Radiography and research: A United Kingdom perspective

European Journal of Radiography (2009) 1, 2e6 available at www.sciencedirect.com journal homepage: http://ees.elsevier.com/ejradi REVIEW Radiography and research: A United Kingdom perspective Christina Malamateniou a,b,* a b Hospital, Imperial College London, London Directorate of Medical Imaging and Radiotherapy, School of Health Sciences, University of Liverpool, Liverpool, UK Received 3 November 2008; received in revised form 3 December 2008; accepted 3 December 2008 KEYWORDS Radiography; Research; Education; Role development Abstract In the past two decades radiography has experienced a wealth of changes, involving the teaching site, learning methods, curriculum, professional status, educational funding, and public expectations. Consequently this period witnessed the transition of radiography from a mainly hospital-linked to a mainly university-linked degree, from a knowledge-based discipline to an evidence-based practice. The early 1990s saw the establishment of graduate programs, the role expansion of radiographers, the technological advancements in medical imaging, the participation of the Radiography Schools in Research Assessment Exercise (RAE) schemes. Given the educational, technological and social advancements the engagement of radiographers in research is emphasized as a priority that will bring the profession forward and help to maintain high standards of patient care. Research in radiography is a requirement, as by definition professions are expected to contribute to the body of knowledge necessary for a profession to progress. Funding, ethical considerations, mentorship, proficiency in research methodology, commitment, and ability to work in a multi-disciplinary team are just a few of the requirements for high quality radiography research. There has been a definite increase in the number of radiographers who are research aware and active as well as in the number of radiographers who pursue purely academic and research careers. However intensification of personal efforts and formulation of strategic decisions are required so that research forms an integral part of the profession. Recent developments in strengthening the research base of radiography are encouraging. ª 2008 Euro-med Congress for Radiographers. Published by Elsevier Ltd. All rights reserved. * Robert Steiner MRI Unit, Imaging Sciences Department, Hammersmith Hospital Campus, Imperial College, DuCane Road, W12 0HS London, UK. Tel.: þ44 20 8 383 1023. E-mail address: [email protected] 1756-1175/$34 ª 2008 Euro-med Congress for Radiographers. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ejradi.2008.12.003 Radiography and research Introduction Systematic enquiry and thorough investigation to establish best practices in healthcare are vital to support the claim to professionalism by radiography practitioners. The possession of a body of knowledge added to by meticulous research has long been recognised as an essential component of professional identity [1]. Traditionally radiography has been a consumer rather than a producer of research [2] as it has a very short research track record. In the recent past research forming the knowledge base of the radiological sciences has been mainly performed by medical practitioners and physicists. Radiography as a discipline was not perceived by its practitioners to require investigation; a reliance on tradition and subjective experience has often been the norm [3]. Although the results of systematic radiography research could provide a satisfactory answer to frequently encountered clinical problems (the quest for the best treatment, the optimal imaging protocol, the most effective care pathway) undertaking research was-and still is- intimidating for many radiographers for various reasons. Strategic decisions by the relevant professional bodies, such as the Society and College of Radiographers (SCoR) supported by corresponding provisions of the radiography academic institutions as well as by personal efforts in the day-to-day clinical practice ascertain the gradual transition to a research-based education and a research-led profession. The research ethos in radiography was introduced in the early 1980s with the instigation of a research project, called Module F [3], into the modular Higher Diploma of the College of Radiographers (HDCR). Radiography has since been in a state of flux with changes occurring both in education and in professional practice, all leading to the recognition that research in this field is ‘‘a requirement and not an option’’ [4]. The aim of this article is to critically review the pivotal historical events that highlighted research as a priority for radiography as well as to provide insights to requirements specific to research in radiography. Updates on the current situation as well as an estimation of future directions are also provided. The ever changing world of radiography: incentives to research In the past two decades radiography has undergone enormous changes, both educationally and professionally. These changes involved the teaching site, learning methods, curriculum, professional status, educational funding, and public expectations. The drive for this change was a recognition by the College of Radiographers that ‘‘the Diploma of the College of Radiographers (DCR) model imposes a didactic, authoritarian and inflexible model on Schools, and an assessment and evaluation procedure which is theoretical and remote from clinical practice’’ [5]. Following this recognition actions were put together to shift the centre of radiography education from the traditional ‘‘School experience’’ to the novel ‘‘University experience’’ and from the award of a ‘‘diploma’’ to the award of a ‘‘degree’’. This involved the 3 move of the teaching site from the hospitals to the University lecture theatres. Most importantly the responsibility for curriculum design was handed over to the radiography education establishments, free to determine