Brown (2004) argues radiography is a profession under pressure and this in turn creates particular challenges for the newly qualified. Organisational changes, changes to professional training and development, changing ideas about the nature of practice and philosophies of care, changing patterns of work and demand for services, the adoption of new technologies and new techniques have created a turbulent environment for practice for professionals working in hospitals. Newly qualified radiographers still have much to learn. In order to make a successful transition to being an experienced practitioner a novice needs to negotiate five major learning challenges, involving:

• Successful engagement with major (and changing) work activities;
• Successful interaction with others;
• Successful learning from experience;
• Commitment to continuing professional development;
• Coping with the demands for flexibility, transferability and work intensification in the workplace.

Successful engagement with major (and changing) work activities

Engagement with core professional tasks

The most obvious learning challenges facing newly qualified radiographers relate to the successful completion of their core professional tasks in practice. Considerable learning for newly qualified radiographers comes from their engagement with work as they move towards becoming experienced practitioners in their own right. The challenge of work itself can lead to significant learning, particularly for the newly qualified. Radiographers need to manage patients under varying circumstances and work as part of a team. Technical and professional knowledge, interpersonal skills and sensitivity are all required. The increased sensitivity to the need to recognise individual differences between patients means that skills of patient management have increasingly come to the fore. Additionally, the work of radiographers is becoming more complex, with the technical and IT skill demands increasing and the underpinning knowledge base also expanding. Skills associated with intra-hospital team working are becoming more important and this can be a particularly sensitive issue for radiographers, as this could be seen to present a challenge to existing hierarchies, as it requires doctors and consultants to acknowledge the expertise of others. This was illustrated by Eraut, Alderton, Cole and Senker (1998) who describe a case where the sensitivities were such that radiographers "put red dots on pictures to casualty officers where they had noticed something broken, thus contributing to diagnoses by often relatively inexperienced doctors without trespassing on their traditional territory" (p.44).

As well as learning from job rotation the newly qualified need progressive exposure to more complex clinical cases. Such learning though often needs to be supported by a process of active reflection and review whereby it is possible to discuss and share with others ideas about the most effective ways to tackle a range of problems in practice. This exposure to a variety of cases and contexts facilitates learning through observation and listening as well as from direct experience (Eraut et al, 1998). Indeed, where the more complex cases are initially handled by more experienced colleagues this is a classic form of learning through legitimate peripheral participation (Lave and Wenger, 1991).

Over time, as they get more experienced, practitioners will be expected to change how they work, for example in relation to how they carry out their initial diagnoses. One characteristic of effective performance of experienced physiotherapists and radiographers is that, like other professionals, they have learned to make some decisions rapidly and intuitively, while others require much more deliberation, analysis and discussion (Eraut, 2000). Newly qualified practitioners have to learn to make these distinctions and this requires a readiness for experienced practitioners to discuss their interesting cases as well as those of the novice, if the novice is to learn to model appropriate patterns of thought. The lack of time for such discussions in a service under pressure could mean that the novice takes longer to reach the stage where he or she can make such discriminating judgements, with the consequence that service delivery could be adversely affected to some degree.

Engagement with changing ways of working

Partly as a consequence of continuing skills shortages and recruitment difficulties, and the pattern of skill ownership of existing staff, all departments were thinking about the use of assistants and other support staff and the boundaries of responsibilities between radiographers and consultants. Where such changes were implemented all staff had to cope with changed patterns of working. For example, the shift of responsibility from consultants to radiographers could mean the latter had to perform a wider range of tasks and were required to use more highly developed clinical and inter-personal skills. These types of changes also reinforced the need for training and support for intra-team working. The demand for more flexible working had also led to the active consideration of skill mixing, particularly in the larger health care units. Skill mixing involved examining both job content and the internal structure of the department in order to address service goals more effectively in the light of recruitment difficulties. There was evidence that the development of the assistant role had contributed towards alleviating some of the constraints on service delivery caused by recruitment difficulties by freeing up valuable practitioner time to deal with more time intensive cases (Brown et al, 2000).

