How prepared are newly qualified allied health professionals for practice in the UK? A systematic review

Literature identified

The search identified 1880 records, and after screening, 14 reports of 13 studies satisfied the inclusion criteria (figure 1). There were two reports of one study.20 28 The grey literature search identified three reports.28–30 The characteristics of the 14 included reports are listed in table 2.

Figure 1
Figure 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram.27

Table 2

Characteristics of included studies

Characteristics of included studies

Of the 14 reports of included studies, 9 were qualitative studies (interviews and focus groups), 3 were mixed method (questionnaires) and 2 were quantitative (questionnaires). Six papers focused on radiographers, three on a mixture of professions, two on paramedics and one each on physiotherapists, clinical psychologists and orthotists. Seven reports of included studies had newly qualified professionals as participants; three had other stakeholders, that is, supervisors and managers; three had a mixture of newly qualified professionals and other stakeholders; and one had students, newly qualified professionals and alumni.

Newly qualified professionals’ preparedness for practice

In the following subsections, we present the synthesis of included studies grouped by profession, with the final subsection presenting cross-cutting themes.

Radiography

When newly qualified radiographers first started work, graduates who had entered a completely new diagnostic department upon graduation reported experiencing reality shock.20 28 Another study of radiographers, where graduates entered the hospital they had carried out their undergraduate placements in, did not report any reality shock.31

New graduates reported being tired from working a full-time job which involved long hours, weekend working, 24-hour shift patterns and being on call. They also found the imaging department to be very busy.31 This was unexpected and something that they reported not feeling prepared for. Participants were also overwhelmed by the amount they still had to learn in the new environment. While this shock only lasted for 3–6 months (reported by participants through longitudinal interviews), it was experienced as a very stressful and emotional time for the newly qualified graduates, making it difficult to fit in and have a smooth transition. Many participants in one of the included studies described this first 3 months with phrases such as ‘absolutely terrifying’, ‘absolutely petrifying’, ‘quite a roller-coaster’, ‘a big learning curve’ and ‘stressful’ (29: 66). These strong emotions were felt by nearly all of the participants at this early stage, highlighting that this was a challenging and frightening time for the new registrants.20

Newly qualified radiographers were concerned about working in areas where they lacked experience and they had a ‘fear of the unknown’, particularly working outside of normal working hours and in operating theatres.31 However, for some, their confidence increased when they had to manage on their own and work things out for themselves.31 Some participants reported that they recognised when they needed support and, in this study, seemed to have no problem asking for support when they needed it. Some were also concerned about taking responsibility for both themselves and for students, as well as checking their images for technical acceptability and justifying the request cards. Interestingly, a few of the newly qualified radiographers in this study seemed to have a desire to cast off the student identity when they started practice.31

One of the included studies highlighted the fact that the role of the graduate radiographer is in a state of flux.32 This is reportedly because current radiography education is mainly focused around a specific type of professional duty, that is, projectional radiography (which produces two-dimensional images) and CT of the head. Graduates’ first posts in clinical practice are defined by the particular department, role function or employer they work for and thus their scope of practice is defined by their particular role. The competences developed in their preregistration training may be used in that role or sometimes new competences may need to be developed via induction programmes and preceptorship to match that role. This was particularly the case for cross-sectional imaging in that a newly qualified graduate may start work in this field and never use their competences developed in projectional radiography again, despite this still being the most commonly used of all the imaging modalities.32

A quantitative study involving a questionnaire completed by newly qualified radiographers (n=85) found that many (77.6%) were confident with their red dot skills (a method to identify potential abnormalities on plain radiographs). However, a sizeable number of respondents reported not being confident in describing abnormalities (approximately 33%). 30% of participants thought Preliminary Clinical Evaluation (PCE) training at university was not suitable, and 55% thought PCE training on placement was not suitable.33

Management and leadership skills were considered a very weak area for newly qualified therapeutic radiographers. Therapeutic radiographers use radiation to treat cancer and tissue defects and the programme reported on in the study was a very specific type.34 The study participants agreed that these competencies are essential in undergraduate education and that further training may be beneficial at Masters level for therapeutic radiographers who take on management roles. Some of the interview participants (including employers) did not believe management skills are essential, since these are often covered by postgraduate programmes.34

Therapeutic radiographer graduates were also reported to be underprepared for quality assurance of equipment used to treat patients. This is because the quality assurance is usually done by the physicist and the therapeutic radiographers have more limited basic quality assurance understanding. The suggested reason for this was that students do not have to get signed off as having taking part in those procedures and usually have practical-type sessions.34

Research competencies of newly qualified radiographers were also found to be underdeveloped for many. The implications of this is that they may be unable to create new knowledge to inform their practice. However, there is a strong emphasis placed on evidence-based practice and preparing graduates to apply research results into their practice.34

Paramedicine

A qualitative study of newly qualified paramedics and managers highlighted the robust theoretical knowledge and practical skills of many paramedic graduates particularly anatomy and physiology, treatment modalities and rationale for treatment.35 However, there was also a reported gap between theory and practice for some newly qualified paramedics, that is, learning in a safe classroom environment versus experiencing it in clinical practice.35 36 The main knowledge gap identified by participants was clinical decision-making, bringing both theory and practice together.35 36 In particular, newly qualified paramedics felt unprepared for making a decision about the care plan for a patient.36 Interviewees suggested that the main reason students did not develop their decision-making skills was because they never had to take responsibility for the patient as there was always a qualified paramedic present.

