Towards the development of a reflective radiographer: challenges and constraints
Department of Medical Imaging and Radiation Sciences,
Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
Currently there is overwhelming support from the health
professions for universities to devise curricular approaches that lead to the
development of undergraduate reflective skills, and over time, reflective
practice. However, in the case of radiography, irrespective of the degree to
which radiographers might engage in reflective practice they constantly
struggle to shed the perception they are little more than technical
operatives.� The four-year Bachelor of Radiography and Medical Imaging was
introduced by Monash University in 1998 with an overt commitment to the
development of a reflective radiographer. Findings from student and supervisor
surveys generally support the program and its aims. However, as the findings
and student feedback will attest, many challenges and constraints continue to
face educators who seek to situate their curriculum within the reflective
practice paradigm. � 2008 Biomedical Imaging and Intervention Journal. All
Keywords: Education; reflective practice; curriculum
Preparing students for entry into the health profession
has always been a challenging undertaking. The curriculum must not only keep up
with the relentless developments in biomedical knowledge, technology and
engineering it must also pay serious attention to what is now known about the
development of clinical expertise . At the same time, health professionals
are being increasingly mandated by Registration Boards and Government and
professional bodies to actively apply critical thinking within the workplace,
demonstrate reflective, creative, communicative and interpersonal skills and,
by association, engage in �reflective practice� [2-8]. Therefore, it is no
longer satisfactory for educators within the health profession to simply
develop the knowledge base of their students. Educators are increasingly
obliged to ensure their students develop the kind of personal and intellectual
capacities that will lead to defensible and ethical decision-making that is
grounded in the best available �evidence� .
Indeed, there has been a paradigm shift towards the need
for educators to close the �gap� between the seemingly stable world of the
academic-shaped as it is by objective and generalisable scientific theories and
the somewhat chaotic world of the practitioner in which experiential knowledge
is accorded a privileged position [1, 10-14]. Additionally, within radiography
at least, educators must respond to pressures from the profession for graduates
who are technically competent [15-16].
As radiography was the last of the health professions to
upgrade from diploma to a degree level of education [17-18], it is not
surprising that in keeping with the trends of the 1990s, academics followed the
lead established initially within teaching and, then nursing, by embracing the
reflective practice paradigm as a means of bridging the so-called �gap� between
academia and the practice setting [19-22]. However, questions are now being
raised within nursing as to whether engagement with the reflective practice
paradigm is worth the effort [2, 6].
This paper will demonstrate how the Bachelor of
Radiography and Medical Imaging has been structured to meet the new challenges
facing radiography educators. In the process, the paper will argue that
educators must continue with their efforts to expose students to the principles
associated with the reflective practice paradigm. At the same time, given the
technological and socio-political context within which radiography is
practised, and the nature of clinical expertise, it will be argued that
educators need to place the practice of radiography at the heart of the
curriculum and ensure the academic content of their courses is contextualised
to the needs and concerns of the practice setting.
The value of the reflective practice paradigm in informing the curriculum*
Why should educators embrace the reflective practice
paradigm? Because engagement in reflective thinking is how practitioners create
knowledge as individuals and, as members of a �community� of practitioners
[24-25]. Reflective thinking is also the bulwark against the all too easy slide
into �habitual� and, in extreme cases �dysfunctional� practice [26-28].