Successful interaction with others

The newly qualified radiographer has to learn to be able to sustain relationships with a range of people, including being able to develop and sustain therapeutic caring relationships with patients. The newly qualified also need to be able to work with colleagues, not least in order that they are able to learn from more experienced colleagues. That this can come through both from watching them in action and through discussions is apparent, although Eraut et al (1998) point out that the extent of such support varies between different communities of practice, with feedback from colleagues being a particularly prominent feature of the work of diagnostic radiographers. Professionals then learn from each other, and the educative function may sometimes be explicit as when radiography staff ‘educate’ each other in the most effective way to use new equipment. It is also common for the newly qualified to learn from colleagues in a variety of less formal ways too.

Morrison (1992) points out that those working in the caring professions also have to deal with issues of emotional involvement, stress and work constraints. This underlines the importance in such circumstances of having mechanisms where individuals can talk these issues through with colleagues. The most effective departments all had such mechanisms in place, although they varied in the extent to which they made use of formal or informal methods (Brown et al, 2000). Taylor (1992) argues that such an approach is vital, as those working in the caring professions need to relate to each other as people, not just in terms of their professional roles. They need to be regarded as people who share the everyday common human qualities of their patients. The more departments become over-loaded the more important it is for colleagues to feel supported, and without that support retention of staff becomes much harder to achieve.

Newly qualified staff have to learn to work with and from other staff too, including other professionals. The ability to communicate effectively across services and disciplines has become a core competence and inter-personal skills when dealing with the public, for education and prevention as well as treatment, have become even more important for those working in this area. In some cases organisation-wide concerns could impact upon skill development of newly qualified staff at departmental level, as where a hospital gave particular attention to improving intra-team communication (Brown et al, 2000). The concern with intra-team communication was considered vital, because although radiographers were being given greater responsibilities for interpretation and marking up X-rays, consultants did not always recognise their expertise. Also radiographers have to work with others to establish the most effective ways of presenting information (especially as there is variation in the local preferences for how information is presented). Where this type of training was successful and all parties had confidence in the expertise of others, genuinely worked as part of a team and appreciated the different roles and challenges facing other members of the team, then a higher quality service was delivered to patients.

It is also worth noting the necessity of not considering the learning and development of radiographers in isolation, but rather focusing upon the skill utilisation of the team as a whole if they are to deliver an efficient, high quality service. Thus radiology departments that adjusted the skills mix according to whether they were able to recruit radiologists, experienced radiographers or the newly qualified, then needed a plan for the effective utilisation of the particular skills mix they had. Intra-team skill development was particularly important in achieving this flexible response.

Newly qualified health care professionals are likely to make a successful transition to becoming experienced practitioners if they are members of a number of networks. Professional networks, regional collaboration and programmes of continuing professional development are all important in the dissemination of good practice, but more informal networks also played a significant role in spreading good practice (Brown et al, 2000). At departmental level it is particularly important to ensure that newly qualified practitioners are tied into such networks. The learning of newly trained practitioners was also facilitated if:

• Regular mutual staff discussions were encouraged;
• Mentoring relationships were in place;
• Formal reviews of practice were held;
• Informal relationships led to work-related discussions at which more ‘provisional’ or ‘riskier’ comments could be made without pretending to be authoritative (such discussions were often held after work and/or in settings away from work).

It is important to acknowledge the role of informal relationships as a means of supporting learning and not to focus solely upon the successful interaction with others in formal settings. Although learning through personal networks is important for less and more experienced health professionals alike (Eraut et al, 1998), the former also have to learn who holds different types of knowledge, how to access it and so on. One key link was often colleagues with whom an individual had trained and who were now working in different hospitals. Such contacts could be important for the newly qualified who did not always initially at least wish to share some of their doubts about aspects of their own work with their new colleagues. Personal networks could also lead to access to required knowledge through chains of contacts.

