Requesting Diagnostic Imaging in Nurse Practitioner Practice: Results of a National Survey

ABSTRACT

Aim

To examine how nurse practitioners in Australia request diagnostic imaging and identify educational and system‐level barriers that influence this practice.

Design

Cross‐sectional national survey.

Methods

An online survey of nurse practitioners in Australia.

Results

Survey responses from 119 nurse practitioners demonstrate that diagnostic imaging is widely used and viewed as integral to nurse practitioner practice, yet educational preparation is inconsistent. Although most felt confident and well‐prepared to request imaging, insufficient imaging content in nurse practitioner programs and knowledge gaps related to radiation exposure and rebate processes were highlighted. Systemic barriers, including restricted patient rebates, organisational constraints and resistance from radiology providers were frequently cited as barriers to practice.

Conclusion

Diagnostic imaging is integral to nurse practitioner practice, yet inconsistent educational preparation and significant structural barriers hinder full utilisation.

Implications for the Profession and/or Patient Care

Reducing structural barriers and enhancing diagnostic imaging education would enable nurse practitioners to work to full scope, reduce duplication in practice and ultimately improve patient access.

Impact

Findings inform an under‐examined component of nurse practitioner practice and highlight priorities for future healthcare policy and education.

Reporting Method

The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for cross‐sectional studies.

No patient or public contribution.

What does this paper contribute to the wider global clinical community?

• Provides the first comprehensive national insight into how nurse practitioners request diagnostic imaging and how this enables them to work to their full scope of practice

• Identifies key systemic, organisational and funding barriers that limit nurse practitioner‐initiated imaging, offering clear targets for reform to improve efficiency and equity in patient care.

• Demonstrates the need for more consistent and robust diagnostic imaging education across nurse practitioner programs to strengthen capability, clinical confidence and safe imaging practice.

Key Points

• Diagnostic imaging is widely used by nurse practitioners (NPs) in Australia as a key component of clinical decision‐making.

• Despite its importance, NPs continue to encounter substantial structural and organisational barriers that limit effective access to and use of diagnostic imaging services.

• Education on imaging is inconsistent and often insufficient.

1. Introduction

The use of diagnostic imaging in clinical practice is increasing worldwide, with the use of computed tomography (CT) and magnetic resonance imaging (MRI) outpacing that of plain radiography (Lu et al. 2024). This finding highlights the importance of medical imaging in healthcare practice but also raises the potential of harm if used inappropriately, such as radiation exposure, incidental findings leading to overdiagnosis, and increased patient anxiety (Smith‐Bindman 2018). Such harm associated with the overuse of diagnostic imaging has been well discussed in the literature (Müskens et al. 2022), stressing the need for high‐quality education for referring and administering clinicians.

Nurse practitioners (NPs) are registered nurses (RNs) who have completed advanced training, enabling them to perform comprehensive assessments, diagnose and manage patient care, including the ability to request and interpret diagnostic tests (Schober et al. 2020). The NP role originated in the United States during the 1960s to address community health needs, particularly for children (Schober et al. 2020). Since that time, the NP role has continued to expand rapidly internationally, including in Australia (Gardner et al. 2021). Central to the NP role is the provision of high‐quality, accessible healthcare focused on enhancing health and preventing disease through direct patient engagement (Schober et al. 2020). In Australia, NPs are experienced RNs who have completed master's level education for endorsement by the Nursing and Midwifery Board of Australia (NMBA) and are authorised to independently request and interpret diagnostic investigations within their scope of practice. A recent scoping review identified limited empirical research on the use of diagnostic radiological investigations by NPs, especially in the Australian context (Kearns et al. 2024). There are no legislative restrictions on NPs requesting diagnostic imaging in most of Australia, apart from two states (South Australia and Queensland), where NPs are restricted to requesting plain film imaging. However, it remains unclear what local policies or constraints may be enforced by individual health or funding organisations.

2. The Study

2.1. Aim

This survey explored nurse practitioners' engagement with diagnostic imaging across requesting, interpreting and performing imaging examinations. As part of a broader series reporting these results, the present article evaluated NPs' requesting of diagnostic imaging in their practice, the educational requirements to support their practice and the barriers in relation to requesting diagnostic imaging in practice.

3. Methods

3.1. Design

This study was a cross‐sectional national survey to describe the requesting of diagnostic imaging by Nurse Practitioners (NPs) in Australia. The study was reported based on the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for cross‐sectional studies (Vandenbroucke et al. 2014).

