In healthcare, the roles of allied health professionals, such as the sonographer, often evolve and require the development of new skills. These changes are usually centered around new ways to deliver care and improve access and/or testing times for patients. Other mechanisms that contribute to the change in roles or extension of roles are the modernization of services. Modernization of services can occur when there is a skilled worker shortage (i.e., sonographer shortage), service redesign (point of care of ultrasound), the need for quality improvement, and the development of new technology. Smooth transitions or natural progressions of roles occur when the new skill or “role” contributes to an individual’s professional aspiration, increases autonomy, and improves job satisfaction. Roles also evolve when there is a need for a more flexible workforce, someone who can do multiple tasks, such as a nurse trained to perform ultrasound or a sonographer trained to also perform ECGs in a clinic where volumes may be low, but they are providing a needed service to a community.
When we discuss extending roles, we also need to discuss how these roles fit into a work group and their respective current scope of practice. Scope of practices change is based on educational standard changes, certification requirements, and policy changes. Educational standard changes are often based on job task analysis surveys, and the needs of the changing healthcare environment. For sonographers, roles may change in the form of being asked to learn an additional discipline, such as an adult cardiac sonographer to cross train into vascular sonography or pediatric echocardiography. With these requests may come feelings of angst or excitement, depending on one’s background and the opportunities available for training in the department that is being asked to make the change.
In the echocardiography laboratory, often these expanded roles are left for the technical director and/or the advanced cardiovascular sonographer to determine how to best implement these new extensions of roles or changes of the local “scope of practice.” When this occurs, based on my personal experience, resources that can be used to assist sonographers to get information about how to implement these changes are the medical director, risk management department, and human resource departments. These resources are valuable in that they 1) make sure the medical director is supportive of the requested change, 2) ensure that risk management supports the extension of this role, and approves of the training plan and implementation of the new role and 3) human resources are involved to add the new skill or extension of the role to the position description. A clinical example might be, all sonographers are now going to perform cardiac and vascular ultrasound examinations. In this instance, there should be a plan worked out with the medical director for how the training is to occur and with risk management to assist with who might be coming to help with the training, and address any legal concerns until individuals develop the skills and become registered in the new specialty. Human resources will assist with review of the current position description and make note of any additional certification requirements that may need to be added to the current position descriptions.
Once individuals are trained, quality improvement is a necessary step to ensure that the new skills acquired are resulting in optimum patient outcomes and are comparable to other benchmarks with other institutions. McPherson et al. (2006), in their review of five work groups noted that the addition of extended roles is often done in an “ad hoc,” fashion and the problem with this type of training is that it does not promote the development of local or national education standards to implement this new skill set. In the case of the sonographer, “ad hoc” training may result in the sonographer learning the new skill, however, it does not ensure that this new skill is being performed to the accepted local or national standards level. Therefore, it is important to develop a well-thought educational plan for training, and use quality improvement tools to ensure that the skill is being practiced at the optimum level.
Another key feature that should be incorporated in monitoring expansion of roles is outcome data. Review articles of extension of services performed internationally demonstrate that new extended roles for allied health professionals seem to be working well in terms of improving access, delivering care, and decreasing wait times, however, there is very little reported on actual patient outcomes. Outcome data is needed to truly demonstrate the effectiveness of extension of roles, in order to know that this change is best for patients.
With these thoughts in mind, it is important to recognize that there are many factors that are always changing in healthcare. Rapidly advancing technology and policy changes set the stage for sonographers to accept new challenges, and master new skills to incorporate new imaging techniques into the laboratory. As these changes occur, sonographers must have a plan to best implement, educate, train, develop quality improvement processes, and follow outcomes to ensure that change is successful in our ever-changing roles and work environment.
Carol Mitchell, PhD, ACS, RDMS, RDCS, RVT, RT(R), FASE is an Assistant Professor of Cardiovascular Medicine at the University of Wisconsin School of Medicine and Public Health. Dr. Mitchell currently services as Chair of the ASE Council on Cardiovascular Sonography Steering Committee.