into consideration. To our knowledge, this is the first recommendation for optimized, specific imaging care delivery by tier. A model for tier-based essential imaging services informs and guides policymakers as they set priorities and make budgetary decisions. In this paper, we recommend a framework for tiered imaging services essential to reduce the global burden of disease and attain universal health coverage (UHC). A lack of access to basic imaging services, even at the lowest tier of the health system, can no longer be justified by cost. Worldwide, affordable modalities of modern ultrasound and X-ray are becoming an accessible mainstay for the investigation of common conditions such as pregnancy, pneumonia, and fractures, and are safely performed and interpreted by qualified professionals. Finally, given the vast gap in access to imaging resources between LMICs and high-income countries (HICs), a scale-up of tiered imaging services in low-resource settings has the potential to reduce health disparities between, and within countries. As the access to appropriately integrated imaging services improves, UHC may be achieved.

Characterising the outcomes, impacts and implementation challenges of advanced clinical practice roles in the UK: a scoping review

OBJECTIVES

In response to demographic and health system pressures, the development of non-medical advanced clinical practice (ACP) roles is a key component of National Health Service workforce transformation policy in the UK. This review was undertaken to establish a baseline of evidence on ACP roles and their outcomes, impacts and implementation challenges across the UK.

DESIGN

A scoping review was undertaken following JBI methodological guidance.

METHODS

13 online databases (Medline, CINAHL, ASSIA, Embase, HMIC, AMED, Amber, OT seeker, PsycINFO, PEDro, SportDiscus, Osteopathic Research and PenNutrition) and grey literature sources were searched from 2005 to 2020. Data extraction, charting and summary was guided by the PEPPA-Plus framework. The review was undertaken by a multi-professional team that included an expert lay representative.

RESULTS

191 papers met the inclusion criteria (any type of UK evidence, any sector/setting and any profession meeting the Health Education England definition of ACP). Most papers were small-scale descriptive studies, service evaluations or audits. The papers reported mainly on clinical aspects of the ACP role. Most papers related to nursing, pharmacy, physiotherapy and radiography roles and these were referred to by a plethora of different titles. ACP roles were reported to be achieving beneficial impacts across a range of clinical and health system outcomes. They were highly acceptable to patients and staff. No significant adverse events were reported. There was a lack of cost-effectiveness evidence. Implementation challenges included a lack of role clarity and an ambivalent role identity, lack of mentorship, lack of continuing professional development and an unclear career pathway.

CONCLUSION

This review suggests a need for educational and role standardisation and a supported career pathway for advanced clinical practitioners (ACPs) in the UK. Future research should: (i) adopt more robust study designs, (ii) investigate the full scope of the ACP role and (iii) include a wider range of professions and sectors.

Workplace factors facilitating the radiographers' assessment of referrals for diagnostic imaging - A qualitative study

INTRODUCTION

Radiology referrals are assessed for appropriate imaging based on the available clinical information. The task is legally the responsibility of the radiologists but could be delegated to radiographers under guidance. Knowledge of how this task is organised in radiology departments is limited. The study aim was to identify workplace factors facilitating the radiographers' assessment of referrals for medical imaging.

METHODS

Five radiographers were recruited by convenience- and snowball-sampling techniques through the online social media platform LinkedIn. The participants represented different private and public hospitals and had from three to above ten years of experience with assessment of referrals for plain and cross sectional imaging. Following a qualitative approach, 60-min in-depth semi-structured interviews were conducted through online video meetings. Interviews followed a topic guide with 15 questions and 20 keywords, previously tested through a pilot interview. Systematic text condensation was performed using NVivo 12, where central themes and underlying subthemes were developed.

RESULTS

Five central facilitating factors were identified, each with subthemes identified as: (1) Formal responsibilities; Documented delegation, Specific role description, (2) Training; Achieving skills, Maintaining skills, (3) Guidelines; Clinical indications, Priority, (4) Resource allocation; Time, Staff, (5) a Supporting environment; Teamwork, Mutual benefits, Feedback and knowledge sharing.

