Radiography (2004) 10, 259e267

The role of support workers in the departmentof diagnostic imagingdservice managersperspectives

Peter Ford)

Royal West Sussex NHS Trust, St Richard’s Hospital, Chichester, West Sussex PO196SE, UK

Received 28 May 2003; revised 4 March 2004; accepted 11 March 2004

Abstract Purpose To investigate the views of NHS Radiology Service Managersin the South of England on the concept of support workers using ionising radiations.Methods Group discussion (on the feasibility of existing helper grade staff beingable to undertake some X-ray examinations) to inform questionnaire. The question-naire was circulated to Radiology Service Managers in the South East of England.Consensus was established through group discussion of the questionnaire findings.Results There was widespread agreement on the need to train non-professionallyqualified staff (eg support workers) to undertake work using ionising radiations.While there was general agreement on the types of radiographic examinations thatthese new [support] workers should be allowed to do opinions differed on what ‘co-horts of patients’ they should be permitted to examine. There was acceptance thatthese support workers should have the opportunity to continue training to qualify asfully state registered radiographers.Conclusions Traditional professional boundaries and concerns about the use ofionising radiations have not stopped agreement amongst some NHS service managersthat the severe shortage of radiographers requires the training of a group of supportworkers to use ionising radiations. In general, there was a high degree of consensuson what examinations they could undertake but further discussion is needed toagree the cohorts of patients these workers should be allowed to examine.ª 2004 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.

KEYWORDSRadiology services;Radiography staffing;Support workers

using ionisingradiations;

Assistantpractitioners;

New ways of working

Introduction

Within the UK there is a national shortage of radio-graphers in radiology departments, with average

) Tel.: D44-1243-788122x3497; fax: D44-1243-831452.E-mail address: pcford1@hotmail.com.

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vacancy rates of 12e15%;1 rates of up to 24% existin some departments. Furthermore, it is likely thatthe number of newly qualifying [state-registered]radiographers is unable to meet the service needand various reasons can be offered to explain this.

Demand for imaging services continues to riseinexorably,2 due in part to the increased emphasison screening and earlier diagnosis to meet the

ers. Published by Elsevier Ltd. All rights reserved.

260 P. Ford

targets of the National Health Service (NHS) Plan.3

Radiographer ‘training places’ have remained rela-tively static over the last 15 years and whilst thenumber of places has been increased substantiallyin recent years, some universities have had diffi-culties in filling their courses. Demographic figuresdemonstrate that the phenomena of finding it hardto fill courses may persist as there is a continuingdecline in the number of 18-year olds (down 24%since 1982)4dwhich means university courses arecompeting from a limited and reducing pool ofpotential students. There is a continuing expansionin all higher education courses with few of themfull before the University clearing system starts.5

Combined with this lack of potential students,radiography courses (BSc Honours degrees) runfor up to 46 academic weeks per year and mayfind it hard to compete with the ‘traditional’ uni-versity courses whose academic year may not ex-ceed 32 weeks. Pay rates are poor set against theincreases achieved in the traditionally comparableprofessions such as teaching and the police ser-vice. This is made worse by the high percentageof radiographers still in the lower grades of thecareer structure despite such initiatives as the‘link radiographer’ re-grading to Senior II levelafter a short post qualifying period.6

Despite the pressure on staff to maintain exist-ing services there has been an increasing emphasison new ways of working and skill-mix re-evalua-tion. Radiographers have been extending their roleand successfully undertaking some of the dutiestraditionally done by medical staff, such as run-ning barium enema lists and reporting skeletalexaminations.7e9 The Royal College of Radiologists(RCR) has acknowledged this and accept its inevi-tability due to the shortage of radiologists.10

Traditionally, the use of ionising radiation inthe National Health Service is largely restricted tostate registered radiographers who were regulatedby the Council for Professions Supplementary toMedicine. The creation of the [new] Health Profes-sions Council has changed the nature of state reg-istration from one of protection of title to one ofprotection of the public. This allows more scopefor flexible working practices providing the titleof radiographer is protected. Additionally, a rangeof Department of Health policy documents andalso new law and amendments to ‘existing’ lawshas allowed health care staff to work outside theirtraditional sphere of professional interests.11e13

Service mangers in a group of hospitals in theSouth of England began recording vacancy ratesof around 25% of all staff and 50% of junior posts,as illustrated in Table 1. From this data, a discus-sion arose on the potential role of support workers

in radiology departments and whether their dutiescould be extended to include some X-ray examina-tions. This article explores Radiology ServiceManagers’ opinions about the potential role thatsupport workers could play in a radiology service.

