The main findings of this study were that radiographers assessed their overall competency and use of individual competencies as being on a high level. We found that both the level and use of several competencies differed in line with the number of years in present position. However, the regression models using age, years in present position and work place only explained a relatively small part of competency, which indicates a multidimensional situation including other factors of importance.
The radiographers considered that they had high competence regarding patient information. ‘Adequately informing the patient’ was an item with a high mean score, irrespective of work experience. The importance of this competence is confirmed by other studies [27, 37]. One must bear in mind that the patient is unknown to the radiographer and rarely encounters the same person again, which makes the encounter particularly transitory and the informative part significant [25, 38, 39]. Studies focussing on nursing in general have emphasised adequate information as an important competence [13, 29] and a requirement for increased patient participation . However, others have found teaching-coaching to be a poorly rated competence among operating room nurses, who also encounter the patient for a short period of time, compared to other nurses . Equally, nurses in a clinical position rate teaching-coaching activities low compared to their counterparts in management positions . Information about radiographic procedures is highly important , especially from the patient perspective. It should be based on a dialogue, adjusted to the situation, and can therefore be provided in many different ways (i.e., oral, written and interactive media) [44, 45]. The information can contain both counselling and teaching with the aim of guiding the patient through the radiographic process and increasing her/his coping skills [46, 47]. All medical imaging departments have a high-tech environment with a great complexity of examinations and treatments, as well as a limited duration of the encounter between the radiographer and patient. Recent technical developments, and especially the evolution of molecular imaging , demand new studies focussing on both patients’ and radiographers’ views as well as on how to provide information.
The radiographers in the present study scored low on ‘Identifying and encountering the patient in a state of shock’, which may demonstrate that it is a complex clinical situation that requires relevant education and many years of experience. Radiographers must have the ability to detect changes in the patient’s condition at an early stage, to monitor and follow the course of events and decide when to terminate an examination . Being vigilant in emergency situations can be of vital importance and involves competencies and requirements based on skill and flexibility. Our findings revealed that the level was lowest among those with short experience, which indicates that the length of work experience may play a crucial part in relation to this competence. Furthermore, the radiographers in the present study considered that they had low competence in ‘Identifying pain and pain reactions’. Many patients experience pain during their hospital stay, and departments often have inadequate pain assessment routines . It is known that several radiographic examinations are associated with pain; thus the radiographer plays an important role in pain management by ensuring that pain is identified and reduced before and during the examination. To minimise pain, patients with a hip fracture, for example, are given higher priority at the medical imaging department . From the patient perspective, even if an examination only takes a few minutes, one should not have to suffer severe pain. The radiographer is responsible for the entire procedure and can be seen as the patient’s advocate. Radiographers’ ability to relieve pain is therefore of high priority both during education and in clinical practice.
Management of situations is a vital competence [31, 40, 50]. We found that the radiographers considered themselves highly competent in ‘Adapting the examination to the patient’s prerequisites and needs’. A radiographer often has to perform examinations on patients who are unable to play an active part in the procedure (e.g., critically injured patients, those suffering from dementia or orthopaedic patients in plaster). These situations demand a high degree of flexibility and the ability to improvise. The competence to adapt can, however, be seen as contradictory in relation to the self-assessed low competencies pertaining to ‘Identifying and encountering the patient in a state of shock’ and ‘Identifying pain and pain reactions’. Radiographers often face anaphylactic reactions in relation to contrast medium and should therefore be confident in managing patients in a state of shock. However, the low score on both of these competencies might be understood as a lack of knowledge related to other medical causes of shock (e.g., severe internal bleeding leading to haemodynamic reactions) as well as the absence of assessment and pharmacological treatment of pain. On the other hand, a radiographer can encounter a critically injured patient without extensive in-depth information about the patient’s medical condition, which might further complicate the situation. However, proper professional training from the beginning of a radiographer’s education in relation to these topics is therefore highly important. Bearing this in mind, the education system, both on basic and advanced levels, as well as quality improvement projects in clinical practice should place more emphasis on these important topics.
