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An Integrative Review of Outcomes and Radiology Nursing
Journal of Radiology Nursing xxx (2018) 1e6
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An Integrative Review of Outcomes and Radiology Nursing Jennifer A. Werthman, MS, MBA, RN, NE-BC * Vanderbilt University School of Nursing, Nashville, TN
a b s t r a c t Keywords: Radiology nursing Health outcomes
The primary aim of this article is to present a broad overview and to describe and analyze the existing literature related to the effect of radiology nurses on health and health outcomes. Combinations of search terms related to the role of the radiology nurse and patient outcomes were used to search three electronic databases. Of the studies reviewed, 15 met inclusion criteria. This review concludes that further work must be completed to obtain an appropriate understanding of the effect of radiology nursing on patient outcomes. Given the lack of literature on this topic, there is significant opportunity to continue research on nursing in radiology. © 2018 Association for Radiologic & Imaging Nursing. Published by Elsevier Inc. All rights reserved.
Introduction Nurses play an essential role within health care and hospital systems. There is substantial evidence from the last few decades which demonstrates the importance of nursing in achieving hospital quality and safety goals. Numerous studies and measures have directly linked nursing to quality and health services outcomes. Examples include studies that assess the impact of nursing on failure to rescue, mortality, pneumonia, urinary tract infections, and patient satisfaction (Aiken et al., 2011; Kutney-Lee et al., 2009; Needleman et al., 2002). Despite the growing body of work over the last few decades defining the roles and value of nursing, there remains limited information that describes the impact of nurses on health-care outcomes in specialized treatment areas such as radiology. Miller and Gerard first described the role of the nurse in radiology in their 1964 article The Nurse on the Radiological Team, which discussed the impact of nurses on the patient as it relates to positive outcomes and accurate diagnoses, given the “… unique position of closeness to the patient (Miller and Gerard, 1964, p. 128).” Formal nursing employment in radiology departments began in the 1970s (Goodhart and Page, 2007). Today, radiology nurses work in both diagnostic imaging and interventional treatment areas. They are responsible for promoting health, comfort, and safety during imaging procedures, patient assessment, education, monitoring of vital signs, patient positioning, and medication administration, including the administration of moderate sedation (Goodhart and Declaration of interest: none. * Corresponding author: Jennifer A. Werthman, Vanderbilt University School of Nursing, 461 21st Avenue, SouthNashville, TN 37240. E-mail address: [email protected].
Page, 2007; Scope and Standards of Practice: Radiologic and Imaging Nursing, 2013). As nurses have more contact with patients than any other provider, they have the potential to make a significant impact on patient outcomes in radiology areas (Dempsey et al., 2014). Existing literature describing the role of nursing within radiology is primarily descriptive. These articles contain information about the activities in which nurses may participate and a generalized discussion of the value of nursing in radiology (Goodhart and Page, 2007; Miller and Gerard, 1964). The extent to which literature exists which measures this value with regard to health-care outcomes is unknown. This article describes the current state of the science regarding nursing impact on patient outcomes within the radiology department.
