ARTICLE IN PRESS
ARTICLE IN PRESS + MODEL Radiography (2006) xx, 1e6 a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / r a d i DISCUSSION How to achieve consultant practitioner status: A discussion paper Maryann Hardy a,*, Beverly Snaith b a Division of Radiography, School of Health Studies, University of Bradford, Trinity Road, Bradford BD5 0BB, West Yorkshire, UK b Radiology Department, Mid Yorkshire Hospitals NHS Trust, Pinderfields Hosptial, Aberford Road, Wakefield, West Yorkshire WF1 4DG, UK Received 4 February 2006; accepted 2 April 2006 KEYWORDS Consultant radiographer; Consultant Practice; Career progression; Advanced practice; 4-Tier structure Abstract Non-medical consultant posts are a relatively new addition to the National Health Service (NHS) workforce, the role first being announced for nurses in 1998 followed by the Allied Health Professions in 2000. They have been described as multidimensional positions that encompass the four core functions of consultant practice: expert clinical practice; professional leadership and consultancy; practice and service development, research and evaluation; education and professional development. Consequently, the purpose of non-medical consultants is to promote and develop practice at the clinical, strategic and policy level. Despite the professional drive to develop consultant radiographer roles, by the end of 2005 only 15 were in post. One of the reasons for this poor appointment rate is the deficiency in suitably qualified and experienced candidates, a finding acknowledged to be an issue across all the non-medical professions. Further, the development of potential consultant practitioners has been hampered by the lack of clearly defined clinical and educational pathways. This paper acknowledges the limited published material available to radiographers wishing to advance to consultant positions. Yet while recognising the need to establish a true consultant career pathway underpinned by an appropriate education and research strategy, it explores the requirements of consultant practice, identifying some opportunities available to radiographers to develop appropriate consultant level skills. ª 2006 The College of Radiographers. Published by Elsevier Ltd. All rights reserved. Introduction * Corresponding author. Tel.: C44 1274 236 578. E-mail address: [email protected] (M. Hardy). Non-medical consultant posts are a relatively new addition to the National Health Service (NHS) workforce. The initial announcement of the creation of nurse consultant posts was made in 19981 with specific details of the role emerging in 1078-8174/$ - see front matter ª 2006 The College of Radiographers. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.radi.2006.04.003 ARTICLE IN PRESS + MODEL 2 the national strategy for nursing publication, Making a Difference.2 Two years later, the extension of consultant practice into the Allied Health Professions (AHPs) was discussed within the AHP strategy document Meeting the Challenge.3 With the publication of these documents, the role of a non-medical consultant was clearly placed in the context of the changing NHS. Further, they defined the core functions of consultancy as expert clinical practice, leadership, education and research,4 functions that contrasted starkly with the purely advisory role recognised within many other non-clinical professions (e.g. management consultant). Initially the United Kingdom (UK) government announced a target of 1000 nurse consultants to be appointed to priority clinical areas including critical care, accident and emergency and intermediate care5 by 2004.1 For AHPs, a much reduced preliminary target of 250 in post by 2004 was set6 but without associated national clinical priorities. Yet, despite the UK government drive and professional desire to progress non-medical consultant practice, only 528 nurse consultants were appointed within 3 years of launching the initiative.7 Similarly in July 2005, 4 years after the initial launch of the consultant AHP role, less than 60 AHP consultants were in post, the majority being within physiotherapy,8 although exact numbers are difficult to quantify. Perhaps one of the difficulties in defining and recruiting to consultant AHP positions has been the lack of national, profession specific targets and clinical priorities from the UK Department of Health to guide their development. However, for radiography, the expectation that specific areas of clinical imaging practice would be identified as appropriate for the development of consultant radiographer posts was clearly articulated within the Department of Health skill mix project.9 Consequently, by the end of 2005, there were 15 consultant radiographers in post. Despite 8 years having lapsed since the introduction of nurse consultants and 6 years since the AHP consultant role was announced, little literature exists to define the process of individual development towards consultancy. Further, little evaluation of how the roles themselves are developing or impacting on patient care or service delivery has been undertaken.10,11 This article continues the series of discussion papers exploring radiographer career progression and builds on a previous publication debating radiographer progression to advanced practitioner status.12 Following a similar format, this article will examine the individual and personal development required by a person aspiring to be a consultant radiographer. M. Hardy, B. Snaith responsibility of non-medical health professions in directing and implementing patient care across health service boundaries.15 As a result, consultant posts have been described as multidimensional with the purpose of promoting and