Successful learning from experience

One line of argument sometimes advanced by managers was that the move to graduate entry had intensified the requirement for further learning while working after formal qualification. The issue was that new entrants might have insufficient experience of exercising the practical skills they need to do the work, resulting in the need for very intensive on-the-job training once they were qualified. In the context of a pressurised workplace environment, however, such training does not always coalesce with the ‘reflective practice’ approach instilled within degree-level training (Brown et al, 2000). Skill deficiencies of recently qualified graduates may relate to their relative lack of knowledge of the particular contexts in which they are working. In particular, they may need support for learning to implement practical principles in particular contexts. This inexperience is partly due to the necessity for teachers to describe practice in generic terms, such that learners will have sets of practical principles with which to cope with the variety of possible practice settings (Brown et al, 2000). On the other hand, the shift of professional training into higher education may lead to rather less emphasis being given to ‘practical knowledge’ and greater emphasis on (academic) scientific knowledge. This may be partly due to teaching by academics who have a disciplinary (academic) background, rather than by professionals with practical experience. This may mean that students are not provided with authentic examples of ‘knowledge use’ in practice (Eraut, 1994). Whatever the reasons, the perception is that graduates lack sufficient understanding of how knowledge is used in practice, and that this makes their subsequent learning from experience even more vital.

It may be that graduates are also less proficient at some practical tasks, simply because they have had much less practice than those trained under the old system. The exposure to a range of experience over time may be particularly significant in the build-up of implicit or tacit knowledge rather than explicit knowledge. The profession as a whole is of course aware of this in the sense that they recognise that new graduates require additional training and that is one reason for widespread use of job rotation in the first two years following graduation. Experienced practitioners, however, may feel that they are increasingly stretched by other duties to give as much time to supervision and support as they should in more ideal circumstances.

Learning from their own experience is important for the newly qualified, but so is learning from the experience of others. Newly qualified staff needs opportunities to discuss and practise thinking about complex cases handled by their more experienced colleagues. This approach to seeking to tackle complexity through interpretation and a shared search for understanding gets to the heart of "the discursive nature of professional practice" (Webb, 1996, p.111). Such an approach does not involve copying the precise way others tackle problems, but rather following the general approach of drawing on knowledge, abilities, skills and attitudes used in an integrated, holistic way (Gonczi, 1994).

The value of extended dialogue to reflective practice is now widely acknowledged, and without this departments could lose their sense of shared purpose, and just react as individual practitioners, without any impetus to improve the quality of practice. This extended dialogue underlines the social nature of learning and working and should, from an activity theory perspective, enable practice in the department (or activity system) to be transformed. By this means both internalisation (socialisation of new staff) and externalisation (developments of new reactions within the activity system) of learning would be facilitated (Engeström, 1992).

Various forms of organised learning support can be used to facilitate the learning from experience of the newly qualified. For example, rotation, clinical supervision and mentoring could all be organised more or less formally (Eraut et al, 1998). The mentor could be just offering support on a serendipitous basis or taking great pains, as in the case of a more experienced radiographer offering support to a less experienced colleague:

"this woman goes out of her way to show her relevant things that come up when she’s not there, shows her lab reports on mammograms she has done, etc, thus building up her expertise more quickly" (p.40).

The challenge facing hospital departments therefore was how best they could support the learning while working of their newly qualified radiographers. Learning could take place as a result of cascading experience, particularly where increased multi-disciplinary work and teamworking placed greater communication demands on staff in addition to those required for dealing with patients. For example, in a radiology department, where a new MRI scanner had been recently introduced, there was a need for radiography staff to ‘educate’ other professionals in the potential dangers of using the equipment incorrectly and the need to adhere to protocols. This sometimes created problems if the other professional was in a superior position and the situation required assertive handling by the junior, as this could present a challenge to established organisational cultures (Brown et al, 2000).