3.2. Data Collection

Data were collected via an online survey using the Research Electronic Data Capture (REDCap) platform (Harris et al. 2009) hosted by the University of Sydney between October 2023 and March 2024. A snowball technique was employed to further distribute the survey via social media and the principal advisors to the Chief Nurses in each state were requested to disseminate the survey within their professional networks. The Australian College of Nurse Practitioners facilitated the distribution of the survey through its social media platforms.

3.3. Survey

The survey was adapted from previous investigations into Australian NP scope of practice (Fong et al. 2020), using the Theoretical Domains Framework (TDF) (Atkins et al. 2017). The TDF provides a theoretical lens through which to view cognitive, social and environmental influences on behaviour and has been used extensively in healthcare research, particularly in identifying barriers and facilitators to behaviours (Atkins et al. 2017). The framework contains 14 domains: knowledge, skills, social/professional role and identity, beliefs about capabilities, optimism, beliefs about consequences, reinforcement, intentions, goals, memory, attention and decision processes, environmental context and resources, social influences, emotion and behavioural regulation (Atkins et al. 2017), see Table S1.

Participants nominated their primary metaspecialty to facilitate data analysis. Metaspecialties are broad clinical practice areas with similar skillsets and expertise to reflect the diverse healthcare needs of populations (Helms et al. 2017). The associated clinical practice standards are research‐derived with the aim of strengthening NP clinical education (Gardner et al. 2021). In Australia, six metaspecialties are recognised in NP practice: ageing and palliative care, child and family health care, chronic and complex care, emergency and acute care, mental health care and primary health care (Helms et al. 2017).

Participants were prompted to reflect on their use of diagnostic imaging, developing capability related to diagnostic imaging and assessing knowledge and confidence about these imaging techniques (Table S1). Participants outlined the models used in requesting imaging such as: independently requested (within the participants' scope of practice without approval or supervision of another health professional), requiring a countersignature by a medical professional or via a structured ordering arrangement.

3.4. Participants

All authorised nurse practitioners in Australia were eligible to participate in the study. A total of 149 survey responses were collected; however, 30 respondents only completed the demographic section and were excluded from further analysis, yielding 119 valid responses.

3.5. Data Analysis

Quantitative data were imported to SPSS version 29.0 (IBM Corp., Armonk, NY, USA) for analysis using descriptive statistics. Free text data were organised and analysed using content analysis with an inductive approach, employing the technique described by Elo and Kyngäs (2008).

3.6. Validity, Reliability and Rigour

Content validity was established by submitting the instrument to scrutiny by a panel of two nurse practitioners, an academic experienced in NP education and a professor of medical imaging science. Three of the authors have extensive experience using surveys as a research method, enhancing the study's rigour. Reliability of the instrument was not assessed.

3.7. Ethical Considerations

Ethics approval was granted by the University of Sydney Human Research Ethics Committee (Project number 2023/372). Participants received written information about the study and provided consent to participate in the survey. No identifying information was collected from participants.

4. Results

4.1. Demographics

The demographics and practice settings of the participants are summarised in Table 1. Three‐quarters of participants identified as female, with an average experience as a NP of just under 8 years. The majority worked in the public health system and just over a quarter reported engaging in private practice at least some of the time. All six metaspecialties were represented, with Emergency & Acute Care being the most frequently reported metaspecialty.

TABLE 1.

Characteristics of study participants.

Age in years (mean, SD)	47	8.22
Number of years endorsed as a nurse practitioner (mean, range)	7.6	1–23

	n	%
Gender
Female	91	76
Male	27	23
Non‐binary	1	< 1
Practice setting
Public	86	72
Private	12	10
Combined public and private	21	18
Location of practice
Major cities	76	64
Inner regional	18	15
Outer regional	19	16
Remote	5	4
Very remote	1	< 1
Metaspecialty
Emergency & Acute Care	41	35
Chronic & Complex Care	23	19
Ageing & Palliative Care	23	19
Primary Health Care	21	18
Mental Health Care	7	6
Child & Family Health	4	3
Highest qualification
Doctoral degree	5	4
Master's degree	112	94
Graduate diploma	1	< 1
Graduate certificate	1	< 1

4.2. Training and Education

Participants were asked about their formal training experiences related to diagnostic imaging before and/or after endorsement as a nurse practitioner. Half (50.5% n = 51) reported that they received formal training before endorsement in requesting imaging and 17% (n = 17) reported that they received formal training to request imaging after endorsement as a nurse practitioner.