CONCLUSION

The study adds new and valuable insights into workplace factors facilitating the radiographers' delegated task of assessing referrals. Workflows adapting such factors benefit radiographers by increasing knowledge and professional development, while positively re-allocating radiologist resources.

IMPLICATIONS FOR PRACTICE

The study findings may support radiology workplaces in establishing or improving referral assessment by radiographers. Subsequently, improved quality of patient services may be achieved.

Radiographers reporting chest X-ray images: Identifying the service enablers and challenges in England, UK

INTRODUCTION

The chest x-ray (CXR) is the most commonly performed x-ray examination in England, UK. Reporting radiographers provide a cost-effective and safe solution for managing CXR backlogs, but not all Trusts support this service development. This study aimed to establish the service enablers and challenges associated with training and employing radiographers to report CXR images in acute hospital sites in England, UK.

METHODS

Approval for this electronic survey was granted in 84 of 146 (58%) Trusts approached. The survey was open for 10 weeks during August to October 2020, comprising of qualitative and quantitative questions. Data was exported in to an Excel spreadsheet where manual thematic analysis was performed. Descriptive statistics were also generated.

RESULTS

Sample size was 75 (89% response rate). Thirty-three departments (44%) had at least one trainee. Most departments (n = 53, 71%) employ at least one CXR reporting radiographer. A total of 121/160 (76%) radiographers report CXRs. Number of reporting sessions shows progression. Factors enabling training and employment arise from service improvements, financial pressures, and developing the workforce. The main challenges relate to staffing issues with a number of associated sub-themes. A small faction indicated lack of radiographer interest to report CXRs due to litigation worries; possibly uncovering a new and emerging issue.

CONCLUSION

Enablers and challenges associated with radiographers reporting CXRs are similar to previous studies. The growth of CXR reporting radiographers and reporting sessions indicates a continuing reliance on radiographers to contributing to managing CXR backlogs.

IMPLICATIONS FOR PRACTICE

It is recommended that potential trainees are explicitly informed of the legal protection that will be provided, to prevent accountability concerns impacting on the continuing progression in this area of advanced practice.

Diversity in radiation therapist/therapeutic radiographer (RTT) advanced practice (AP) roles delivering on the four domains

INTRODUCTION

Advanced practice roles are well documented, and continue to respond to the changing landscape in radiotherapy and oncology. In the UK the highest level of AP for the therapeutic radiographer/radiation therapist (RTT) is the consultant radiographer. These posts should meet the four domains of practice, as set out in national guidance. Here we aim to describe well established roles that meet this criteria, and provide subgroups of examples.

METHODOLOGY

Three AP post holders with over 10 years AP experience completed a questionnaire adapted from the consultant radiographer toolkit. These were completed in conjunction with guidance and framework documents. The examples were to demonstrate how they achieve a high level of practice in clinical and expert practice; professional leadership and consultancy; education, training and development; and practice and service development, research and evaluation. Participants then categorised results to add subgroups to each domain.

RESULTS

The questionnaire was completed by three RTTs specialising as a lung consultant radiographer (LCR), a neuro-oncology consultant radiographer (NCR) and a lead research radiographer (RR). Each post holder described how they meet the criteria by discussing the benefit they make to their profession, department and patients. All posts had examples for all criteria, achieving consultant practice. Clinical and expert practice was the dominant domain for the clinical specialist posts, and professional leadership and research evaluation was the strongest domains for the RR.

CONCLUSION

All three consultant RTTs have demonstrated expert practice with clear and transparent examples of their professional practice which evidence the four domains of consultant practice. Following two decades of AP practice for RTTs there is a need to be strategic in the development of future posts with a prospective view on succession planning that safeguards their longevity.

Quality assessment with diverse studies (QuADS): an appraisal tool for methodological and reporting quality in systematic reviews of mixed- or multi-method studies

BACKGROUND

In the context of the volume of mixed- and multi-methods studies in health services research, the present study sought to develop an appraisal tool to determine the methodological and reporting quality of such studies when included in systematic reviews. Evaluative evidence regarding the design and use of our existing Quality Assessment Tool for Studies with Diverse Designs (QATSDD) was synthesised to enhance and refine it for application across health services research.

