With some nurses based in primary care struggling to get their radiology referrals accepted, Nursing in Practice investigates the issues they’re facing and what solutions are on offer.
This week, as part of efforts to speed up cancer diagnosis, advanced nurse practitioners were among the healthcare professionals in general practice to receive new radiology referral powers to directly request imaging services.
However, these powers are no use if ANPs can’t make use of them and feel pushed aside, as some of them have reported to Nursing in Practice and on social media.
This comes after Professor Alison Leary, chair of healthcare and workforce modelling at London Southbank University, suggested in an August Twitter post that East and North Hertfordshire NHS Trust was not accepting radiology referrals from ANPs as a blanket rule.
The trust denies this, saying that there are ‘protocols in place to allow nurses and allied health practitioners across all areas of the Trust to request all imaging modalities’. However, the comments sparked a wave of complaints.
Nurses and advanced nurse practitioners flooded the comments with stories of requests for images being rejected and hospital services implementing blanket restrictions on their powers of referral.
A GP, Dr Mike Smith, went so far as to say that hospital radiology departments in his area ‘don’t accept’ referrals ‘from any clinician in primary care’.
Many other commenters suggested that, as nurses, their requests for imaging were not being taken seriously
A chest pain specialist and ANP from Gloucester replied by saying that there was ‘certainly a difference in how referrals from advanced practice nurses are vetted compared to other clinicians’.
Liz Anderson, chair person of the National Nurses Nutrition Group, said of her experience on Twitter: ‘I’ve done the [Ionising Radiation (Medical Exposure) Regulations] course. Written a [Standard Operating Procedure]. They still say no. Because how can a mere nurse know what they are doing?’
One nurse who spoke to Nursing in Practice, who asked to remain anonymous, is a primary care advanced clinical practitioner working in the West Midlands and also works as an agency nurse on weekends.
The anonymous nurse said that, depending on the role he is working in on the day, he is subject to different protocols and has completely different referral rights.
They said that it’s ‘frustrating’ that ‘while my competency and qualifications don’t change, what I’m allowed to request changes based on what uniform I’m wearing’.
‘It’s not that I’m not being taken seriously. It’s purely bureaucracy,’ they added. ‘There is a good relationship between myself and the doctors, but paperwork is paperwork.’
They added that it was ‘so demoralising’ having to ask a doctor to make an X-ray referral on their behalf.
They said: ‘An advanced clinical practitioner needs to be publicising our role and what we do. Part of what we should do is sell ourselves and explain our specific role but having to go to a doctor for a chest X-ray flies in the face of what we’re trying to do.’
However, many other nurses, including Cheshire-based ANP Emma Crowe, who have since spoken with Nursing in Practice, disagree.
‘I don’t think that our referrals aren’t taken seriously,’ Ms Crowe told Nursing in Practice, ‘but I do think that hospitals are overwhelmed, and some will get sent back incorrectly.’
However, Ms Crowe still believes that rejected referrals pose a serious problem for ANPs.
As a nurse, Ms Crowe said: ‘If a specialist in secondary care says you haven’t made a valid referral, you might just accept that and automatically think you’ve done something wrong.
‘But if you’ve made a referral that you believe is valid, you need to challenge it, and we need to feel empowered to challenge it.’
But Ms Crowe agrees that this is more than just about wasting time on referrals: this is a matter of professional pride.
She said: ‘As an ANP, it’s really important that your referral letters are really professional for our reputation. It’s about representing ourselves professionally as well as possible.’
Working with radiology
Helen Lewis, an ANP working in Wales, said that she was having issues with the neurological department not accepting referrals.
‘The department said we can’t accept these because ANPs won’t give us the information,’ she explained.
‘So I rang a neurologist, I asked him what he wanted in the referrals, he told me, and that’s what I put in the referral. I haven’t had a single neurological referral sent back to me since that time, but I do tend to throw the kitchen sink at them.
‘You’re always going to get referrals that are a one liner, but that’s not enough. You need to explain why the referral is needed.’
Representatives of the British Institute of Radiology (BIR) say that their members frequently report that referrals from general practice lack the necessary information to meet the strict requirements of IRMER.
Some radiology departments across the country are now beginning to realise that there is an issue and are looking for a better way to manage access to radiology.
Dr Ravi Ayer is clinical director of radiology at University Hospitals Dorsett, said he became interested in the issue after receiving a letter ANP working in the oncology day unit.
‘It was an extremely well written request for quite a comprehensive set of services for a diverse range of patients,’ said Dr Ayer.
However, Dr Ayer wasn’t happy signing of on the request; he said that he was no longer ‘comfortable being the sole arbiter of who gets requesting rights or not’.
‘I’m a doctor,’ said Dr Ayer, ‘so I don’t know what kind of training that nurse has, I don’t know what kind of supervision she has or whether this is an appropriate use of a nurse’s time.
‘Doctors don’t realise that nurses have a lot more regulation on top of them, so I really wanted nurses to comment on this.’
From this inspiration, Dr Ayer will soon be implementing a system in which nurses will provide an appraisal of whether or not a given nurse should receive referral rights.
When a nurse requests referral rights their request will be approved by a nurse and a radiologist before it ever reaches Dr Ayer’s desk. His only role, at that point, would be to ensure that this wouldn’t overstretch the hospital’s resources.
This, he believes, will provide the best possible combination of giving nurses access to radiology services and ensuring that nurses are still working within their scope of practice.
‘I am a wholehearted believer in health care professionals performing at the top of their license and role expansion for nurses;’ concluded Dr Ayer. ‘That is very much the future.’
‘My only idea is that it should be done responsibly and with regulatory protection in place for the nurses involved.’
The view from radiology
Radiology referrals are not arbitrarily decided but rather, follow a strictly defined legal code.
‘It all starts with the law,’ explained Helen Hughes, a radiographer with 30 years of experience and professional service radiology manager at Betsi Cadawaldr University health board, on why a radiology referral from an ANP might be rejected.
Radiographers, or other IRMER practitioners, have the final say on whether any referral to radiology goes ahead and they are required to ensure that the benefits of any use of ionising radiation outweigh the risks.
‘It doesn’t matter how much a referrer says they would like an x-ray or a CT scan to be done,’ said Ms Hughes. ‘If the IRMER practitioner says ‘no I haven’t got enough information to justify this request’, legally it cannot go ahead under any circumstances.’
Mrs Hughes added that something as simple as using an abbreviation on a referral can mean that the doctor legally must reject the proposal due to the risk of misinterpretation.
The law also clearly demarks who is able to issue requests for radiology.
Ms Hughes also said that only radiology departments have the authority to decide who can refer to their departments and for what. Consultants of any kind must be formally entitled to refer within a specific scope of practice.
‘I write every year to every single doctor to tell them they’re entitled and what they are allowed to refer for and under what conditions, and this is exactly the same for nurses and ANPs’, in that they have ‘to be entitled in writing and have a defined scope of practice’.
Not only is the law exact on who can issue radiology requests and under what circumstances, but the consequences are also severe.
If a radiologist approves a request which comes from an un-approved clinician, or a request lacking evidence, they can be prosecuted under criminal law.
Radiology departments are frequently and thoroughly inspected to ensure that every single request is coming from an entitled referrer and has sufficient evidence.