The amount of education received as part of their NP degree was reported as insufficient by 68% of respondents (n = 68), while 31% (n = 31) reported that it was the correct amount, with one respondent reporting that it was excessive for their requirements.

5. Requesting Diagnostic Imaging

Most participants (83%, n = 99) reported that they request diagnostic imaging in their practice, at the time of the survey. Participants who reported that they request imaging were asked to rate the importance of this to their scope of practice on a Likert scale (1 = very important, 5 = not important). Requesting imaging was rated as ‘important’ or ‘very important’ by 91% (n = 90) of respondents. Among those who did not request imaging (n = 20), 19 reported that the ability to do so would enable them to work to their full scope of practice. Participants responded to open‐ended questions regarding the importance of requesting diagnostic imaging to their current practice. Making a diagnosis to inform practice, screening and enabling full scope of practice were identified as reasons why requesting diagnostic imaging was reported as important.

Participants were also asked to identify any barriers they experienced when requesting diagnostic imaging. Barriers that were reported included resistance from radiology service providers, the impact of limited NP‐initiated diagnostic items available for patients to claim reimbursement via the Medicare Benefits Schedule (MBS), a comprehensive list of medical services subsidised by the Australian government, and a range of access‐related and organisational factors. These included access to radiology services outside of usual hours or in regional areas, and employer‐imposed limits on the types of imaging NPs are permitted to request.

6. Knowledge and Confidence

Participants were asked to rate their knowledge related to aspects of diagnostic imaging using a five‐point Likert scale, ranging from 5 = excellent to 1 = very poor. Participants self‐rated their knowledge related to knowing the most appropriate imaging to order as highest, although 17% (n = 16) of respondents agreed that they often need assistance in choosing the most appropriate imaging examination. Knowledge of the requirements for patients to claim government rebates was rated the lowest (Figure 1).

FIGURE 1.

Self‐rated knowledge scores related to diagnostic imaging (n = 101). [Colour figure can be viewed at wileyonlinelibrary.com]

Participants were asked to rate their self‐confidence and preparedness related to aspects of diagnostic imaging. Confidence in providing information about the risks and benefits of proposed imaging was high, with 86% (n = 87) agreeing or strongly agreeing they felt confident in doing this. Most participants (79% (n = 80)) also agreed or strongly agreed that they felt well‐prepared to request diagnostic imaging.

7. Methods of Requesting

Participants were asked to report the methods of requesting medical imaging. The rate of requesting imaging independently was highest for plain X‐ray and lowest for MRI (Figure 2).

FIGURE 2.

Methods of requesting by imaging modality (n = 119). [Colour figure can be viewed at wileyonlinelibrary.com]

8. Types of Imaging Requested

Participants reported the diagnostic investigations they had requested over the prior month. Findings related to plain X‐rays, ultrasound, CT scan and MRI are represented in Table 2. Plain X‐rays of the chest and limbs were the most frequently reported images requested over the prior month. Pelvic, vascular and abdominal ultrasounds and CT of the abdomen and brain were also reported as being requested frequently. The top 10 investigations reported by participants within each metaspecialty are presented in Table 3. The full list of investigations reported by participants within each metaspecialty is available in Table S2.

TABLE 2.

Diagnostic images requested (n = number of NPs who requested these images in the last month).

	n	%		n	%
Plain X‐ray			CT scan
Chest	70	59	Abdomen	30	25
Limb	51	43	Brain	30	25
Abdomen	30	25	Chest	16	13
Pelvis	26	22	Guide interventions	14	12
Spine	15	13	Face	12	10
Orthopantomogram	6	5	Extremities	8	7
			Renal tract	2	2
			Spine	1	1
Ultrasound			MRI
Pelvis	42	35	Brain	14	12
Vascular	42	35	Musculoskeletal	13	11
Abdomen	38	32	Liver	1	< 1
Heart	19	16	Abdomen	1	< 1
Soft tissues	10	8
Genito‐urinary/Renal tract	7	6
Joints	6	5
Brain	5	4
Guide procedures	4	3
Skeletal	2	2
Breast	1	< 1
Cancer screen	1	< 1
Liver	1	< 1
Lung	1	< 1
Neck	1	< 1
Thyroid	1	< 1

TABLE 3.

