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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
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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
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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
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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.
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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
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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.
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