Methods The following questions were used to guide the literature search and analysis: (1) Are studies available in the literature describe nursing in radiology and their relation to outcomes? (2) How are the studied outcomes defined? Both nursing in radiology and outcomes were defined very broadly to include any literature that may link the two topics. The current “radiologic and imaging nurse generalist” is defined as a “licensed registered nurse who demonstrates clinical skills and knowledge in radiologic and imaging nursing and imaging technologies (American Nurses Scope and Standards of Practice: Radiologic and Imaging Nursing, (2013), p. 10).” A 2007 survey conducted by the Association for Radiologic and Imaging Nursing and the Radiologic Nursing Certification Board identified imaging and interventional/therapeutic radiology as the two major practice
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areas within radiology nursing, encompassing sixteen specific modalities (Practice Analysis of Radiology Nursing, 2010). These modalities include general diagnostic imaging, computed tomography, magnetic resonance imaging (MRI), interventional radiology, nuclear medicine, neurointerventional radiology, cardiac catheterization, breast health/women's health, ultrasound, radiation therapy, information technology, positron emission tomography, vascular ultrasound, cardiac stress testing, vascular access, and other (Practice Analysis of Radiology Nursing, 2010). Studies describing radiology nurses practicing in any of these modalities were included. Outcomes were defined as a patient, treatment, health service, or nursing-sensitive outcome that was linked in some way to the presence or practice action of a radiology nurse within any of these modalities or practice categories. Nursing-sensitive outcomes, as defined by Doran (2011) in Nursing Outcomes: The State of the Science, include functional status, selfcare, symptom management, patient safety, patient satisfaction, psychological distress, health-care utilization, and mortality (Doran, 2011). These nursing-sensitive outcomes were chosen based on their extensive study and the supporting literature defining their specificity to nursing. PubMed, CINAHL, and PsycINFO were used to obtain literature for review. Terms used in the search included combinations of the following words: radiology, imaging, nurse(s), nursing, role, nurse's role, and radiotherapy/nursing. Terms used in the search to identify literature related to patient outcomes included combinations of the following words: outcomes, patient outcomes, outcome assessment, treatment outcome, morbidity, mortality, heath services outcomes, patient functional status, patient safety, patient satisfaction, self-care, symptom management, psychological distress, and health-care utilization. Specific Boolean operators and methods to achieve variations in terms were used. Search terms for all strategies were confined to the article title or abstract to obtain the most relevant results. Studies published in the English language which described nursing as having an effect on health-care outcomes were reviewed. To achieve maximum results for all search strategies, dissertations and quality-improvement studies were included. Articles not describing primary research, articles using only author opinion, or articles that simply described the role of the radiology nurse, with no discussion of outcomes, were excluded. This review did not include a study of the potential effect of advanced practice nurses (ie, nurse practitioners) on outcomes. No limitations were placed on the geographic location or year to obtain the maximum results. All literature had to be accessible via the Vanderbilt University library systems. Results Using the described search methods, a total of 748 records were retrieved (Figure 1). A title review identified 111 articles appropriate for abstract review after duplicates were removed. Twentynine records met the inclusion criteria and underwent full-text review. Of these 29, 15 met inclusion criteria (Table 1) (Applegate et al., 2016; Bluemke and Breiter, 2000; Crego, 2014; Crego et al., 2017; Dong et al., 2016; Faithfull et al., 2001; Gamulka et al., 2005; Gonzales and Rutledge, 2015; Janjan et al., 1992; Johnson et al., 1997; Lang and Berbaum, 1997; Mason et al., 2002; Ochonma et al., 2015; Rose and Yates, 2015; Sury et al., 1999).
PubMed (n = 597)
CINAHL (n=118)
PsycINFO (n = 33)
Title and/or abstract review after duplicates removed (n=559)
Full text review (n=29)
Two additional articles added as a result of abstract review (n = 2)
Included in review (n = 15)
Figure 1. Search strategy.
radiotherapy, peripherally inserted central catheter (PICC) services, and diagnostic imaging. Sample sizes ranged from 19 to 36,352 patients. The majority of studies were completed or used data from a single hospital or clinic setting, whereas two studies used data from the Pediatric Sedation Research Consortium (PSRC) database that collects data from >30 individual facilities in and outside of the United States (Crego, 2014; Crego et al., 2017). Most studies reported a combination of the male and female adult population (>18), with one focusing on men receiving radiotherapy for prostate and bladder cancer (Faithfull et al., 2001). Five studies reported an entirely pediatric population (Crego, 2014; Crego et al., 2017; Gamulka et al., 2005; Mason et al., 2002; Sury et al., 1999). Six studies were completed in China, the United Kingdom, Canada, Nigeria, and Australia (Dong et al., 2016; Faithfull et al., 2001; Gamulka et al., 2005; Ochonma et al., 2015; Rose and Yates, 2015; Sury et al., 1999). The remaining studies were completed in the United States (Applegate et al., 2016; Bluemke and Breiter, 2000; Crego, 2014; Crego et al., 2017; Gonzales and Rutledge, 2015; Janjan et al., 1992; Johnson et al., 1997; Lang and Berbaum, 1997; Mason et al., 2002). All studies used quantitative research methods with a variety of design approaches including, descriptive, quasi-experimental, and experimental. Three studies used single-group designs, whereas the rest reported the use of two or more groups (Gamulka et al., 2005; Gonzales and Rutledge, 2015; Sury et al., 1999). Two studies reported the use of random assignment to study the effectiveness of their intervention (Dong et al., 2016; Faithfull et al., 2001). Most studies describe primary research using prospective data collection, whereas three studies were retrospective reviews of databases (Bluemke and Breiter, 2000; Crego, 2014; Crego et al., 2017). These retrospective reviews focused on sedation administration and divided their samples into groups based on provider characteristics to study their outcomes of interest. The range of outcome measures identified in these studies include sedationrelated adverse events, successful MRI images, morbidity, patient satisfaction, successful PICC insertion, procedural anxiety, pain, continuance of life activities, mood, and responses to nursing care in accordance with the broad scope of search terms.