both delivery methods and content [6]. The training experience provided by Schools emphasized on the demonstration of knowledge, comprehension and the application of that knowledge, all of which belong to the lower levels of the educational hierarchy proposed by Bloom [7]. On the other hand the educational experience provided by the University embraced the higher levels of Bloom’s educational hierarchy, namely analysis, evaluation and synthesis, with increased weighting on the facilitation of learning. It was this establishment of the graduate radiography programmes that brought a shift in the educational focus from knowledgebased to evidence-based. Evidence-based practice, as the integration of individual expertise with the best available external evidence from systematic research [8], is by definition research-led; this research-mindedness became the ultimate target for radiography education and practice. The concept of Evidence Based Radiography emerged as ‘‘radiography which is informed and based on the combination of clinical expertise and the best available researchbased evidence, patient preferences and available resources’’ [27]. Another incentive to research promotion in radiography was provided by the Research Assessment Exercise (RAE) that took place in 1996 and 2001. After nearly a decade of established graduate education it was time for the Radiography Departments in the UK to submit their research output for a peer-review process and allow exposure to external scrutiny. A varying proportion of funding a University would receive from the government would depend on the institution’s research performance, academic staff research profiles and the research income generated from external sources (medical charities, funding councils). In anticipation of the imminent RAEs engaging in research activity and establishing a research culture were obviously advantageous in a personal and institutional level [2]. Along with the changes in education, training and university funding there have also been changes within the framework in which radiographers have been required to operate [9e11], that stressed the importance of research culture in the profession. The introduction of the four tier service delivery model [12] in clinical practice identified four levels of escalating competencies and responsibilities within a multi-disciplinary team, which, in ascending order of seniority were: the assistant practitioner, the practitioner, the advanced practitioner and the consultant practitioner. This model promoted new clinical roles and extended responsibilities for the radiography staff. As different studies have shown role development of radiographers was identified in the following areas: administration of intravenous injections, barium enemas, red dot system, reporting in ultrasound, skeletal, barium enemas, mammography, nuclear medicine, paediatrics and chest radiography [13,14]. Research was highlighted as one of the key tasks for the newly established level of consultant practitioner; many other functions have been assigned to this role, including expert clinical practice, professional leadership and consultancy, education, training, practice and service 4 development and evaluation [15]. Consequently the consultant radiographer was identified as a key player in taking the clinical research agenda forward either by providing leadership and/or by engaging in the process itself [16]. Team leadership and contribution to the evidence base by engaging to research was also expected by the advanced practitioners [12]. Furthermore research in radiography is required not only as part of the role extension but as a necessary tool to keep up-to-date with the recent and ongoing technological advances in the field of medical imaging but, most importantly, to actively contribute to this evolutionary chain. Rapid and continuous developments in the radiological hardware and software have significantly revolutionised existing clinical practices by enabling minimisation of radiation dose, by delivering high quality medical images, by shortening the length of the examination, by offering non-invasive alternatives, by providing additional diagnostic information (e.g. functional studies). Recent advances include the introduction of digital radiography [17], multi-slice computed tomography (CT) [18], high field magnetic resonance imaging (MRI) [19], the integration of structural imaging technologies (such as CT or MRI) with functional imaging capabilities (such as positron emission tomography (PET) or single photon emission computed tomography (SPECT) [20]), just to name a few. The radiographer, at the forefront of the medical imaging team, is required to deal with this amount of constantly updating technological complexity in a fast, efficient and confident manner with the ultimate goal to provide optimal patient care; being an active member of the research community and knowing how to critically appraise the research outputs in the field will enable him to do so. Last but not least the emerging concept of the ‘‘expert patient’’ has- not surprisingly- placed additional knowledge and skill demands on radiography staff [4]. Patients are now making use of all the available resources in order to get information about diagnostic procedures and radiographic examinations; this enables them to be selective in healthcare services and choose what best meets their needs. A range of government strategic decisions has empowered and supported the accessibility of such information, along with the widening internet availability. Research awareness and involvement offer high calibre knowledge and profound understanding of the radiographic procedures that enables the radiographers to offer optimal healthcare services to their patients. Research demystified Educational, professional and social changes in the world of Radiography, as highlighted above, provided a wealth of incentives to research awareness and research activity. But what is research? The