Method

The group of Radiology Service Managers, indicatedabove, discussed the difficulty of maintainingimaging services, and decided that new workingpractices were necessary to overcome staffingshortages. Building on the initial Radiology ServiceManager ideas a questionnaire was developedaround extending the role of support workers andthe new duties they might undertake.

The questionnaire was piloted among volunteersfrom the group of Radiology Service Managers.After minor alterations to the wording of one ques-tion the questionnaire was sent to 16 RadiologyService Managers. All these managers were em-ployed in NHS hospitals in the South of England.Selection of the 16 Managers was because all wereknown to have ‘radiography’ vacancies and/or hadbeen advertising for staff within the last 3 months.This form of ‘sampling’ is referred to as ‘purposivesampling’.

The questionnaire consisted of a mixture ofclosed quantitative questions, and exploratoryqualitative ones that allowed more explanationof answers. The questionnaire was in two parts.The first part was a survey of existing practice bysupport staffdincluding helpers, assistants andaids. The second part asked about possible role en-hancement for existing support workers or and‘new staff groups’. This included what additionalduties they could undertake, specifically in the ap-plication of ionising radiation. The Managers werealso invited to suggest the types of examinations,

Table 1 Vacancy rates in a number of hospitals incentral southern England

Number ofvacancies

Vacancies atradiographer grade

23 out of 60 wte 12/16 radiographer grade13 out of 40 wte 11/15 radiographer grade12 out of 41 wte 10 radiographer grade9 out of 36 wte 7 radiographer grade12 out of 56 wte 9 radiographer grade8 out of 40 wte 9 radiographer grade

Source: South Thames (West) Imaging Managers minutes.NB ‘wte’dwhole time equivalent.

Role of support workers 261

the length of training, and core syllabus that mightapply to support workers.

The questionnaires were analysed using descrip-tive statistics (quantitative data) and thematicanalysis (qualitative data). Due to the high degreeof consensus, and simple nature of the question-naire, it was very quick and easy to produce an ac-curate summary of the answers provided and noindependent analysis was considered necessary.Some of the qualitative results were then circu-lated to the original group for further discussionto draw out more detail from the concepts, in ef-fect a Delphi technique.14 As this process involvedstaff and their views, but no patient or other con-fidential data, no ethical permissions were sought.

Results

All questionnaires were returned from the 16 Man-agers. Below is set out the questions and an indica-tion of the response(s).

Question 1 asked whether there is a role for asupport worker in radiology greater than the pres-ent helper/dark room technician. All but twoagreed that there was, a 88% positive rate.

Question 2 asked whether national vocationalqualification (NVQ) training was available to sup-port workers. At the time only four Managers(25%) indicated that they had used this form oftraining for support workers. Of the remaining12, three (18%) indicated that they were due tostart this using NVQ training quite soon. Whilethere was widespread appreciation of the valueof this role and the need to expand it, there was100% agreement that these individuals should notbecome radiation deliverers.

Question 3 provided an opportunity to identifywhat additional duties this role could be expand toinclude. Table 2 indicates the results. Most of theseroles were support for radiographic and nursingduties. Despite the reservations about radiationdeliverers stated in question 2, simple X-ray proce-dures and digital fluoroscopy were mentioned. Nocontext was given for this and it is unclear whattype of additional support it was suggested thatthese existing staff could provide.

Question 4 asked if Managers agreed with theconcept of a support worker operating equipmentgenerating ionising radiation. Similar to the an-swers to question 1 there was 88% agreement withonly two disagreeing.

Question 4 (a) asked what types of X-ray exam-ination support workers could do. Table 3 shows

the examination areas and number of times thesewere mentioned.