METHODS

Secondary data were collected through a literature review of all articles identified using Google Scholar that had cited the QATSDD tool from its inception in 2012 to December 2019. First authors of all papers that had cited the QATSDD (n=197) were also invited to provide further evaluative data via a qualitative online survey. Evaluative findings from the survey and literature review were synthesised narratively and these data used to identify areas requiring refinement. The refined tool was subject to inter-rater reliability, face and content validity analyses.

RESULTS

Key limitations of the QATSDD tool identified related to a lack of clarity regarding scope of use of the tool and in the ease of application of criteria beyond experimental psychological research. The Quality Appraisal for Diverse Studies (QuADS) tool emerged as a revised tool to address the limitations of the QATSDD. The QuADS tool demonstrated substantial inter-rater reliability (k=0.66), face and content validity for application in systematic reviews with mixed, or multi-methods health services research.

CONCLUSION

Our findings highlight the perceived value of appraisal tools to determine the methodological and reporting quality of studies in reviews that include heterogeneous studies. The QuADS tool demonstrates strong reliability and ease of use for application to multi or mixed-methods health services research.

An analysis of advanced and specialist posts in diagnostic radiography: Do job descriptions describe advanced practice?

INTRODUCTION

Underpinned by a multi professional advanced clinical practice (ACP) framework, role consistency in practice level and education has been advocated across allied health professions. However little research has evaluated ACP expectations in radiography. This study identified the capability requirements of advanced and specialist diagnostic radiographers and mapped these to home country advanced practice frameworks and the Society and College of Radiographers (SCoR) Education and Career Framework.

METHODS

A consecutive sample of UK job advertisements was collected over six months and analysed for role focus, professional and clinical responsibilities, reporting or procedural expectations and knowledge and experience. Qualitative content analysis was used to scrutinise capabilities during role mapping.

RESULTS

A total of 42 job descriptions were analysed across UK Trusts and Health Boards, with 31 roles (73.8%) containing the terms advanced or specialist. Half of the advertised roles expected proficiency in reporting (n = 21; 50%). Responsibilities mapped to the practice outcomes of the SCoR framework in 31 roles (n = 31/42; 73.8%). The English documents (n = 40/42; 95.2%) evaluated against the multi professional framework identified significantly (χ2 = 14.6; p < 0.01) fewer capabilities (n = 13/40; 32.5%). Clinical practice was reflected broadly in textual behavioural descriptors however, leadership, education and research responsibilities were internal and operational in nature.

CONCLUSION

This analysis of diagnostic radiographer job descriptions has demonstrated that many posts advertised as 'advanced' differ from advanced practice roles defined by the multi professional ACP framework, although they meet professional body standards.

IMPLICATIONS FOR PRACTICE

Utilisation of diagnostic radiographers as 'true' advanced clinical practitioners remains intermittent. Greater consistency in job descriptions is required to strengthen radiography advanced practice and support radiographer development.

Characterising the evidence base for advanced clinical practice in the UK: a scoping review protocol

INTRODUCTION

A global health workforce crisis, coupled with ageing populations, wars and the rise of non-communicable diseases is prompting all countries to consider the optimal skill mix within their health workforce. The development of advanced clinical practice (ACP) roles for existing non-medical cadres is one potential strategy that is being pursued. In the UK, National Health Service (NHS) workforce transformation programmes are actively promoting the development of ACP roles across a wide range of non-medical professions. These efforts are currently hampered by a high level of variation in ACP role development, deployment, nomenclature, definition, governance and educational preparation across the professions and across different settings. This scoping review aims to support a more consistent approach to workforce development in the UK, by identifying and mapping the current evidence base underpinning multiprofessional advanced level practice in the UK from a workforce, clinical, service and patient perspective.

METHODS AND ANALYSIS

This scoping review is registered with the Open Science Framework (https://osf.io/tzpe5). The review will follow Joanna Briggs Institute guidance and involves a multidisciplinary and multiprofessional team, including a public representative. A wide range of electronic databases and grey literature sources will be searched from 2005 to the present. The review will include primary data from any relevant research, audit or evaluation studies. All review steps will involve two or more reviewers. Data extraction, charting and summary will be guided by a template derived from an established framework used internationally to evaluate ACP (the Participatory Evidence-Informed Patient-Centred Process-Plus framework).

