My career journey started in 2007 when I enrolled on the BSc Diagnostic Radiography and Medical Imaging undergraduate degree at University of Wales, Bangor. I qualified with a 2.1 and took up my first post in 2010, where I stayed until late 2016. During this time, I worked mainly in general radiography, interventional radiology and acquired the role of department mandatory training facilitator. The pivotal point in my career; came in 2016. There was an advert for a Lead Radiographer in a new prison. Something about it was drawing me in. I was curious. The opportunity to experience the building of a new radiology suite within a new healthcare facility, let alone within a new prison was appealing. With nothing to lose and perhaps a lot to gain, I submitted my application.

My time ‘behind bars’

In late 2016 I began my time “behind bars”. I served a three-year sentence and was released from this post on good behaviour at the end of 2019. This was the most colourful part of my career to date. There was a lot of blood, sweat and tears that went into the build, service set up and fulfilment of this role. However, it also brought plenty of laughter, lifelong friendships and camaraderie like nothing I had seen before.  There were many experiences which warmed my heart; impactful patient interactions which will stay with me forever and have shaped who I am as a health care professional.

Transferable skills from this post were abundant, teamwork, resourcefulness, patient care, clinical skills, time management, organisational skills, people management and human resources knowledge. The resilience and growth as an individual were immeasurable, and each experience developed my empathy and problem-solving / de-escalation skills. 

Prison is a unique environment. It exposed me to a whole new world, with a whole new language. Ultimately this post exposed me to roles, responsibilities and experiences, not typical of a radiographer and a service need provided me with an opportunity to embark on an advanced practice journey down an atypical path. This experience saw my come out of my comfort zone and thrive.

Developing my skillset 

Project management 

Initially, my primary role was to project manage the build and installation phase, liaising between all stakeholders, prison project team, prison security, the health board, medical physics, prison contractors, health board contractors, manufacturers and suppliers. Overseeing the installation of three pieces of equipment, in addition to the procurement of essential accessory equipment and consumables. 

Operational leadership

I started as part of the prison health project team and remained in post to continue as part of the prison health operational team. Once I had overseen the equipment installation and all the relevant radiation and electrical testing and secured medical physics sign-off, it was my duty to set up and lead the in-house radiology service. This included general radiography, dental radiography and ultrasound imaging. There was also a pad within the grounds to accommodate an MR van.

Ahead of the prison opening I was involved in the planning and execution of scenario testing. This consisted of three days of trialling potential scenarios in order to identify any issues with contingency planning and move into the prison operational state. It was important to test the processes; as if a real situation; in real time, and identify learning and adaptions required prior to opening. All health care related scenarios were led by myself, which saw me running across the vast 100+ acre site- what an incredible experience though.

Setting up a service 

Once the equipment had been installed, I could focus my attention on setting up the service. There was mostly paperwork during this time, ensuring all the correct legal requirements were in place, as well as local policies and procedures. Adaptions to the health board local rules had to be made to include the prison as a new ‘community site’, addressing prison officer accompaniment, and amending the three-point ID check for prisoner patients. Equipment logs, maintenance and service records, QA testing programmes and baselines all had to be established. Service and maintenance contracts had to be agreed and secured. All radiology staff had to go through vetting and once cleared, complete prison induction training. There were also multiple risk assessments to complete. Finally, training records were devised and completed with each member of staff for each system training completed.

Integrated role – wearing many hats!

The healthcare service delivery model was a new one. It was a fully integrated multi-professional health and wellbeing service. This model was designed to provide safe and effective care, whilst also providing service resilience. For me, this essentially meant taking on roles and responsibilities I would not normally have as a radiographer. These roles included: First responder, Shift co-ordinator, Mental Health First Aider  ACCT reviews (Assessment, Care in Custody and Teamwork process), Reception health screening, Medication administration and management checks.

Supervision 

One of the most valuable things the integrated model introduced me to was supervision - clinical, management, peer and group supervision. As it stands, unlike our nursing colleagues, radiographers are not required to undertake and therefore do not routinely participate in clinical supervision. This is an area which will help to advance practice¹. Supervision was something I had never previously encountered as a radiographer but was embedded from the beginning at the prison. 

Supervision is also a regular and key component of my current role in ED; I have regular sessions with my team leader and Consultant Educational supervisor. Continual professional development (CPD) and supervision should be a high priority for health professionals². It provides many benefits. Personally, it was key in my career progression and continues to support my job satisfaction, reflective practice, health and wellbeing.