A recent critical clinical learning experience from a 2007
first year Monash radiography student (extracts reproduced with permission - Please note: all student and practitioner names including hospitals are
instructive in this respect:
�The hospital I went had a vast range of patients and poses
a great threat to the spread of infection (sic)� An elderly inpatient was
brought to the radiology department from a ward for abdominal x-rays.� The ward
was known to have patients with gastro.� In general most of the radiographers
involved in the examination used protective measures� There was however a
radiographer � who found it unnecessary to apply protective barriers and follow
the hospital protocol� I found the situation troublesome. I believe the
situation was handled poorly by that specific radiographer and perhaps even by
other radiographers involved.� None of the radiographers who correctly followed
the infection control protocol took it upon themselves to check everyone
participating in the examination was wearing protective clothing before the
patient was handled�� Ultimately, I believe the level of patient care was
compromised due to the failure of a radiographer to correctly follow
Educators have always known that the learning of theory
cannot tell someone how to practise [25, 29].� Neither do competency-based
descriptions of professional practice adequately capture the essence of
professional knowledge [2, 23, 30 - 32].� Even in a profession that is
completely mediated by technology such as radiography, Sch�n�s  assertion
that traditional forms of knowledge are bounded in the practice setting by
�artistry� in the form of �problem framing�, �improvisation� and
�implementation�, holds true.� The following excerpt from a 2000 first year
Monash radiography student�s (extract reproduced with permission) critical
clinical learning report illustrates this point:
�By the end of the first week, it was clear that not all
doctor�s requests were precisely correct in terms of the radiographs required.�
Often, much more information is relayed directly from verbal communication with
the patient.� One such outstanding case appeared whilst I was assisting Kathy
(a radiographer with 8 years experience) on an in patient (sic).� The request
form for this elderly patient had ordered for an AP and lateral projection of
the hip joint (normal protocol in the hospital) as she had undergone a total
hip replacement. However, the patient continually complained about her leg.�
After querying about where and how the pain was initiated, it was decided that
a shot of the whole femur would be done.� The commendable outcome was that a
fracture at the tip of the pin was captured � and only seen on the AP
projection (sic). If the conventional projections suggested by the doctor had
been undertaken, such a fracture would have never been seen. Due to rational
communication with the patient the problem was identified�.
Therefore, whilst students need to know the rules and
underlying principles of the practice, they need to be given opportunities to
learn how to adapt these rules and fit the theory to the particular problem at
hand [23, 33-34]. According to Harris , it was Sch�n who demonstrated that
competent practical action is contingent upon competent practical reasoning
which involves �knowing-in-action�, �reflection-in-action� and
�reflection-about-action�.� Furthermore, it is the ability of the practitioner
to define the problem or make a puzzling situation coherent, which Sch�n 
argues is the crucial precursor for the application of technical or scientific
knowledge to the problem at hand.
Reflective practitioners are unusually adept at handling
situations of uncertainty, uniqueness and conflict . In the midst of
confusion, they bring to the surface a host of cognitive and emotional assumptions,
critically re-examine them, pose new questions, construct effective judgements
and, in the process, develop new or modified action theories [5, 23, 29,
36-37]. Reflective practitioners know how to use reflective processes to break
out of habitual responses to their practice .
Is the reflective practice paradigm strong enough to overcome the influence
of the prevailing socio-political context?
Few educators would disagree that reflective practice is a
�good thing� . Nevertheless, revelations from patients, whistleblowers and
students raise the question as to whether the reflective practice paradigm is
robust enough to truly prepare students for entry into professions that are now
simply seen as part of the health care industry, which is increasingly
dominated by the �invisible� hand of the marketplace and recourse by patients
to litigation [40-41].�
For example, it appears that the public hospital system in
Australia remains in a permanent state of �chaos� [42-44]. Many in the wider
community must be wondering how members of professions supposedly dedicated to
meeting the needs of the sick and dying, could systematically ignore the pleas
of a woman in a major Sydney emergency department before she miscarried in the
toilet. The woman�s husband reportedly criticised the hospital for providing no
�care and comfort� . The following extract from a student informant who was
given the name Veronica, gathered in the context of the author�s doctoral study
into the practice of radiography supports this experience of public hospital
�I was questioned by my supervising radiographer as to what
I was doing? I said that I was helping the patient change as the patient was
having difficulties.� Also, because we were not busy, I felt that I had time to
chat to the patient.� I was told not to waste my time talking to my patients.�
My supervisor told me if they want better service they should go to a private
practice� (Baird, 1998, p337).