Question 4 (b) asked about the length of trainingthese new staff should receive; responses are illus-trated below:

Table 2 Additional duties existing support staffcould undertake

(a) What additional duties would you like them tobecome involved in?1. More patient orientated tasks2. Nursing dutiesdtrolley setting/biopsy3. Clerical4. Quality assurance5. Ultrasound6. Endoscopy7. Positioning in computed tomography/

magnetic resonance imaging8. CT oral contrast and injector

(b) And also1. Simple X-ray procedures2. Digital fluoroscopy

Table 3 Examinations support workers couldundertake

The specific areas identified and number of timesthese were mentioned as suitable for supportworkers to be trained to undertake1. Chests 122. Extremities 123. Abdomen 34. Dental 35. Barium screening 36. Spines 17. Protocol work 18. Bone densitometry 1

Areas where there were divided views1. Accident and emergency work2. Contrast studies

Areas where it was felt they had no role1. Mobile radiography2. Paediatrics

Training Number of times suggested

� 1 year 2� 12/18 months 1� 1e2 years 5� 2 years 4� After 6 months ‘on the job’ a further 3 months per

discrete module was suggested� No response 3

262 P. Ford

Question 4 (c) asked what Managers felt a coresyllabus should contain. All subjects suggestedare listed in Table 4.

Question 4 (d) was in two parts, the Managerswere asked:

(i) Should the support workers be able to progressto qualify as a radiographer?

� 11 felt they should� 1 thought it possible� 1 specifically disagreed with the idea� 3 did not answer the question.

(ii) Over what additional timescale should this‘progression’ be?

One respondent felt this only provided an‘access’ entry to BSc course for those withoutAdvanced [‘A’] level qualifications. Another feltaccess should not be allowed for 2 years therebycreating a useful workforce rather than alternativeaccess to existing training.

Question 4 (e) Table 5 shows what the newworker should not be allowed to do.

Question 4 ( f) asked Managers to add any fur-ther observations they had about this topic. Theonly comments made were:

� Should be a 2-year-programme� Preferably a national initiative

Table 4 Core syllabus

1. Applied anatomy butnot physiology

2. Radiographic technique3. Care of the patient4. Radiation protection

and IRMER legislation5. Very limited physics

and equipment6. Others Film assessment

Information technologyHealth and safetyCardio-pulmonaryresuscitation

� 1 year 2� 12/18 months 1� 18/24 months 1� 2 years 3� No response 7

� The support worker should be a ‘plain filmworker’ who would be able to concentrate onimproving the ‘patient experience’

� It is important to have careful ‘vetting’ ofpotential students

Focus group

Once the questionnaires were returned a focusgroup, consisting of seven Radiology Service Man-agers, then considered the responses to ‘question4’ (indicated above). Every option suggested inthe questionnaire regardless of the number oftimes it was mentioned was listed for furtherdiscussion.

The focus group discussed the options suggestedbefore indicating their agreement/disagreementwith the responses. The results below show howmany individuals in the focus group supported eachsuggestion:

Agreement on what a support worker could examine

Area suggested Level of support

Extremities 7Chests 7Abdomens 7Spines 6Dental 6All plain films 4Accident and emergency 2Fluoroscopy 5Contrast studies No support for doing

IVU examinationsBone densitometry 5

Table 5 What could they not do?

1. Skull/abdomen2. Contrast studies (no use of iodinated

contrast)3. Fluoroscopy4. Mobiles5. Theatre6. Nuclear medicine7. CT/MRI8. Ultrasound9. Additional views10. Work unsupervised11. Paediatrics12. Shift duties/on call13. Accident and emergency work

Role of support workers 263

The Managers suggested some restrictions insupport of these responses, these included ‘sup-port workers’ must:

� be supervised� work at Diploma College of Radiographers(DCR) levela

� within the context of IRMER13 the supportworker would be classified as an operator only

� not become involved with paediatric cases orportable X-ray work.

Question 4 (b) looked for whether there wouldbe agreement on how long training should be.

Question 4 (c) explored areas of agreement onsyllabus content.

Question 4 (d) explored time delay before pro-gressing to train as a radiographer.

Length of the additional training to stateregistration.