Service development 

After the service was set up and running, it was important to review and explore service improvement and development. Initially, service review was undertaken with patient satisfaction surveys and via the healthcare focus group. Radiology referrer meetings identified issues with the receipt of radiology reports by referrers and issues with referral scopes. 

In my role, I proposed an in-house minor injuries service. Within the imaging service we were  fortunate to have the imaging available for remote review and a hot reporting service available during normal working hours. I approached the DGH, and the Trauma and Orthopaedic (T&O) team there were overwhelmingly agreeable and very supportive in the setup of remote advice for injury management, image review and/or follow-up arrangements. My long-term aspirations were to introduce telemedicine to further develop the service. 

My new chapter: embarking on advanced clinical practice

During my supervision it was identified that my job plan had the capacity to increase the clinical component; and could allow me to participate in the service delivery as well as leading. In order for me to progress into this I would require further training. I embarked on an Advancing Clinical Practice Masters programme. I studied a range of modules such as Clinical Assessment, Clinical Diagnostics, Minor Injuries Assessment and Management, Research Methods, Advancing Clinical Practice and a Dissertation. My dissertation focused on the impact of independent prescribing on diagnostic radiographer advancing practice. These modules allowed me to deliver the Minor Injuries service but also provide support to my GP colleagues. It was my dedication and determination to provide timely, on-site diagnostics which I was nominated for the Radiographer of the Year award and proudly won for the Welsh region in 2019.

Post-sentence rehabilitation - moving on 

Everything happens for a reason. My grandfather always used to say; “what is meant to be, will be”. It was time for me to move on from this role. This post was the grounding for a career differing from the norm, leading to trail-blazing and a fulfilling career.

After a brief period of reflection, consideration and locum working I had a chance conversation with a lecturer at university, who mentioned a standalone minor injuries unit looking to expand their team. After successful application and interview, I commenced as an Emergency Care Practitioner in the Minor Injuries Unit, working alongside paramedic and nursing colleagues - assessing, referring for imaging where appropriate, diagnosing and treating minor injuries. Patient Group Directives (PGDs) allowed me to issue pain relief and prophylactic antibiotics/tetanus vaccinations. This short but valuable posting, with an incredible team of very knowledgeable and experienced professionals, further enhanced my skills in all clinical areas, but importantly gave me experience in caring for female and paediatric patients.

As I came to the end of my master’s qualification, I was interested in taking up the role of an Advanced Clinical Practitioner (ACP). However, I did face some challenges and found that as a diagnostic radiographer without independent prescribing, posts were hard to come by. It appeared there was a mismatch between higher institutions and NHS employers. Although independent prescribing was not deemed a core module on the master’s degree, the majority of NHS employers deemed it to be an essential criterion. On one search for ACP vacancies, 176 were available. I was only eligible to apply for 3 out of 176 posts. Luckily for me three of the posts available at the time listed independent prescribing as desirable rather than essential. 

Two roads diverged in a wood, and I, I took the one less travelled by, and that made all the difference - Robert Frost³

The first radiographer as an ACP in emergency medicine 

I applied for one of the ACP vacancies in the Emergency Department at Aintree University Hospital. I was selected for interview. Following a 9am clinical paper and a three-person interview panel, I headed home to await a phone call to hear if I had been successful, or not. The phone did not ring all afternoon or evening, so when it eventually rang at 8.45pm I had already decided I had not been successful, assuming this would be the courtesy call and opportunity for feedback. I was offered the post; but as they never had a radiographer apply before, the department wanted to make some enquiries with clinical governance, legal leads and the Royal College of Emergency Medicine (RCEM). 

The conclusion was that I would be the first radiographer that RCEM were aware of in an EM ACP post. Given my ACP Masters qualification, my prison, GP and Minor Injuries experience, and the knowledge I had demonstrated at interview, I was more than qualified and capable to do the role. There were tears of joy and  the realisation of how special this was started to sink in. 

Since starting in post in April 2020, it has been an adventure! Those first few months were a steep learning curve for me. Thankfully I have been very well supported by the ED family. Being part of such a vast team has to be one of the highlights of my job, from my amazing ACP team to the wider ED team and the vast array of teams we work alongside. The consultant body and nursing team have always been welcoming and helpful. There are 11 in our ACP team, led by the first paramedic EM ACP to achieve RCEM accreditation in the Northwest. Our greatest strength is our rich skills mix. Our team is made up of varying professions and backgrounds and we each bring something different to the team. We have nurses from trauma, surgical, primary care, spinal and critical care backgrounds, a paramedic, and me, a radiographer. 