Unlike other health professions, radiographic practice is
completely mediated by technology. Irrespective of the imaging modality,
radiographic practice in Australia is also supervised by medical practitioners
many of whom are partners within a profit-driven radiology industry [41,
47-48]. As a consequence, attempts by radiographers to engage in �virtuous�
practice are regularly influenced by the imaging protocols established by
radiologists and the imperatives of the sector to meet its �bottom line� [41,
Sonia (another informant) found the habit of radiographers
in �hurrying� patients along instead of stopping and explaining things to them,
quite disconcerting.� She told me that the radiographers she had worked with
�get the patient against the bucky with the cassette in place before the
patient has had a chance to comprehend what is going on�.� In fact, Sonia found
that during her time at Primrose Square Hospital the radiographers made her
feel that she had been in the way.� Their overriding concern was �to get the
patient done and get on to the next one� (Baird, 1998, p334).
These examples confirm the observations made by Eraut 
- when he argued that due to institutional pressures and constraints, the
critical monitoring of practical action can become difficult to maintain. As a
consequence, mistakes occur and patient care is compromised. The following
excerpt from a 2002 first year Monash radiography student�s critical clinical
learning report (extract reproduced with permission) provides an illustration
of what many would regard as poor professional practice:
�The initial breakdown in communication was not helped when
the attending doctor told the patient in much the way as referring to a
mischievous child �you have two choices you either have the x-rays or you go
out of the door!�� The radiographer then proceeded to use forceful actions to
move the patient � most communication was blunt��
According to the student, the patient in question was not
under the influence of any drugs. Pressures to conform to �entrenched custom
and practice�  within the health sector characterises the delivery of
health mitigating against effective service delivery virtually forcing busy
practitioners to develop habitual approaches to their practice [40, 46, 49].�
�The communication element of the Professional Skills
subject was good but not realistic. You don�t have time to sit down with the
patient for 5 minutes beforehand for a chat� (Monash Student 22, clinical
debriefing session Semester 1 Year 1 2000)
Hence, it should not come as a surprise that at least
within nursing, concerns are now being expressed as to whether the �certitude�
surrounding the capacity of the reflective practice paradigm to produce �better
patient care� is justified [2, 6].�
However, educators must not give up. There are very valid
reasons why the reflective practice paradigm should command our attention.
Dewey  argued a long time ago that it is only through reflective thought
that individuals can be empowered to take control of their destiny. It is only
through a conscious engagement in reflective thinking, he believed,
practitioners could more fully know themselves and, in the process, come to
adopt an inquiry-based approach to their actions . However, at the same
time, Dewey also recognised that those human capacities of flexibility,
responsiveness and self-awareness need to be developed and that the level of
their development is contingent upon the kind of experiences students have
during their undergraduate years [26, 50-53].
Responding to the challenges
As the previous discussion has plainly indicated,
educators face a daunting task in developing a curriculum that is strong enough
to prevent it from simply reinforcing the �reproduction� of radiography in the
way it has always been performed. Whilst students are provided with lectures,
tutorials, laboratory exercises, positioning classes and multi-media programs
about radiography, it is only when they actually experience what it is like to
position a patient for a radiograph that the potential for meaningful entry
into the radiography profession can be realised.
�The clinical tutor did an excellent job in assisting me.
He provided almost constant supervision without being smothering. This has
definitely resulted in a highly beneficial experience� (Monash radiography
student, Year Two Semester One, 2001)
Hence, the curriculum must address the role played by
experience in creating the conditions for learning to occur and the role of
reflection in creating knowledge. Secondly, the curriculum must ensure students
develop an appropriate knowledge base and realise the value of propositional
knowledge in the workplace. In other words, educators must address the
�interplay between formal knowledge � and experiential knowledge� in the
development of clinical expertise . Thirdly, there is a need for educators
to use a model of clinical skill development that acknowledges the
developmental nature of skill development and the complexity of professional
competency whilst at the same time reminding practitioners that judgments about
a student's performance must reflect the experiential level of the student.
Finally, strategies must be in place to support students as they confront the
reality of front line radiographic practice.