Years Number of managers

1e1.5 32 4

Subject area Number of Managers

Anatomy 7Applied physiology 7Technique 7Care of the patient 7Physics (limited) 4Equipment (limited) 5Radiation protection 7Photography (limited) 4Information technology 3Film assessment 7Data protection 6Health and safety 7CPR training 7

Time delay Number of Managers

Immediately 1After 1 year 1After 2 years 5

a The ‘DCR’ was formerly the qualifying award for Radiogra-phers with the UK. By the mid-1980s the course was typicallyorganised over three years. Upon qualification the studentwould gain State Registration and be allowed to practice asa radiographer. By the early 1990s the DCR was replaced bya university-based graduate system (BSc with Honours).

It was recognised that the combined length oforiginal and additional training should be no longerthan 3 years.

Question 4 (e) looked at what support workerscould not do (or may be possible if stringentlysupervised)

Question 4 ( f) provides further comments fromthe group

� The support worker course must be a universitybased

� Support worker entry requirements should be 5GCSE, access course to GCSE, or for maturestudents advanced prior experiential learning(APEL).

� A strong preference for a national [academic]initiative was suggested, but there was anexpectation that in clinical practice therewould be some local variation.

Discussion

A number of professions (notably in pharmacy andphysiotherapy) have developed support workergrades to allow the state registered professions toovercome workforce shortages and also developtheir roles. This approach to skill mix developmenthas been highlighted by the Department of Health3.

The initial Radiology Service Managers groupdiscussion developed from this idea. They met

Length of time ( years) Number of Managers

1 31.5 22 2

Work area Never With directsupervision

MRI 7 0CT 6 1Angiography/interventional 5 1Contrast studies (no IVU) 1 5Mobiles 1 4Theatre 1 4Paediatrics 3 2Skull 1 3Accident and emergency 0 4Nuclear medicine 3 3Ultrasound 4 3Shift duties 6 1On call 1 5Additional views 1 4

264 P. Ford

under the definition by Kitzinger of a Focus Group([16] p. 103)

‘‘Focus groups are group discussions organ-ised to explore a specific set of issues.Thegroup is ‘focussed’ in the sense that itinvolves some kind of collective activity’’.

While the principle that focus groups evolvedfrom was that participants were all unknown toone another that was not the case here. All thegroup members were qualified radiographers whohad known one another for some time and werecomfortable in one another’s company. This en-abled the ‘unthinkable’ to be said which initiallystarted the discussions and then helped to developthem.

Morgan17 suggested that it is the interaction be-tween members of the group that develops theconcepts and insights and draws more from thegroup than would occur from the members individ-ually. This appears to have been the case as in theinitial group discussions there was reluctance bysome managers to the idea of non-radiographersusing ionising radiation. It was only after a coupleof meetings about the legislative, professional andpractical implications that the initial reservationswere overcome. Their reservations helped shapethe initial concepts.

Discussions included identifying the role thata support worker trained in radiation safety, anat-omy and technique could fulfil within depart-ments. It was not envisaged that they would bemulti-tasking, but there was debate over preciselywhat tasks would be suitable, and what theyshould definitely not be allowed to do. These dis-cussions took about 3 months.

The limitations of this approach according toReed and Roskell ([18] p. 770) are that

‘‘the results can be difficult to extend intofuller understanding of the phenomena understudy’’

They recommended integrating other data to ob-tain a more rounded view of the phenomena beingstudied.

The use of a questionnaire to ask the views ofa wider audience was an attempt to verify if theideas of a small group, who might have very localstaffing problems, had wider support. It wasa way of introducing more data, as suggested byReed and Roskell,18 and broadening the debateinto areas that might require the more detaileddiscussion.

Piloting the questionnaire within the originalgroup of managers allowed the opportunity forthose who had the most reservations to ensure

that sufficient weight was put into exploring areasthey felt uneasy, or particularly strongly, about inan anonymous setting. This allowed an evaluationof the questionnaire design. It may also have hadthe advantage of speed as all questionnaires wereresponded to very quickly. This process of develop-ing a questionnaire, piloting, distributing and ana-lysing it took a further 3 months.

The questionnaire was sent to Radiology ServiceMangers in hospitals believed to have particular re-cruitment difficulties. At the time it was felt thatthese problems were essentially a South Coast ofEngland one but that they would become a nationalproblem before long.

