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Required Multicompetency: Fact or Fiction?

There are approximately 624 Joint Review Committee on Education in Radiologic Technology (JRCERT) accredited radiography programs in the United States, including 2693 clinical sites.[1] During the 1996-97 academic year, 8595 radiographers graduated from these programs.[2]

Radiography faculty review published curriculum outlines from many sources, but generally rely on the ASRT Curriculum Guide[3] to plan a sound academic curriculum for their students. Other curriculum suggestions come from advisory committees made up of radiology and hospital administrators; from local, state and national educator meetings and from the ARRT Radiography Content Specifications. The ASRT Curriculum Guide and the ARRT's Radiography Content Specifications, Radiography Task Inventory and Radiography Didactic and Clinical Competency Requirements define what a radiographer should know prior to taking the ARRT examination in radiography 0- Reid, personal communication, January 21, 1998).

Tables 1 and 2 list the ASRT curriculum units and the ARRT content categories. The ARRT updates its Radiography Examination Content Specifications and Radiography Task Inventory every 5 years. The most recent ARRT Task Inventory resulted in the addition of 16 items to the previous list.[4] These items do not reflect a significant change in the radiographer's traditional duties and responsibilities, as they represent only 11.6% of the total Task Inventory list. With the exception of urinary catheterization, bone densitometry, bronchoscopy, electrocardiography and phlebotomy, the remaining tasks noted in Table 3 appear to have been coupled with radiologic imaging in the past and should not be considered outside the domain of the staff radiographer. Many of these tasks have traditionally been performed by other allied health or nonradiography personnel. These new tasks will need to be included in radiography program curricula.

Table 1 ASRT Curriculum Units

Ethics in radiologic sciences Introductory law in the radiologic sciences Medical terminology Radiologic sciences patient care Human structure and function Radiographic procedures Medical imaging and processing Imaging equipment Evaluation of radiographs Radiation physics Radiation protection Radiation biology Radiographic pathology Introduction to quality improvement Computers in the radiologic sciences Pharmacology and drug administration

Table 2 ARRT Content Categories

Radiation protection Equipment operation and management Image production and evaluation Radiographic procedures Patient care

Table 3 Recent Additions To the ARRT Task Inventory

Process digital/electronic images Use RIS (Radiology Information System) Use teleradiology or PACS Enteroclysis Retrograde uretrogram Retrograde urogram Mammography Sialography Urinary catheterization Bone densitometry Bronchoscopy Nephrostogram Sinus injection ECG Phlebotomy

The ARRT also recently introduced a new Radiography Didactic and Clinical Competency Requirement.[5] Published materials from the ASRT and ARRT indicate that radiography skills, tasks and competencies (not other allied health, imaging or nursing skills, tasks and competencies) are being taught in accredited radiography programs and certified by examination.

Current managed health care environment economists, insurance conglomerates, health maintenance organizations and hospital and radiology administrators would apparently like to impose more cross-training (multicompetency) and multicredentialing such as sonography, nuclear medicine, CT and MR technology, along with basic laboratory tasks and patient-care duties on registered radiographers. According to Dowd and Tilson,[6] "multi-credentialing is obtaining certification beyond that area or discipline in which your program primarily provides instruction" and cross-training is "providing additional training and instruction but not certification beyond that area or discipline in which your program primarily provides instruction."[6]

Health care reform, rapidly expanding technologies and a growing emphasis on cost containment through managed care administrative practices has changed the radiology department's approach in caring for patients. Combined, these factors are forcing radiographers to expand their skills beyond basic clinical practice.[7] The Pew Commission recommended that all health care practitioners "possess an expanded set of competencies" by the year 2005.[8]

The emergence of cross-trained technologists, multicredentialed technologists and multicompetent technologists has, in many cases, already changed the overall make-up of radiology departments. Terrell-Nance and Thomas[7] reported that "financial constraints and the need to improve work force utilization will result in the need for large numbers of multicompetent, cross-trained technologists, particularly in smaller hospitals."

