Experiences of consultant breast radiographers regarding breast imaging services in the United Kingdom

Introduction

Consultant allied health practitioners were introduced in the United Kingdom (UK) at the turn of the century to back-up medical practitioners when it became increasingly clear that the workload in health trusts was becoming insurmountable and patients were being subjected to long wait times.^[1,2] In the context of this study, the establishment of national breast cancer screening programs in the mid-1990s increased the demand for breast imaging services.^[1] In 2000, the UK government announced an intention to create non-medical consultant posts to provide expert clinical staff and enhance the delivery of care to patients.^[2] This saw the creation of the post of consultant breast radiographer.

It is now several years since the introduction of this post and studies from nursing professionals have been undertaken to evaluate the role of the consultant breast radiographer. Some still feel the duties of these practitioners are not well defined. Redwood et al.,^[3] evaluating the role of nurse consultants, argued that the consultant role has not been well documented. Crouch^[4] states that the role needs a definition to help with succession planning and to establish its value. Reeves^[5] concurs that radiography literature to date has only looked at the potential and prerequisites for the appointment of these consultants.

According to Reeves,^[5] whatever the field of practice, an appointment to consultant posts must be on merit, with practitioners being able to demonstrate that their skills and expertise are at the highest level and that they can put these to use in the best interest of patients. Consultants will need to demonstrate a breadth of knowledge across their discipline but vitally, will demonstrate and be acknowledged for the breadth of their knowledge and its integration into their field of radiographic practice.^[6] These two authors opinioned that the direction given by the department of health that the title “consultant practitioner” would apply only to new posts which was not positive.^[7] They argued that radiographers already practicing competently at the consultant level and fulfilling the appropriate criteria should be formally be recognized and appointed as consultants.

Several consultants allied health professionals have since been appointed in the UK, but debate still rages as to whether they are performing their roles as expected. While practitioners, themselves, argue that they are performing their roles, some authors contend that they have performed their clinical roles but have failed to perform the other three core functions of professional leadership; practice and service development, research and evaluation; and education and training.^[5,6]

Since the establishment of consultant posts in the UK, there is little research conducted to investigate the experiences of consultant breast radiographers to the delivery of breast imaging services. Therefore, this study aimed to explore the experiences of consultant breast radiographers regarding breast imaging services in the UK. The study findings can be helpful to the UK and other countries planning the development of breast imaging services.

Methods

This study was part of a larger study that focused on the role of the consultant breast radiographer and factors that lead to the development and implementation of this leadership role in the UK. A qualitative research design was used to conduct the study. According to Bowling,^[8] qualitative research provides a framework to explore and analyze issues in a flexible yet thorough way. This approach provided a greater depth of understanding of the phenomena from a personal perspective.^[9]

This helped the researcher to understand the experiences of consultant breast radiographers regarding breast imaging services in the UK.

Results

Four themes emerged following thematic analysis [Table 1].

Discussion

The establishment of screening breast imaging services in the UK created significant service demands. The department of health estimated increase in workload by 40%.^[13] However, there were not enough breast radiologists to meet all the demands. To meet the increased workload, a four-tier career structure was developed which led to the development of the consultancy roles.^[14] As Ford^[15] states the shortage of radiologists was a major factor in the establishment and implementation of radiography consultancy posts in the UK. This concurs with our findings where breast radiographers reported undertaking advanced roles even before being appointed as consultants in breast imaging due to increased demand.

This study found postgraduate education and training as an important element in the development of the breast consultancy role. According to Jones,^[16] the masters’ level of education provides sufficient knowledge, critical thinking skills, and support higher level practice. This agrees with the findings of our study. However, the College of Radiographers suggests that doctoral qualification should be an essential requirement for consultant practice.^[15] The breast imaging training consisted of theory and clinical practice and delivered using a blended learning approach. The literature revealed that blended learning is the most preferred method for postgraduate radiography studies because many radiographers undertake training while working.^[17,18] Blended learning is a combination of the traditional face-to-face classroom and distance or online educational methods.

