The job competency of radiological technologists in Korea based on specialists opinion and questionnaire survey

Purpose Although there are over 40,000 licensed radiological technologists (RTs) in Korea, job competency standards have yet to be defined. This study aims to clarify the job competency of Korean RTs. Methods A task force team of 11 professional RTs were recruited in order to analyze the job competency of domestic and international RTs. A draft for the job competency of Korean RTs was prepared. A survey was then conducted sampling RTs and the attitudes of their competencies were recorded from May 21 to July 30, 2016. Results We identified five modules of professionalism, patient management, health and safety, operation of equipment, and procedure management and 131 detailed job competencies for RTs in Korea. “Health and safety” had the highest average score and “professionalism” had the lowest average score for both job performance and importance. The content validity ratios for the 131 subcompetencies were mostly valid. Conclusion Establishment of standard guidelines for RT job competency for multidisciplinary healthcare at medical institutions may be possible based on our results, which will help educators of RT training institutions to clarify their training and education.


Introduction
The professional standards of competency for radiological technologists (RTs) should be identified for upholding professional conduct within the field. The International Society of Radiographers and Radiological Technologists (ISRRT), in addition to countries such as the United States, have previously outlined the professional standards for RTs [1,2,3,4]. Nonetheless, the job competencies for Korean RTs have not been identified yet. In Korea, since 1961, 41,404 RTs have been issued a practicing license [5]. However, only a few studies have been performed on the job analysis [6]. To the best of our knowledge, no studies were found on the subject of RTs job analysis from the search engine of Korean National Assembly Li-brary [7]. Using the key word "radiological technologist job competency" in the PubMed Central, ten articles were found [8], but no articles dealt with the RTs job analysis.
Job competency comprises the standards of education, components of the licensing examination, and contents of the certification training program [9,10,11]. Therefore, our study aimed to clarify the job competency of Korean RTs and focus on the following three overarching questions: first, what are the core competencies required for Korean RTs?; second, what are the sub-competencies required for Korean RTs?; and third, are the identified competencies for RTs valid?

Study design
This was a cross sectional study including a descriptive analysis. For the purpose of this study, we recruited a task force team of professional RTs with an average of over 20 years of radiology-related educational or practical experience, which included the following 11 members: the president, four vice presidents, and two directors of the KART (Korean Radiological Technologist Association); three professors in radiological technology; and a manager of RTs in a general hospital. We consulted the team 7 times to evaluate the current guidelines outlined for the competencies of RTs as indicated in the ISRRT of Australia, United States and Canada, and evaluated the Korean RTs job analysis [6]. We studied with the team the "guidelines for the education of entry-level professional practice in medical radiation sciences" of the ISRRT, the "competency requirements" of the ARRT (American Registry of Radiologist) [2]. We closely examined the five standards, 20 descriptors, and 69 outcomes [3] of the AIR (Australian Institute of Radiography). The CAMRT (Canadian Association of Medical Radiation Technologists) had 5 modules, 20 sections, and 131 competencies [4], but we were not able to find any validity results of these competencies.
The team categorized the competencies of Korean RTs into the following: core competency, sub-competency, and more detailed competency. Subsequently, a survey (Appendix 1) was developed and distributed, from May 21 to July 30, 2016, to RT professors, RT managers in large healthcare organizations, and general RTs to evaluate the validity of the recommended competencies outlined by the team.

Materials and subjects
Survey items related to the job competency of domestic and international RTs were analyzed. The results were subsequently used to prepare a draft for the job competency of Korean RTs. The survey was then disseminated to RTs, with the expertise and attitudes of job competency specialists additionally acquired.
The core competencies required for Korean RTs are categorized into five elements: "professionalism," "patient management," "health and safety," "operation of equipment," and "procedure management." The five core competencies were further subdivided into 24 sub-areas, and then further into 131 specific competencies.
The survey questions were assessed using a 5-point Likert scale: 1 = not at all valid, 2 = not valid, 3 = neutral, 4 = valid, and 5 = very much valid. The surveys were distributed to each hundred RT professors, RT managers in large healthcare organizations and general health institutions. Overall, 175 out of 300 questionnaires were returned: 45, 43, and 87 questionnaires were returned from each of the above survey groups, respectively. After excluding inappropriate responses such as missing data, 147 answers were used for the final statistical analysis.

Statistics
The survey results evaluating the job competency of Korean RTs were analyzed using PASW SPSS Statistics ver. 18.0 (SPSS Inc., Chicago, IL, USA). Differences in the mean score between the importance and work performance for the core competency and sub-competency were analyzed by Independent-sample t-test. Korean RTs were first analyzed for the distribution frequency, and the mean re-sults were recorded. The content validity ratio (CVR) and Cronbach's α of each job competency were calculated by analyzing the mean, standard deviation, quartile, and median. The Cronbach's α of the survey results was 0.99. The CVR was calculated by the following formula.
ne: number of the valid (point 4,5) From the CVR results, we followed Lawshe's theory and considered the lowest ratio below 0.33 as invalid [12].

Ethical approval
Students' informed consents were obtained.

Characteristics of the respondents of the questionnaire survey
The survey respondents included Korean RT professors, RT team managers, and RTs working as general technicians. The mean number of years for either working or teaching within the profession was over 10 years, as shown in Table 1. RTs from primary or secondary hospitals constituted 49.5% of the respondents, and 50.5% of the respondents were working at tertiary hospitals. Raw data were available from Supplement 1.