Nurse practitioners requesting imaging by metaspecialty (n = number of NPs who requested these images in the last month).

Chronic and complex care (n = 23)			Ageing and palliative care (n = 23)			Emergency and acute care (n = 41)
	n	%		n	%		n	%
CT—Abdomen	9	39	X‐ray—Chest	11	48	X‐ray—Chest	35	85
X‐ray—Chest	8	35	X‐ray—Limb	8	35	X‐ray—Limb	31	76
X‐ray—Abdomen	5	21	X‐ray—Abdomen	7	30	US—Vascular	26	63
US—Abdomen	5	21	X‐ray—Pelvis	5	21	CT—Brain	21	51
US—Cardiac	4	17	US—Vascular	5	21	US—Abdomen	17	41
US—Vascular	4	17	X‐ray—Spine	3	13	US—Pregnancy	17	41
X‐ray—Limb	3	13	US—Abdomen	3	13	CT—Abdomen	16	39
CT—guided interventions	3	13	CT—Brain	3	13	X‐ray—Pelvis	16	39
PET	2	10	CT Cardiac	3	13	US—Pelvis	12	29
CT—Brain	2	10	US—Pelvis	2	10	X‐ray—Abdomen	9	22
			US—Renal	2	10	CT—guide interventions	9	22

Child and family health care (n = 4)			Mental health care (n = 7)			Primary health care (n = 21)
	n	%		n	%		n	%
X‐ray—Chest	4	100	US—Abdomen	1	14	X‐ray—Chest	13	62
X‐ray—Abdomen	4	100	US—Liver	1	14	X‐ray—Limb	11	52
US—Brain	4	100				US—Cardiac	9	42
MRI—Brain	3	75				US—Abdomen	9	42
						US—Vascular	9	42
						X‐ray—Abdomen	5	24
						US—Pregnancy	5	24
						US—Pelvis	5	24
						CT—Abdomen	5	24
						CT—Brain	5	24

Plain X‐rays of the chest and abdomen were reported by participants in every metaspecialty except by participants working in mental health care. Other imaging requested by NPs across the majority of metaspecialties included ultrasound of the abdomen and CT Brain. A patterns chart of imaging examinations requested by NPs from each metaspecialty is represented in Table 4.

TABLE 4.

Summary of imaging examinations requested by participants within each metaspecialty.

	Chronic and complex care (n = 23)	Ageing and palliative care (n = 23)	Emergency and acute care (n = 41)	Child and family health (n = 4)	Mental health care (n = 7)	Primary health care (n = 21)
Plain X‐ray
Chest	✓	✓	✓	✓		✓
Limb	✓	✓	✓	✓		✓
Abdomen	✓	✓	✓	✓		✓
Spine		✓	✓			✓
Pelvis	✓	✓	✓			✓
OPG	✓	✓	✓			✓
Hip	✓		✓
Mammogram	✓		✓			✓
Facial bones		✓
USS
Cardiac		✓	✓	✓		✓
Abdomen	✓	✓	✓	✓	✓	✓
Vascular	✓	✓	✓			✓
Pelvic	✓	✓	✓			✓
Head			✓	✓
Neck			✓
Breast	✓		✓
Liver	✓
Renal Tract		✓		✓		✓
LUT			✓			✓
Limb		✓	✓			✓
Hip				✓		✓
Soft tissue		✓	✓			✓
Thyroid						✓
Guides intervention	✓	✓	✓			✓
CT scan
Brain	✓	✓	✓			✓
Chest	✓	✓	✓			✓
Abdomen	✓	✓	✓			✓
Limb			✓
Spine			✓
Guides intervention	✓	✓	✓			✓
Pelvis	✓
Neck	✓		✓
Facial bones			✓			✓
Dental			✓
Renal tract			✓
Liver	✓
CT Angiogram	✓
MRI
Liver	✓
Brain	✓	✓	✓			✓
Pituitary	✓
Spine	✓		✓			✓
Limb			✓			✓
Abdomen			✓
Soft tissue			✓
Other
PET	✓	✓
V/Q scan	✓
Fluroscopy	✓	✓	✓
BMD		✓
Fibroscan					✓
WBBS						✓

Abbreviations: BMD, Bone Mineral Density scan; CT, Computed Tomography; LUTS, Lower Urinary Tract; MRI, Magnetic Resonance Imaging; OPG, Orthopantogram; PET, Positron Emission Tomography; USS, Ultrasound Scan; V/Q scan, Ventilation/Perfusion scan; WBBS, Whole Body Bone Scan.