developing practice at a clinical, strategic and policy level.16 Common to all non-medical consultant roles is the concept of the 4 core functions;4 Expert clinical practice Professional leadership and consultancy Practice and service development, research and evaluation Education and professional development. These functions provide guidance to individuals aspiring to consultant status as to the expectation of the role. But, rather than being a novel approach to role design, they appear to have been abridged from the work of Hamric17 and the development of clinical nurse specialist roles in the United States. Subsequently this was adopted by Manley18 in the conceptualisation of advanced and consultant nurse practice in the UK. Although further publications have suggested other important aspects of the consultant role such as collaboration, modernisation, change management and ethical decision-making skills,4,16,19 these additional criteria can be subsumed within the 4 core functions, demonstrating the variability in personal and professional attributes necessary for consultant status. Importantly, many published and described activities are not exclusive to any one core function but instead, often inform development across them all. With the exception of expert clinical practice which has an associated minimum clinical focus of 50%,20 the percentage of time to be spent undertaking each core function by a consultant is not specifically delineated. However, there is a fundamental expectation that consultant practitioners will be involved in activities related to each. This paper will introduce and discuss a range of activities that advanced practitioners may participate in, both to develop and demonstrate consultant level skills. It is not intended as an exhaustive list of consultant practice criteria, nor to suggest that on their attainment, automatic progression to consultant practice status will be achieved, as this is dependent upon the clinical needs of an employing organisation. Instead, this paper hopes to stimulate discussion on career progression to consultant practice and promote role development initiatives. What is a consultant practitioner? Transition to consultant radiographer practitioner: a historical perspective The consultant practitioner is defined as providing clinical leadership within a specialism, bringing strategic direction, innovation and influence through practice, research and education.13 Consultant AHP posts, like those of their nursing counterparts, are intended to improve the quality of patient care through the integration of education and research within the clinical practice setting and by retaining experienced staff to strengthen professional leadership.3,14 The development of consultant roles has allowed individual professions to promote clinical direction and leadership from within,8 acknowledging the contribution and Non-medical consultants have emerged from a variety of professional backgrounds including management, clinical practice and academia.20 Indeed, those persons currently in post as consultant radiographers have not typically followed the advanced practice clinical route advocated by the College of Radiographers.21 Instead, through their own admission,22 they have undertaken a tortuous pathway of personal and professional development, accepting learning opportunities from a wide variety of arenas. Perhaps the reasoning for such convolution in learning and progression was the traditional lack of opportunity for career ARTICLE IN PRESS + MODEL How to achieve consultant practitioner development within the clinical sphere to support radiographers ambitious to move the profession forward.23 Transition to consultant radiographer practitioner: future post-holders It is expected that future consultant post-holders will have a planned personal development pathway established whilst still a radiographer practitioner to facilitate career progression in line with the well-publicised Education and Professional Development framework.21 However, for this expectation to be realised and evolve as an effective strategy, the radiography profession must acknowledge the necessity to broaden the scope and skills of advanced practitioners beyond the boundaries of currently accepted clinical radiographic practice.12 Price concurs with this view, suggesting that a lack of understanding around advanced practice may hamper the introduction of consultant radiographers.24 Further, he has questioned whether there are currently appropriate education and training programmes in place to develop potential consultants, arguing that the proposed education and training infrastructure to underpin new practice models and pathways23 has yet to emerge. The functions of consultant level practice necessitate the individual to have the basic skills and competencies associated with specialist or advanced practice status as a minimum requirement. These skills and competencies should then be expanded in breadth and complexity13,14 to enable individuals to operate autonomously at a strategic level. Despite advanced practice being promoted nationally as an expectation of a career health professional, there still exists a shortage of adequately experienced and/or educated non-medical professionals who are able to automatically progress to consultant status. In particular there has to date been an observed shortage of applicants to consultant posts who possess evidence of appropriate educational achievement.25 3 be evidenced by responsibility for a diverse clinical case load, including tasks that may traditionally have been undertaken by a medical doctor, clinical interventions, and examinations on patients presenting with