It was not all plain sailing once in post sadly, and my biggest barrier at the beginning was actually Radiology! There was initial reluctance from the radiology department to grant me non-medical referrer entitlement. Concerns were voiced whether a radiographer in an EM ACP role was possible. With assurances from the ED Clinical Director, SCoR officers and union reps, this was resolved, and I am pleased to say relations are much better these days. It did humour the ED team that I had been disowned and hindered by my own profession!

“Imposter Syndrome” has reared its ugly head from time to time, but is to be expected, I am told, and far more common than I had realised. People navigating new things or places or consider themselves different to their peers will commonly experience this. The high standards I set myself and the expectation I put on myself that in this role I am representing not just myself, but the radiography profession as well, I am the perfect recipe for an imposter⁴ .

Meeting the four pillars of advanced practice 

To ensure I am working at the level of an advanced practitioner, my job plan allows me to work across the four pillars with the greatest emphasis on clinical.

Education: I am a visiting University Lecturer, I present at study days, and I provide informal training sessions and in-house teaching.

Leadership and management: I am currently the Presidential Alternate on SoR UK council, a role which I am thoroughly enjoying and learning plenty. I am an assessor for the Health and Care Professions Council (HCPC) and within ED I am involved in Junior doctor inductions. My background allows me to educate colleagues on radiation protection awareness, to better inform their risk / benefit decisions, and advise them on modality strengths. Since in post, I have been able to negotiate a much broader scope of referrals for the EM ACP team, allowing our access to imaging to be more comparable. 

Research: I continue to push for radiographer independent prescribing, sharing my research findings wherever I can, being a case study to add to the evidence being collated by the SoR. I am also involved with clinical trials, audits and quality improvement projects.

Clinical: I work across all areas of ED – from “see and treat”, “minors”, “majors” to “resus” and major trauma, and I see the full acuity of patient presentations. My qualifications and training include venepuncture, venous cannulation, arterial blood gases, fascia iliaca blocks, ECG interpretation, Interosseous access, transfusion, POCUS, Advanced Trauma Life Support, Advanced Paediatric Life Support, and Advanced Life Support.

I perform clinical examinations. I can refer for diagnostics such as ECGs, bloods and imaging. I commence treatment where required. I review diagnostics once they are available. I make a clinical plan according to my working diagnosis and make the decision to admit or discharge and refer into other services as required. 

What next? 

Radiographer Independent Prescribing. Each patient seen by myself will require involvement of one other clinician, as I am unable to prescribe any medications. Being able to independently prescribe would provide safer and more efficient care. Fingers crossed, with continued efforts from the SCoR and a legislation amendment, it will not be in the too distant future.

Royal College of Emergency Medicine accreditation Our team has the first paramedic EM ACP to achieve RCEM accreditation in the Northwest. It would be wonderful to have the first ever radiographer EM ACP accredited too! To achieve accreditation, you are deemed to be working at the level of an ST3/CT3 EM Doctor. The previous RCEM curriculum for accreditation was endorsed for nurses and paramedics only. Under the revised curriculum, the college welcomes accreditation applications from ACPs from all professional backgrounds; however, independent prescribing is a key requirement. Although I am continuing to complete areas of my portfolio and working towards evidencing other areas of the curriculum; until I can evidence recognition as an independent prescriber; I will be unable to achieve accreditation. 

Breaking down barriers

Future roles should embrace the unique contribution various staffing groups can make to create a workforce with a rich skill mix, providing safe and high-quality care.⁵ In keeping with the multi-professional framework, there is work to be done around the inconsistencies in training, competencies, expectations, definitions and title use through reviews of new and indeed existing roles.⁶ 

Final thoughts 

These are exciting times. Role development and service redesign are interdependent and the rising demands requiring changes will provide radiographers with new opportunities.⁷ Environmental pressures and new clarity and confidence surrounding advanced practice will further promote organisations embracing opportunities.⁸ There are reports of having to break down barriers⁷ when radiographers have previously ventured into roles and places no one has been before⁹ and this has certainly been my experience, but it has been worth it. Nadaf¹⁰ proposed that the awareness of advanced practice needed increasing, suggesting campaigns by means of case studies and narratives to achieve this.  Case studies have been recommended for evaluation of roles¹¹ and I hope that by sharing my story and offering myself as a case study to raise awareness and support the campaign for radiographer independent prescribing. 

To those considering venturing down the advanced practice path, take the leap. You will need perseverance and determination, and regular supervision sessions will help greatly. I wish you every success.

The difference between the impossible and the possible lies in a person’s determination - Tommy Lasorda¹²

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