The College of Radiographers’ Education and Career Framework (fourth edition): insights from a national implementation study

Challenges for the workforce

At present, the radiography profession is underrepresented outside the clinical setting, a fact well-documented in the literature. Indeed, the lack of opportunities for radiographers has been cited as a significant contributor to workforce attrition. There is limited time and resource for radiographers to engage in 'four pillars' activities; radiographers often feel insufficiently challenged in their work, with little opportunity to exercise the full extent of their skills, or pursue the full extent of their interests; and critically, the constant need the fight fires erodes all space for self or system improvement (1) (2).

Research and evidence-based practice are universally recognised as being central to the delivery of safe and effective services. Despite this, few research studies see radiographers acting in key decision-making roles. Given the lack of opportunity and inspiring role models, radiographers often feel disconnected from research in their professional practice. Indeed, only 0.3% of radiographers are working towards, or hold, a doctoral level award. Meanwhile, as of 2021, fewer than 10 radiographers have been awarded fellowships through the National Institute of Health Research (NIHR) funded Integrated Clinical Academic Programme, a success rate incongruent with the size of profession (3).

Similar pictures are painted elsewhere: in the sphere of Allied Health Professional (AHP) strategic leadership, radiographers are woefully underrepresented. Radiographers account for the third largest AHP workforce, but a recent study found that only 1.8% of Chief AHP roles (or equivalent) are occupied by radiographers. The shortage of radiographers in strategic roles inhibits our professional voice and capacity to influence and enact transformational change. As an associated consequence, there exists a dearth of mentors to inspire, instruct, and build confidence in radiographers to pursue leadership positions (4): as the timeless adage goes, “you can’t be what you can’t see”.

The radiography profession has the potential to provide a singular contribution to service redesign and improved patient care. Nonetheless, our collective light remains steadfastly hidden under a bushel. The reasons for this are undoubtedly complex, but a lack of exposure, opportunity, and role-modelling are assuredly contributory factors. It is hoped this article will, to a lesser or greater extent, inspire and guide radiographers to take a leap and explore new terrains, bringing their unique and transferable talents to new challenges, claiming new ground for themselves and the profession.

‘Beauty and the beast’ – the ECF and the implementation study

The publication of the fourth edition of the ECF in November 2022 was timely, fulfilling a burgeoning need within the profession (5). With numerous drivers for change in the mix, including shifting population needs, technological advances, and emerging government policy, the radiography profession is required to keep pace (6). In part, this requirement can be met through role development and extended scopes of practice, a notion endorsed by The NHS Long Term Workforce Plan (7). However, there exists an expectation that knowledge and responsibility are in step with the level of practice (8). This is where the ECF comes in: offering guidance for the education and professional development of the workforce, the ECF promotes safety, responsibility, and improved patient outcomes (5).

The ECF is, therefore, an essential resource. However, policy documents do not necessarily lead to practice change or yield desirable impacts, as often there is a dissonance between policy intent and policy in-action. It is not enough to assume that, simply because a policy is ‘on the books’, it has been implemented in practice as intended or designed (9) (10) (11). In 2023, with this truth looming large over the ECF, an implementation study was conducted to understand and address the policy implementation gap. The next sections of this article will focus on the key steps taken to initiate and progress the project.

‘No man is an island’ – surrounding yourself with the right people

The implementation study formed part of a Clinical Education Improvement Fellowship (CEIF), supported by NHS England (South East) Workforce, Training, and Education, the Florence Nightingale Foundation, and Canterbury Christ Church University (CCCU). From CCCU came academic support in the shape of an academic supervisor, who played an integral role over the course of the project lifecycle. The author, on commencing the fellowship, possessed relatively little research experience: as such, the guidance provided by the supervisor, academic and otherwise, was invaluable. Also invaluable was the support of the other Clinical Education Improvement Fellows, though for different reasons. The 2022-23 CEIF cohort was comprised of 10 fellows, fostering an environment of encouragement, empathy, camaraderie, critical friendship, and peer support, one in which individual challenges could be worked through as a collective, and little victories could be shared and celebrated.

Given the scope and scale of the implementation study, which spanned the diagnostic radiography profession across England, the need for representation and polyvocality was recognised early on. To this end, a steering group was brought together shortly after the project’s inception. A simple idea, perhaps, but no simple task. Several ingredients were key to transforming this ambition into a reality. This included the following universal suggestions:

• Develop a clear and compelling narrative to capture the interest of stakeholders.

To persuade stakeholders to commit their time and effort to a project, it is essential to speak to their specific interests and communicate, clearly and concisely, the project aims and intended impacts (the ‘so what?’). Preparing a two-minute elevator pitch, one which can be readily adapted as the situation dictates, is a worthwhile exercise.

