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Advanced Practitioner

The advanced practitioner category encompasses the considerable depth and breadth of radiographic practice. Predominantly, advanced practice relates to expert clinical practice in association with one or more other functions, for example, team leadership, education, research, and service development.

Advanced practice also includes roles which are based mainly on service management, research or education. At this level, practitioners have developed expert knowledge and skills in relation to the delivery of care in diagnostic imaging or radiotherapy and oncology in a wide range of care settings or environments.

For non-clinical fields of practice, the model is similar, supporting career development for radiography managers, researchers and academics. A key feature of an advanced practitioner role is that they are enabled to develop innovative practice and to identify where service and quality improvements can be achieved.

Research undertaken in 2009 into the effects of Agenda for Change (AfC) on career progression highlighted the diversity of roles being undertaken that may constitute advanced practice. A variety of titles have been used to describe this level of practice including specialist and advanced practitioner and some hybrid, ‘split contract’ and clinical/academic roles were identified. Effect of Agenda for Change on Career Progression of the Radiographic Workforce37 (2009).

The advanced practitioner will be an integral member of the radiography team but will also interact with the relevant multidisciplinary teams to ensure delivery of high quality, effective care.

Advanced practitioners with research, management or academic roles will be expected to deliver efficient and effective services within their domains.

Education requirements

The SCoR believes that the educational requirements to support this level of post registration practice are education and/or development through work place learning and practice to N/SVQ level 4/5 and/or master’s level qualifications, or their equivalents.

Pay and grading

The NHS pay spine places advanced practitioners in Bands 7 and 8, depending upon the exact nature of the role and subject to its evaluation against the advanced practitioner profiles.

Accountability, autonomy and responsibility

Advanced practice is part of a continuum and, as a result, the advanced practitioner’s level of autonomy and responsibility will be determined by his or her individual competencies and the practice setting. The extension of skills must be underpinned by appropriate education and training and clinical practice must lie within locally agreed protocols and clinical governance frameworks. Advanced practitioners are accountable for their professional actions. As their careers develop at this level they will be reflective practitioners with highly developed judgment and decision-making skills. They will contribute significantly to the clinical management of individual patients and will liaise effectively with other professionals.  They may provide supervision for assistants, students and other staff and will delegate tasks as appropriate. In delegating tasks to non-registered staff, they will retain responsibility for the episode of care. They will work closely with medical and non-medical consultants in their field and will also be engaged in personal clinical supervision or an alternative model depending upon their practice setting.

Support and resources

Advanced practitioners will be engaged in relevant continuing professional development. The nature of the advanced practice role demands that the individual is actively involved in career-long learning to support the continuing acquisition of the necessary depth of knowledge. Advanced practice roles will be influenced by local service provision and identified needs. To be able to contribute fully to evolving service developments, advanced practitioners need access to wider development opportunities and further education to ensure that they are well placed to deliver new and innovative patient focused services.

  • A Framework for Professional Leadership in Clinical Imaging and Radiotherapy and Oncology Services38 (2005)
  • Implementing Radiography Career progression: Guidance for Managers22 (2005)
  • Implementing the career framework in radiotherapy – policy into practice39 (2009)
  • Positioning Therapeutic Radiographers within Cancer Services: Delivering Patient-Centred Care31 (2006)
  • Protected Study Time - Guidance for Radiographers, Managers and Union Representatives20 (2009)
  • A Charter for Protected Study Time in Scotland21 (2008)
  • A Strategy for Practice Development in Radiography6  (2005)
  • Learning and Development Framework for Clinical Imaging and Oncology3  (2008)

The role of the radiographer as an advanced practitioner

The advanced practitioner will demonstrate expert clinical practice to secure service delivery of the highest quality. The core function is to engage in expert clinical practice to deliver high quality patient- focused care in Diagnostic Imaging or Therapeutic Radiography, or the equivalent, in service management, research and education.

The Advanced Practitioner role may incorporate other supporting functions such as:

  • team/professional leadership
  • practice and service development
  • education and  training
  • research and development.

The above supporting functions may be equally divided within the job specifications for advanced practitioner roles or, more likely, they will be weighted to support the particular scope of a specific advanced practice role.