The philosophical position of the Bachelor of Radiography and Medical
The four-year Bachelor of Radiography and Medical Imaging
commenced in 1998. The curriculum was heavily influenced by the research
findings of the author. In essence, as a consequence of an extended period of
data collection in the �field� utilising participant methodology, the author
came to the conclusion that existing curricular approaches failed to empower
graduates to change radiographic practice .
Thus, the Monash course reflects a strong commitment to
the experiential learning theory first espoused by Dewey and his notion of
reflective thinking later re-defined by theorists such as Kolb  in terms of
a learning cycle and Sch�n in terms of reflective practice . It
acknowledges the contextual learning theory espoused by Coles  and, just as
importantly, mental schema theory from cognitive psychology [56-57]. Attention
is also paid to the insights educators have gained from the critical theory
associated with Habermas  and constructivism with its origins attributed to
Kant, Piaget and the pragmatic school of philosophy [59-60]. The clinical
assessment tools used within the clinical studies units are congruent with the
�novice to expert� model of skill development associated with Dreyfus and
Dreyfus and introduced into nursing
by Patricia Benner.
Phase one: translating the philosophy into a practical reality
If the gap between the university and the clinical world
is to be bridged, it is helpful to conceptualise the curriculum in terms of a
learning campaign with distinct yet interrelated phases . Phase one relates
to the on-campus program.�
The contextual learning theory associated with the work of
Coles  originally informed the creation of a vertically and horizontally
integrated academic program. It was Coles  who demonstrated that without a
clear clinical professional context being presented to students, theory remains
inert and is treated by students as somewhat superfluous to practice. Therefore
in the Monash course, students are introduced to anatomy, physiology, pathology,
and radiographic anatomy and pathology a semester at a time so a strong
alignment with the corresponding imaging modality, which is addressed in either
the Radiographic Imaging and Methods or Medical Imaging and Methods units and
experienced in the clinical rotation, can be achieved. In the first year of the
course this means general radiography and in the second year complex general
radiography and digital subtraction angiography (DSA). In the third year,
students engage in computed tomography (CT) and medical ultrasound (US). In
final year, students study magnetic resonance imaging (MRI), undertake
additional CT and DSA clinical studies and complete an inquiry-based research
In the first year Radiographic Imaging and Methods units
and in the third year Medical Imaging and Methods units students also actively
engage in a series of practical classes in general radiography, medical
ultrasound and CT. These classes are designed to facilitate the development of
relevant schemata without which students struggle to structure and make sense
of their clinical experiences.�
Contextual learning theory makes other demands upon
educators. Attention must also be paid to the teaching methods used within the
course. From the second year onwards, a case-based learning with a
computer-based program, developed within the Department by members of the
course team, is increasingly used. It is called Student Oriented Learning
About Radiography and referred to as SOLAR. This teaching
approach additionally promotes the use of group learning activities and,
through the medium of case presentations, peer learning .�
The development of professional skills
There are four professional skills units within the
course. It is these units that prepare students to complete the second type of
Clinical Learning Contract used during clinical studies, namely the
Professional Development Learning Contract.