complex needs.4 Critical to the role is competency and credibility as a clinical practitioner, something which traditionally the hierarchical career progression did not reward. As a result, it is not possible to specify the particular skills and knowledge necessary for an individual to demonstrate expert practice as they may be across the whole spectrum of radiography practice and beyond into new domains. However, it is possible to introduce some generic opportunities that may be available to radiographers to enhance their development as a recognised clinical expert. Education to support clinical practice Masters’ level clinically focussed education is suggested to provide sufficient underpinning knowledge, in particular with respect to critical thinking skills, to support higher level practice.25 However, although a large number of radiographer practitioners undertake Master’s level modules as part of role extension or advancement, few complete the educational requirements for the award of a Masters degree despite many person specifications for consultant positions identifying the achievement of a Master’s degree as a desirable quality.4 Another school of thought is that a doctoral qualification, whether PhD or professional doctorate, should be an essential requirement of consultant practice to demonstrate sufficient independent academic learning.4,14,21 Indeed, Manning and Bentley27 have suggested that a Masters degree alone will provide insufficient preparation to fulfil all of the core functions of a consultant radiographer. However, in reality, the very small number of radiographers outside of academia with doctoral degrees makes this expectation of consultant radiographer a medium to long term aspiration. Reflection Core function 1: expert clinical practice It has been suggested that an individual should be required to have a minimum of 8 to 10 years post-registration experience4,20 including 3 years at advanced or specialist practitioner level,4 to be eligible for a consultant position. For radiographers, no such specific time scales exist but it is an expectation that an individual will have had sufficient clinical experience to have developed as a specialist or advanced practitioner, appreciating their own role, and that of imaging or oncology within the context of modern health care and medico-legal frameworks. Additionally, extensive clinical experience will facilitate individual radiographers to develop a clear idea of their preferred clinical direction and contribution to the imaging or oncology service. Typically, expert clinical practice will be anatomy or condition focussed rather than modality based as is commonly accepted within practitioner and advanced practitioner roles. Additionally, where the high degree of specialisation associated with advanced practice may lead to narrowness of vision, a clinical expert operating at consultant level should be able to explore many avenues to find solutions to a variety of clinical problems.26 This may Although commonly associated with academic study, reflection is a positive learning tool for clinical practitioners allowing them to critically examine clinical incidents, case studies, personal decision-making and interactions to inform personal development and guide new learning. Reflection may best be undertaken within a supportive clinical governance structure, where practitioners are encouraged to critically analyse and share their experiences to benefit service provision. A possible approach to this may be the implementation of a clinical supervision framework and peer review although departmental clinical conferences and clinical review seminars may also offer appropriate opportunities. Multi-disciplinary team working Consultant practice implies a broad spectrum contribution to health care provision and therefore, to progress to consultant status, radiographers need to demonstrate effective skills in communicating with, and contributing to, the multi-disciplinary team (MDT). Attendance at, and contribution to, MDT meetings related to clinical expertise ARTICLE IN PRESS + MODEL 4 will facilitate the development of specialist clinical knowledge, create networking opportunities and improve understanding of the role of other health professionals in relation to patient care and service delivery. Further, MDT meetings may also present opportunities to develop new skills outside the current scope of practice for radiographers or initiate involvement in research and service developments. However, to benefit fully from the opportunities that may arise, radiographers need to be flexible in their working hours as many MDT meetings are undertaken before, or after, clinical sessions or during the lunch period. M. Hardy, B. Snaith Appraisal is intended to be a two-way discussion on progress to date and establishment of a future career pathway. Annual appraisal is also a useful opportunity to evaluate personal leadership qualities and seek the opinion of all staff grades (above, below and peers) within radiography as well as those outside the profession, to identify personal leadership strengths and weaknesses. This type of evaluation is in keeping with the NHS 360 appraisal strategy advocated as part of the leadership qualities framework.28 Consultancy Core function 2: professional leadership and consultancy Many qualities pertaining to leadership could equally be applied to expert clinical practice. However, the context of this section is the development of leadership skills rather than the application of leadership in clinical practice. Many educational programmes are available to NHS employees of all grades to learn the fundamentals of leadership theory28,29,30 although