• Utilise networks and networking platforms.

Building relationships is well worth the effort and perseverance required to build them. First, identify the key stakeholders, and then take steps to connect with them. Make use of all available channels, including social media platforms, critical connectors, and professional organisations. Do not be deterred by an apparent lack of interest from individual stakeholders: it is neither personal, nor does it strip the project of its value. Oftentimes, people simply do not have the time or space to accommodate your request. Where feedback is provided, positive or negative, this should be given the consideration it deserves.

• Help stakeholders to help you.

A good project manager will make it as easy as possible for stakeholders to engage in the project, removing unnecessary burdens and obstacles. In this pursuit, be clear about the ask (what is needed, at what stage, and why), and maintain a tight grip on the project administration (a notion expanded upon in the next section).

‘Fortune favours the prepared’ – plan your work, then work your plan

To maintain the many moving, interrelated parts which comprise a research project, careful planning and forethought are essential. Project management tools, designed to facilitate the process, are varied and abundant. The extent to which these add value depends on the study and individual preferences. However, in the opinion of the author, preparing a Gantt chart is a worthwhile enterprise, as it provides a graphical representation of activity against time, enabling the user to monitor and manage progress.

Also essential is the project plan: this document acts as a blueprint, detailing the schedule and scope, aims and objectives, responsible persons and stakeholders, and milestones and deliverables. To complement the project plan, one should also prepare a communication strategy, risk register, and action log. As well as steering the project toward success, these documents lend credibility and inspire confidence in stakeholders. However, to a lesser or greater extent, over the course of its lifecycle, the project will inevitably evolve. As such, a project should be designed with sufficient flex, and people should be primed to respond positively to change, where necessary.

‘Life through a lens’ – adopting a conceptual framework

The ECF implementation study was informed by normalisation process theory (NPT), acting as a lens through which the study was designed, the data interpreted, and the findings transformed. NPT focuses on the work of individuals and collectives to normalise a complex intervention; in other words, the work required of stakeholders to embed (make routine) and integrate (make sustainable) a new practice (12) (13). The theory is comprised of four core concepts: coherence (the sense-making work), cognitive participation (the relational work), collective action (the operational work), and reflexive monitoring (the appraisal work).

As a conceptual framework with sociological leanings and origins in healthcare, NPT was a natural fit for the ECF implementation study: it provided a set of tools with which the translational gap between policy and practice could be examined from a whole-system perspective (14) (15). As such, NPT became the golden thread running through the entire project, providing a robust theoretical underpinning, lending credibility and cohesion to proceedings. The study design was mixed methods and NPT was neatly woven into the data collection and analysis:

• The online consultation survey was adapted from the normalisation measure development (NoMAD) instrument, a validated questionnaire template based on NPT (16,17).
• The consultation workshops (four in total) were semi-structured in design, with the four core NPT constructs embedded into the topic guides.
• The framework approach was adapted for the qualitative data analysis, deductively inserting NPT as a pre-existing theoretical frame, the four NPT constructs acted as core themes within the analytical framework (18).

Following on from the data collection and analysis, NPT gave structure to the next phase of the project: the development of study-derived recommendations to enhance the implementation of the ECF. These recommendations, drawn directly from the study data, were grouped into four strategic priorities, based on the four core NPT constructs.

In summation, the careful selection and adoption of a conceptual framework has enlivened the ECF implementation study. NPT provided a strong foundation and scaffold, on and around which the project was engineered. It afforded rigour to the study design and ensured concordance between the separate elements. Though it requires confidence to implement a conceptual framework, and building confidence takes time and effort, the results in this case were well worth the energy expended to obtain them.

‘Looking backwards to move forwards’ – final reflections

These observations are borne from the author’s experiences and, therefore, do not represent (nor are they intended to be) the ‘last word’ on project management. Rather, they represent a collection of key learnings from a national study, as conducted by a self-described novice researcher. As such, this article is intended to inform radiographers with a burgeoning interest in research and strategic leadership. Additionally, one hopes this account will encourage others (whether novice or expert) to share their stories, thus inspiring more of the radiography workforce to blaze new trails.

Teaching through storytelling holds a particular power. Stories breathe life into learning; they bridge gaps between theoretical concepts and the ‘the real world’, harnessing human connections to do so. There is a growing body of evidence to support the learning potential of storytelling, both vicarious and transformative. Of note, the latter opens the mind to shifting ideas, world views, and notions of self, including identity and capability (19). Story sharing can, therefore, empower radiographers to view themselves in a different light: to see themselves, for example, occupying a research or leadership role which, previously, may have felt unobtainable. While this does little to overcome the practical barriers, the simple act of storytelling may, in a small but significant way, help right a wrong within the radiography profession.