DISSEMINATION

The review will produce important new information on existing activity, outcomes, implementation challenges and key areas for future research around ACP in the UK, which, in the context of global workforce transformations, will be of international, as well as local, significance. The findings will be disseminated through professional and NHS bodies, employer organisations, conferences and research papers.

Does a radiographer-led palliative radiotherapy pathway provide an efficient service for patients with symptoms of advanced cancer? The Northampton experience

Aim:

To investigate whether a radiographer-led radiotherapy pathway can provide an efficient service for patients requiring treatment for symptomatic skeletal metastases.

Materials and Methods:

A retrospective review of 425 courses of palliative radiotherapy was conducted. Data was analysed assessing diagnosis, dose/fractionation, time from referral to treatment, gender, age, inpatient/outpatient status and referring clinic location for radiographer- and clinical oncologist-led cohorts.

Results:

Patients aged ≥70 years were more likely to be planned by radiographers (n = 162/57, p < 0·001). Patients were more likely to be treated with 8 Gy in single fraction than with 20 Gy in five fractions (n = 279/136, p = 0·012). The median referral to treatment time in 8-Gy single-fraction prescriptions was 3 days for radiographer-led versus 7 days for clinical oncologist-led cohorts. In all patients and in 20 Gy in five-fraction prescriptions, it was 4 versus 8 days. A comparison of all prescriptions (p < 0·001), 8 Gy in single-fraction (p < 0·001) and 20 Gy in five-fraction prescriptions (p = 0·001) showed radiographer-led procedures as enabling faster access to treatment in each category.

Findings:

A radiographer-led service can facilitate faster access to treatment than a clinical oncologist-led pathway for an appropriately selected patient caseload.

An evaluation of CT head reporting radiographers' scope of practice within the United Kingdom

INTRODUCTION

This study investigated the scope of practice of CT head reporting radiographers in the UK, and to compare adherence to professional body standards.

METHODS

An online questionnaire was utilized applying both multiple-choice and response (closed questions), and qualitative open question free-text responses. The 30 questions covered four key areas of demographics, the scope of practice, referrals, and ongoing competence, as described in professional body national guidance standards. The questionnaire was disseminated (convenience sampling) via Twitter and email to the National CT Head Reporting Special Interest Group. Responses were transcribed and coded; the results applied descriptive statistics to summarise observations of the study sample.

RESULTS

The sample of participant response data analysed was n = 54. Most respondents were from England, with a postgraduate certificate award in clinical reporting, and a mean length of 8.3 years of reporting experience. The accepted referral pathway included a wide range of medical and surgical specialities, including both in and outpatients and acute and chronic pathways. Furthermore, 96.2% of the sample had a scope of practice that authorised referral recommendations to a broad and inclusive group of medical and surgical teams, and if required further or repeat diagnostic imaging. To maintain quality and evidence of ongoing competency, all radiographers were involved in audit cycles.

CONCLUSION

The data collected confirmed the reporting practice within this sample group aligns to national recommended guidance. The data provided key information on the range and variation of individuals scope of practice within age restrictions of patients, examination types, referral teams, and ongoing competency practices.

IMPLICATIONS FOR PRACTICE

This paper details the scope of practice of CT head reporting by radiographers and the contribution made to the healthcare sector.

CO-score; a new method for quality assessment of radiology reports

INTRODUCTION

Studies on assessing radiology reports commonly calculates sensitivity, specificity and accuracy, which estimates if the observer has tendency to overdiagnose, overlook pathology, or both. This pilot study examines a new method for assessing the quality of radiology reports, based on the patients' clinical outcome.

METHODS

Two observers evaluated five hundred reports by four experienced reporting radiographers on X-ray images of the appendicular skeleton. The observers categorised the reports as true or false and gradated the quality of the report from 1 to 3 based on the patients' clinical outcome. We developed a new performance score, called the Consequence of Clinical Outcome (CO-score), which combines the amount of incorrect reports and the severity of errors, to assess the overall quality of the reports. A low CO-score represents high quality with few or inconsiderate errors.