The purpose of the survey described in this article was to evaluate if recent graduates were not finding employment or were having difficulty finding employment if they were educated only in the tasks and items reviewed and adopted by the professional organizations. It was deduced that if graduates were being taught information based solely oil the ASRT Curriculum Guide, the ARRT Radiography Content Specifications, Radiography Task Inventory and Radiography Didactic and Clinical Competency Requirements, and those graduates were having difficulty finding employment as a result of not receiving various cross-training or multicompetency/multicredentialed-type task instruction, program curricula would need to be altered and the ARRT would need to review its task inventory and other testing criteria.

The survey was conducted to determine if skills taught outside the domain of the staff radiographer were becoming more common and considered necessary for entry-level employment.

Review of Literature

In 1993 Terrell-Nance and Thomas[7] surveyed 150 hospitals of varying sizes. Radiology managers were asked to rank the importance of 18 skills, proficiencies and attributes, and to indicate whether they were being met by radiographers. (See Table 4.) Survey results indicated that radiology managers considered the first 13 basic radiography skills to be important.

Table 4 Skills, Proficiencies and Attributes Identified by Terrell-Nance and Thomas(*)

1. Applies anatomy, physiology and positioning to obtain radiographs with proficiency.

2. Sets exposure factors for optimum radiographs and minimum patient exposure.

3. Evaluates radiographs for positioning and quality.

4. Practices radiation protection and provides public education about radiologic safety.

5. Provides attention, care and comfort to patients.

6. Initiates lifesaving first aid and basic life support.

7. Knows safe limits of equipment operation and recognizes malfunctions.

8. Can practice and adjust to radiographic procedures with independence.

9. Knows and can practice quality assessment, continuous quality improvement and quality control skills.

10. Possesses oral and written communication skills.

11. Possesses customer service skills.

12. Practices cost-containment measures.

13. Is aware of legal and ethical responsibilities.

14. Possesses ARRT certification.

15. Possesses baccalaureate degree.

16. Is interested in supervision and management.

17. Is interested in becoming multicompetent or cross-trained.

18. Knows and can perform computed tomography, magnetic resonance imaging, nuclear medicine, ultrasound, basic nursing skills, basic laboratory skills, cardiac cath/vascular and/or mammography.

(*)(Reprinted with permission from: Terrell-Nance S, Thomas J. Managers' expectations of radiographers: a survey. Radiol Technol. 1995;66:359-363.)

When considering the need for cross-training, the baccalaureate degree may become even more important because many associate degree program directors may be unable or unwilling to incorporate cross-training programs into their 2-year programs.[7] Eighty-six percent of managers surveyed by Terrell-Nance and Thomas thought it was important for radiographers to display some interest in acquiring or having some supervisory and management skills.

Terrell-Nance and Thomas[7] also concluded that "in addition to performing basic radiography exams, technologists also will be expected to know their legal and ethical responsibilities, be adept in quality assessment and quality control, possess communication and management skills, practice cost containment and provide customer service. In addition, radiographers will need to increase their marketability by becoming multicompetent and possibly by earning a baccalaureate degree."[7]

Methods and Materials

A questionnaire was mailed to 1000 randomly selected radiography program graduates who passed the ARRT certification examination in October 1996 or March 1997. A breakdown of the surveys returned by geographical area shows a random distribution, as illustrated in Fig. 1.


The survey instrument contained a set of 12 questions and required approximately 6 minutes to complete. The questionnaire was reviewed by 2 educators.

The questionnaire, a cover letter and a stamped return envelope were mailed to the sample group in October 1997. Of 1000 questionnaires mailed, 462 were returned for a response rate of 46.2%.


Survey Questions 1 Through 6

Of the 462 respondents, 372 (80.50%) took the ARRT examination in October 1996, and the remaining 90 (19.48%) in March 1997. Three hundred ill: teen (68.18%) attended college-sponsored programs while 147 (31.81 %) graduated from hospital-based programs.