It is acknowledged that a possible weakness ofthe approach used was that most of the individualsinvolved knew each other and were personallyknown to the researcher. The researcher did notdiscuss the subject of support workers with othersoutside the group and as far as is known neither didthe members of the group. The act of sending outthe questionnaire may have alerted the respond-ents to the researchers general views, but theydid not have to agree. Anonymity was given to re-spondents and even for those generally in favouranonymity allowed reservations they still held tobe raised about particular aspects of the role. Onlytwo respondents were opposed to support workersusing ionising radiations, and one of them was alsoopposed to any extension of the current duties ofthe present helper grades.

Once the results were analysed they were col-lated and then redistributed to the original group.This process was a modification of the Delphi tech-nique. Delphi has been used in a number of modi-fied forms, all of which have advantages anddisadvantages.15 The common aspect to the tech-nique is a series of responses by a group or groupsto the same questions, with additional analysis ateach stage to elicit consensus agreement.

Questions 1 and 2 set the scene in the depart-ments the service managers managed. They recog-nised that the support workers were capable ofa wider job role and it was appropriate to providesuitable training. The reasons for the choice ofNVQ training, or lack of it, were not explored. An-swers to question 3 about what additional dutiespresent [support worker] staff could undertake rai-ses the question of why staff are not undertakingthese roles now if there are radiographic vacanciesand the service is under pressure. All departmentshave slightly differing systems of work, and with-out a full explanation of local circumstances someanswers were difficult to interpret in context.

One respondent suggested that support workersbecome involved in the use of contrast media

Role of support workers 265

injection pumps in CT. It is difficult not to feel thatthis is a cause for alarm and contrary to safe clin-ical practice. However, the general range ofanswers shows that there is still potential to de-velop this role. This is an area that warrants fur-ther research. Question 4 (Table 3) shows thatthere was a large degree of unanimity in the listof plain X-ray procedures that support workerscould be trained to do. There seemed to be univer-sal agreement that the majority of plain film workcould be covered.

There was some confusion around answersabout contrast studies. The focus group discussedthe reservations expressed in this area and feltthat the problem arose around the issue of the levelof supervision. (1) The use of a support worker inbarium studies was felt to be acceptable. The radi-ologist or radiographer undertaking the examina-tion is present in the examination room, andusually there is nursing support, so it was felt thatthere was sufficient direct supervision. (2) Strongreservations were expressed about iodine contraststudies. These are potentially more dangerous forpatients, but it was felt that if they were supervisedas strongly at the point of delivery as barium studiesit would be appropriate for iodine studies to be in-cluded in the new role. In retrospect, the wordingof questions around contrast studies needed ex-panding to differentiate between barium and iodin-ated contrast.

The role of support workers examining patientsfrom accident and emergency created widely di-vergent views. Strong opposition was expressedto allowing anyone without full radiographer train-ing to work in this particularly challenging area.Following discussion it was recognised that carefulsupervision and triage could create a safe workingenvironment for an experienced support worker.Many patients are relatively fit and co-operativeand as long as there was proper patient triage, su-pervision and high standards of radiography en-forced safe practice could be guaranteed.

While bone densitometry was felt entirely suit-able there was unanimity that mobile radiographyand examinations of small children were totallyoutside the scope of this role. The recurrent themein all these discussions was that the degree of su-pervision dictated the range of examinations thatwould be acceptable.

The majority of Radiology Service Managers ap-proached provided clinical placements for radiog-raphers in training in their departments but theirknowledge of current training practice was notexplored. Two different views were expressed onthe length of training for the new role both inthe questionnaire and focus group. Answers were

fairly evenly split between 1 and 2 years. Giventhe Manager’s seniority and years since qualifyingit is likely that they would have all trained underthe old 2-year (rather than 3) DCR system. Thismay have influenced their answers as they wereperhaps envisaging a version of ‘their’ trainingscheme. The Radiology Service Managers also ap-peared to remember important aspects of theirown training and identified areas where they feltlittle theoretical instruction was necessary (egphysics and equipment). Equally, they identifiedareas they felt important to cover such as radia-tion protection, patient care, and anatomy as wellas radiographic technique. They were not support-ive of a great deal of pathology instruction butadditional suggestions did include some informa-tion technology training, and data protection andhealth and safety issues.

