I extend my gratitude to the editor for the invitation to write this commentary on experiences as a transnational academic radiographer. Rewinding the clock, and like most ‘budding’ radiographers, my acceptance onto a diagnostic radiography degree programme was an exciting moment. I began my undergraduate studies in the South East of England in 2006. This provided a critical platform to learn about our profession, supported with contrasting and intertwining components as a former computing apprentice within a large pharmaceutical company, and prior to that, working alongside my father in his construction company. At the outset radiography was appealing given its interconnections with science, technology and patient contact, supported with its strong vocational approach, educationally. I am reminded and grateful to the radiographers who offered their time and patience in practice; closely facilitated with academic delivery at the local university. Recalling the latter with pedagogical approaches around radiation principles and interprofessional learning, which were not only insightful but progressive in content and teaching style. These reflections have certainly facilitated my own teaching and learning approaches today.

My decision to embark onto a PhD was fortuitous by virtue upon observing film-screen, computed radiography and digital radiography during my undergraduate studies. This was not only a unique period but drove my interest into pursuing the facets of professional practice, combined with advancing technology. This resulted in the publication of original papers capturing its impact on ionising radiation,¹ professional practice,^2,3 image acquisition,⁴ and patient care – later emerging as ‘person-centred care’⁵. This was supported by the same institution, which resulted in the publication of my thesis ‘Radiography observed: an ethnographic study exploring contemporary radiographic practice’.⁶ 

The reflexive educator: Traditions and influences affecting educational development and practice

Cultural awareness without cultural competence

My first educator role took place in East Anglia, United Kingdom, with a strong teaching focus. This role remained critical to my own teaching and learning as a junior academic and still influences today. The support of senior colleagues within this institution remained paramount given the understandings of curriculum development, pedagogy and assessment design. This was coupled with innovation whilst maintaining academic integrity within the higher education setting. 

My desire to work and live overseas, however, remained at the forefront, and naturally opposed comforts of home, coupled with familiarity, including family, friends and everyday customs/norms. My wish to immerse myself overseas looked to primarily offer professional and personal growth, intertwined with lifelong learning. Looking back, a key outcome of this is cultural awareness. The virtues of living in the United Arab Emirates, my first overseas role offered alternate customs and traditions previously unobserved or experienced. Attending work Sunday to Thursday was normal given spiritual emphasis every Friday.⁷ In addition, linguistically, engagement with the local language, Arabic, created shared value allowing greater understand and immersion within the culture. The delivery of higher education was read, written and spoken in English, yet I intended to learn and speak Arabic when appropriate. For instance, a common greeting would be: ‘Hello, good morning, how are you?’, pronounced and translated as ‘Marhaba, Sabah al-khayr, kayfa Halak?’⁸ ( مرحبا صباح الخير كيف حالك), which would be supported with accepted words and/or phrases used interchangeably, facilitating everyday conversations with peers.

Another cultural importance reflects my respect for the Holy period of Ramadan; the need to fast between certain hours and latterly observe Eid al-Fitr and Eid al-Adha, notable celebrations within the calendar. I would also attend, through invitation, ceremonious fast-breaking meals during this period, commonly known as Iftar. These experiences not only provided me with a conscious respect and attention to cultural and spiritual norms, but identified how little I knew and understood about these practices and customs. Reflecting, without these experiences, would my cultural awareness be mindful of the traditions of fasting and ceremonies activities albeit in a university or other workplace setting in my home nation – I suspect not. 

