Are you an Advanced Practitioner?

Dr Nick Woznitza is a CoR accredited consultant practitioner, an ASMIRT accredited advanced practitioner and a clinical academic with joint appointments at Homerton University Hospital and Canterbury Christ Church University, UK. He is also a Trustee of the British Institute of Radiology and Overall Winner of the 2017 Chief Allied Health Professions Officer Awards 2017.

Radiographer role extension and advanced practice (AP) is expanding. Building on the work of ultrasound, therapeutic and diagnostic radiographer pioneers, recognition that advanced practice can improve imaging and oncology care has spread across the globe. Perhaps the most obvious contribution is direct clinical care, enabled by expert clinical skills possessed by advanced practitioners; treatment planning, site specialist therapeutic radiographers in radiotherapy, acquisition and interpretation of ultrasound, insertion of vascular access, performing and reporting fluoroscopy and clinical reporting of X-rays, CT or MRI examinations. It is this element that has been the main driver – creating capacity and facilitating patient focused streamlined services with reduced waiting times and, possibly, improved outcomes. But are expert clinical skills the only requirement, the only differentiator, between practitioner and advanced practitioners? I would argue yes – that advanced practitioners are not just a direct replacement for medical or physics staff for certain tasks, it is about transforming the patient experience and pathway.

Review of advanced practitioner guidance produced by several professional bodies including the CAMRTASMIRT and CoR would suggest not. While expert clinical skills, and the additional responsibilities that these bring, are central to advanced practice, they are not the only requirement. Stemming from the additional roles is a requirement for enhanced communication, clinical leadership, education and research. In many circles, including radiographers, service managers and even advanced practitioners, the requirement for the additional capabilities are often overlooked. I would argue that, without all aspects being addressed within a role, that many advanced practitioners by title are more of a clinical specialist than an advanced clinical practitioner with skills and core capabilities across all pillars of practice, and thus with limited capacity to innovate . In some aspects, the APs in Canada and Australia are at an advantage. Advanced practice in the UK has intentionally been a more organic process, with the original drivers being to develop roles encompassing the four core domains, to meet local service need and therefore to deliver innovation.  However, often roles have been developed which encompass only clinical specialism.  Whilst the CoR has had an accreditation process for advanced and consultant practitioners for a number of years, and initial uptake has been relatively slow, this is now increasing reflecting the new drive within the UK for advanced and consultant practice across the non-medical professions. As Canadian and Australian advanced practice roles are relatively new they have taken the opportunity to embed all key elements into the development and credentialing of specific AP roles. However with the supporting accreditation process offered by the College of Radiographers and the publication of national frameworks across the UK with clear definition of the core capabilities advanced clinical practice roles must now clearly be developed to encompass the four core domains of practice.

Two examples, I think, illustrate this. Patient communication has always been central to practice, explaining procedures, radiation risks and pathways. However, there is a step change in skills required to move from explaining why a chest X-ray has been requested and how to obtain a high quality diagnostic image to explaining to a patient that their X-ray is abnormal and that further tests are required. Unless advanced practitioners are supported through structured learning and mentorship, these skills are often developed in a haphazard way, and patient care and experience will suffer.

The second example comes from frequent discussions with current and aspiring advanced practitioner radiographers the most controversial skill expected of APs is research. Many see this as a ‘luxury’ item, something that is done by academics and an unnecessary (or unwanted) distraction from direct clinical care. “Why do I need an MSc when I’ve completed my PgD in reporting? How can I be expected to conduct research, I’m far too busy?” In my opinion, this couldn’t be further from the truth. As healthcare professionals we are required to ensure all of our practice is evidence based.

But, unfortunately, radiography is a research immature profession. And I would argue, that if one pinnacle of our profession, the advanced practitioners, cannot contribute to the evidence base, then who can? How can other professions value our additional contribution to patient care if we cannot support our expert clinical skills with robust research evidence? And, as advanced practice roles become embedded and more mature, how can we demonstrate, to patients, to clinicians and to those that dictate health policy, that what we do adds value, that service transformation produces better patient outcomes, that, in essence, our contribution has impact?

This month’s article, reviewing the implementation of a new patient pathway based on radiographer advanced practice, addresses several of these questions. The new communication skills required by the advanced practitioner was proactively addressed. At the feasibility stage evidence for possible beneficial impact was examined – did this initiative improve diagnosis? Was the new service safe?

In closing, I would like to ask all current and aspiring advanced practitioners a question…. Are you fulfilling all the aspects of advanced practice? And, can you evidence your contribution? If not you are acting in the capacity of a clinical expert within a specialism. This could be a pathway to development as an advanced practitioner.


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