Sedation and Outcomes Study Details Subjects in the studies reviewed included patients seen in multiple radiology services, including interventional radiology, magnetic resonance imaging (MRI), computed tomography,
Six of the 15 studies focused on aspects of procedural sedation in relation to sedation-related adverse events (Applegate et al., 2016; Bluemke and Breiter, 2000; Crego, 2014; Crego et al., 2017; Mason et al., 2002; Sury et al., 1999). Bluemke and Breiter (2000) used
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Table 1 Articles included in the review Authors
Aim/purpose
Setting
Outcomes
Key findings related to nurses
Applegate et al. (2016)
Determine incidences of alarm events and number of alarm events with advanced monitoring Describe safety and effectiveness of conscious sedation and efficiency of sedation in MRI Describe the characteristics, sedation practice, and nurse outcomes in MRI, CT scan, and ultrasound procedures Describe differences in sedation-related adverse events by provider type
Gastroenterology and interventional radiology procedures at hospital in the United States MRI at hospital in the United States
Fewer alarm events in advanced vs. standard monitoring
Unable to determine the influence of the procedural sedation nurse
Sedation is safe and effective and specialized nurses are beneficial
Data obtained from the Pediatric Sedation Research Consortium Database
Adverse sedation event totaled 727 (5.78%)
Decreased sedation time and lower costs are associated with the use of specialized sedation nurses Challenging to compare complication rates due to limited literature
Data obtained from the Pediatric Sedation Research Consortium Database
RN þ MD sedation teams higher odds of adverse events
Dong et al. (2016)
Examine the effect of nursing intervention in MRI
MRI at hospitals in China
Faithfull et al. (2001)
Evaluate the effectiveness of nurse-led vs. conventional follow-up on morbidity and patient satisfaction for patients receiving pelvic radiotherapy Evaluate nurse-inserted PICC program (insertion rate success and periprocedural and long-term procedural complications) Describe patient-reported pain and anxiety levels at preprocedural, intraprocedural, and postprocedural steps Describe response to oral care and analgesic treatment protocol for patients with head and neck cancer
Radiotherapy services at hospital in the United Kingdom
Success rate of MRI and quality image is higher in the group receiving nursing intervention No difference in symptom score between the two groups. Higher levels of satisfaction in nurse-led group and additional cost reduction 69 PICCs successfully inserted by nurse (71.1%); no insertion complications, 13.4% required removal before therapy completion Pain (>4) noted by small number of participants; preprocedural anxiety noted by a range of patients (22%68%). Patients with daily nursing intervention, defined oral care, and pain protocol showed improved pain management Patients receiving intervention reported less disruption in life activities and more positive mood
Bluemke and Breiter (2000)
Crego (2014)
Crego et al. (2017)
Gamulka et al. (2005)
Gonzales and Rutledge (2015)
Janjan et al. (1992)
Johnson et al. (1997)
Lang and Berbaum (1997)
Evaluate nurse-provided intervention based on the self-regulation theory on patient QOL during and after radiation therapy Patients' perception of pain after education intervention for IR staff
PICC services at hospital in Canada
IR at hospitals in the United States
Radiotherapy services at hospitals in the United States
Radiotherapy services at hospitals in the United States
IR at hospitals in the United States
Patients pain scores were lower after training than baseline conditions
Mason et al. (2002)
Multiphase study to develop a ketamine sedation program
IR at hospital in the United States
No sedation failures or significant adverse events occurred
Ochonma et al. (2015)
Assess ethical conduct of radiographers and radiology nurses on patient satisfaction
One public and one private hospital in Nigeria
Radiographers high professional service delivery. Satisfaction higher in favor of private hospitals
Rose and Yates (2015)
Describe patient responses to nursing care after implementation of the person-centered care model Safety and efficacy of nurseled sedation for MRI
Outpatient radiotherapy canters in Australia
Patients satisfied with nursing care despite changes in well-being throughout radiation therapy course 5% failure rate of sedation and no adverse airway events
Sury et al. (1999)
Hospital in the United Kingdom