Several studies have reported challenges faced by radiographers during their postgraduate studies. Participants complained of the fragmentation of the education and training for consultant breast radiographers. Modules were undertaken in different universities which were reported as a challenge because trainees had moved from one place to another. Although the clinical training was undertaken in the workplace, some radiologists were not interested to be involved in the training of consultant breast radiographers. In other words, they had a negative attitude toward the role extension of radiographers. Radiologists and medical resistances have been cited in previous studies as a potential barrier to radiographer role development.^[19] Trainees also faced the challenge of a lack of time due to work, school, and family responsibilities. This finding concurs with that of the study by Ugwu et al.,^[18] where a lack of time and family responsibilities were identified as a barrier for radiographers pursuing postgraduate studies. The delivery of training through blended learning minimizes the trainee’s isolation from their families.

Four domains of practice were reported in this study: Clinical expert, professional leadership, research and evaluation, and education and training. The role of clinical expert was directly related to breast imaging services and included reporting on all mammograms and ultrasound scans, performing biopsies, and wire localizations for theatre. Breast consultant radiographers worked independently which involved the communication of results and diagnosis to patients. This was challenging and effective communication skills were identified as vital to a consultancy role. Springett and Dunmall^[20] pointed out that effective communication is at the heart of quality health care. It decreases the anxiety and distress felt by patients and improves the satisfaction of both patients and practitioners.^[21] However, communication skills were not integrated into the curriculum for breast consultant radiographers. For this reason, some had to undertake a separate communication skills course. There is a necessity to integrate this topic into future postgraduate studies.

Breast consultant radiographers also undertook non-clinical roles: Professional leadership, research and evaluation, and education and training. These three roles identified in our study were also discussed by Hardy and Snaith^[1] as the core functions of a consultant practitioner. The College of Radiographers^[22] identifies education and training as one of the roles of consultant practice. However, clinical education was not integrated into the training program. Steinert^[23] argues that educational principles and theories are useful in showing clinical educators approaches that can inform and improve teaching and learning. However, global literature shows that most of the radiographers teach without training in educational principles.^[24,25] This can lower the standards of radiography clinical education. Steinert^[23] recommends supporting postgraduate trainees through the integration of clinical education in their training programs.

Our study also identified consultant radiographers are leaders. This agrees with Hogg et al.^[26] who stated that consultant radiographers are leaders who manage their caseload. Yielder^[27] identified the six qualities of an effective leader: Patience, empathy, a good speaker and listener, creativity, positivity, and effective feedback provider. The other role of consultancy included performing audits. Clinical audits are important in checking performance against standards with the view to improving patient care.^[28] This study also revealed that consultant radiographers were responsible for conducting research. Reeves^[5] states that research and publications must be embedded in the work of all consultant radiographers. However, our study found that radiographers did not research due to increased clinical workload. To encourage consultant radiographers, undertake clinical auditing and research, protected time for these activities should be provided by departmental managers.

Breast consultant radiographers worked independently, but this exposed them to litigation. Alderson and Hogg^[29] stated that as the role of consultancy expands in clinical practice, so does the potential of their involvement in legal claims and these arise from a multitude of circumstances such as failure to detect an abnormality on a radiograph. However, to avoid these legal claims, Keenan et al.^[30] suggested good practice and adhering to protocol. Radiographers can also be covered under the legal principle of vicarious liability. In the workplace context, an employer can be liable for the acts or omissions of its employee, if acted within the scope of practice.^[30] This means that radiographers should not perform new roles without guidelines and agreements with their employers.

Price and Edwards^[31] found that consultants enjoy the full support of their professional organizations and medical colleagues alike. This concurs with our findings where most of the breast consultant radiographers felt that networking with other consultant radiographers proved to be very helpful as more consultant posts were created. The consultant group meetings facilitated by the Society and College of Radiographers also encouraged consultants to demonstrate professional leadership, a requirement to the post. Attending such meetings became apparent that many consultants had to deal with very similar issues and, therefore, it should be beneficial if they are highlighted so that similar problems could be avoided.

Conclusion

The UK government’s policy focused on modernizing the National Health Service and making it more responsive to patient’s needs and this created more service demand. The shortages of radiologists together with a growing demand for radiological services accelerated the introduction of extended role activities in radiography, including breast imaging. One such role is the consultant radiographer job roles, which are broad and include clinical activities often similar in nature to those delivered by radiologists, professional leadership, teaching and education, and service improvement.