RESULTS

The results showed no direct connection between high accuracy and low CO-score. All radiographers achieved high levels of accuracy (range: 96.8%-100%) but varied in CO-score (range: 0.00-0.14). One radiographer achieved an accuracy of 97.6% but a high CO-score of 0.14 as four reports had clinical consequence for the patients and five reports lacked minor details. One report was classified as true positive but was inadequate and led to wrong treatment.

CONCLUSION

This study shows that true reports can affect the patients' clinical outcome and reports classified as false can represent insignificant errors. The new CO-score gives a more nuanced view of the reporting quality by including the patients' clinical outcome in the performance score.

IMPLICATIONS FOR PRACTICE

We suggest that the CO-score is included as a supplement to the common methods in future studies assessing the quality of radiology reports as well as in clinical audits.

The journey to radiographer advanced practice: a methodological reflection on the use of interpretative phenomenological analysis to explore perceptions and experiences

Introduction:

This paper is a methodological reflection on the use of interpretative phenomenological analysis (IPA) utilised in the context of a qualitative research project that explored perceptions and experiences of the journey to radiographer advanced practice.

Methods and materials:

A two-phase qualitative research explored the perceptions and experiences. Phase 1 reviewed reflective diaries (n = 12) kept during the educational phase of the practitioner journeys. Phase 2 included one-to-one, semi-structured interviews (n = 6) which were recorded, transcribed verbatim and reviewed using the IPA six-stage thematic analysis for practitioners embedded in the advanced practice role.

Findings:

Key themes arising from reflective diary analysis informed the interview content; and following interview transcription, data immersion and IPA, 12 emergent sub-themes generated 3 superordinate themes.

Discussion:

Theoretical perspectives and application of the methodology are discussed. The phenomenological and interpretative qualities of IPA have the potential to provide unique and valuable insights into lived experiences of individuals. It is hoped that this researchers’ reflections are transferrable for those interested in employing a qualitative methodology for radiotherapy and oncology research.

Conclusion:

Therapeutic radiographers work within rapidly changing environments from technological, treatment and care perspectives. With continued development and change, the impact of research utilising an IPA methodology may allow exploration of perceptions and experiences from a range of key stakeholders with the potential to increase the research base.

Criteria Used for Priority-Setting for Public Health Resource Allocation in Low- and Middle-Income Countries: A Systematic Review

OBJECTIVES

This systematic review aimed to identify criteria being used for priority setting for resource allocation decisions in low- and middle-income countries (LMICs). Furthermore, the included studies were analyzed from a policy perspective to understand priority setting processes in these countries.

METHODS

Searches were carried out in PubMed, Embase, Econlit, and Cochrane databases, supplemented with pre-identified Web sites and bibliographic searches of relevant papers. Quality appraisal of included studies was undertaken. The review protocol is registered in International Prospective Register of Systematic Reviews PROSPERO CRD42017068371.

RESULTS

Of 16,412 records screened by title and abstract, 112 papers were identified for full text screening and 44 studies were included in the final analysis. At an overall level, cost-effectiveness 52 percent (n = 22) and health benefits 45 percent (n = 19) were the most cited criteria used for priority setting for public health resource allocation. Inter-region (LMICs) and between various approaches (like health technology assessment, multi-criteria decision analysis (MCDA), accountability for reasonableness (AFR) variations among criteria were also noted. Our review found that MCDA approach was more frequently used in upper middle-income countries and AFR in lower-income countries for priority setting in health. Policy makers were the most frequently consulted stakeholders in all regions.

CONCLUSIONS AND RECOMMENDATIONS

Priority-setting criteria for health resource allocation decisions in LMICs largely comprised of cost-effectiveness and health benefits criteria at overall level. Other criteria like legal and regulatory framework conducive for implementation, fairness/ethics, and political considerations were infrequently reported and should be considered.