following section attempts to briefly review certain crucial issues about research with specific references in the radiographic practice. Research can be defined as ‘‘an original investigation undertaken in order to gain knowledge and understanding’’, based on the Research Assessment Exercise definition [21] or as ‘‘ the attempt to derive generalisable new knowledge by addressing clearly defined questions with systematic and rigorous methods’’ based on the C. Malamateniou Department of Health (DoH) definition [22]. Research is not an abstract concept; it is a vital part of education as it facilitates learning through evidence. Generally there are different classifications of research depending on the methods used. Qualitative is the research that seeks to examine the meanings, perceptions, experiences and understanding of those involved in the behaviour, activity or event under study and generates non-numerical data, e.g. a patient’s description of their pain rather than a measure of pain [23]. Qualitative interviews, focus groups, observational methods, diary methods and document/text analysis are just some of the popular qualitative methods commonly employed in healthcare research [1]. On the other hand quantitative research is the one that seeks to establish causal relationships between two or more variables and generates numerical data or data that can be converted into numbers. Useful quantitative techniques in healthcare include clinical trial methodology, experimental design, survey instruments, and statistical analysis. These methods proved really useful to answer research questions that pertain to core radiography clinical practice such as the choice of the optimal imaging protocol for radiation dose minimisation. Irrespective of the research methodology employed, the radiographic domain is wide open for researchers to explore different areas of its constituent elements: people, practices and technologies [1]. According to previous studies the highest priority is given to aspects of optimisation of diagnostic image quality, dosimetry and radiation dose reduction [3,27]. Further areas of particular interest relate to the extended role of the radiographer, the introduction of new medical imaging capabilities and techniques, human resource issues, the aspects of technological innovation, investigations and treatment and effectiveness of different diagnostic procedures. Research comprises a series of steps or stages which are usually undertaken in a logical order but may frequently overlap; and radiography is no exception. The initial step involves the identification of the research problem, the formulation of the research question(s) that need to be answered. Following that the research question is refined and put into the context of the literature. Depending on the nature of the problem and the level of prior knowledge of the researcher in relation to the area of study a research hypothesis may be developed as a statement about the predicted relationship between the variables examined. The challenging part is to gather all the required evidence to test (confirm or reject) this hypothesis. In order to do that all elements relevant to the research topic (research setting, subjects and sample size, ethical approval, data collection and analysis methodology) should be carefully planned. Usually it is quite helpful to carry out a pilot study that enables the researcher to identify early on challenges and opportunities and make corresponding adjustments. After that data collection can take place, followed by analysis. Once the final results have been reached and conclusions have been drawn most researchers identify new areas for future research. The research process described above is known as the ‘‘research cycle’’ [24]. In order for a research project to be successful, not only in radiography but in any discipline, certain requirements should be met. First of all appropriate mentorship should Radiography and research be provided by senior researchers, as research can be quite frustrating to the novice. Furthermore the aspirant researcher should have a variety of personal qualities and hold or acquire the necessary transferable research skills to be able to cope with the workload and the diversity of the tasks undertaken. The researcher specifications should comprise commitment and curiosity to systematically explore and never assume, open-mindedness and versatility to adapt to the constantly changing circumstances and to be able to work in multi-disciplinary teams, diligence in performing the experiments to prevent common mistakes that will hinder reaching meaningful conclusions, autonomy to be able to work unsupervised. Furthermore a wide range of transferable skills are essential to ensure safe and efficient research practices: knowledge of the literature research strategies and fluency in the utilisation of the online search engines, proficiency in statistical methodology, writing, presentation and computer skills. For radiographic research, in particular, that deals with human subjects, excellent communication skills are essential. Additionally important practical issues should be resolved prior to data collection; these comprise securing the funding [25] required to compensate for the various research expenses (research students’ support, consumables, travel costs, computing time, equipment, stationery) and gaining ethics approval from the relevant research committees to be able to proceed with the application of the research protocols. The concern for ethical rigour in particular has become an integral part of healthcare research as research involving human participants inevitably raises questions of ethical proprietary [26]. Certain principles should be followed as an appropriate foundation of research ethics in the healthcare context and in radiography, in particular: patient safety and comfort should be prioritised, the participants’ right to withdraw from the study at any time should be respected, consent