significant underpinning knowledge needs to have been previously acquired and applied in clinical practice12 in order to achieve consultant level leadership skills. However, evidence suggests that the success with which individuals are developing leadership behaviours and transferring them into clinical practice is variable.4 One of the challenges with specifying leadership as a core function of consultancy is the difficulty in defining, structuring or evaluating clinical leadership. Current thinking is that leadership is not attached to a post or position, but instead is a set of behaviours resulting from personal characteristics and personal and professional development.4 Consequently, leadership is a combination of inherent and learned behaviours and as a result, a range of leadership styles are recognised. The most favoured of these currently is transformational leadership which incorporates aspects of empowerment and motivational management to facilitate practice development and promote opportunities for all team members to contribute to, and own, clinical practice developments.4,19,31,32 Although consultant status may be the aspiration of many individuals, consultancy in this context relates to the combination of all 4 core functions and their application in clinical practice. It encompasses providing advice to other senior colleagues in the health care team, including medical staff, providing direction to clinical and service developments, invited evaluation of other services both within and out with the radiographers employing organisation, and contribution to strategic organisational decisions. It is possible to gain such experience locally through involvement in MDT’s, research, education and strategic work force shadowing. Additionally, there are opportunities to engage in activities through the professional or regulatory body such as Council membership, assessor or visitor. All of these will provide excellent networking opportunities and access to mentorship. However, with consultancy also comes the issue of political awareness, as the consultant becomes part of the business and service planning team, both for their own service but also for their specialist area through local, regional or national fora. As a result, knowledge of current national strategies and associated priorities is essential for an aspiring consultant and can be gained both through clinical development and reading publications such as the Heath Service Journal and Department of Health Bulletins, such as the AHP, Chief Nurse or Chief Executive. Core function 3: practice and service development, research and evaluation Education Practice and service development Accepting the challenges of leadership training identified above, education is perhaps one of the most succinct methods of demonstrating leadership knowledge for consultant practice. However, in many departments, access to leadership education programmes is often limited to senior staff and managers as costs can be prohibitive and competition for places high. For radiographers interested in undertaking leadership training, there are a number of independent online leadership education packages and postgraduate courses in leadership development as well as NHS courses available, some of which may be undertaken as part of a Master’s education programme. Clinical appraisal process One of the most undervalued tools for personal and professional development is the annual appraisal process. At consultant level the focus is strategic service developments including the evaluation of current services and planning of new initiatives. The movement towards protocol driven care and establishment of care pathways provides opportunities to engage in the modernisation of services as an active participant. However, it must be recognised that as leadership skills are developed, an individuals primary role may be one of facilitation rather than contribution to the process. Small scale projects within departments focussing on workflow changes may provide an opportunity to develop both self and others. Development and regular review of guidelines and protocols, both within and out with radiography, will offer an opportunity to be involved in the development of services and also to engage with clinical and managerial staff. ARTICLE IN PRESS + MODEL How to achieve consultant practitioner Research and evaluation In order to appropriately evaluate service, it is important to establish practice benchmarks, incorporating local and national practice standards, to ensure that patient care and service quality are optimised. It may be possible to contribute to the development of professional benchmarks through professional body or special interest group activities. Once standards have been established, the initiation of regular audit of practice will permit individuals to develop organisation and project management skills and encourage the implementation of research findings. At consultant level the emphasis may be on encouraging and motivating others to take a leading role, providing support and mentorship, rather than personally directing the audit process. However, it is incumbent upon the profession to generate and evolve its own knowledge base rather than be an uncritical consumer of research.27 Research may be considered by some in the profession to be an ivory tower activity peculiar to academics and those undertaking formal academic study both at undergraduate and postgraduate level. Although attitudes are gradually changing with respect to published research in line with increasing use of evidence based practice, there is still a reluctance to undertake primary research. This could be related to a poor