Another example of cultural awareness stems from my time residing in Australia. As a British Citizen it is important to recognise how cultural and historical contexts play important roles. I have previously written about the possibility of discourteousness within this space,⁹ with a strong sense colonialism remaining. For instance, the public holiday observed in Australia, the 26^th January, is generally referred as ‘Australia Day’ – the anniversary of the 1788 arrival of the First Fleet at Port Jackson in New South Wales. Yet, it is also recognised as ‘Invasion Day’ or ‘National Day of Mourning’ among indigenous communities and supporters. This cultural awareness is important, personally, as a senior colleague and associate professor in a higher education whereby I facilitate the development of medical imaging programs and curriculum design. This self-positionality is consciously intertwined by acknowledging my own cultural awareness in curriculum development, for instance. Importantly, this is recognised by the Australian Health Practitioner Regulation Agency in Australia (AHPRA) seeking to ensure that for culturally safe and respectful practices to emerge, health practitioners must: ‘acknowledge colonisation and systemic racism, social, cultural, behaviour and economic factors which impact individual and community health’ .¹⁰

This leads me to question how well medical imaging programmes transnationally respond to wider or even historical cultural differences, particularly those attributed with living with and among indigenous people. Further, the recently published standards of proficiency, section five, by the Health & Care Professions Council (HCPC) promotes recognition from an equality and diversity perspective in the United Kingdom whereby non-discriminatory and inclusive approaches are adopted.¹¹ The need to respond to ‘all groups’ in standard 5.1. could offer a platform expanding on more ‘lived’ and ‘immersed’ cultural experiences by individuals given it will provide broader historical and cultural context that perhaps might not be cognisant. By simply learning and understanding about broader cultural differences, vis-à-vis cultural awareness, it can challenge our academic positionalities and help develop consultation with curriculum development, whilst enhancing our recognition of equality and diversity in radiography education. 

Espousing cultural awareness, as recognised above, strongly differs from what might be accepted as ‘cultural competence’. In my view, we are observing professional statutory and regulatory bodies shifting towards softer skills with our graduates, coupled with ongoing professional competencies. Whilst this should be celebrated given the multifaceted social-cultural complexities within our practices, we should remind ourselves that cultural awareness is not binary. To be ‘culturally aware’, does not infer cultural competency because it will depend on the independent ontology and inherent social construction of individuals through both immersion and interaction – see Plato’s Theory of the Cave, which resonates.¹² In short, the meaning of ‘cultural awareness’ does not disregard competency per se, it accepts the complexity and unique experiences by a society and/or (sub-)group of people/individuals. 

Independent living: Homesickness, healthcare and other ‘must dos’  

The global mobility of healthcare professionals is widely reported with various factors being cited.¹³ In addition, there are ongoing shortages of radiographers worldwide, recognised as a ‘global crisis’.¹⁴ On reflection my move overseas has enabled both personal and professional growth, driven by a strong sense of curiosity. I remained curious of living and working in countries unfamiliar to my own. Whilst these experiences have been profound, there are contrasting emotions that follow. It is important to identify homesickness.¹⁵ Homesickness naturally arises amongst expatriates moving away from their home nation and acknowledged within the literature, leading to feelings of loneliness and isolation.¹⁵ The feeling of isolation and loneliness is critically intertwined with cultural adjustment given there might be a ‘culture shock’ especially in environments unfamiliar with the need to adjust to new cultural norms. 

My own feelings of loneliness and isolation were helped with support of immediate family members. This was and remains a strong motive for both enjoyment and purpose. Importantly, connecting with others in the community, via local clubs, groups and/or online communities is essential for social engagement and finding a sense of community. The use of everyday technology supported staying in touch with friends and family whilst exploring new surroundings and local activities, reaffirming our opportunity of living and working overseas. Other ‘nitty gritty’, but critical elements, which I remained ignorant at the time, was the need to acquire (and maintain) residency and healthcare status. The need to carry and present healthcare and/or national identification cards when entering hospitals or healthcare establishments felt (and still feels) unfamiliar. An individual’s residency and/or visa status may not wholly provide access to areas of healthcare unless supported with health insurance and/or reciprocal healthcare agreements. The need to acquire a local driving license, attest passports and certificates, coupled with local equivalency were foreign to me, yet critical for local mobility and workplace sustainability. 