One way learning from experience has become more formalised is through the increasing expectation that health care professionals will engage with their work in a way that makes greater use of formal evidence than in the past. The call for evidence-based practice to be used as a basis upon which to make clinical judgements requires greater attention to be given to an understanding of the nature of research and what constitutes clinical evidence (including issues of validity, reliability and generalisability) (Gray, 1997; Greenhalgh, 1997; Sackett, Richardson, Rosenberg and Haynes, 1997). In this area of learning through evidence provided by research and examples of good practice newly qualified (graduate) staff sometimes had an advantage over some less qualified but more experienced colleagues. This was because of the shift of emphasis in initial training towards understanding the rationale for evidence-based practice. Some departments found particular attention and support needed to be given to those practitioners who did not possess a degree or equivalent qualifications and were less likely to be familiar with research (Brown et al, 2000). Newly qualified staff were likely to be familiar with models of reflective practice. However, the model of the reflective practitioner requires time to be made available for professionals to reflect upon their experience, actions and thinking as a basis for continuing to develop their expertise. Newly qualified staff needed time to reflect with others on their practice at a time when all staff were often feeling stretched by demands on their time in practice.

Commitment to continuing professional development

In health care continuing professional development (CPD) is often specified as a requirement of professional practice. In this context, however, it should be remembered that formal education and training provide only a small part of what is learned at work by professional staff (Eraut, Alderton, Cole and Senker, 1999). Even where hospitals had the capacity to provide formal training, there was sometimes a reluctance to release staff when departments were under-strength and working at full stretch and this increased the de facto reliance upon learning through working. This could be effective, but only if the requisite support was available for on the job learning. This too was not always forthcoming. Hence staff at all levels in some departments felt there were times when they were working at the limits of their knowledge and understanding, and that this may have compromised their effectiveness to some degree and resulted in slower patient throughput (Brown et al, 2000).

The importance of CPD is therefore officially recognised by hospitals, but the commitment may be compromised in practice. However, the drive for CPD and further training creates a strong lifelong learning culture within the practitioner community, but this is not always complementary with meeting the full range of demands on services. Budgetary constraints as well as quality and efficiency targets in meeting patient demand sometimes resulted in the ‘rationing’ of training particularly among intermediate level staff (Brown et al, 2000). All departments had to live with examples of training being squeezed because of more immediate pressures, but the more effective departments did not allow this to become standard practice, rather after cancellations in one period they moved training up their list of priorities for a subsequent period.

Formal CPD may also play a role in an individual learning additional specialist skills where these were not fully covered initial training. For example, specialist skills were required for work in specialisms, such as mammography, ultrasonography, skeletal reporting and paediatrics in radiography. In addition, in some areas, such as paediatric radiography, staff needed to have two years general radiography experience and were only recruited at senior level. Progression for clinical staff had traditionally tended to be into managerial roles, although the creation of clinical specialist roles in recent years in some case study departments / services had given greater opportunities for career development and this acted as an incentive to undertake further CPD. Responses to recruitment difficulties sometimes included the use of in-house training or the funding of courses in particular specialist areas.

An individual’s commitment to CPD, however, should not just involve participation in formal staff development, as practitioners are also expected to engage in their own self-directed learning. As Eraut et al (1998) point out this should involve individuals in an active role in finding out on their own initiative what they need to know. This could include learning through reading papers, journal articles and case histories.

Coping with the demands for flexibility, transferability and work intensification in the workplace

The hallmark of successful professional practice is the ability to draw on knowledge, abilities, skills and attitudes used in an integrated, holistic way (Gonczi, 1994). This approach to the performance of professional tasks draws attention to three important features. First, complex professional duties can be performed in a variety of ways. Second, these duties can draw on different combinations of knowledge, skills, abilities and attitudes in effective performance. Third, this approach implies that there is scope for professional judgement, not least in the ability to balance competing demands and the pressures of time. This means that individuals may come up with very different ways of responding to the demands for flexibility, transferability and work intensification in the workplace. Indeed one way forward for the newly qualified and experienced practitioners alike may be to review the different ways individual practitioners seek to tackle their workload as a whole. By this means it should be possible to discuss and share ideas about the most effective ways to tackle a range of problems in practice.