Skeletal trauma reporting; perceptions and experiences of radiographer practitioners exposed to the reporting role

INTRODUCTION

Increased demand for diagnostic imaging and professional body directives have resulted in radiographer reporting which requires postgraduate education due to the associated high degree of autonomy and complex decision making. Little research has focused on the transition from practitioner to the skeletal trauma reporting role.

METHODS

Two-phase, qualitative research using Interpretative Phenomenological Analysis (IPA) explored perceptions and experiences. Phase 2, one-one, semi-structured interviews (n = 6) were recorded, transcribed verbatim and reviewed using the IPA six stage thematic analysis, generating three super-ordinate themes. Researcher reflexivity, ethics and quality assessment were considered.

RESULTS

This paper reflects the IPA generated from Super-ordinate Theme 2; Exposure to the reporting role. Participant reflections indicated positive opinion with agreement that combining the reporting role with the diagnostic radiographer role enhanced practice and increased job satisfaction. Potential for stress associated with increased responsibility and accountability was described but there was recognition that skeletal trauma reporting was what they had chosen and been educated to do.

CONCLUSION

The interpretative approach and IPA for Super-ordinate Theme 2, fills a gap in existing knowledge, providing a unique and valuable insight into perceptions and experiences of practitioners as they became exposed to the skeletal reporting role.

IMPLICATIONS FOR PRACTICE

Participants were on their journey to advanced practice with plans to further develop their role. Excellent clinical practice had been demonstrated as well as facilitating learning with others. If there is expectation to achieve all domains associated with advanced practitioner status then time, commitment and support is essential from employers and management.

Interprofessional work in early detection of breast cancer: An integrative review

OBJECTIVES

To identify the roles of health care staff in interprofessional work related to breast cancer detection and diagnosis.

KEY FINDINGS

A comprehensive search was performed using PICO to support inclusion and exclusion criteria. A shortened version of the STROBE checklist ensured evaluation of the studies. 21 included studies resulted in three main categories describing the role of health care professionals; (1) Communicating breast cancer awareness; (2) The Professional's tasks; (3) Efficacy of Interprofessional Teamwork relative to the profession and the individuals.

CONCLUSIONS

Health care professionals' roles in the breast cancer diagnostic process were described mostly from each professional's viewpoint. Support from leadership and management is needed in order to promote interprofessional work, which will benefit health care professions, professionals, and the patient.

A systematic review of 7 years of research on entrustable professional activities in graduate medical education, 2011-2018

PURPOSE

This review aimed to synthesise some of the extant work on the use of entrustable professional activities (EPAs) for postgraduate physicians, to assess the quality of the work and provide direction for future research and practice.

METHOD

Systematic searches were conducted within five electronic databases (Medline, Scopus, Web of Science, PsycINFO and CINAHL) in September 2018. Reference lists, Google Scholar and Google were also searched. Methodological quality was assessed using the Quality Assessment Tool for Studies with Diverse Designs (QATSDD).

RESULTS

In total, 49 studies were included, classified as Development of EPAs (n = 37; 76% of total included), Implementation and/or assessment of EPAs (n = 10; 20%), or both (n = 2; 4%). EPAs were described for numerous specialties, including internal medicine (n = 14; 36%), paediatrics (n = 8; 21%) and psychiatry (n = 4; 10%). Of the development studies, 92% utilised more than one method to generate EPAs. The two most commonly used methods were developing initial EPAs in a working group, (n = 27; 69%) and revising through deliberation (n = 21; 54%). Development papers were of variable quality (mean QATSDD score = 20, range 6-41). Implementation and assessment studies utilised methods that included observing trainee performance (n = 6; 50%) and enrolling trainees in competency-based curricula, which included EPAs (n = 4; 33%). The methodological quality of these implementation studies varied (mean QATSDD score = 19.5, range = 6-32).

CONCLUSIONS

This review highlighted a need for: (i) consideration of best practice guidelines for EPA development; (ii) focus on the methodological quality of research on EPA development and of EPAs, and (iii) further work investigating the implementation of EPAs in the curriculum.

