assessment of clinical competence in therapeutic radiography: a study of skills, characteristics and...

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Radiography (2007) 13, 147e158

Assessment of clinical competence in therapeuticradiography: A study of skills, characteristics andindicators for future career development

Christine Jackson

Centre for Clinical and Academic Workforce Innovation, University of Lincoln, Mill 3, Pleasley Vale Business Park,Outgang Lane Pleasley Mansfield, Notts, UK

Received 26 May 2005; accepted 6 December 2005Available online 20 February 2006

KEYWORDSCompetence topractice;Careers frameworkfor the NHS;Clinical skills inradiotherapy;StLaR HR Plan Project

Abstract Purpose: The aim of this study was to measure the competence of one national(United Kingdom) cohort of newly qualified therapeutic radiographers (n Z 62) following com-pletion of their undergraduate training programme and examine skills and characteristicswhich might indicate future career development.Method: Questionnaires comprising 14 assessable skill areas/characteristics were sent to all UKradiotherapy departments. Each department agreeing to participate in the study identified thenumber of staff who were eligible and agreed to take part. The 14 assessable areas were com-pleted by senior therapeutic radiographers with a working knowledge of the radiographerbeing assessed. Assessment grades were allocated to each skill/characteristic using a validatedset of performance descriptors.Conclusion: Analysis of the levels of competence achieved demonstrated that the majority(59/62) of newly qualified therapeutic radiographers were judged by senior staff to be compe-tent in clinical practice, although many responders commented that newly qualified staffbenefited greatly by an additional period of post-registration supervision in order to consoli-date clinical skill development.

A small number of radiographers (n Z 6) were judged to be highly competent. They achievedgrades which were indicative of an exceptionally high standard across all 14 skill areas. Theskills and characteristics demonstrated by this subset include adaptability, a well-placedself-confidence, high level of clinical skill and evidence of effective critical thinking andreflection.

This first post-registration year is a critical time for future career development. Those lack-ing in confidence to deal with patients or operate equipment or those requiring additional clin-ical support must be supported and mentored in order to achieve the required levels ofcompetence. Those radiographers, who clearly demonstrate high standards of competence

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148 C. Jackson

and possess skills more usually seen with experience, should be encouraged and supportedearly in their careers to maximise their potential across the range of career pathways withinthe profession.ª 2005 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.

Introduction

Therapeutic radiographers are required to demonstrate anarray of skills within their professional portfolio.1

To add to this complexity, some of these skills (thosebased on technical areas) require continual updating inorder to keep pace with the technical demands of the role.Therapeutic radiographers are required to adapt and re-spond to technological changes, driven by equipmentmanufacturers who are striving to maintain the competitiveedge in radiation technology.

The wider picture of therapeutic radiography within thecontext of the NHS also demands an ability to adapt andupdate skills. The National Health Service is often de-scribed as undergoing constant change and in recent timesthis change agenda has been driven by the NHS Plan.2

Emerging work streams from the NHS Plan include NHSworkforce development in terms of both capacity by in-creasing numbers of staff and capability by developingnew ways of working, both of which hold relevance to theradiography profession.

With the concept of change in mind, an importantconsideration for educators within therapeutic radiographytoday is how to ensure that current undergraduate educa-tion programmes are fit for purpose. This is in terms ofproducing a workforce which is seen to be competent in allaspects of clinical practice, and at the same time encour-aging staff to develop higher skills which are considerednecessary for new role development and successfullymanaging change. Higher level skills in the cognitivedomain, for example, would be evidenced by demonstra-tion of adaptability, critical analysis and problem-solvingwithin the context of technical skill delivery.

This article focuses on the level of competence achievedby a cohort of therapeutic radiographers who qualified inthe United Kingdom (UK) and, in particular, reviews thehigher level skills exhibited by a number of the cohort,considered by senior colleagues to have a very highstandard of competence. These higher level skills such asthe demonstration of well-placed self-confidence, prob-lem-solving and reflective skills and adaptability are keyskills to develop for staff engaged in the future direc-tion of therapeutic radiography and other healthcareprofessions.3,4

This survey of competence took place during 1998 and itcould be argued that the results may not have relevance forstudents currently studying on higher education pro-grammes in therapeutic radiography. However, it is evidentfrom the analysis of the survey that the skills identified,particularly in those radiographers judged to possess higherlevel skills, are important in terms of nurturing our futureprofessional leaders in therapeutic radiography.