9. Discussion

This study examines how nurse practitioners request and use diagnostic imaging in their practice, along with their knowledge, confidence and the educational and system‐level barriers that influence their practice. The use of diagnostic imaging by NPs has not been extensively explored, especially in the Australian context (Kearns et al. 2024).

There is limited publicly available demographic data on endorsed NPs through AHPRA. This constrains direct comparison with the national NP population. Demographics from this study have been compared to a previous national survey of NPs that utilised similar methodology (Fong et al. 2020). Overall, our sample was comparable in terms of age, gender, practice setting and qualifications. However, a higher proportion of participants in our study were working in major cities compared to this national survey (64% vs. 54%).

Participants reported requesting imaging across a range of modalities, including plain X‐rays, Ultrasound scans (USS), Computed Tomography (CT) scans and Magnetic Resonance Imaging (MRI). In a study of NP work patterns in one Australian state, requests for diagnostic imaging were reported in 68.4% of clinical encounters (Lowe et al. 2021). Consistent with our findings, imaging was requested across a similar range of modalities. The extent to which modality selection reflects patient need, clinician expertise or the influence of rebate availability remains unknown. Our study builds on these findings by reporting diagnostic imaging use in the primary metaspecialty of the participants and by exploring the barriers experienced by NPs in the use of diagnostic imaging. The ability to request a full range of imaging was identified as enabling NPs to work to their full scope of practice and provide quality care.

Participants reported that the content on diagnostic imaging offered as part of the NP master's degree was generally considered insufficient. This is similar to studies from the USA that also reported that most NPs felt ill‐prepared to request imaging (Logsdon and Gleason 2015) and that more curricular imaging content was needed (Kirkland and Champion 2018). This problem is not confined to NP practice. Insufficient education in diagnostic imaging has also been reported in the medical literature (Glenn‐Cox et al. 2019). There is no available data on how much imaging education is provided in NP programs across Australia and national accreditation standards for NP programs do not prescribe specific content about diagnostic imaging (ANMAC 2015). Future research to explore NP student education requirements across metaspecialties would be valuable.

In our study, the range of imaging requested varied across the six metaspecialties, reflecting differences in scopes of practice. In the Australian context, NPs are endorsed without specific specialty focus and NP course curricula reflect this (ANMAC 2015). The nurse practitioner clinical learning and teaching framework was developed to guide learning and teaching across the six identified metaspecialties (Gardner et al. 2021). Integrating this framework in the development of imaging education may be a viable pathway to ensuring relevant curriculum development in this area.

Despite the reported insufficiency of imaging education in NP degrees, self‐rated knowledge was reported as high by participants in relation to the most appropriate imaging to request and participants reported feeling well‐prepared to request diagnostic imaging. Previous studies support the appropriate requesting of imaging by NPs in emergency (Aledhaim et al. 2019; Lau et al. 2013) and primary care settings (Mafi et al. 2016; O'Reilly‐Jacob et al. 2019). High self‐rated knowledge in requesting diagnostic imaging may reflect self‐directed learning, with half of the participants reporting that they undertook education on requesting imaging before endorsement as an NP and others reporting similar education following endorsement. One of the key attributes of capable learners is the ongoing ability to develop their skills and knowledge beyond formal education. A capability approach to the education of NP students is widely discussed in the literature (O'Connell et al. 2014; Whitfield et al. 2024) and the inclusion of capability theory in curricula is specified in the Australian NP Course Accreditation Standards (ANMAC 2015). Empowering NP students to set their own goals and enhancing their capacity for continuous learning in diagnostic imaging may help them to personalise their ongoing education to align with their specific practice context. However, while a capability‐based approach supports NP self‐directed learning, it cannot substitute for mandated minimum competencies in radiation safety and risk–benefit assessment, given the well‐established patient safety risks associated with ionising radiation.