to participate should be informed, confidentiality, anonymity and privacy should be preserved, patient data should be protected. Absence of at least one of the abovementioned prerequisites could obstruct the smooth progression of radiography research. This view is also supported by a study by Challen et al. in a population of radiographers, which has shown that the major perceived deterrents to research in radiography were the lack of time, lack of funding and lack of knowledge of research methodology [3]. Once all the requirements are met, as described above, there are various responsibilities that a radiographer may take on in a research work environment, depending on the nature and the owner of the research project, the structure and organisation of the workplace, seniority and the involvement that the radiographer wishes to have in a specific research investigation. Areas where the research skills of a radiographer could be essential include patient safety and efficient communication with the participants of the research study, radiation protection issues, diagnostic image quality management and optimisation of diagnostic protocols, evaluation of new techniques, quality assurance and quality control of the radiographic equipment, rigorous data collection and systematic data analysis, dissemination of the body of knowledge produced by publications or conference presentations [27]. Most importantly the clinical expertise and technological ‘‘know-how’’ that is 5 offered by radiographers in a research environment is invaluable in establishing the link so often missing between science and medicine. Research itself can be flawed; this implies that radiographers have the responsibility not only to conduct and communicate research but also to critically appraise research outcomes, findings, results and to put them into the context of clinical practice; that will fulfil their mission to provide optimal healthcare for their patients. Current situation and future directions In 1994 the Society and College of Radiographers set up a Research Group with a remit to develop a research strategy for the profession with ultimate goal to encourage all radiographers to engage in research. Since then research in radiography has moved from practically non-existence to a core academic module and a professional requirement. Different developments confirm this transition. First of all there are now a significant number of established peerreviewed and impact-rated radiography journals indicating the amount of radiography research produced to justify the need for publications specific to the profession [28]. Moreover radiography research is further disseminated by different recognised conferences of national, European and international calibre. Further the quantity and quality of the research output of Radiography Academic Institutions has significantly improved between the two RAE submissions in 1996 and 2001 as shown by the average and individual ratings; the results of the 2008 RAE are therefore eagerly anticipated [29]. Additionally there are now a large number of postgraduate qualifications offered by Radiography Departments (Taught Masters’ and Masters’ by research courses) and many radiographers are already qualified at this level. Similarly the number of radiographers awarded a PhD (or registered for a PhD) is increasing as personal communications with the Society and College of Radiographers professional officers for Research reveal [30]. All these advances suggest that systematic efforts for the establishment of a research culture in radiography have been rewarded; however there is a need for further strategic decisions in order to fully integrate research into the profession. As a crucial step towards this direction a five-year plan for research in radiography was approved by the Council of the Society and College of Radiographers in 2001. The aim of the document was to ‘‘strengthen knowledge and improve research capacity and capability’’ [31] but it also highlighted the future priorities of the research agenda in radiography. The development of purely research-led career pathways, the increase in postdoctoral radiographer researchers (from 0.04% in 2001 to at least 3% in 2010), the appointment of funded Chairs in Radiography, the annual evaluation of research activity within the profession, the establishment of ‘‘centres of expertise’’ for the provision of mentorship and succession planning, the support in research funding applications and the facilitation of knowledge dissemination were just a few of the suggestions emphasized. This document substantiated the urging need to raise the research profile of radiography for the ‘‘advancement of the profession and for the benefit of the patients’’. 6 Conclusions Having reviewed the recent developments in radiography that underline the importance of research in the profession it is now evident that research should not be viewed merely as an academic exercise or a course requirement; it should be seen as a ‘‘real engine for change and innovation’’ [3]. Research, as it was explicitly shown, is not a simple process; it comes with many responsibilities and commitment required by all radiographers in order to become research aware, research active or research leaders for providing the best evidence and knowledge-based care for their patients. The communication of research is as important as the research itself [32,33], as unpublished findings are not classed as research; therefore future efforts should be directed towards the encouragement of research dissemination in leading journals [34]. Currently research in radiography is highlighted as a priority. The increase in quality and quantity of the research output in radiography is encouraging. Systematic efforts should be strengthened and focused to maintain high research standards and ascertain the smooth and full integration of research culture into the radiographic practice. 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