A UK survey exploring the assistant practitioner role across diagnostic imaging: current practice, relationships and challenges to progression

OBJECTIVE:

Skill mix has been established as one method of maintaining imaging service delivery, with vertical and horizontal substitution of roles and tasks. Assistant practitioners (APs) have been undertaking limited imaging practice for almost two decades, but there remains a paucity of evidence related to the impact of their roles.

METHODS:

This article reports on an electronic survey of individual APs within the NHS in the UK to explore utilisation, role scope and aspirations.

RESULTS:

Responses were analysed from APs (n = 193) employed in 97 different organisations across the UK. The majority work in general radiography or mammography, with very few responses from other imaging modalities. Training routes varied across modalities, with most achieving Band 4 under Agenda for Change on completion of education. Limitations on practice vary between organisations and modalities, with many reporting blurring of the radiographer-AP boundary. Many aspire to continue their training to achieve registrant radiographer status, although there were clear frustrations from respondents over the lack of overt career prospects.

CONCLUSION:

Integration of the role into imaging department practice does not appear to be universal or consistent and further research is required to examine the optimal skill mix composition.

ADVANCES IN KNOWLEDGE:

Skill mix implementation is inconsistent across modalities and geography in the UK. Opportunities for further workforce utilisation and expansion are evident.

Is a nurse consultant impact toolkit relevant and transferrable to the radiography profession? An evaluation project

INTRODUCTION

Consultant posts were developed to strengthen strategic leadership whilst maintaining front line service responsibilities and clinical expertise. The nursing profession has attempted to develop tools to enable individuals to evaluate their own practice and consider relevant measurable outcomes. This study evaluated the feasibility of transferring such a nursing 'toolkit' to another health profession.

METHOD

This evaluation was structured around a one-day workshop where a nurse consultant impact toolkit was appraised and tested within the context of consultant radiographic practice. The adapted toolkit was subsequently validated using a larger sample at a national meeting of consultant radiographers.

RESULTS

There was broad agreement that the tools could be adopted for use by radiographers although several themes emerged in relation to perceived gaps within the nursing template, confirming the initial exercise. This resulted in amendments to the original scope and a proposed new evaluation tool.

CONCLUSION

The impact toolkit could help assess individual and collaborat ive role impact at a local and national level. The framework provides consultant radiographers with an opportunity to understand and highlight the contribution their roles have on patients, staff, their organisation and the wider profession.

The Clinical Specialist Radiation Therapist (CSRT): A case study exploring the effectiveness of a new advanced practice role in Canada

INTRODUCTION

The Clinical Specialist Radiation Therapist (CSRT), is a new advanced practice (AP) role for radiation therapists (RTTs). Following training, education and evaluation, the CSRT performs specific duties in autonomous ways, making advanced clinical decisions in their area of specialization. This case study examines the CSRT's impact on quantity (i.e., increasing capacity), improving quality and stimulating research and innovation.

METHODS

Between 2007 and 2016, 23 CSRTs worked in 10 cancer centres in various AP position. A standardised metrics package, focusing on wait-times, patient volumes, patient throughput, time-savings, quality initiatives, satisfaction, research and innovation was developed and used to collect qualitative and quantitative data. Data were self-reported by the CSRTs but electronic databases, pre/post-studies, surveys and interviews were also used.

RESULTS

Quantity projects (n = 76) related to patient volumes, wait-times, patient throughput and time-savings increased capacity and allowed more patients to enter the system. The presence of a CSRT allowed, on average, 13 additional patients (either new or re-treated) to be seen, at their respective cancer centre, per month. An average of 1.4 yearly quality improvement initiatives were led by each CSRT, which contributed to improvements in quality of care and satisfaction. CSRTs demonstrated a high level of involvement in research, innovation and knowledge translation activities, either as leaders or part of interprofessional teams.

CONCLUSION

CSRTs positively impact quantity (capacity of the system), quality, research and innovation. Future efforts include permanent and sustainable team integration, practice standards, formal and comprehensive educational preparation, and approaches to consistent, valid assessment of AP in radiation therapy.