Moving from diploma to degree-basedqualification

In the UK, the move from diploma-level qualification (DCR)for state registration to degree-level qualification tookplace during the 1990s and during this period, a numberof reports commented on the need for specific expertisewithin the NHS workforce. For example, the Department ofHealth5 (focusing attention on the complete restructuringof cancer services in England and Wales) expected staffinvolved in the delivery of cancer care to have up-to-dateexperience in all areas of cancer care including technicalexpertise.

The Department of Health6 in the report, ‘‘A HealthService of All the Talents: Developing the NHS Workforce’’,is critical of education providers responsible for pre-regis-tration training, describing an ‘‘over-academicisation’’ ofbasic training and an education regime which left staffinsufficiently prepared for their first few months of work.It is of interest therefore to establish whether the aboveconcern holds true for therapeutic radiography. Are newlyqualified therapeutic radiographers sufficiently preparedfor their first few months of work?

A survey of the competence levels of the then newlyqualified workforce (1998) in therapeutic radiography wasundertaken. The results of the survey together witha number of specific findings on higher and lower levels ofcompetence are presented in this article.

Defining competence in clinical practice

Competence can be defined as possession and demonstra-tion of knowledge, skills and abilities to meet the occupa-tional standards of a profession.7 Although it is notproposed that the relative merits of the various modelsof competence are discussed here, there are a number ofmodels of competence used in education and training ofhealth professionals which range from competence beinga finite and defined level of skill to a model of competenceas a continuum. The approach taken in many undergradu-ate programmes is to look at a competence continuumfrom novice to expert as described by Benner.8 This modelargues that competence can be based on a scale of achieve-ment, relating to a specific set of criteria upon whichjudgements of competence can be made. It is also impor-tant to build into a competence model for the therapeuticradiography profession, behaviours which encourage futurerole development. For example, the ability to managechange by combining high competence in technical skillsand patient care with the ability to project and predictfuture professional directions has great currency in today’s

Assessment of clinical competence in therapeutic radiography 149

NHS. Holmes9 supports the view that competence should bebased on capability as opposed to what has been done inthe past. He also argues that assessment of competenceshould not be confined to measuring average level perfor-mance but should be based on the ability to define superiorperformance.

Models proposed by Barnett10 and developed by Brennanand Little11 suggest that health professionals, where thereis a need for complex cognitive and technical processes,should adopt a model of competence which incorporatesboth operational competence (know how) and academiccompetence (know that) thus providing a better curriculumbase which has a chance of bridging the theoryepracticeinterface. The range of skills and characteristics assessedin the competence survey reflects both operational andacademic dimensions and supports the concept of assess-ment of capability.

Competence to practice e the rationalebehind the survey

The late 1980s and early 1990s was a transitional period inthe history of radiography education when pre-registrationtraining programmes moved from diploma to degree-levelentry, with the majority of courses providing a BSc (Hon)programmes in England and BSc with or without honourselsewhere in the UK. There were concerns expressed,anecdotally, by clinical staff within the profession aroundthe level of clinical competence of newly qualified thera-peutic radiographers. The principal cause of the concernrelated to the reduction in the number of designated clinicalhours, with an increase in academic hours, in some of theprogrammes compared to that of the previous diplomaprogrammes. These views, together with the aforemen-tioned general concerns from the Department of Health,generated the impetus to look at the levels of competencedemonstrated by newly qualified therapeutic radiographers.

Methodological issues

In order to measure the level of competence in the newlyqualified therapeutic radiography staff, a national survey ofone annual cohort of ex-students was undertaken in orderto test the following hypothesis:

‘‘The competence achieved by graduate entry thera-peutic radiographers is at a standard expected by theirprofessional colleagues in clinical practice.’’