In the first year, radiation safety and ethics, the
concept of profession, infection control, professional communication, first aid,
principles of scientific writing and the psychosocial basis of behaviour and
illness are addressed. The link between these topics and the clinical world is
achieved by students through the completion of a structured observation of
clinical communication skills and critical clinical professional learning
experience reports using a style reported by Benner :
- Introduction: what happened
- How the experience affected my professional development
- My thoughts about the situation
- What the theory has to say about the situation
- The significance of the experience
The second semester in second year professional skills
unit is concerned with facilitating knowledge about patient assessment and
management from a nursing perspective, the evidence-based paradigm, radiation
therapy, nuclear medicine and research methodology. The final professional
skills unit is embedded within the second semester in the third year unit
dealing with breast imaging and dosimetry where students undertake additional
study in ethical theory and medical law. Students apply this new knowledge
during their clinical placement by completing a series of critically reflective
The second phase: the management of the clinical studies units
The management of the clinical studies units, of which
there are eight, is highly structured and characterised by the use of Learning
Contracts, Learning Portfolios, and the Novice to Expert Model of Clinical
Throughout their clinical studies� attachments, students
use learning contracts as a means of ensuring clarity about the objectives of
each clinical rotation and the nature of assessment. The supervising
radiographer and student discuss and sign the contracts. The signature of the
student indicates their intention to do their best to complete the contract. To
record progress in meeting Learning Contracts for the Development of Competence
in Radiography, space is provided within the various Workbooks for students to
write up Weekly Case Reports and Log Entries. The nature of these reports and
an analysis of the structure of the Clinical Workbooks will be the subject of
Assessment strategies within clinical studies
All of the clinical assessments are structured around the
idea that students will move through the various stages from beginner to
intermediate beginner and advanced beginner practitioner and finally attain the
level of competent practitioner by the end of the course.� By the end of the
first year, students demonstrate the characteristics of an advanced beginner in
relation to general radiography performed on cooperative patients. By the end
of the second year, they achieve the advanced beginner stage in respect to
contrast imaging, mobile radiography and trauma imaging. The level of competent
practitioner in general radiography is achieved by the end of third year. In
respect to CT, students are expected to reach the level of advanced beginner by
the end of the third year and the status of competent radiographer by the end
of the fourth year. The level of intermediate beginner in ultrasound of the
upper abdomen is expected to be achieved by the end of third, and in MRI, in
In the diploma courses in radiography, competency was seen
as a linear process that could be objectively assessed. However, does the
successful performance of a series of radiographic steps constitute competence?
At degree level of education, students must know how to perform radiographic
examinations and be able to justify their clinical decisions. Indeed, in a
study undertaken to ascertain if graduate nurses were better decision makers
than non graduate nurses, Girot  concluded that �those exposed to academia
are more effective decision-makers than non-graduates in practice�. It was the university
experience that created the conditions for the development of critical
reasoning capacities and which subsequently made the difference in the clinical
setting. The same must occur for radiography students if the attainment of
graduate status for the profession is to be justified.
This means clinical assessment proformas must go beyond
requiring clinical assessors to make inferences from a series of observations
that students know what they are doing.� The proformas need to require students
to verbalise their clinical decisions and actions.
The assessment strategy must also oblige students to
engage in a conversation with themselves about their professional progress
along the novice to expert continuum. In all year levels, students are required
to complete a series of critical self assessment exercises that must be
discussed with their supervising radiographers. Students must identify their
strengths and weaknesses and develop personal action plans that are verified
and linked to their written statements.
The third phase: Closing the loop
The final phase relates to how links with the students are
maintained during the clinical studies and the need to debrief students upon
their return to the university. A structured form of clinical liaison occurs during
all of the clinical placements together with personal site visits and follow-up
telephone contacts. Students need to feel supported throughout their clinical
studies. Indeed, it is only by engaging with students and radiographers in �the
field� that educators can truly evaluate the efficacy of the tools that have
been created to facilitate the achievement of the clinical studies objectives.
Is there any evidence that Monash graduates are developing into reflective
The results from two surveys conducted in 2001 and 2006,
respectively, appear to provide some evidence that the majority of graduates
from the Bachelor of Radiography and Medical Imaging are developing the
capacity to engage in reflective practice.
The Value of the Collection and Evaluation of Reject Radiographs in
Encouraging Students to Reflect upon their Learning
In 2001, 36 students comprising the third year cohort were
invited to participate in a two-week audit of their reject radiographs.
Students were also asked to complete an audit form and submit a reflective
piece about the value of the exercise. Students were also asked to report upon
the number of sub optimal radiographs that were put through for reporting.
