TMCnet News
Breaking down the barriers [Synergy (UK)](Synergy (UK) Via Acquire Media NewsEdge) Fostering a culture of research in a radiology department. In 2013, the Department of Health (DoH) captured the importance of research for the health professions by stating1: "In a difficult financial environment, we need new approaches if we're going to improve quality and productivity. We think we can get more out of health and social care services if we encourage innovation and base more decisions on evidence about what works." Although the National Health Service (NHS) has endorsed research since its inception in 1948, the passing of the Health and Social Care Act (HSCA)2 created unprecedented powers for the organisation to meet the need for research, and use the evidence it creates to inform patient care. It requires the Secretary of State for Health, the NHS Commissioning Board, Clinical Commissioning Groups (CCGs) and Monitor to conduct and commission research activity. Passing of the HSCA2 also prompted publication of the NHS Constitution for England by the DoH, a document intended to establish the principles and values of the NHS in England going forward3. Particularly pertinent was the mention of NHS England's commitment to promoting, conducting and using research. Similarly, from the NHS England Research and Development Draft Strategy4, which at the time of writing has finished its consultation period, emerged the concept that only clinical services that have robust research evidence will be commissioned in the future. This could have remarkable implications for NHS services, and accentuates the need for them to consider research conduct and implementation for the sustainability of service provision, and ultimately patient care. A 2011 survey of 990 adults in Great Britain was conducted to investigate the importance of health care research to the public5. Ninety seven percent thought it was important for the NHS to support research into new treatments for patients, whilst 94% believed that their local NHS trust should be required or encouraged to support research. This survey highlights that organisational engagement in research, via an informed and research active workforce, is called for by the public. The proficiency standards of the Health and Care Professions Council6 require all registered radiographers 'to evaluate research and other evidence to inform their own practice'. In support of this, the Society and College of Radiographers' (SCoR) five-year strategic plan for research7 aims for all radiographers to be engaged in research at some level, either by conducting, leading, or being users of, research. This document also recognised that the majority of perceived and real barriers to research in radiography fall into two categories: research capacity and capability, and funding. It concluded that the development of a strong research culture is a necessity for the continued development of the radiographic profession. In a 2012 Scope of Practice survey8, the number of departments in the United Kingdom employing radiographers with a substantive research role (0.2 whole time equivalent and above) rose by three-fold from 2008, but was still disappointingly low at 17%. The aim of this pilot service evaluation was to investigate the barriers and facilitators for the development of a research culture locally, before proposing an action plan for change, and recommendations for future work. Method This pilot service evaluation was undertaken in a single radiology department in the South of England. Taking a qualitative approach, three clinical radiographers (one each from bands 5, 6 and 7) were purposefully sampled, based on their diverse responsibilities and job roles, which between them included experience in x-ray, dual-energy x-ray absorptiometry (DXA), computed tomography (CT) and management. All participants had worked in the department for over ten years, and included one male and two females. Participants were asked to propose barriers and facilitators towards the conduct and implementation of clinical research in their workplace. Informed consent was gained from all participants, then data was collected by making notes, and analysed using thematic analysis. Participant comments were then critically appraised by the author, and are presented as themes, supported by direct quotes, literary evidence, an appraisal of national research infrastructure, and personal reflection. The conduct and implementation of research are referred to collectively in this article as 'research culture'. Findings Five themes emerged: time, finance, apathy, resistance to change, workforce skill mix. Time and finance The financial requirements of research in a resource constrained NHS were cited as a major barrier to its conduct, one participant noting that "it all costs". Research costs such as medical examinations, materials and dissemination, are often unmet, with direct research income. Skills in grant writing and project budgeting also require dedicated time and training to develop. Another participant noted that: "clinical work takes precedence", suggesting that time is a barrier. One approach to overcoming this is to acquire funding for somebody to backfill a researcher's clinic duties. The National Institute for Health Research (NIHR) was established in 2006 to provide a framework through which the Department of Health (DoH) can develop and manage research staff and infrastructure of the NHS7. For nurses, midwives and allied health professionals, NIHR provides fellowships to support those following a clinical academic career pathway9, to combine roles in clinical practice and research. The awards also provide financial support for backfilling a clinicians clinical duties and similar funding strategies are available from other charitable organisations and academic institutions. Thus arguably, such opportunities should address concern regarding the funding of research. There is still a need, however, for departments to rationalise the potential short term productivity loss when releasing individuals to undertake research, whilst speculating on the longer term gain. The logic appears sound, but the short term impact may still result in resistance to such departmental changes. Apathy and resistance to change The first