Pre-survey design considerations

A competence questionnaire was selected as the instru-ment used to assess the level of competence in the study.The questionnaire consisted of 14 statements, each relatingto a specific skill area/characteristic considered to benecessary for a newly qualified practitioner to possess.Each of the 14 statements was developed through a detailedrole analysis of clinical activity of basic grade therapeuticradiographers in Trent.12 The role data were then used to

inform the development of clinical competence assessmentas part of the undergraduate BSc (Hon) programme in Ther-apeutic Radiography at the University of Derby.13 Annualauditing of the assessment marking scheme and markingreliability of individual staff within and across the clinicaldepartments using measurements of mean, standard devia-tion and confidence intervals (95%) demonstrated thatthe assessment tool was consistently reliable across theprogramme. This is particularly important when the assess-ment tool is to be used across a number of clinical depart-ments and by a number of assessing radiographers. A surveyinvolving assessment at a national level requires a pre-tested assessment tool which can be used equitably acrossthe cohort to deliver reliable results.

The 14 areas are in two sections, each with seven skillareas and are shown in Tables 1 and 2. (Technical andPatient Management Skills e blue background and Profes-sional and Communication Skills e yellow background).

Grading of competence

The performance of each student in each of the 14 skillareas/characteristics is graded according to a set ofcompetence descriptors AeF with:

A Exceptionally high standard. Evidence of ability tothink and act independently;

B Very good standard. Evidence of sound grasp of factsand concepts;

C Generally a sound competent performance. Mainlyerror free;

D Competent performance with some weaknesses. Addi-tional support required;

E Limited performance of competence. Weaknesses.Limited understanding of facts and concepts;

F Major shortcomings in competence to practice. Perfor-mance containing serious errors and inaccuracies.

When this was used for the undergraduate assessment,each of the skill areas contained a set of specific perfor-mance criteria for each year of training, linked to the over-all grading system (to allow for progression of competencedevelopment) but it was considered appropriate to use theoverall grading descriptors for this competence survey.

Grade C is considered the standard of achievementexpected i.e. the level of competence agreed to be safepractice.

Table 1 Skill areas for assessment of competence:technical and patient management skills

Technical and patient management skills

Knowledge and terminologyAbility to perform techniques and proceduresSafe working practicesUtilisation of treatment dataAccepting responsibilityAdministrative proceduresDose calculations

150 C. Jackson

Grades E and F are considered to be unacceptable levelsof performance.

The grades equated to a range of clinical marks whichreflected standard university marking schemes for under-graduate honours degree programmes.

For the purposes of this survey, the grades AeF wereconverted into a numerical range 1e6 with grade A (1)relating to the highest level of competence. This allowedfor some numerical comparisons of data sets.

The figures shown in this article use the numericalgrades to depict levels of competence.

National survey e the pilot

The pilot study was undertaken on 11 newly qualifiedtherapeutic radiographers who were six months post-regis-tration and at a number of different centres in the UK. Nochanges were required to be made to the test instrument.

The national competence survey

Every department of radiotherapy in the UK was contactedby post. Each head of department was sent an explanatoryletter outlining the rationale for the survey. A number ofquestionnaires (5) were supplied for each contact. Furtherquestionnaires were supplied on request.

Out of a total of 60 departmental contacts, 45 depart-ments responded and out of 45 responders, 32 departmentshad newly qualified therapeutic radiographers willing toparticipate. Heads of participating Radiotherapy Depart-ments were invited to provide free text comments on theaspect of clinical competence.

A total of 62 questionnaires were returned from the 32participating departments. A Society of Radiographers datasource indicated that in 1998, 118 therapeutic radiogra-phers had qualified. However, it was not possible toaccurately trace the whereabouts of all 118 radiographersas not all take up first posts within a UK radiotherapydepartment. Best estimates would suggest that a return of62 responses was likely to represent between 60e75% ofthe available pool.

The competence questionnaire

The questionnaire contained two parts, A and B.

Table 2 Skill areas for assessment of competence:professional and communication skills

Professional and communication skills

Team workProfessional conductConfidenceCommunicating messagesGiving information and instructionsAttending to patients and establishing rapportListening and questioning skills

Part A consisted of a number of questions relating to theundergraduate clinical programme undertaken by each ofthe assessed radiographers. This section was completed bythe radiographer undergoing the competence assessmentand included:

� Degree classification awarded,� Working in previous training department Y/N,� During training e % time spent in clinical practice,� Clinical rotation details i.e. single department or rota-

tion through a number of departments associated witha Higher Education Institution.

