Increasing training capacity in Radiography training

Opinion Piece by Warren Foster

Diagnostic Radiography is considered by the NHS to be a ‘shortage specialism’ and the need to increase training capacity in the UK has been the subject of much ongoing discussion.

A recent article by Emma Hyde and Charles Sloane entitled Diagnostic Radiography Education: Time for Radical Change? engages with the shortage of Diagnostic Radiographers and looks at solutions.

Head of the School of Radiology at AECC University College, Warren Foster, responds to key points raised in this article – and by the wider industry – and suggests further solutions for change.

Shortage of Radiography students

“I think it’s true that we’re not currently training enough Diagnostic Radiography students and a key reason for this is that we can’t get access to enough clinical placements. There aren’t enough Radiographers to train increased levels of students using the current training model.

“The issue is that we haven’t trained enough Radiographers for the last 10 years and we have also seen a massive expansion in the use of medical imaging. This is primarily because there has been a change in medical practice; imaging has increasingly been used as a vital confirmation tool for clinical judgement, rather than purely as a diagnostic tool.

“We urgently need to train more Radiographers, as we have all seen from the Richards Report, if we are going to keep up with demand.”

Barriers to increasing capacity

“I think some of the barriers that have been outlined are true barriers and some are perceived barriers. For example, there is a belief that placement students are resource-intensive in hospitals and a drain on existing staff capacity.

“My view is that if you’ve got students in your department, and you’re looking after them well, then they’re an asset to you. Obviously, in those first few weeks of their placement, you do need to invest time and energy in training them, but they become useful very quickly.

“In my experience, there are a large number of Radiology Assistants that are employed to help Radiographers because Radiographers are overloaded. I believe that students can help here too.

“In this way, students also learn a wider range of skills. I think it’s really important that all Radiographers have a variety of skills, and that they’re doing tasks including changing  linen. That’s part of the job.

“It’s a really positive thing to have students embedded in the clinical environment. Students have the chance to observe professionals and as they progress through their training, they can become more and more valuable.”

Potential solution: increasing placement capacity

“Something I really believe in, is increasing teaching capacity in hospitals. At the moment, one Radiography student is assigned to one Radiographer, working in one room. That’s the current model. That’s why in the south East of England, there’s only 40-45 places for Diagnostic Radiography students.

“Meanwhile, we train nurses in groups of four. Nursing students learn from watching their colleagues, seeing where they have done well and where they have made mistakes. I think this is a much better model. Peer-to-peer learning has been demonstrated as a valuable component of adult learning.

“If you assigned two Radiography students to a Radiographer, rather than one, you’re effectively doubling placement capacity. If you increase this to four – you’re quadrupling capacity immediately. Although students would arguably be doing less physical X-rays, they will still be learning from each other and gaining valuable experience.

“Hospitals are also often less keen to take on students over Christmas and in the summer – due to annual leave requirements for existing staff. This is understandable. However, if there is a robust training model in place, a hospital should be able to take students all year round.

“If you’re training students to be valuable and helpful to the team, they should be alleviating this pressure around annual leave, rather than adding to it.

“Or perhaps it’s a case of working with Universities to take on extra third year students during the summer, who can potentially be more valuable when staff numbers are lower. Year One and Year Two students can do their placements when staff numbers are at full capacity.

 “Then we can go from student placements taking place 30 weeks of the year to 50 weeks of the year – and we’ve nearly doubled the numbers again.“At the moment, students work 9am to 5pm, five days a week on placement. There is also scope to adjust this: if students worked 8am to 6pm, four days a week, we’ve again increased training capacity.

“The Radiography department is open 24/7. I wouldn’t advocate for First Year students to be working night shifts, but by the time students reach second or third year, night shifts become part of the training. We need to look at using the whole working day.

“Lots of hospitals are doing 8am to 8pm, three days a week, and we’ve actually trialled this with our Isle of Wight students. That means they also have two days per week when they can concentrate on their studies, reflect and recover.

“If we started using weekends too, this again gives scope to double placement capacity.”

Changing our mindset to increase capacity

“For too many years, Radiographers have felt over-worked and that they lack the capacity to train students. Students have been considered a drain on resources.

“We need to turn this idea on its head and recognise the extra capacity that students bring. If they are trained to be effective and helpful, they can alleviate the workload of Radiographers. It needs to be culturally acceptable within a Radiography department to always have a student nearby, like it is in Nursing.

“Every Radiographer needs to play a role in student education. What it comes down to is the fact that you can’t say that we’re not training enough Radiographers and then also resist taking on greater numbers of students.”

Potential solution: simulation in education?

“There is an argument that we should be increasing our use of simulation to increase training capacity. I don’t believe that you can simulate all the skills of Radiography: it gets too complicated too quickly.

“My belief is that simulation should support students in preparing for clinical placement. It’s great for showing them how equipment works and giving them an understanding of common pitfalls.

“Our programme at AECC University College includes a lot of simulation in Year One and I think that works well. We use our Simulation Lab to show students how to turn an X-Ray kit on and off, we teach them general positioning, and we teach them about the common faults that Radiographers make.

“Simulation doesn’t help with learning about breaking bad news, developing good communication skills with patients, or with handling complicated trauma. The only way to teach someone these aspects of the job is by putting them into real-life situations.

“It’s the same with theatres: you can simulate the environment of a theatre, the sterile technique, and working with others, but you can’t simulate what it’s really like. There’s no substitute for actually putting students into these situations and then supporting them through it. 

“Something like VERT [virtual environment of a radiotherapy treatment room] is a great place to start. It gives students confidence, it allows them to make mistakes before they get to the clinical environment, but the further they get into the programme, the less valuable simulation becomes.”

Content of Radiography training

“There’s also a call to look at how we train students, in terms of the skill mix that we want them to learn at University.  The argument is that we should be focusing less on a broader spectrum of training and concentrating more on the basic skills of Radiography.

“For example, we include things like Head CTs in general Radiography skills and perhaps we need to review this.

“We train Ultrasound as a specialty, after completion of general Radiography training. We don’t try and incorporate this training at the beginning. However, when it comes to CT Heads, and basic CT understanding, we do. This is driven by a need for Radiographers to do Head CTs when they are on call, to reduce the on-call commitment. This again comes down to a shortage of CT Radiographers.

“This might have been a mistake; really we want to be training Radiographers in general skills and things like Ultrasound, Angiography, CT, MRI and Nuclear Medicine should perhaps form a second tier of postgraduate education.

“My view would be that we should absolutely minimise the curriculum for undergraduates and in order to compensate for that, we should have a better structure of postgraduate education.”

“Alternatively, we could consider having more than one route of entry. We’ve been talking for some time about offering Ultrasound as a Direct Access course – and we know there are registration issues with that – but perhaps we could also consider this for other areas of Radiography too.

“Why don’t we have a route that goes directly in to CT? In reality, once general Radiographers specialise in something like CT, they very seldom do general Radiography ever again. Instead of a two-tier system, where you do general Radiography and then specialise, we should consider having Direct Access routes into Nuclear Medicine, MRI and CT.” 

Warren Foster

Above: Warren Foster