  • The knowledge, understanding and skills required for this role are stated in the Learning and Development Framework for Clinical Imaging and Oncology3 (2008)

Accreditation of Advanced Practitioners

The Society of Radiographers (SoR) has established accreditation of advanced practitioners to:

  • ensure there is national consistency in the standards of practice
  • secure transferability of those standards across the NHS and other health care sectors
  • recognise explicitly the professional achievements of individuals
  • provide clarity for professionals and service users on the nature of advanced  practice in clinical imaging and radiotherapy and oncology
  • promote the value of advanced practice skills and status
  • support the development of emerging advanced practitioners in a systematic way and so facilitate succession planning within services
  • support accredited advanced practitioners to remain demonstrably at the leading edge of their specialism
  • build on existing frameworks for advanced  practice

For the purposes of accreditation, the definition of an Advanced Practitioner is:

"An individual who has significantly developed their role and who consequently has additional clinical expertise in a defined area of practice, accompanied by deep underpinning, evidence based knowledge related to that expertise. They make appropriate clinical decisions related to their enhanced level of practice, directly impacting on the patient care pathway."

This definition has been derived from the Skills for Health definition of Advanced Practitioner which can be viewed at skillsforhealth.org.uk/careerframework/key_elements.php 

The processes of initial accreditation and re-accreditation relate to the four core functions of higher level practice (Table 1). These provide a framework within which continuing professional development can be evidenced to ensure it is appropriate to advanced practice roles.

Table 1: Core Functions of Higher Level Practice

  • Expert Practice
  • Professional Leadership and Consultancy
  • Education, Training and Development
  • Practice and Service Development, Research and Evaluation

Information about the accreditation process and how to apply for accreditation can be found at http://www.sor.org/public/ap_accred.htm.

Successful applicants will receive accreditation for two years and will need to seek re-accreditation on a two-yearly cycle. The evidence for initial and subsequent re-accreditation must be submitted through CPD Now, the SoR’s online CPD management tool. Evidence must clearly relate to the learning outcomes detailed in the Learning and Development Framework for Clinical Imaging and Oncology.

It is recognised that the scope of practice of advanced practitioners varies widely and increasingly so. In England, policy initiatives such as implementation of the NHS Next Stage Review  http://www.official-documents.gov.uk/document/cm74/7432/7432.pdf   will see diagnostics being delivered within community and primary care settings.  In Scotland, policy around access and choice is described in ‘Shifting the Balance of Care’ (2008) http://www.scotland.gov.uk/Publications/2008/09/03103300/0  and in Wales, future health care policy is described at http://www.wales.nhs.uk/sitesplus/829/home. These all require a highly educated workforce that can work autonomously and independently within agreed clinical governance frameworks.

A number of key principles emerge from these policy developments, including:

  • self referral to Allied Health Professionals
  • QIPP / cost effective quality care
  • leadership
  • innovation.

All these require AHPs to be involved in decision making at local level around models of care, effective use of skills and resources and the further development of AHPs to drive forward the quality of care and services provided. Guidance related to specific areas of practice is given below and, while a broad range of practice areas are considered, these are examples and not a definitive list. Indeed, advanced practitioners may be found in all areas of clinical imaging and radiotherapy and oncology.

Radiotherapy and Oncology

The Cancer Reform Strategy has identified where therapeutic radiographers can play a significant role in ensuring that the cancer care pathway can smooth the transition between primary and acute care by establishing the role of Community Liaison Expert Radiographer Practitioner  http://www.nhs.uk/conditions/Cancer/Pages/Introduction.aspx 

http://doc-lib.sor.org/role-community-liaison-expert-radiographer-practitioner

The demand for expansion of radiotherapy services requires that the skill mix of the radiotherapy and oncology team is re-examined. The role of the radiographer in treatment planning, dosimetry and treatment is set to increase to meet the demand for intensity modulated radiotherapy (IMRT) and image guided radiotherapy (IGRT). This is being supported by an e- Learning for Health project and a national programme in England designed through the National Radiotherapy Implementation Group (NRIG) to deliver training to the multi-professional team for IMRT  http://web.archive.org/web/20101218104543/http://www.cancer.nhs.uk/radiotherapy/imrt.htm

A recent report (2007) from the National Radiotherapy Advisory group (NRAG) states that “a significant proportion of routine work could be delivered by appropriately trained non-medical Health Care Professionals working within agreed protocols. This will free consultant medical staff to focus on the more complex clinical work”. NRAG advocates implementation of the SoR’s career progression framework. Department of Health, Radiotherapy: developing a world class service for England - Report to Ministers from National Radiotherapy Advisory Group40  (2007)

Further guidance may be found in the following:

  • Cancer Reform Strategy – 2 years on41 (2009) http://www.nhs.uk/NHSEngland/NSF/Pages/Cancer.aspx
  • Radiotherapy moving forward: Delivering new radiography staffing models in response to the Cancer Reform Strategy5  (2009)
  • On Target- Ensuring Geometric Accuracy42 (2008)
  • Towards Safer Radiotherapy43 (2008)
  • Implementing In-Vivo dosimetry44 (2008)

Image interpretation and reporting

Reporting by radiographers, initially established in ultrasound, has now become firmly embedded within the scope of practice of advanced practitioners. IR(ME)R legislation requires that each examination involving ionising radiation must have a formal report.  The proportion of unreported images has been reduced both by the introduction of technology such as PACS (Picture Archiving and Communication Systems) and, importantly, by radiographers undertaking the reporting of diagnostic examinations An improving picture? Imaging services in acute and specialist trusts45 (2007).