Part B of the questionnaire related to the assessment of the14 skills’ statements to be completed by a senior super-vising radiographer. The selection of the assessing radio-grapher was an internal decision to each department.The constraints of the ethical considerations around dataanonymity meant that it was not appropriate to specifyan identifiable radiographer for the assessment process.However, clear guidelines on radiographer expertise inassessment were provided for each participating department.

Results

Figs. 1e14 show the range of grades achieved by the radiog-raphers in each of the 14 skill areas.

The x axes indicate the level of competence awarded toeach of the assessed therapeutic radiographers: 1 is equiv-alent to an A grade (highest level of competence), 2 Z Bgrade, 3 Z C grade 4 Z D grade, 5 Z E grade and 6 Z Fgrade (lowest level of competence).

None of the 62 radiographers in any of the 14 areas wasawarded an F grade, indicating that no assessed radiogra-pher was considered to have any major shortcomings in anyof the 14 skill areas. However, a small number of staffreceived E grades and this is discussed later in this section.The spread of the assessment grades is shown for each skillarea in Figs. 1e14.

Discussion

General level of competence

Each of the 62 therapeutic radiographers was assessed in 14skill areas, providing 868 (62 ! 14) grades of competence.Nil responses were recorded for three grades, leaving a totalof 865 responses. Out of 865, a total of 13 responses(0.015%) were graded at E (an unacceptably low level ofcompetence), leaving the remaining 852 responses at gradeD or above. Furthermore, it can be seen from Figs. 1e14that for each assessed skill area, over 70% of the radiogra-phers were assessed as having achieved high levels of com-petence, denoted by grades A and B (numerical 1 and 2,respectively).

The results would indicate therefore that there was atthe time of this survey, a high level of satisfaction aroundthe competence of newly qualified therapeutic radiogra-phers. What now follows is a more detailed look at somespecific results of the survey.


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1 2 3 4 5Level of Competence

Figure 1 Knowledge and terminology.

Therapeutic radiographers with a lower thanexpected level of competence

There were 13 E grades within the surveyed group andthese were attributed to three therapeutic radiographers.

One radiographer received an E for accepting responsi-bility. The same radiographer also received four grade Ds,which may suggest that this radiographer required furtherclinical support.

The remaining two radiographers received five E andseven E grades, respectively and, in both cases, the highestgrade awarded was C. All radiographers carrying out theassessments were invited to provide free text comments.This was particularly encouraged if lower grades weregiven.

Although the number of radiographers considered in thissurvey as demonstrating lower than expected levels ofcompetence was low (3/62), it is, nevertheless, of concernto the profession. It raises a question around the level ofcompetence achieved by the three radiographers on qual-ifying. It should be noted, however, that comments re-ceived from the staff assessing the three radiographers

suggested that their competence levels were expected toimprove during the first (post-qualifying) year.

A survey of this nature could not have been undertakenunless anonymity was protected. To identify staff under-going the assessment process was considered to have beenunacceptable to participants and likely to have reduced theparticipation rate.

Comments provided by the assessors indicated thatfurther periods of supervised clinical experience wererequired and were being provided. It was noted that theless competent radiographers were unable to exerciseindependent judgement and demonstrated lack of confi-dence in clinical areas. A period of supervised practice andmentorship provides the additional support to enable lessconfident staff to improve their clinical skills in a controlledand supported environment.

Therapeutic radiographers with a highstandard of competence

Figs. 1e14 indicate that over 70% of the total group in thesurvey were judged to be highly competent, receiving A

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Figure 2 Ability to perform techniques and procedures.

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Figure 3 Safe working practices.

or B grades across the 14 assessed areas. The high standardof competence achieved by such a large percentage of thecohort was very gratifying to see and although this studywas undertaken on only one national cohort (1998) of newlyqualified therapeutic radiographers, the results do givesome weight to the acceptance of the hypothesis

‘‘The competence achieved by graduate entry thera-peutic radiographers is at a standard expected by theirprofessional colleagues in clinical practice’’

Additional comments from assessors indicated that thenewly qualified radiographers were considered by seniorstaff to be in a period of post-qualification learning andtherefore attached great importance to newly qualifiedstaff seeking support where necessary.

Competence in relation to whether radiographersremained in their training departments epost-qualification

It could be argued that a number of external factors mayhave an influence on the standard of competence achieved

by each of the assessed radiographers. The survey ques-tionnaire requested data on whether the radiographerundergoing the competence assessment was based ina radiotherapy department associated with his/her pre-vious undergraduate training programme. Radiographerswho remained in a clinical department associated withtheir undergraduate training, it could be argued, would bemore likely to achieve higher grades in some sectionsbecause of familiarity with equipment and procedures.