Doctoral profile of the medical radiation sciences: a baseline for Australia and New Zealand

INTRODUCTION

Research is critical to evidence-based practice, and the rapid developments in technology provide opportunities to innovate and improve practice. Little is known about the research profile of the medical radiation science (MRS) profession in Australia and New Zealand (NZ). This study provides a baseline of their doctoral activity.

METHODS

A cross-sectional survey of MRS professionals in Australia and NZ holding a doctorate or undertaking doctoral studies, was performed using an online tool (Bristol Online Survey® , Bristol, UK). A chain-referral sampling technique was adopted for data collection. An email invitation with a link to the survey was generated and distributed through email and social media. The survey contained questions related to participant demographics, doctoral status, qualification route, funding and employment.

RESULTS

There were 63 responses to the survey comprising 50.8% diagnostic radiographers (DRs; n = 32), 23.8% radiation therapists (RTs; n = 15), with the remaining 25.4% (n = 16) equally split between sonographers and nuclear medicine technologists (NMTs). A total of 40 (63.5%) of respondents had completed their doctoral qualification. In NZ, only DRs held a doctoral award constituting 0.3% of DRs and 0.2% of the total registered MRS population. In Australia, there was a greater proportion of doctoral NMTs (n = 8/1098; 0.7%) than RTs (n = 15/2394; 0.6%) and DRs (n = 27/12,001; 0.2%).

CONCLUSION

Similar to other countries, findings show a very small percentage of doctoral MRS professionals in Australia and NZ. Strategies to engage and support individuals in research, up to and beyond doctoral study, need to be embedded in practice.

Are reporting radiographers fulfilling the role of advanced practitioner?

BACKGROUND

Advanced practice roles are emerging in all disciplines at a rapid pace and reporting radiographers are ideally placed to work at such level. Advanced practitioners should demonstrate expert practice and show progression into three other areas of higher level practice. Most existing literature has focussed on the image interpretation aspect of the role, however there is little evidence that plain film reporting radiographers are undertaking activities beyond image interpretation and fulfilling the role of advanced practitioner.

METHOD

Letters were posted to every acute NHS trust in the UK, inviting reporting radiographers to complete an online survey. Both quantitative and qualitative information was sought regarding demographics and roles supplementary to reporting.

RESULTS

A total of 205 responses were analysed; 83.3% of reporting radiographers describe themselves as advanced practitioner, however significantly less are showing progression into the four core functions of higher level practice. A total of 97.0% undertake expert practice, 54.7% have a leadership role, 19.8% provide expert lectures and 71.1% have roles encompassing service development or research, though most of these fall into the service development category. 34.5% felt that they were aware of the differences between extended and advanced practice though much less (9.3%) could correctly articulate the difference.

CONCLUSION

Few individuals are aware of the difference between extended and advanced practice. Though the majority of plain film reporting radiographers identify themselves as advanced practitioners, significantly less evidence all four core functions of higher level practice. The number of individuals undertaking research and providing expert-level education is low.

Radiographer reporting in the UK: is the current scope of practice limiting plain-film reporting capacity?

OBJECTIVE

To update knowledge on individual radiographer contribution to plain-film reporting workloads; to assess whether there is scope to further increase radiographer reporting capacity within this area.

METHODS

Reporting radiographers were invited to complete an online survey. Invitations were posted to every acute National Health Service trust in the UK whilst snowball sampling was employed via a network of colleagues, ex-colleagues and acquaintances. Information was sought regarding the demographics, geographical location and anatomical and referral scope of practice.

RESULTS

A total of 259 responses were received. 15.1% and 7.7% of respondents are qualified to report chest and abdomen radiographs, respectively. The mean time spent reporting per week is 14.5 h (range 1-37.5). 23.6% of radiographers report only referrals from emergency departments whilst 50.6% of radiographers have limitations on their practice.

CONCLUSION

The scope of practice of reporting radiographers has increased since previous studies; however, radiographer reporting of chest and abdomen radiographs has failed to progress in line with demand. There remain opportunities to increase radiographer capacity to assist the management of reporting backlogs.

ADVANCES IN KNOWLEDGE

This study is the first to examine demographic factors of reporting radiographers across the UK and is one of the largest in-depth studies of UK reporting radiographers, at individual level, to date.