Despite the recognition that this would be a lim-ited training scheme no one was totally opposedto workers having an opportunity to continuetraining to obtain a full professional qualification.There was some uncertainty about how soon thiscould be done. There was a suggestion that thereshould be a gap of 1 or 2 years after initial train-ing before continuing, otherwise what was thepoint of training these people to support workerlevel (ie they may as well have simply entereda BSc Radiography degree in the first instance).This disregarded any consideration about thenumber who would want to continue to full stateregistration.

It was recognised that in theory the total train-ing time should be around the 3 years of currentundergraduate training. Organisation of this wasan issue for the academic institutions when devel-oping the syllabus but there were those with reser-vations about whether this was an adequatetimeframe.

The issue of what radiographic work was notsuitable for these workers was an alternative ap-proach to the question already asked about whatthey could do. It was a way of cross-referencingthe original answers. Reservations were repeatedabout accident and emergency and contrast stud-ies but there were some new themes.

The principal that shift duties and on call wouldnot be appropriate was universally accepted,although it was thought that some large hospitalsmight be in a position to challenge this view if theyhad a large number of staff on shift and so wereable to undertake adequate supervision. Reserva-tions were also expressed about mobile and theatrework. If work is done under protocol the reserva-tion about not being able to undertake additionalviews to the standard protocols was interesting,

266 P. Ford

and links to the topic of supervision. There was nodefinition of additional views.

Despite recognition that these support workerscould be trained to undertake useful roles in inter-ventional procedures, CT and MRI, working underclose supervision, there was universal agreementthat this was an inappropriate role. In discussionit was observed that qualified radiographers arevery keen to obtain experience in these special-ities, and in which there is a skill shortage. Block-ing opportunities for them to go into these areas bythe use of support staff was expected to createdissatisfaction, leading to retention problems, andexacerbate the skills shortage by not developingthe next generation of skilled professionals ableto run this complex technology.

The further comments section was used to rein-force the view that there was general recognitionof the need to open entry gates and be as flexibleas possible in recruiting. There was universalagreement that training such workers should bea national initiative, but that realistically trainingwould probably have to be implemented at a locallevel.

Mention was made that if this role is developedit has implications for the traditional undergradu-ate degree students taking a 3-year universitycourse. The opportunity to gain state registration,albeit over a longer timeframe, could have attrac-tions as students would be paid employees and lesslikely to incur large debts as at present. In additionit may not be necessary for them to have such highentry qualifications.

It was suggested that a possible model would befor the existing undergraduate training system tocontinue with a full 3-year course, followed by a1-year post-qualification period concentrating onplain film radiography. After achieving a set ofcompetencies radiographers could justify gradingto Senior II and start their career progression. Thesupport workers would assist them by undertakingmost plain film radiography. This would allow ra-diographers to have the opportunity to developthe highly specialised skills required for advancedpractice.

Conclusions

There was a large measure of agreement amongthe participants to this study that a new supportworker is needed who would be trained to use ion-ising radiation. Despite some minor disagreementsabout aspects of the concept it showed that thereis widespread professional understanding that the

present recruitment crisis needs radical thinkingto solve the problems.

While there was a consensus about the types ofexaminations that would be suitable for supportworkers to undertake there was disagreementabout the patient cohorts that would be accept-able. There is the need for more debate about theexact nature and extent of the duties this newcategory of worker might undertake. The needfor adequate and correct supervision both of train-ing and working practice was felt to be key to thesuccess of the concept.

It was felt that this new worker could be trainedover 1e2 years to undertake the majority of plainfilm examinations. Academic training may be simi-lar to the ‘old’ DCR. After possibly a 1-year proba-tionary period to establish their knowledge theywould have the option of a further 1e2 years train-ing to become a state registered radiographer. Inessence this is the pattern proposed by the Depart-ment of Health in A Health Service for all theTalents: Developing the NHS workforce.19

Acknowledgements

This project would never have come to be devel-oped without the support and contribution madeby the South Thames (West) Service Managers,and in particular Mrs Pat Lowes. The invitation byProfessor Roger Dyson to talk at Keele UniversityManagement Unit encouraged more research anddevelopment of the initial concepts.

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