All four qualified paramedics who participated in this study reported that they often lacked in confidence when they graduated, particularly in what were seen to be softer skills, that is, people management and decision-making rather than clinical challenges about patient assessment and treatment.36 Some newly qualified paramedics had strong concerns about their registration being at risk, which for some, it had reportedly resulted in defensive practice. This was perceived to be due to their lack of confidence. It was purported that their lack of exposure and experience made them feel more vulnerable.

It was reported by all paramedics and managers that newly qualified paramedics would be very unlikely to operate effectively as an independent practitioner and that they required a period of supervised practice before being able to practise independently.35 Leadership, clinical decision-making and ‘putting it all together’ were identified as areas where the most work needed to be done by ambulance services as part of the supervised practice period. Participants highlighted that level of responsibility given to students on placement varied from observation only to active participation in patient care and this was based on what the ambulance team members felt would be appropriate for students to do. As a result, the student may not have achieved the outcomes for the placement or reached the required level of competency.

Physiotherapy

A questionnaire study of newly qualified physiotherapists found that physiotherapy programmes generally prepare graduates well for practice against the HCPC standards of proficiency but not for physiotherapy-related clinical skills including exercise prescription, psychosocial skills and patient management.37 It was reported that graduates were well prepared to practise safely and effectively, understanding the key aspects of the knowledge base, as well as communicating effectively within ethical and legal boundaries. However, three HCPC standards of proficiency were rated by respondents as being ‘indifferent’. These included competencies of autonomy, awareness of culture, inclusion and diversity with the ability to draw on knowledge to inform practice.37 A small qualitative study of physiotherapists found that physiotherapy graduates had limited practical experience of working on-call rotas and treating very sick patients in an acute hospital environment.38

Orthoptists

Using focus groups with newly qualified orthoptists and their mentors, the preceptorship programme of the British and Irish Orthoptic Society was explored. This study had a particular focus on the embedding of public health campaigns such as Make Every Contact Count and healthy conversations in clinical practice. They found that it was difficult for newly qualified orthoptists to implement public health behaviours with patients when they first graduated. New orthoptist graduates’ lack of confidence was found to be a barrier to embedding public health into clinical practice.39

Clinical psychologists

A questionnaire study found that prospective, current and alumni trainee clinical psychologists reported feeling confident in most leadership skills outlined by the British Psychological Society but that the doctoral programme was effective in developing just under half of the skills.40 Participants reported high levels of confidence but low levels of programme effectiveness in the awareness, building and maintenance of interpersonal relationships, an understanding of the emotional impact of change (including resistance), emotional intelligence and/or resilience, and understanding of diversity, values, ethics and integrity. This may have been because individuals developed these skills in other contexts or outside of the taught programme. Participants reported that the programme helped to develop an ability to use evidence, data collection, outcomes and audit to constructively critique current service practice, but participants did not feel confident in this skill. Similarly, participants also indicated a relative lack of confidence in skills in coordinating research teams (supervisors, governance officers, collaborators).

Mixed professions

A questionnaire study of HCPC registrants’ preparedness for practice found that 80–92% of respondents agreed that they felt prepared to practice.30 However, there was some disagreement in terms of being prepared for understanding what they need to do to remain registered and receiving the grounding to practice as an autonomous professional. Although these areas equated to <10% of responses overall, paramedics (68–87%) and occupational therapists (66–91%) reported lower levels of agreement.30

A mixed-methods study found that on the whole, the results suggested that newly qualified HCPC professionals are prepared for practice.29 However, there were some ‘other’ stakeholders, for example, educators, managers and professionals who felt that the standard of newly qualified professionals is not high enough. Many respondents indicated that the expectations of students needed to be managed before graduating, so that they were aware of the role of a newly qualified professional. There were some concerns about the impact of the variability of both the placement experience as well as the role and training of the practice educator. The findings revealed concern, mainly from service users, that some newly qualified registrants are unable to relate to service users in an appropriate way.

A study of occupational therapists and physiotherapists found that some participants highlighted that newly qualified staff who had undertaken a placement in a similar environment to their first post were quicker to understand the expectations of the job role, clinical reasoning skills and systems of working.38

Cross-cutting themes

We identified four common themes across the professions. The first was around clinical decision-making and taking responsibility, which was key to being an autonomous clinical practitioner. Some newly qualified radiographers had concerns about working in areas where they lacked experience, taking responsibility for themselves and students, and describing abnormalities on a radiograph. In paramedicine, a few were concerned about making a decision about the care plan for a patient, while many physiotherapists felt unprepared for exercise prescription and patient management. The studies of the mixed professions reported some disagreement about receiving the grounding required for autonomous practice. The second common theme across the professions was around leadership skills. These were considered a weak area for some radiographers and paramedics but were a strength for many clinical psychologists. The third theme was around research and critical appraisal skills. Research competencies of radiographers were reported to be underdeveloped and while the clinical psychology programme helped students develop these skills, some did not feel competent in applying these skills to practice. Finally, the fourth theme related to knowledge base in that many physiotherapy and paramedics were prepared for understanding key concepts of the knowledge base.

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