Sedation provider type (RN alone, MD alone, RN þ MD team) has implications for adverse events Nursing intervention aided in the success of MRI and image quality Nurse-led follow-up effective in increasing patient satisfaction and decreasing cost
Nurse-led PICC insertion program showed high success rate and low complications
Radiology nurses should be aware of pain levels and potential need for nonpharmacologic strategies Daily intervention by radiation therapy nurse aided in more effective pain management Radiation therapy nurses can use self-regulation theory ebased interventions for patients undergoing radiation therapy Radiology personnel trained in nonpharmacologic strategies can effectively help lower patients' pain during procedures Radiologist-supervised nurse-administered ketamine administration program successful for patients who may otherwise require general anesthesia Nursing is accountable to radiographers in the hospitals; unable to determine the specific impact of nurses in radiology Patient-centered nursing care can improve patient care in radiation therapy Nurse-led sedation service for pediatric MRI is successful in this hospital
CT ¼ computed tomography; MRI ¼ magnetic resonance imaging; PICC ¼ peripherally inserted central catheter; RN = registered nurse; MD = medical doctor; IR = interventional radiology; QOL = quality of life.
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an internal hospital sedation database, whereas Crego (2014) and Crego et al. (2017) used secondary data from the PSRC. Each of these studies specifically noted the contribution of the radiology sedation nurse. For example, Crego et al. (2017) used the PSRC database to examine the differences in adverse events based on provider type. Out of 36,352 cases reviewed, the lowest odds of adverse events were found in individual provider teams (registered nurse alone [odds ratio, 0.46] or medical doctor alone [odds ratio, 0.53]) when compared with the registered nurse þ medical doctor sedation teams in MRI procedures (Crego et al., 2017). Crego (2014) reviewed sedation practice and outcomes of sedation administered for a pediatric population of 12,584 cases sampled from the PSRC. Registered nurses administered sedation and monitored the patients in all these cases. The author found 727 (5.78%) adverse events occurred in this population, with the most common being inadequate sedation (n ¼ 196) and desaturation (n ¼ 138) (Crego, 2014). However, the author noted the significant challenges interpreting these results given the lack of published data on adverse events related to nurse-administered sedation. Bluemke and Breiter (2000) analyzed a sample of 4,761 sedation records over the course of 8 years to study the safety, effectiveness, quality, and efficiency of moderate sedation for MRI examinations. Of the 4,761 patients requiring sedation during the study period (March 1991 to November 1998), 4,453 (93.5%) received successfully, with 20 recorded adverse events (0.42%). Sedation times were compared among a group of four radiology nurses who performed 76% of the total sedations, other radiology nurses who performed sedation less often, and inpatient nurses from the hospital units of the individual patients. Among all three groups, the four radiology nurses who routinely performed sedation had the shortest sedation time and least variability (23.6 ± 15.2 minutes) compared with the other radiology nurses (26.8 ± 20.1 minutes) (p < .001) and the inpatient nurses (47.3 ± 36.6 minutes) (Bluemke and Breiter, 2000). The remaining three studies describing adverse sedation events were reports of the development of new sedation programs and procedures. Applegate et al. (2016) addressed advanced (addition of acoustic respiratory monitoring and processed electroencephalography) vs. standard monitoring, finding fewer alarm events in advanced, monitored patients. Mason et al. (2002) described the development of a nurse-administered ketamine program for pediatric patients undergoing interventional radiology procedures, and Sury et al. (1999) described the development of a nurse-led sedation service for pediatric MRI patients. All authors concluded that their respective programs were safe and effective options for nurseled sedation programs. Nursing Intervention and Outcomes Five studies described the success of specific nursing interventions on patient outcomes (Dong et al., 2016; Faithfull et al., 2001; Janjan et al., 1992; Johnson et al., 1997). Three of the four of these studies describe interventions for patients receiving radiation