The results from this survey showed that this was not thecase (Table 3). The example given here looks at the compe-tence levels in the skill area: ‘‘Administrative procedures’’and compares the standards achieved for radiographerswho remained in a previous training department againstthose who moved away.

Competence in relation to clinical rotationduring training

Fifty-one radiographers received training in more than oneclinical department.

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1 2 3 4Level of Competence

Figure 4 Utilisation of treatment data.


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Figure 5 Accepting responsibility.

Eleven radiographers received training in just oneclinical department.

Comparisons of the competence grades for each of the14 skills areas, revealed no differences in the levels ofcompetence between those who experienced clinical rota-tion and those who did not. However, further studies wouldbe required to further verify these findings.

The final section relates to the characteristics and skilllevels of therapeutic radiographers who were judged in thissurvey to be highly competent.

Radiographers judged to be performingat an exceptionally high standard

Six radiographers were assessed as being extremely com-petent in all 14 assessed areas.

Free text comments from assessing radiographerssupported the awarding of high grades with the followingstatements:

� this radiographer already demonstrates a high degreeof adaptability and problem-solving skills when it comesto new and difficult situations;� well-placed self-confidence which enables this radio-

grapher to perform at a high level of technical skill;� evidence of effective critical thinking and reflection.

Already teaching others;� demonstrates a critical awareness of radiotherapy

techniques and has already begun to change and addto departmental practice;� is able to see new opportunities, develop protocols and

identify gaps in service provision.

It was noted that the six radiographers who were assessedto be performing at this high level were awarded either1st or 2.1 honours degree although with the small number(n Z 6) involved here, the classification profile should beinterpreted with some caution. What is more helpful isthe assessment profile across each of the 14 skill areas bydegree classification.

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Figure 6 Administrative procedures.

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Figure 7 Dose calculations.

In 13 out of the 14 skill areas, therapeutic radiographersawarded 1st class degrees had the lowest mean values(indicating that this group were awarded the highestgrades).

The one exception was for skill area: ‘‘Dose calcula-tion’’, where radiographers awarded a 2.1 classificationachieved the highest grades.

Table 4 shows the mean values plotted against thedegree classification for the skill area: ‘‘Professionalconduct’’.

The profile suggests that degree classification for thisparticular cohort was an accurate indicator for levelof competence demonstrated during the first yearpost-qualification. However, further surveys would needto be undertaken in order to examine any correlationbetween performance and degree classification.

The assessment profiles of staff judged to be highlycompetent are extremely encouraging as it demonstratesthat the profession is capable of identifying key skills andcharacteristics demonstrated by therapeutic radiographersearly in a professional career. That is not to say that weshould neglect those radiographers who develop higher levelskills later in their careers. Indeed, the approach most often

encouraged in professional development is one whichsupports the needs of the individual at all stages in thecareer pathway. However, identification of key skills andpersonal characteristics during this early stage could benefitthe individual and the profession. Providing staff early intheir career with choice and flexibility for career pathwayswhich play to their strengths (clinical, academic or both)demonstrates a commitment from within the radiographyprofession to the concept of continuing professional de-velopment. Advanced level skills and behaviours shown bythe highly competent radiographers in the competencesurvey should be nurtured, supported and developed furtheras they are critical to a profession which is continuallyevolving in both technical and professional arenas.14,15

Recommendations

We are seeing more flexible and progressive role opportu-nities for therapeutic radiographers, supported throughsuch initiatives as the Career Framework for the NHS16

and the NHS Knowledge and Skills Framework.17 The CareerFramework considers the progression of clinical career

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Figure 8 Team work.


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1 2 3Level of Competence

Figure 9 Professional conduct.

pathways from level 1 e Initial entry, through to levels 8/9e Consultant Practitioners/More senior staff. In order thatcareer flexibility and potential can be maximised, wemust now consider how academic career pathways can bedeveloped which complement and link more closely to clin-ical careers. If this is successfully achieved, career flexibil-ity and role development can be further enhanced.