appreciation of the relevance of research in developing radiographic practice but also, despite education in research methods being a component of every undergraduate course in the UK, a large number of graduates do not feel confident in applying or using these skills in practice. The development of research knowledge through the facilitation of journal clubs, involvement in local research and audit projects and completion of Master’s level research projects will provide individuals with some research knowledge. However, inherent within any consultant role is the development of new knowledge through research and individuals aspiring to consultant positions need to be able to lead and direct research projects, using appropriate methods and analysis strategies. As a result, in the context of research, the argument for doctoral education for consultant radiographers is strong. But every researcher has to start somewhere, and research skills may be best developed through collaboration within research networks across NHS and higher educational institutions. Additionally, although it may be the role of the consultant to mentor junior clinical staff, individuals should not be afraid to recognise their personal need for mentorship, particularly within new areas of practice. Core function 4: education and professional development Although advanced practitioners are recognised as having a role to play in the education and development of radiographers and students at both undergraduate and postgraduate level, preparation for consultant level practice focuses beyond didactic teaching to the creation of learning opportunities to enhance the development of others. Involvement in the development and progression of professional education programmes, including those formally delivered within higher education institutions or 5 developed in collaboration with special interest groups and the professional body, and encompassing a multi-disciplinary audience, more accurately reflect the role of the consultant. Additionally, the consultant radiographer may initiate, or be called upon to contribute to, the development of innovative and untested education programmes. Importantly, for aspiring consultants, the development of new knowledge and the education of others may often mean operating outside the ‘comfort zone’ in order to stimulate discussion and promote active learning. For radiographers not directly involved in delivering formal education, the demonstration of consultant radiographer skills in education and professional development can also be achieved through the publication and presentation of educational material. Ideally at this level, work should be submitted to peer reviewed journals and conferences. For individuals new to writing, support may be available from clinical colleagues, hospital research departments and journal editorial teams.33 Transition to consultant radiographer practitioner: interim developments It is evident from the expectations of consultant practice outlined in the 4 core functions and discussed above that a skills gap may exist within the current radiography workforce. This apparent skills deficiency is not peculiar to radiography, but is acknowledged to be an issue across all non-medical professions. Difficulties in recruiting and retaining staff to consultant nurse posts have been reported7,34,35 and it has been suggested that there remains a lack of practitioner preparation for the role.36,37 In order to address this, some trusts have initiated consultant training programmes to identify and develop potential consultant candidates.7 These training posts, termed trainee or associate consultants, have tended to identify individuals within a Trust who have the potential to reach consultant status and whose specific learning and developmental needs can be met by a locally devised programme. The first trainee consultant radiographer post was advertised in 200538 but other routes to consultancy such as a three year ‘registrar’ programme36,39 have also been established. Indeed one strategic health authority is co-ordinating the development of these posts under the leadership of an associate dean for consultant practitioner development.40 Conclusion From the discussion above, and the acknowledgement of current limitations in progressing consultant status radiographers, the future of the 4 tier structure and the career progression framework must be to identify individuals early in their careers and support them though an appropriate career development programme. Currently, there are no clearly defined clinical or educational pathways to consultant status and this creates uncertainty among clinicians, managers and educators. Only the establishment of a true career pathway, underpinned by an appropriate education and research strategy will result in the critical mass of suitably qualified individuals necessary to effectively lead and develop radiographic practice and realise the ARTICLE IN PRESS + MODEL 6 ambitions of individual practitioners, the profession and the modern NHS. This paper has discussed some aspects of role development considered by the authors to be important to radiographers working towards consultant status. But this subject area is relatively under examined within radiography and as a result, it is hoped this paper will promote professional discussion at all levels and encourage the development of early career pathway plans for capable and ambitious radiographers. M. Hardy, B. Snaith 19. 20. 21. References 22. 1. Department of Health. NHS Plan: a plan for investment, a plan for reform. London: Department of Health; 1998. 2. Department of Health. 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