Changes in working patterns and service delivery will see radiographers increasingly accepting referrals from non-medical healthcare practitioners and acting as Referrer across a range of modalities. E-Learning for Health http://www.e-lfh.org.uk/ is developing an on-line learning tool for image interpretation that can be accessed by radiographers.

Other guidance and resources may be found at:

  • Medical Image Interpretation and Clinical Reporting by Non-Radiologists: The role of the Radiographer46  (2006)
  • Clinical Imaging Requests from non- Medically Qualified Professionals47 (2008)
  • Team Working within Clinical Imaging: A contemporary view of skills mix48 (2007)

National service frameworks and care pathways

The introduction of national strategies such as Stroke Management  The role of the Radiographer in Stroke Management49 (2008) https://www.sor.org/learning/document-library/role-radiographer-stroke-m... and new screening programmes will require more radiographers to develop expertise in particular areas of disease and patient management supported by the leadership qualities that enable them to bring about necessary changes in working practices and workflows. In the near future, initiatives linked to the diagnosis and management of Acute Chest Pain are expected to impact on cardiac and cardiology services. Similarly, developments are likely in relation to interventional radiology services.

Guidance on the above and other similar developments are placed on the National Institute for Health and Clinical Excellence’s website very regularly www.nice.org.uk and also on the SIGN site in Scotland http://www.sign.ac.uk/.

Forensic imaging

Proposals for non- invasive autopsy and the frequent use of imaging to provide forensic evidence require the radiographer to have a sound knowledge of the legal procedures and processes involved with clear radiographer leadership.

A number of guidance documents relate to this area of activity:

  • Guidance for Radiographers providing Forensic Radiography Services50 (2009)
  • The Filmless Department: use of images as evidence in legal proceedings51 (2006)
  • Drugs Act (2005) www.opsi.gov.uk/acts/acts2005/pdf/ukpga_20050017_en.pdf
  • Skeletal Survey for Suspected NAI,SIDS and SUDI: Guidance for Radiographers52 (2009)

Ultrasound

The demand for ultrasound examinations is expanding not only by volume but also into primary and community care to meet the access and choice agenda. Expansion is also driven by the implementation of national screening programmes such as those for fetal anomaly and abdominal aortic aneurysm screening. There is also a major initiative to try and diagnose cancer as early as possible, musculo-skeletal ultrasound examinations are also rapidly increasing in number.  Such services will require advanced practitioners to perform these examinations and to co-ordinate multi-disciplinary teams and manage services. Ultrasound guided biopsies, joint injections and other invasive techniques are now performed by advanced practitioners and are within the overall scope of practice of the profession. https://www.sor.org/learning/document-library/scope-practice-2013

There are a number of other documents of relevance to the advanced practice ultrasound workforce:

See www.sor.org Scroll to the bottom of the page and select ‘policy and guidance document library’(on the left).

Then select ‘ultrasound’ in the ‘topics’ filter box on the right and click ‘apply’.

Education and Training; Research and Development

Some advanced practitioners will develop enhanced skills related to education and training and may have this function formally recognised within their job role. Such activity may include the teaching and assessing of learners such as assistant practitioners, student radiographers, radiographers and other practitioners developing extended roles and skills. Inevitably, as patterns of care change to a patient- focussed approach, the radiographer may well be involved in the teaching and supervision of other healthcare professionals. This multi-disciplinary involvement strengthens the core function of working across professional boundaries and provides a basis of evidence for career advancement. At this point, some may wish to formalise their role through  Clinical Imaging and Oncology. The Approval and Accreditation of Educational Programmes and Professional Practice: Practice Educator Accreditation Scheme57 (2006)  or to move into the HE sector to take up a formal teaching role.

In developing enhanced clinical skills and demonstrating evidence- based practice, new roles and practices may provide the opportunity for developing research skills and contributing to, or leading, clinical research. This may lead to formal recognition as a researcher either wholly within the healthcare service or as a joint appointment with an academic institution.