Participants reported low knowledge about the ionising radiation levels of different imaging modalities. This has previously been highlighted in the emergency department setting (Ditkofsky et al. 2016). Poor knowledge about ionising radiation by practitioners who request diagnostic imaging has been reported in the literature across health professions for many years (Brown and Jones 2013; Mellis et al. 2024). It is interesting to note that despite low self‐rated knowledge about ionising radiation of different imaging examinations, the majority of participants felt capable of providing information about the risks and benefits of proposed imaging. While accountability for safety and appropriateness of imaging ultimately sits with the radiologist/service provider, it is argued that knowledge of ionising radiation is needed to justify the choice of diagnostic imaging (Mellis et al. 2024) and to provide enough education to patients to ensure informed consent (Brown and Jones 2013). While Mendelson (2022) argues that the level of risk is unproven for individual examinations and that truly informed consent cannot be gained, he agrees that the principle of justification requires the referrer to have enough knowledge about ionising radiation to assess the risks and benefits of the examination. Though supporting NP capability in defining their own education goals, inappropriate use of diagnostic imaging poses risks to patient safety. In the UK, EU‐derived guidance has led to the development of a recommended training framework for clinicians who refer for radiological investigations (Hughes et al. 2022). To strengthen safe and evidence‐based imaging referrals, regulatory bodies in Australia should consider implementing a similar training framework in radiation safety for all authorised imaging referrers.

Self‐rated knowledge was also low in relation to the requirements for MBS rebates. This may reflect that only 28% of participants (n = 33) reported engaging in private practice. At the time of the survey, diagnostic investigations requested by NPs in the public system were not funded by the MBS, unless the investigation was to be undertaken in private radiology services. The limited reimbursement for diagnostic imaging investigations within the MBS was identified as one of the barriers to requesting diagnostic imaging outside of publicly funded hospitals. There are limited diagnostic imaging tests that attract an MBS rebate when requested by an NP (Australian Government Department of Health and Aged Care, n.d.). At the time of this survey, CT scans and MRI examinations, along with a range of plain film X‐rays and US, did not attract a patient rebate when requested by NPs (Australian Government Department of Health and Aged Care, n.d.). Higher numbers of requests for CT scans and MRIs were reported as requiring authorisation by a medical practitioner, reflecting this barrier. While there have been some changes to patient rebates on imaging requested by NPs, significant limitations persist. Such limitations in access to MBS reimbursements for diagnostic tests when requested by NPs have previously been reported as limiting access to care for patients and resulting in duplication and fragmentation of patient care (Currie et al. 2019; Helms et al. 2015).

Participants also highlighted the importance of imaging in allowing NPs to work to their full scope of practice, particularly in relation to diagnostic reasoning and surveillance. This is echoed by those respondents who reported that they did not request imaging. Scope of practice is defined as that which an individual NP is competent, educated and authorised to perform. The scope of practice of individual NPs can be influenced by multiple factors, including federal and state legislation and local organisation policies (Scanlon et al. 2016). Local barriers including those related to health care organisations and access issues were also reported by participants. Restrictions placed on NP practice by their employing organisations have previously been identified as a barrier that can prevent NPs working to their full scope of practice (Torrens et al. 2020).

10. Limitations

This study has some limitations. At the time of the survey, there were 2900 endorsed NPs in Australia (AHPRA 2024). The number of participants enrolled in the study represents only 4% of the NP workforce. The findings represent insights from self‐selected participants, so selection bias is a possibility. It is probable that NPs who don't engage with diagnostic imaging did not respond to the survey. In addition, there are low numbers of participants enrolled from some metaspecialties, so results may not be generalisable to other NPs in these metaspecialties. Participants were not asked to identify any steps taken to ensure that images requested balanced the risks of radiation exposure with expected benefits. Another limitation relates to the lack of reliability testing of the online questionnaire.

11. Conclusion

Findings of this study demonstrate that diagnostic imaging is a central component of nurse practitioner practice in Australia, supporting clinical decision‐making and enabling full scope of practice. Imaging education within NP programs was considered insufficient, highlighting the need for strengthened educational preparation. Despite legislative authority to request imaging in most jurisdictions, significant structural and organisational barriers persist, including limited patient rebates and local restrictions on autonomous requesting, underscoring the need for policy reform.

Author Contributions

Mary Kearns: conceptualisation, methodology, formal analysis, investigation, writing the original draft, writing review and editing. Patrick Brennan: writing review and editing, supervision. Christopher Helms: writing review and editing. Thomas Buckley: conceptualisation, methodology, statistical analysis, writing review and editing, supervision.

Funding

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Table S1: Survey Questions and Theoretical Domains Framework.

Table S2: Number of NPs who requested imaging types by metaspecialty.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.