In order to respond effectively to the demands for flexibility, transferability and work intensification in the workplace requires a collective as well as an individual response. Departments need a sense of shared purpose, and this highlights the social nature of learning and working which should enable practice in the department to be transformed. However, departments as well as individuals are constrained in how they can respond, because of the need to pay attention to institutional performance indicators, which themselves were often explicitly linked to targets set by government. All staff seemed well aware of the need to pay attention to performance targets outlined in departmental plans for service delivery (patient throughput; waiting lists; waiting times and so on). All departments actively reviewed their performance against such targets, and particularly where targets were based upon per capita funding, newly qualified staff could feel under pressure to reach experienced worker standards as quickly as possible.

The most obvious manifestation of work intensification came from the rapidly increasing demand for some radiography services. Active management at departmental level was required to cope with this increase in demand. Some departments extended opening hours and introduced more flexible patterns of working, although these goals could sometimes conflict. A balance also had to be negotiated between handling demands for greater efficiency and improved quality. The consequences of the increasing demand for services for newly qualified staff were both direct and indirect. The direct consequences were reflected in their own increased workload and the indirect consequences came from less time available for some senior staff to devote to training because of the increased time they spent on departmental management responsibilities. For these reasons caseload management and time management have become much more important at the individual level and newly qualified staff in particular may require support to do this effectively. It may also be that the increasing drive for efficiency and performance within health care systems may limit the time practitioners for activities that convey caring rather than just competence.

Besides general problems some departments were faced with particular pressures because patterns of individual career development and departmental recruitment practices meant that they had large numbers of relatively inexperienced practitioners in some services. What is particularly apparent here is that support for the learning of newly qualified radiographers at work needs to be placed in the broader context of work in their departments (or across departments) as a whole. Using an activity theory perspective, the focus of learning in the department as a whole should alternate between socialisation of staff and framing of new approaches to developments at a departmental level, involving the continuing switching between the internalisation and externalisation functions of learning (Engeström, 1992).

At a departmental level Brown et al (2000) identified several key factors that had enabled departments to battle successfully with the considerable constraints and challenges they faced. These were:

• Proactive rather than reactive management;
• Recognition of the benefits of investing in training;
• Willingness to evolve new models of service including developing collaborative arrangements with related service providers;
• Willingness of staff to work as part of a team and appreciate the different roles and challenges confronting other team members;
• Recognition of the centrality of learning through work for newly qualified staff and paying particular attention to the allocation of work and supporting these individuals (Brown et al, 2000, p.32).

Concluding discussion

How best to support the learning of newly qualified staff needs to be informed by a contextualised understanding of what it is that the newly qualified have to learn in an environment characterised by flexibility, transferability and work intensification. The context is important because different configurations of staff may radically change the opportunities for different forms of learning. For example, those departments that regularly recruit newly qualified staff (because of high staff turnover coupled with a lack of experienced applicants) will probably need to have in place more formal systems of mentoring, supervision or other support. This will be required in order that the less experienced have opportunities to discuss and practise thinking about complex cases handled by their more experienced colleagues. This may be less vital in those departments where there is a more even balance of more and less experienced staff and as a consequence where there may be more informal opportunities for such discussions to take place. The newly qualified need to practise using their professional judgement, not least in the ability to balance competing demands and the pressures of time. Active reflection and review on different ways practitioners seek to tackle their workload as a whole may be one means by which it is possible for practitioners to discuss and share ideas about the most effective ways to tackle a range of problems in practice.

Traditionally the focus of the continuing development of professional competence in the health sector has been upon skills, methods and techniques. The professional skills of developing and implementing therapeutic plans and negotiating client goals continue to be required. However, the organisational (and administrative) competencies necessary to successful performance in the organisation; and the social-communicative competencies relating to the department, team or professional group’s practical environment are becoming even more important than they were in the past. These, however, may receive comparatively little attention either in formal training or informally during learning while working. This is despite work intensification and the sheer volume of work to be completed resulting in organisational or departmental difficulties becoming more intense. Radiographers have to learn to deal with complexity, contradictions and uncertainty. This in turn means that the organisational and social-communicative aspects of professional performance become more significant, with a consequent emphasis upon planning, acceptance of responsibility, independent action and social skills. Helping, teaching/coaching, clinical diagnosis and monitoring remain at the heart of professional expertise, but effective management of a caseload as a whole, as well as of individual cases, has become more important.

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