Twenty-two students, each of whom attended a different
hospital-based radiology department or private radiology practice, submitted
their radiographs. The number of rejects ranged from 3 to 120. The average
repeat number per student (excluding the two extremes) was 14. The numbers,
however, are not the key issue. The key research interest was the views of
students regarding the usefulness of the exercise. Without exception, the
students who completed the exercise found it worthwhile. The following
reflective comments, firstly from Stan and secondly from Igor, gives educators
cause for hope:
�Overall I found this exercise to be beneficial in making
me think about why I was repeating a radiograph rather then just chucking the
reject in the bin and having another shot. Hopefully being aware of why I was
repeating films will mean I repeat less radiographs and will make me a better
�I found my collection of repeat radiographs to be quite
minimal. I believe this was partly due to the fact that at my centre the staff
were very helpful and friendly which made me feel comfortable enough to ask
questions and perform examinations alone.� In feeling comfortable I also
believe that I felt more competent and as a result fewer repeats occurred. �. I
am not sure as to why I had fewer repeats (being conscious of the audit or
feeling more competent in performing examinations) however I was constantly
thinking as to how to get the best exposure, positioning etc as to reduce my
repeats.� In sum I believe that the audit did get me thinking more about the
examination as to reduce the number of repeats however, I also felt more
comfortable and confident which I am sure also was a contributing factor as to
why there were fewer repeats�.
As a result of the feedback from all of the students
including the following comments from Pete, all students are now given
opportunities to complete a reject analysis in the context of their
Professional Development Learning Contracts in the second semester of first
year and the first semester of second and third years.
�From the limited number of repeats I have had to repeat it
would seem that my positioning is the largest cause of repeats and I will take
more time when positioning patients to make sure this is accurate.� I believe
this exercise is a good reflective piece and is of benefit to myself and should
be included in the second and third year of the course�.
A 2006 audit of the quality of Monash Radiography graduates
In semester one of 2006, a formal audit of the quality of
graduates from the course was conducted by the Department of Medical Imaging
and Radiation Sciences. The findings formed part of the re-accreditation
portfolio submitted by the Department to the Australian Institute of
Radiography in July 2006. Fifty accredited clinical departments were invited to
complete the questionnaire comprising 71 questions. Forty completed
questionnaires were returned. The audit process was conducted by the Monash
University Centre for Higher Education Quality. For the purposes of this
discussion only, responses to a select number of statements have been provided
below in Table 1.� Whilst many respondents ticked the 'sometimes' option, no
one disagreed with any of the statements. The responses indicate that the
curriculum for the Bachelor of Radiography and Medical Imaging has the
potential to meet its goals.
In 1998, the author discovered a gap between the
day-to-day practice of radiography and what it could be . Reports from
current students suggest that there are still radiographers who are failing to
live up to the highest ideals associated with a profession. Therefore,
irrespective of the need for radiography students to master their
technologically-mediated craft, educators must continuously create learning
experiences that signal to students they must come to understand that in the
university setting, knowledge is something that is open to �contestation� and
From within the reflective practice paradigm, knowledge is
not something that is �out there� waiting to be discovered. Rather, knowledge
construction occurs as students struggle to reconcile the theories and concepts
found in text books with clinical realities and practical experiences.
Ultimately, it is an engagement with the process of reflection that makes the
creation and integration of knowledge possible and opens the door for the
development of a reflective radiographer.
Thus, the challenge for radiography educators is to
construct a curriculum that acknowledges the continued need for students to
gain technical competency whilst attending to the university imperative that
students develop those critical and reflective thinking skills traditionally
associated with a �higher education� . The overriding concern of the
curriculum must be to empower students to develop their own critically-informed
practice �scripts� . Even in these difficult times of a deliberate intrusion
into health care of corporatisation, manageralism and the market place ,
educators must not lose sight of the potential for education to effect change
Table 1 Selected responses to the audit
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|Received 8 October 2007; received in revised form 4 December
2007, accepted 5 December 2007
Correspondence: Department of Medical Imaging and Radiation Sciences, School of Biomedical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria 3800, Australia. E-mail: firstname.lastname@example.org (Marilyn Baird).
Please cite as: Baird MA,
Towards the development of a reflective radiographer: challenges and constraints, Biomed Imaging Interv J 2008; 4(1):e9
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