Collective opinions of the survey respondents
The performance and rated importance of the core competencies of Korean RTs: The analysis of the core competency of Korean RTs and the level of importance for which they were rated showed an overall mean score of 4.412 points for importance and 4.133 points for performance (P< 0.001). A statistically higher score was attributed to the importance of the five core competencies compared to the work performance of the respondents for the same criteria. "Health and safety" was indicated as being the most important, followed by "procedure management," "operation of equipment," "patient management," and "professionalism" ( Table 2). "Health and safety" had the highest score for the performance criteria.
The performance and importance for the sub-competencies of Korean RTs: The scores for the rated importance and performance of each of the sub-competencies of Korean RTs were comparatively analyzed. The results of the comparison for the sub-competencies and the level of importance assigned by the Korean RTs are shown in Table 3. With the exception of sub-competency, "A.6: use of resources," the remainder of the 24 sub-competencies showed significantly higher scores for importance than for performance. The most important sub-competency was "C.3: radiation safety practices" (mean= 4.729, P = 0.000), whereas "B.2: patient safety" (mean = 4.404, P = 0.015) had the highest score for performance.

Statistics
The survey results evaluating the job competency of Korean RTs were analyzed using PASW SPSS Statistics ver 18.0 (SPSS Inc., Chicago, IL, USA). Differences in the mean score between the importance and work performance for the core competency and sub-competency were analyzed by Independent-sample t-test. Korean RTs were first analyzed for the distribution frequency, and the mean results were recorded. The content validity ratio (CVR) and Cronbach's α of each job competency were calculated by analyzing the mean, standard deviation, quartile, and median. The Cronbach's α of the survey results was 0.99. The CVR was calculated by the following formula.
From the CVR results, we followed Lawshe's theory and considered the lowest ratio below 0.33 as invalid [12].
http://jeehp.org J Educ Eval Health Prof 2017; 14: 9 • https://doi.org /10.3352/jeehp.2017.14.9 CVR of detailed competencies: A CVR of 0.33 was defined as the minimum for which a score was considered valid; a ratio lower than 0.33 indicated that the competency was not valid. CVR analysis was performed with the subdivided competencies for an increased accuracy. The invalidity ratio from each panel category was considered, but the overall total ratio was factored into the final decision. Therefore, the result indicated that all five core modules consisted of valid competencies, and 131 sub-competencies showed positive results except for two sub-competencies scored as invalid competencies by the statistical analysis, which were "B.3.7: perform venipuncture" (CVR= 0.197) and "E.3.5: perform rectal tube insertion" (CVR = 0.306). Sub-competencies such as "applying ALARA (as low as reasonably achievable) principle" (CVR= 0.986), "apply knowledge of radiation effects and risks" (CVR= 0.959), and "use protective devices and apparel for personnel" (CVR= 0.959) showed high valid CVR results (Table 4).

Discussion
All the CVR scores turned out to be appropriate in all five modules; module A (professionalism) showed 0.719 mean CVR score, module B (patient management) 0.754, module C (health and safety) 0.845, module D (operation of equipment) 0.766, and module E (procedure management) 0.767. Also, most of the categories showed appropriate CVR values, ranging from the highest score of 0.986 (C.3.1) to the lowest score of 0.415 (B.3.11), except for two catego-    http://jeehp.org J Educ Eval Health Prof 2017;14: 9 • https://doi.org/10.3352/jeehp.2017.14.9 cated that rectal tube insertion would be appropriate with a CVR value of 0.526, while the RT managers and general RTs responded that the procedure would be inappropriate with CVR values of 0.310 (RT managers) and 0.200 (general RTs), thereby showing a difference in opinion between academics and clinical RTs. In addition, there were slight differences in opinions of each of the professional groups with regards to the overall appropriateness of some of the detailed competencies. The general RT group indicated that two of the detailed competencies B.3.7 (perform venipuncture necessary for the test) and E.3.5 (perform rectal tube insertion) were clinically inappropriate. These competencies were categorized as invasive practices at the time of the evaluation during the certification of medical institutions in Korea [13]. Therefore, these procedures are delegated to either physicians or nurses in Korea, despite being listed as a responsibility of RTs internationally, such as in Canada [4,14]. Accordingly, there appears to be a difference in opinion between the clinical RTs and the academics.
Although the responsibilities of RTs are usually limited to radiation tests, treatment for these procedures have been restricted to fundamental concepts, requiring further evaluation through national licensing examinations [15,16,17]. Therefore, this study has highlighted and provided further insight into the previously poorly characterized aspects of the field, such as the attitudes of specialist RTs and other aspects including legal and ethical qualifications, interdisciplinary communication, infection control, drug control, and others.
Further research, in addition to more detailed definition and establishment of the work competencies of Korean RTs, is necessary as this would form the foundation for the education of prospective students and for the improvement of the license examination process. Additionally, this would also improve the work place efficacy for Korean RTs at medical institutions.
There are some limitations in this study and further considerations to be noted. In Korea, studies on the job competency of RTs are lacking. The response rate of the surveys in our study was only 58%, which may be due to the fact that the surveys contained too many questions for the respondents to answer promptly. We were also unable to establish the sub-competencies for each specialized field, since many studies only focused on the more common competencies of RTs who work in radiology, nuclear medicine, and radiotherapy. Future studies on the sub-competencies for each specialized field should be performed on the basis of our study results.
In conclusion, we attempted to establish a standard guideline for RTs in Korea. Having provided the basic outline of RT job competency, our results will help the educators of RT training institutions to clarify their training and educational content which will lead to more appropriately skilled RTs.