References

1. Nightingale J, Sevens T, Appleyard R, Campbell S, Burton M. Retention of radiographers in the NHS: Influencing factors across the career trajectory. Radiography. 2023 Jan 1;29(1):76–83. 

2. Nightingale J, Burton M, Appleyard R, Sevens T, Campbell S. Retention of radiographers: A qualitative exploration of factors influencing decisions to leave or remain within the NHS. Radiography. 2021 Aug 1;27(3):795–802. 

3. Simcock IC, Reeve R, Burnett C, Costigan C, McNair H, Robinson C, Arthurs OJ. Clinical academic radiographers – A challenging but rewarding career. Radiography. 2021 Oct 1;27:14–19. 

4. Eddison N, Healy A, Darke N, Jones M, Leask M, Roberts GL, Chockalingam N. Exploration of the representation of the allied health professions in senior leadership positions in the UK National Health Service. BMJ Leader. 2023 Aug 24;0: 1–8. 

5. The College of Radiographers. Education and Career Framework for the Radiography Workforce (4th edition) [Internet]. 2022 Nov 25. Available from: https://www.sor.org/getmedia/b2f6bf07-668f-4155-950a-b9d96c48eae1/12604-CoR-ECF-Interactive-v9a.pdf

6. Knapp KM, Courtier N. The future role of radiographers. Radiography. 2021 Oct 1;27:1–2. 

7. NHS England. NHS Long Term Workforce Plan [Internet]. 2023 Jul 17. Available from: https://www.england.nhs.uk/wp-content/uploads/2023/06/nhs-long-term-workforce-plan-v1.2.pdf

8. Snaith B, Beardmore C. Enhanced practice: A strategy to resolve the inconsistencies in advanced practice implementation. Radiography. 2021 Oct 1;27:3–4. 

9. van Schalkwyk MC, Harris M. Translational health policy: towards an integration of academia and policy. Journal of the Royal Society of Medicine. 2018 Jan 1;111(1):15–17. 

10. Peters S, Sukumar K, Blanchard S, Ramasamy A, Malinowski J, Ginex P, Senerth E, Corremans M, Munn Z, Kredo T, Remon LP, Ngeh E, Kalman L, Alhabib S, Amer YS, Gagliardi A. Trends in guideline implementation: an updated scoping review. Implementation Science. 2022 Jul 23;17(1):50. 

11. Chriqui JF, Asada Y, Smith NR, Kroll-Desrosiers A, Lemon SC. Advancing the science of policy implementation: a call to action for the implementation science field. Translational Behavioral Medicine. 2023 Nov 5;13(11):820–825. 

12. Corrigan AE, Lake S, McInnes RJ. Normalisation process theory as a conceptual framework for continuity of carer implementation. Women and Birth. 2021 Mar 1;34(2):204–209. 

13. Murray E, Treweek S, Pope C, MacFarlane A, Ballini L, Dowrick C, Finch T, Kennedy A, Mair F, O'Donnell C, Ong BN, Rapley T, Rogers A, May C. Normalisation process theory: a framework for developing, evaluating and implementing complex interventions. BMC Medicine. 2010 Oct 20;8(1):63. 

14. Huddlestone L, Turner J, Eborall H, Hudson N, Davies M, Martin G. Application of normalisation process theory in understanding implementation processes in primary care settings in the UK: a systematic review. BMC Family Practice. 2020 Mar 16;21(1):52. 

15. McEvoy R, Ballini L, Maltoni S, O’Donnell CA, Mair FS, MacFarlane A. A qualitative systematic review of studies using the normalization process theory to research implementation processes. Implementation Science. 2014 Jan 2;9(1):2. 

16. Rapley T, Girling M, Mair FS, Murray E, Treweek S, McColl E, Steen IN, May CR, Finch TL. Improving the normalization of complex interventions: part 1 - development of the NoMAD instrument for assessing implementation work based on normalization process theory (NPT). BMC Medical Research Methodology. 2018 Nov 15;18(1):133. 

17. Finch TL, Girling M, May CR, Mair FS, Murray E, Treweek S, McColl E, Steen IN, Cook C, Vernazza CR, Mackintosh N, Sharma S, Barbery G, Steele J, Rapley T. Improving the normalization of complex interventions: part 2 - validation of the NoMAD instrument for assessing implementation work based on normalization process theory (NPT). BMC Medical Research Methodology. 2018 Nov 15;18(1):135. 

18. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Medical Research Methodology. 2013 Sep 18;13(1):117. 

19. Robertson A. Storytelling for Learning in a Diagnostic Radiography Community of Practice. Doctoral Thesis; Lancaster University. 2019:1–219.