barrier mentioned by one participant was a perceived lack of enthusiasm and desire amongst their colleagues to conduct and implement research - "people sometimes just can't be bothered". This was reinforced by a second participant, who suggested that "not all radiographers are interested in research", and that newly qualified practitioners "want to focus their efforts on becoming competent at the clinical elements of their role". The subject of apathy in the radiography profession was systematically explored by Yielder and Davis10. The primary conclusions of their work were that apathy can be interpreted as a defence against fear of the unknown, and that amongst radiographers in Australia, this may be attributed to a historical lack of autonomy and responsibility associated with medical dominance. This phenomenon was first examined in 19 7 8 by Larkin11, and has since been observed amongst primary care staff in England12, British nurses13-14, and radiotherapy treatment review radiographers in England15. It is less well documented, though, amongst diagnostic radiographers in England. It is also possible that cultural norms adopted by the radiography profession, as part of its evolution, may contribute to the apparent presence of apathy expressed in this evaluation. Perhaps a lack of enthusiasm for research can be attributed to fear associated with a lack of understanding. Whilst, personally, this is easier to appreciate in clinicians that have not received research training, it is less understandable in those that have. This may be explained in part by the comments of one participant, who proposed that the undergraduate research training and dissertation projects can be "boring and withdrawn from clinical practice".This suggests that apathy towards research amongst research-trained clinicians, could at least in part, be a consequence of poor experience at a fundamental stage of professional development and identity setting. One participant pointed out that "people are resistant to change unless it is managed appropriately, even if it is beneficial to them or their situation". Hogg et al16 propose that leaders at the local level of the NHS are central to the improvement of service delivery at the NHS/patient interface, "where they share their vision of excellent care, and lead and implement change through others".This suggests that effective leadership and change management is integral to the development of a research culture in the department. Workforce skill mix The impact of workforce skill mix and its role both as a barrier and facilitator of research was noted. One participant suggested that the appraisal system could facilitate research activity in the future. By "identifying the clinical interests of radiographers", appropriate research projects could be "introduced into their development plan".They also noted the potential facilitatory role of the preceptorship programme. Preceptees are given the opportunity to identify ongoing learning needs following the programme. In its documentation, there is currently a checklist for individuals to tick the areas in which they require further training - research is not included at present, but could be. From personal observation of staff recruitment and attrition, it seems that the majority of successful band 5 radiographer candidates worked at the hospital during a student clinical placement, and thus there has been an influx of newly-qualified radiographers with a basic introduction to research conduct and implementation. As noted by Hogg17, however, despite this introduction, many radiographers still do not engage in research post-qualification. Perhaps this could be attributed to the culture that graduates find themselves working in following qualification18, or perhaps this is a genuine lack of enthusiasm. Future exploration of perceived barriers to undertaking research in newly qualified radiographers is therefore warranted, in order to prevent loss of potential patient benefit. For those without the skills, but a desire to conduct research, there is an abundance of support in radiography, which can help overcome this barrier. The SCoR has an established research group, as well as a professional officer for research, who seek to encourage radiographers to use research in practice and promote the profession's knowledge base. Furthermore, SCoR have recently developed a special interest group where members interact and network, fostering a culture of collaboration and peer support. There are also a number of bodies that support allied health research. The Allied Health Professions Research Network (AHPRN)19 grew from the National Physiotherapy Research Network and consists of a series of hubs throughout the UK. Hubs frequently hold events where individuals can learn new skills and benefit from networking with experienced clinicians and researchers from other professions. SCoR, and a growing number of other bodies, help individual clinicians to develop research skills by providing study days, all of which can be used to facilitate a research culture in radiography. Limitations There are a number of limitations to this pilot service evaluation. Participants were purposefully selected by the researcher introducing sample selection bias. Secondly, a sample of three participants was taken from a department of 30 radiographers which limits its external validity to an extent that the findings cannot be applied to other departments, and certainly not to the profession of radiography as a whole. It does, however, provide important baseline information of the perceived local barriers to research engagement, and informs the themes that could be developed if this investigation were to be replicated on a larger scale. Resistance to change, time and finance were noted by all three participants, whereas the other themes were only mentioned by one. This suggests that the former may reasonably be applied to the individual department, but the remainder should be interpreted with caution until further investigated with a larger sample. The proposed action plan was informed by themes emerging from all three participants. The findings reported and interpreted in this study will have been influenced by the author's own views and experiences, although approaching the evaluation