According to survey data, 403(87.22%) were employed at a full-time job (ie, more than 37.5 hours per week); 40 (8.65%) were employed part time (ie, less than 20 hours per week) and 19 (4.11%) were not employed in radiography. (See Table 5.) Of the 19 not employed in radiography, 4 continued their education in sonography, radiation therapy or nuclear medicine. The remaining 15 who could not find work in radiography reported the skills they believed they lacked in order to secure employment. Table 6 identifies mammography, CT and sonography as the areas most frequently cited as desirable additional skills beyond basic radiography for employment.

Table 5 Survey Respondents' Employment Status And Place of Employment (n = 462)
  Full time                    278 (60.17%)
  Part time                     20 (4.32%)
  Full time                     64 (13.85%)
  Part time                     11 (2.38%)
Physician private practice
  Full time                     22 (4.76%)
  Part time                      9 (1.94%)
Urgent care facility
  Full time                     14 (3.03%)
Mobile facility
  Full time                     15 (3.24%)
Free-standing imaging center
  Full time                     10 (2.16%)
Unemployed                      19 (4.11%)

Table 6 Breakdown of Responses to Question 7

Were you told by the person who interviewed you that you would have been hired if you had additional training in areas other than the training you received in your school of radiography, and if so, what were those areas?
Mammography            7
CT                     5
Sonography             4
Nursing                3
ECG                    3
MR                     2
Nuclear medicine       2
Specials/angiography   2
Phlebotomy             2
Medical lab            1
IV therapy             1

Survey Questions 7 Through 12

One hundred eighty-five (40.04%) respondents indicated that they secured employment within weeks after taking the ARRT examination; 106 (22.94%) respondents reported they found employment within months of taking the exam; 126 (27.27%) found a job prior to taking the ARRT examination; 38 (8.22%) found a job before graduating and 7 (1.51%) respondents were in the military.

Two hundred thirty-five (50.86%) of the 462 total respondents were employed in general radiography and 208 (45.02%) were employed to perform other tasks in addition to radiographic procedures. As shown in Table 7, these 208 respondents identified 26 nonradiographic tasks they were hired to perform. One hundred eighty-one (87.01%) of the 208 respondents indicated that their employer provided "on-the-job training" or "sent them for training" in the nonradiographic tasks.

Table 7 Breakdown of Responses To Questions 8 and 9
Were you hired solely for radiography duties?

Yes              235
No               208
No job            19

If you checked "No" above, what additional imaging
or other medical responsibilities are you required to

CT                57   Medical asst.      3
Mammography       55   Ortho              3
Nursing           33   Venipuncture       3
ECG               30   IV therapy         2
Sec/clerical      28   Nuclear med.       2
Medical lab       14   Trauma             2
Bone density      12   Audiology          1
Phlebotomy        11   C-arm              1
MR                 8   Cath lab           1
Sonography         6   ECC                1
Other              5   Operating room     1
Specials/angio     5   Physical therapy   1
Fluoro             4   Rheumatory         1

Eighteen (9.94%) of the 181 respondents noted having received CT training after graduation or while employed; 7 (3.86%) respondents had CT instruction or acquired practical CT experience while enrolled in their radiography program.


The intent of this survey was to determine if skills traditionally considered outside the domain of a staff radiographer were not only becoming more common, but now are considered necessary for entry-level employment. Survey results indicated that 96% of respondents found employment and 87% of respondents obtained full-time employment. Fifty-eight percent of respondents were hired to perform only entry-level radiographic tasks, primarily in hospital settings, and were employed full time in radiography primarily in the hospital setting, but had to perform nonradiographic tasks or skills as part of their job. Only 3% of respondents were turned down or thought they were turned down due to not having nonentry-level radiographic tasks or skills. Therefore, it can be concluded that most employers only considered entry-level radiographic tasks or skills when hiring.