therapy (Faithfull et al., 2001; Janjan et al., 1992; Johnson et al., 1997). Dong et al. (2016) tested a nursing-specific intervention on 60 patients undergoing MRI to determine the completion rate and quality of the image. The intervention group was taught during the preprocedural, intraprocedural, and postprocedural steps of the MRI, resulting in a completion rate of 96.67% in the intervention group vs. 66.67% in control and a ‘diagnosable’ image in 96.67% vs. control (76.67%) (Dong et al., 2016). Faithfull et al. (2001) describe a nurseled intervention based on the participant's comprehensive understanding of their cancer diagnosis for men undergoing pelvic radiotherapy. Although there was no difference in the overall symptom score between intervention and control groups, there was an associated cost reduction of 31% (p < .001) in the intervention
group vs. control group and higher reported satisfaction levels in the intervention group vs. control group (p < .002) (Faithfull et al., 2001). Janjan et al. (1992) describe the use of a tailored nursing intervention for patients undergoing radiation therapy for head and neck cancer. In this study, the patients were seen daily by a radiation therapy nurse who assessed pain level via a 15-question survey, and if necessary, the nurse immediately adjusted the analgesic regimen. Patients receiving this intervention reported a reduction in moderate to severe pain compared with the control group (Janjan et al., 1992). Johnson et al. (1997) described an education intervention based on self-regulation theory for patients receiving radiation therapy. The four-part intervention resulted in the intervention group experiencing less disruption in activities and a more positive mood over controls (Johnson et al., 1997). The final article by Rose and Yates (2015) described responses to nursing care after the implementation of a person-centered care model for patients receiving radiotherapy treatments. This intervention focused on support provided to the family and patient by the radiation oncology nurse. The authors reported no significant difference in measured aspects of quality of life, patient satisfaction, anxiety, and depression; however, patients identified the nurse as an important source of information (Rose and Yates, 2015). Program Implementation Two studies reviewed the implementation of new hospital programs and their impact on patient outcomes. Gamulka et al. (2005) evaluated a nurse-led PICC program for pediatric patients to address the need for timely long-term intravenous access for their patient population (Gamulka et al., 2005). Sixty-nine PICC lines were successfully placed by the nursing team, out of 97 attempts (71.1%). Lang and Berbaum (1997) tested an educational intervention for nonpharmacologic methods on radiology personnel to determine the effects on patients’ perception of pain during interventional radiology procedures (Lang and Berbaum, 1997). Staff training resulted in lower reported pain scores for patients than baseline condition (1.48 vs. 2.54 [p ¼ .001]), emphasizing the importance of nonpharmacologic options for pain control (Lang and Berbaum, 1997). Survey Methodology The final two studies were descriptive studies using survey methodology to describe outcomes including pain, anxiety, and patient satisfaction (Gonzales and Rutledge, 2015; Ochonma et al., 2015). Gonzales and Rutledge (2015) surveyed the preprocedural, intraprocedural, and postprocedural pain levels using an 11-item numeric rating scale (0 to 10 scale) for 53 patients undergoing arteriovenous fistulogram, arteriovenous declotting, chest/arm port placement, or tunneled catheter placement. Anxiety was seen in a wide range of patients (22-68%), whereas pain greater than a score of four (0-10 scale) was seen in a small number of participants (11/ 53) (Gonzales and Rutledge, 2015). The study completed by Ochonma et al. (2015) assessed patient satisfaction among 300 patients receiving treatment in the radiology departments of two hospitals in Nigeria. The authors used a cross-sectional design with review of ethical conduct of both the radiographers and radiology nurses and its impact on patient satisfaction in this setting (Ochonma et al., 2015). The authors concluded that specifics of conduct such as obtaining informed consent before treatment and explanation of the procedure, equipment, or experience had an impact on the satisfaction levels of the patients. There was no mention of the influence of nurses aside from their accountability to the radiographers (Ochonma et al., 2015).