An interesting finding was that the radiographers in the present study considered themselves to have low competence in ‘Participating in quality improvement regarding patient safety and care’. This is in line with other studies regarding competence [31, 40, 50] and can be understood in the light of the rapid development of high technology, increased national requirements in radiation safety and patient care, as well as economic demands .
We found that both age and years in present position correlated significantly with the competencies in ‘Nurse-initiated care’ and ‘Technical and radiographic processes’ as well as with the RCS as a whole. However, the R2 values in the linear regressions were very low, and years in present position and work place were not significant in the two dimensions or in relation to the RCS as a whole. When examining the literature, no previous studies regarding factors associated with radiographers’ self-assessed competence were found. According to Benner  and Dreyfus and Dreyfus , five levels of professional pathway ‘from novice to expert’ are described as the basis for gaining increased skill and competencies. The progress from a novice to an expert is almost always combined with many years of experience. However, the number of years of experience does not automatically mean that the individual will reach the competent, proficient or expert levels . The lack of association between self-assessed competence and age, years in present position and work place in the present study indicates that there are several other variables that should be taken into consideration, such as the radiographer’s own level of knowledge and/or competence as well as the use of evidence-based knowledge at the actual department. An experienced radiographer working at a university hospital (i.e., using evidence-based knowledge) with in-depth knowledge of both ‘Nurse-initiated care’ and ‘Technical and radiographic processes’ might have better ability to evaluate lack of competence compared to a newly qualified radiographer with little experience working at a district hospital. A multi-rater feedback (i.e., 360° feed-back) could be used as a possible additional description of radiographers’ competencies .
Effects of the education system or the individuals’ habitual behaviour in clinical practice might be other possible factors of importance. Even if radiographers have theoretical knowledge, routines in the clinical situation are often based on unconscious habitual behaviours , which might influence the newly qualified radiographer’s opportunity to implement her/his theoretical knowledge in clinical practice, thus affecting both her/his self-assessed level and use of competence. However, a habitus can also be used consciously, toward a specific goal , to encourage improvement. From a methodological perspective, the RCS is a newly developed instrument showing good validity and reliability . We decided to divide our relatively large national sample into four groups to describe the progress of competency. The variation regarding years in present position was good, despite the fact that one of the four groups had a smaller number of participants. Most participants had a university/high school education. However, no comparisons were made between participants with different levels and types of education or frequencies of use since so few of them had higher education (i.e., master or doctoral degree). There was a predominance of female participants, 88 %, in the present study. This reflects the sex distribution among Swedish radiographers and may therefore not be seen as a bias for the result. Structural equation modelling could be another statistical method for assessing associations between different variables and competencies. Besides, future research could focus on comparisons between self-assessment and outside assessments, based on health-care personnel and/or patients regarding clinical competence among radiographers.
Relevance to clinical practice
Medical imaging departments are central in the health-care service. Self-assessments of competence, especially using a validated tool such as the RCS, are highly important for clinical practice. Results from competence assessments could be used in areas such as patient safety, planning and evaluating competence development, as well as in management. The two dimensions in the RCS, ‘Nurse-initiated care’ and ‘Technical and radiographic processes’, illuminate a relationship between technological and caring competence and provide a more detailed picture of radiographers’ clinical competencies. This can contribute to a baseline in terms of educational needs (i.e., in basic and further education, as well as in clinical practice), but also for evaluating quality improvements related to radiographers’ clinical work situation. Moreover, it could also be valuable for radiographers to reflect on their own competence, role and development possibilities since a competence assessment may be a rewarding process as it provides information about less obvious matters in clinical practice. The information obtained may also help safeguard the patients’ health and emphasise nursing issues and not merely the technological aspects of the procedures. Furthermore, knowledge derived from competence assessments may be used in different areas of professional development and education areas in various health care settings. Knowledge about radiographers’ clinical competence can contribute to the development of new routines and a more individualised approach to improving their work situation. Focussing on different competencies, e.g., the findings that the radiographers considered themselves least competent in ‘Preliminary assessment of images’, may highlight the fact that assessment of images is still not a common task for Swedish radiographers. An important implication for clinical practice is the perceived low competence in managing situations that are complex or difficult (e.g., handling pain and patients in a state of shock), which requires more attention on the part of the specific work place and the education system.