Although 52% of the respondents indicated a need to perform nonentry-level radiographic tasks or skills, no specific nonradiographic task or skill consistently emerges from the data. This variation in nonentry-level radiographic tasks or skills makes it difficult to conclude which, if any, of the nonentry-level radiographic tasks or skills should be given special attention in radiography program instruction, as the survey results show that employers provide additional training to newly hired graduates as part of the radiographers' ongoing employment. This observation is based on the fact that 87% of the respondents hired to perform radiography and nonradiography tasks or skills indicated that their employers provided them with on-the-job training during employment. Recent graduates were not denied employment because of lack of skills. Educators and professional organizations may wish to consider the survey results when designing curricula.

Fifty-two percent of respondents were employed in hospitals and were required to perform more than 1 nonentry-level radiography task or skill. Although these responses were small and varied, it might be concluded that in today's radiology health care environment, having a radiographer on staff with CT, mammography, nursing, ECG, secretarial/clerical skills, laboratory and phlebotomy skills may be desirable to some hospital radiology managers, but the lack of these skills did not preclude recent graduates from acquiring a job.

Could it be that employers understand that the ARRT, ASRT and JRCERT have constructed program curriculum guidelines and standards to assure that entry-level graduates primarily possess strong radiographic clinical competencies and that employers are willing therefore to provide on-the-job training and money for future nonentry-level radiographic task and skills training? Will employers expect radiography programs to incorporate more of these nonentry-level tasks and skills into the curriculum? What will happen to the high radiographic skill levels of graduates if faculty have to give less attention to traditional radiographic instruction and begin nonentry-level radiographic task and skill instruction or cross-training in their programs?

If faculty do not "take away" from the curriculum but are forced to introduce nonradiography tasks and skills into the curriculum by lengthening the academic program time, will students choose to enroll in radiography programs that are more expensive as a result of higher teaching and operating costs? Will the newly cross-trained/multicredentialed graduates be paid ail increased hourly wage for the additional work responsibilities they will be asked to perform? Will hospital and health care administrators continue to allow on-the-job training and funding for "in-house" training? Further research is needed to determine employer sentiments on these issues.


[1.] JRCERT 1997 Annual Report. Chicago, Ill: Joint Review Committee on Education in Radiologic Technology; 1997.

[2.] Health Professions Education Directory 1997-1998. 26th ed. Chicago, Ill: The American Medical Association.

[3.] ASRT Radiography Curriculum Guide. Albuquerque, NM: American Society of Radiologic Technologists; 1993.

[4.] ARRT RAD Task Survey List. St. Paul, Minn: American Registry of Radiologic Technologists; December 1997.

[5.] ARRT RAD Clinical and Didactic Competencies Requirement List. St. Paul, Minn: American Registry of Radiologic Technologists; September 1998.

[6.] Dowd S, Tilson E. Managed cafe's impact on radiologic science education. Radiol Technol. 1997;69:70.

[7.] Terrell-Nance S, Thomas J. Managers' expectations of radiographers: a survey. Radiol Technol. 1995;66:359-363.

[8.] The Pew Health Professions Commission. Healthy America: Practitioners for 2005. J Allied Health. 1992;21:3-22.

Robert J. Slothus, M.S., R.T.(R), is director and associate professor in the department of medical radiography at The Pennsylvania College of Technology, an affiliate of Penn State University. He is also a doctoral candidate in the workforce education and development program at Penn State University. Mr. Slothus has been an ASRT member since 1977 and a medical radiographer since 1972.

Reprint requests may be sent to the American Society of Radiologic Technologists, Communications Department, 15000 Central Ave. SE, Albuquerque, NM 87123-3917.

[C] 1999 by the American Society of Radiologic Technologists.
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No portion of this article can be reproduced without the express written permission from the copyright holder.
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Title Annotation:radiography
Publication:Radiologic Technology
Article Type:Statistical Data Included
Geographic Code:1USA
Date:Jul 1, 1999
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