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Discussion
Limitations
This review identified significant opportunities for the continued study of radiology nursing. A synthesis of the available literature shows an overall lack of studies that examine the role and impact of radiology nursing on patient outcomes. The range of literature represents a time period of approximately 25 years, with the earliest identified study completed by Janjan et al. in 1992. Given the fact that radiology nursing, as a formal employment specialty, is described as early as the 1970s, 15 publications studying radiology nursing and outcomes over a period of approximately 50 years represents a significant dearth of evidence (Goodhart and Page, 2007). This deficiency is especially poignant in the era of health-care reform and ‘value,’ within which understanding the work and contribution of the nursing profession becomes vital. Notably, nurse-administered sedation is a major component of many radiologic procedures, yet the study of sedation outcomes is limited (Patatas and Koukkoulli, 2009). Crego (2015) published a general overview of the current state of nursing standards for procedural sedation, calling regulation in the United States “fragmented and poorly documented (Crego, 2015, p. 55).” As described, only six studies focused on aspects of procedural sedation in relation to adverse sedation-related events (Applegate et al., 2016; Bluemke and Breiter, 2000; Crego, 2014; Crego et al., 2017; Mason et al., 2002; Sury et al., 1999). Unfortunately, the generalizability of these studies is limited based on their use of only pediatric populations, internal hospital databases, and individualized single-site program implementation and development. The small number and limits of these studies is certainly due in part to the lack of large-scale available sedation outcomes data. Sedation continues to be a priority for the radiologic population, and various surveys have attempted to assess its use within radiology. A 1997 survey of radiologic practices queried the 1,713 members of the Society of Cardiovascular and Interventional Radiology (Mueller et al., 1997). Of the 634 that responded (37% response rate), a reported 90% of therapeutic procedures used a “drowsy/arousable” level of sedation, whereas 87% reported the presence of a full-time radiology nurse (Mueller et al., 1997). Korzewski et al. (2016) described practices during the endovascular therapy for acute ischemic stroke. Although the authors note that a certified registered nurse anesthetist or anesthesiologist was typically responsible for sedation management in these patients, 51.69% of the hospitals indicated that sedation may be provided by the registered nurse (Korzewski et al., 2016). Vari and Gangi (2017) described a survey of sedation practice throughout Europe, noting that the current state of the literature indicates varying practice patterns and levels of sedation for similar procedures (Vari and Gangi, 2017). Their respondents describe sedation administration by an anesthesiologist (48.3%), followed by the nurse (43.2%) and the interventional radiologist (~30%) (Vari and Gangi, 2017). As more procedures are completed within radiology which require sedation administration, nurses in these areas will be called upon to use this specialized skill (Murphy, 2013; Tuite and Rosenberg, 2005). Buerhaus et al. (2017) recently identified health-care reform as one of the four top challenges faced by the current nursing workforce in the United States (Buerhaus et al., 2017). In their view, the shift from fee-for-service to value-based purchasing could be beneficial for nurses as organizations begin to focus on providing the best possible outcomes at the lowest cost (Buerhaus et al., 2017). However, this perceived benefit is dependent on nursing being influential on these best possible outcomes. More research is needed to further define nursing's role.