Relevant guidance is given in:

  • Clinical Imaging and Oncology. The Approval and Accreditation of Educational Programmes and Professional Practice: Practice Educator Accreditation Scheme57  (2006)
  • Research and The Radiography Profession: A Strategy and Five Year Plan27 (2005)
  • National Research Ethics Service http://www.nres.nhs.uk/
  • NHS Evidence www.evidence.nhs.uk

Health and Safety; Radiation Protection

All clinical departments of diagnostic imaging, nuclear medicine and radiotherapy require someone to keep an overview of issues pertaining to radiation protection. This individual may be designated as a Radiation Protection Supervisor and must have sufficient authority to ensure that the provisions of the Ionising Radiation Regulations are upheld by all operators and practitioners. They may have a role in developing protocols around justification and referrals and as such, may be an advanced practitioner.

A section of the SoR website is dedicated to Radiation Protection and the following guidance is relevant:

  • Student radiographers and trainee assistant practitioners as ‘Operators’ under IR(ME)R 2000/200658 (2009)
  • Clinical Imaging requests from non-medically qualified professionals47 (2008)
  • A Guide to understanding the Implications of the Ionising Radiation (Medical Exposure) Regulations in Radiotherapy59 (2008)
  • The Ionising Radiations regulations 1999 (IRR ’99): Guidance Booklet60 (2009)
  • IR(ME)R 2000 and IR(ME) Amendment Regulations 2006  http://doc-lib.sor.org/irmer-2000-and-irme-amendment-regulations-2006
  • Pregnancy and Work in Diagnostic Imaging Departments61 (2009)
  • Protection of Pregnant Patients during Diagnostic Medical Exposures to Ionising Radiation62 (2009)

Of additional interest for those working with Magnetic Resonance scanners is the document Safety in Magnetic Resonance Imaging63 (2007).

Other guidance documents relate to:

  • moving and handling
  • avoidance of musculo-skeletal disorders64, 65
  • infection control66

There has been some debate as to whether a radiographer who has undergone additional training in aspects of radiation physics and protection can fulfil the requirements to act as a Medical Physics Expert under IR(ME)R. The view of the SCoR is that a degree in radiography fulfils the initial requirement for a science degree as required by the Regulations.

Information Management andTechnology

The widespread introduction of Radiology Information and Management systems and PACS has provided development opportunities for radiographers with an interest in Information Management and Technology. Maintenance of these systems and their utilisation in clinical audit and research requires considerable experience and knowledge of information technology. Relevant guidance is contained in:

  • The Filmless Department; use of images as evidence in legal proceedings67 (2006)
  • Information Management & Technology: Implications for the Radiography Workforce35 (2006)
  • Information Management & Technology: further advice and guidance on curriculum68 (2008)

Further development of advanced practitioners

In gaining accreditation as an advanced practitioner and developing skills allied to each of the core functions, the natural route of progression for those wishing to have an enhanced clinical role is to consultant practitioner. This will require the individual to focus on a particular area of clinical activity in considerable depth. At the present time there are consultant radiographers in a variety of clinical settings, for example: diagnostic image reporting, ultrasound, breast screening services, neuro-radiology, trauma care, gastro-intestinal medicine, site specific and technical specialists in radiotherapy and oncology.

Many advanced practitioners will build on their leadership and management skills and become service managers and leaders. It is important that these individuals are recognised for their ability to influence service provision not only within their own departments but within the local health community. This is ever more important as the responsibility for commissioning care lies within the primary care community which, traditionally, has limited interface with services delivered mainly in acute settings. Increasingly, service managers and leaders will take lead roles in moving services closer to patients in community and primary health care centres. Key roles for service managers and leaders are developing and delivering new models of service delivery and, as stressed in the ‘Next Stage Review in England’, for AHPs to become fully engaged in commissioning processes.

Developing the workforce of the future is an important career pathway for advanced practitioners to grow and sustain both the current and future workforce. A key role is that of practice development facilitator, supporting workforce development and aligning this to service needs and priorities, often on a multi-disciplinary basis. Advanced practitioners foster links with FE and/or HE providers in their clinical roles and may build on those to develop further the educational component of their roles, moving on into formal clinical-academic posts or lectureships within the HE sector.  

Clinical and service innovation requires proper audit and evaluation, some of which needs to be multi-centre if new techniques and treatments are to have proven utility. Engagement in such activity is a natural development pathway for advanced practitioners aiming to build a career in research, enabling them to gain knowledge, skills and experience as members of relevant audit, evaluation and research teams and groups. This may progress to co-ordination roles for clinical trials locally or nationally, to research links with academic partners, and to leading research proposals and bids for funding as well as the research itself for projects that are funded.

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