These reflections and experiences as an expatriate from the United Kingdom (UK) to the United Arab Emirates and Australia leads me to think about the management and support of expatriate students and staff within university and hospital settings. A quick search within the radiographic literature shows little research focusing on homesickness, isolation and/or ‘cultural shock’ amongst staff or students moving to the UK. Given the growing need and resultant global mobility of staff, supported with international students, a current gap exists. Research exploring radiographer/academic experiences could help provide insight into the wellbeing amongst this group of individuals, whilst ensuring adequate support where appropriate. I foresee findings offering insight in several ways. First, it would provide insight for managers recruiting staff from overseas, thus anticipating support accordingly. Second, for students, let us think how an 18-year-old student might feel about leaving their home country for the first time to study overseas. 

As we observe the global movement of healthcare professionals, and through observation, mobility of academics transnationally, we should start thinking about what might motivate individuals to move overseas and importantly, how they become settled and accustomed to the culture around them.  

Academia overseas: Welcoming the radiographic ‘all-rounder’?

My academic work has offered significant insight and as a result, led working with colleagues from varying institutions. A common thread amongst my peers is the desire to advance the field of radiography in both education and research. This has led to the development of professional networks and collaboration in research, either with projects and/or as a PhD supervisor. This inevitably provides an opportunity that would have previously been unavailable. Further, my experiences of working in the United Kingdom, United Arab Emirates and Australia has offered alternate ideas to pedagogical delivery, coupled with adapting to alternate landscapes and more notably adapting to varying cultural contexts. 

A key observation is how each environment differs, requiring versatility. For instance, in the last 10 years I have been asked by line managers and/or course directors to deliver modules based on ‘expertise’, which is often not only dependent on departmental need, but perhaps more significantly the social construct of ‘my expertise’ – this is briefly explored in my PhD thesis – the ‘white coat’ whereby social constructions are based on attire or perceived scientific knowledge and understanding. This has involved image interpretation, informatics and digital imaging, foundations of radiographic science, research methods, radiation biology and dosimetry, computed tomography, practice placement, professional practice and magnetic resonance imaging. Whilst confident in my delivery, in accordance with learning outcomes, it brings into question the need to remain versatile and perhaps some acceptance of the ‘all-rounder’ in medical imaging. 

In the game of cricket, the all-rounder is a player within the team who contributes with both the bat (scoring runs for their team) and ball (bowling to take wickets for their team). The all-rounder is generally considered a key player that contributes with both the bat and the ball, thus potentially having greater influence on the game. How synonymous is the ‘all-rounder’ in cricket with academia and/or a graduating radiographer? First, the idea of becoming or exposing oneself as an ‘all-rounder’ or ‘jack of all trades’ might be risky. Is it someone without a specialism, and subsequently a ‘master-of-none’? Does this ability to move between teaching topics, different publications, and within different institutions, impact our ability to ‘profess something’? This raises a broader question in what might count to be recognised as a ‘Professor in Diagnostic Radiography’ or ‘Professor in Medical Imaging’. Whilst outside the scope of this commentary, I do want us to question the perception of ‘professor’ within our discipline worldwide. A professor might fulfill a single focus or modality within the medical imaging space, yet it could be argued that this somewhat becomes counter-intuitive given progressive developments with our professional capabilities, most notably the HCPC requiring graduate radiographers to perform a broad range of computed radiography examinations and perform standard magnetic resonance imaging examinations. In response, are we by some version, developing radiographers in becoming these ‘jack of all traders’ and ‘all-rounders’, whereby general radiography, computed tomography and magnetic resonance imaging remains central in becoming a clinical practitioner. Central, and arguably the challenge, is that radiographers must not only know how to acquire imaging but understand with sound optimisation. 

An open-ended conclusion

The invitation to write this commentary has been welcomed, enabling reflection on experiences as a transnational academic radiographer. There are few written accounts of what it takes to work and live overseas in academia. This opportunity has not only allowed me to reflect on experiences, but importantly link emerging themes in our profession. By further understanding my own role and experiences I anticipate it might lead researchers and academics to think about cultural awareness and independent living for either themselves or others around them. Notably, as our profession evolves, with radiographers becoming ever more accustomed to performing various imaging modalities upon graduation, the role of the radiographer all-rounder might become just as valuable as the player on the cricket field.  

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