The competence survey has demonstrated that newlyqualified therapeutic radiographers, in the first year post-registration, are capable of achieving high levels of clinicalcompetence with identifiable professional characteristics.In addition, senior staff had indicated that the first yearpost-qualification is an important time for all staff requiringadditional clinical mentoring and support.

Returning to the discussion around the lower thanexpected levels of competence for three radiographers, itis perhaps a question for the profession to consider in thefuture. Further national surveys could be considered,possibly using an updated assessment tool which is

reflective of current curriculum approaches. This couldprovide the profession with an opportunity to collectcumulative data sets on professional competence witha view to identifying more fully, national characteristicsaround skills and competence levels and possible trends.

The data set for this survey is now 7 years old, but theprinciple of examining professional competence and iden-tifying skills to support future career pathways for thera-peutic radiography is relevant to our profession today.Identifying early in a career, future leaders who maybecome the educators, researchers, professors and consul-tant practitioners in the radiography profession is animportant step in developing and maintaining professionalworkforce capability and capacity.

It is timely and appropriate for the profession to nowconsider more carefully, career progression which em-braces academic pathways in therapeutic radiography, asa parallel but linked initiative to complement the CareerFramework for the NHS.

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Figure 10 Confidence.

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Figure 11 Communicating messages.

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Figure 12 Giving information and instructions.

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Figure 13 Establishing rapport.


Level of Competence

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Figure 14 Listening and questioning skills.

Table 3 Skill area: administrative procedures

Mean grades for staff who became employed in their previous training department compared to staff that moved away

Group 1 Group 2

Employed by previous training department Not employed by previous training departmentCases where the assessed radiographer is employed

by his/her training department (n Z 19)Cases where the assessed radiographer is not

employed at his/her training department (n Z 43)Mean 2.4737 with a 95% CI for mean (2.00089e2.9384) Mean Z 2.5116 with a 95% CI for mean (2.2317e2.7915)

The mean values for both groups are similar andlie between the B/C grades

Frequency

Grade achieved Number of cases Grade achieved Number of cases

Group 1 Group 2

A (1.0) 3 (16%) A (1.0) 5 (12%)B (2.0) 7 (37%) B (2.0) 18 (42%)C (3.0) 6 (31%) C (3.0) 13 (30%)D (4.0) 3 (16%) D (4.0) 7 (16%)

The frequency tables show a similarity of distribution between the two sets of cases and the means of the two are very close.

Table 4 Summaries of professional conduct grades bydegree classification

Degree class Mean mark Std Dev Cases

1st class Hon 1.6667 0.8165 62.1 1.7879 0.6963 332.2 1.8750 0.7188 163rd 2.5000 0.7071 2Pass degreea 1

For entire population 1.8103 0.7122 58

Missing cases Z 4.a No observations can be made about the one radiographer

awarded a pass degree because this radiographer is likely tohave trained outside England where a pass degree is a recog-nised qualification for UK registration.

References

1. The Society of Radiographers. A strategy for the education andprofessional development of therapeutic radiographers. TheSociety of Radiographers; 2000.

2. Department of Health. The NHS plan. London: Department ofHealth; 2000.

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4. Butterworth A, Jackson C. Clinical academic careers for educa-tors and researchers in nursing. Journal of Research in Nursing2005;10(1):85e97.

5. Department of Health. The Report by the Expert AdvisoryGroup on Cancer to the Chief Medical Officers of Englandand Wales: a Policy Framework for the Commissioning of Can-cer Services. London: Department of Health; 1995; EL 95 (51).

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7. Jarvis P. Adult and continuing education. London: Routledge/Falmer; 1995.

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9. Holmes L. Taking the lead on professional standards. PersonnelManagement 1992;24(11) [36(4)].

10. Barnett R. The limits of competence: knowledge, higher edu-cation and society. Buckingham: OU Press; 1994.

11. Brennan J, Little B. A review of work based learning in higher edu-cation. Sheffield: Department for Education and Employment; 1996.

12. Jackson CS. The current training programme for therapeuticradiographers. Is it meeting the needs of radiographers in the

1990s? (unpublished thesis) 1993; M.Phil., University ofNottingham.

13. BSc (Hon) Therapeutic radiography programme handbook;1992e2001; University of Derby.

14. Pithers R, Soden R. Critical thinking in education: a review.Educational Research 2000;42(3):237e49.

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