from an ethnographic standpoint allowed the author to develop an action plan which may facilitate the conduct of, and use of, research in the department. Departmental action plan Based on the pilot study, the department started a bi-monthly educational programme in September 2013, which involves radiographers leading a session over a one hour period. The remit is flexible, and encourages the following: * Presentation and discussion of audit activity and ideas * Presentation of research projects * Discussion of evidence based changes to clinical practice * Presentation of case studies * Consultation of evidence to inform sessions In the relatively short lifespan of the programme, attendance levels have remained high, at approximately 30% of the radiographic workforce. This may be attributed to the general enthusiasm and support of radiographers for the programme, the financial support offered by management to provide food, the variation in content, or perhaps the desire of radiographers to support the colleague leading a session - for who, in some cases, it is their first experience of presenting or managing an activity. On the other hand, attendance levels are limited by running the programme at lunch time during the week, meaning that there is always a need for a number of staff to continue seeing patients Formal feedback is to be sought one year after implementation of the programme, by asking colleagues to complete a survey. It does seem important, though, to invite continuous informal feedback, and for this to inform improvements so that the development of the department is influenced by its staff. The department has made good early progress in the direction of encouraging a research culture, but identification of numerous barriers suggests that further work is required. This enquiry appears to support the notion that it is difficult to retain interest in research amongst students once they have graduated, and that this is potentially influenced by the lack of a research culture at departmental level18. The primary suggestion for further development is for the department to forge a collaboration with the local university and its third year student radiographers undertaking their dissertation research project. This would give radiographers their first opportunity, in most cases, to experience postgraduate research, and enable student radiographers to benefit from the clinical knowledge and experience of qualified radiographers. It could also facilitate the integration of research and clinical practice. By encouraging radiographers to propose research projects arising from clinical issues, they would benefit from being able to experience the entire process of research: from an idea, to a question, to an evidence-based answer that can be applied to the improvement of patient care. Student radiographers, meanwhile, may be more hkely to enjoy a project that has a clear impact on clinical practice. The long-term objective of the initiative is to encourage participation in research amongst students and radiographers alike. Reid and Edwards20 found that the creation of a research radiographer position improved, amongst other things, staff development and involvement, job satisfaction, income generation, and the profile of radiology. The study did not investigate the impact of the role on patients, so this is a suggested area for future research. This pilot evaluation highlights the value of developing a research culture in the department, to support the expansion of research activity on a local and national level. Providing support for a dedicated role, such as a research radiographer, would assist radiographers to translate ideas into feasible studies, provide general methodological help, source financial assistance, and engage the department with other professionals, departments, hospital research studies, and commercial research studies. Recommendations Although intended as a service evaluation, a number of interesting topics have emerged. The primary recommendations are for departments to consider implementing a similar programme, engage in sharing of practice (perhaps through the SCoR special interest research group), and to undertake a larger study to evaluate the impact of such, including the perceived barriers to participation in research amongst radiographers. Understanding and overcoming these issues is key to the continuing development of a research culture. It would also be useful for departments that have successfully fostered a strong research culture to disseminate their approach, as well as the associated benefits to patient care. Conclusion Engagement in research amongst radiographers is essential. Evidence from research informs optimal service dehvery, establishes patients' priorities for research, informs planning and dehvery of cost effective, sustainable care, and fosters collaboration with other professionals. The need for research in radiography is of particular importance because technology, which is central to our work, is rapidly changing, as are the services provided. As a pilot study, this evaluation provides introductory evidence of some of the perceived barriers to developing a research culture in the department. Progress has been made over the last two years, and the proposed action plan aims to continue development by overcoming the barriers evidenced both here, and in the wider radiographic literature. Acknowledgements I would like to thank the radiographers of the studied department who took the time to discuss the subject. I would hke to acknowledge: Northern Devon Healthcare NHS Trust. Dr Lindsey Cherry, Faculty of Health Sciences, University of Southampton. Miss Fiona Mellor, Anglo-European College of Chiropractic. Dr Karen Knapp, Medical Imaging, University of Exeter. Mr Karl Nottage and Mrs Vivien Easton. References for this article can be found at http://www.s0r.0rg//learning/Iibrary-pubIicati0ns/itp This article has been prepared following local guidance relating to the use of patient data and medical images. To comment on this article, please write to [email protected] About the Author Mr Call um Birch Diagnostic Radiographer, Northern Devon Healthcare NHS Trust. NIHR MRes Clinical Research Student, University of Southampton. (c) 2014 Society & College of Radiographers |