Potential sources of bias include the use of English language studies only and a single author review of each article for inclusion/ exclusion criteria. The wide search and the range of outcomes in the identified studies made comparing and contrasting studies challenging. It is additionally difficult to generalize the results of studies completed outside of the United States to hospitals within the United States given the potential for differences in hospital and radiology structure and the radiology nursing role. This review focused on direct care radiology nursing and did not include the impact of advanced practice nurses such as nurse practitioners that may be used in different practice models. It is additionally possible that radiology nurses are involved in performance-improvement activities within their institutions that may not be commonly published in peer-reviewed literature. Conclusion Radiology nurses participate in a rapidly advancing technological field and have the opportunity to make substantial impacts. Potential areas for exploration include radiology nursing and sedation administration, the role of advanced practice nurses, greater exploration into nurse-led programs and procedures, and the general impact of radiology nurses on specific outcomes such as patient satisfaction and other quality and safety metrics. This review describes a sizable lack of evidence but also significant opportunity to study these nurses and document their essential role on health-care outcomes for the patients they serve. References Aiken, L.H., Cimiotti, J.P., Sloane, D.M., Smith, H.L., Flynn, L., & Neff, D.F. (2011). The effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Medical Care, 49(12), 1047-1053. Applegate, R.L., 2nd, Lenart, J., Malkin, M., Meineke, M.N., Qoshlli, S., Neumann, M., et al. (2016). Advanced monitoring is associated with fewer alarm events during planned moderate procedure-related sedation: a 2-part pilot trial. Anesthesia and Analgesia, 122(4), 1070-1078. Bluemke, D.A., & Breiter, S.N. (2000). Sedation procedures in MR imaging: safety, effectiveness, and nursing effect on examinations. Radiology, 216(3), 645-652. Buerhaus, P.I., Skinner, L.E., Auerbach, D.I., & Staiger, D.O. (2017). Four challenges facing the nursing workforce in the United States. Journal of Nursing Regulation, 8(2), 40-46. Crego, N. (2014). Pediatric sedation: using secondary data to describe registered nurse practice in radiology. Journal of Radiology Nursing, 33(4), 166-180. Crego, N. (2015). Procedural sedation practice: a review of current nursing standards. Journal of Nursing Regulation, 6(1), 50-56. Crego, N., Baernholdt, M., & Merwin, E. (2017). Differences in pediatric noninterventional radiology procedural sedation practices and adverse events by registered nurses and physicians. Journal of Pediatric Nursing, 35, 129-133. Dempsey, C., Reilly, B., & Buhlman, N. (2014). Improving the patient experience: real-world strategies for engaging nurses. The Journal of Nursing Administration, 44(3), 142-151. Dong, G.Q., Wang, W.W., Deng, K., & Wang, G.L. (2016). The pilot study of radiology nursing intervention in abdominal 3-T Magnetic Resonance examination. Revista da Escola de Enfermagem da U S P, 50(6), 961-964. Doran, D. (2011). Nursing outcomes the state of the science (2nd ed.). Sudbury, MA: Jones & Bartlett Learning. Faithfull, S., Corner, J., Meyer, L., Huddart, R., & Dearnaley, D. (2001). Evaluation of nurse-led follow up for patients undergoing pelvic radiotherapy. British Journal of Cancer, 85(12), 1853-1864. Gamulka, B., Mendoza, C., & Connolly, B. (2005). Evaluation of a unique, nurseinserted, peripherally inserted central catheter program. Pediatrics, 115(6), 1602-1606. Gonzales, M., & Rutledge, D.N. (2015). Pain and anxiety during less invasive interventional radiology procedures. Journal of Radiology Nursing, 34(2), 88-93. Goodhart, J., & Page, J. (2007). Radiology nursing. Orthopedic Nursing, 26(1), 36-39. Janjan, N.A., Weissman, D.E., & Pahule, A. (1992). Improved pain management with daily nursing intervention during radiation therapy for head and neck carcinoma. International Journal of Radiation Oncology, Biology, Physics, 23(3), 647652. Johnson, J.E., Fieler, V.K., Wlasowicz, G.S., Mitchell, M.L., & Jones, L.S. (1997). The effects of nursing care guided by self-regulation theory on coping with radiation therapy. Oncology Nursing Forum, 24(6), 1041-1050.
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Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., & Zelevinsky, K. (2002). Nursestaffing levels and the quality of care in hospitals. New England Journal of Medicine, 346(22), 1715-1722. Ochonma, O.G., Eze, C.U., Eze, S.B., & Okaro, A.O. (2015). Patients' reaction to the ethical conduct of radiographers and staff services as predictors of radiological experience satisfaction: a cross-sectional study. BMC Medical Ethics, 16(1), 1-9. Patatas, K., & Koukkoulli, A. (2009). The use of sedation in the radiology department. Clinical Radiology, 64(7), 655-663. Practice Analysis of Radiology Nursing. J Radiol Nurs, 29(4), (2010), 109-128. Rose, P., & Yates, P. (2015). Patients' outcomes related to person-centred nursing care in radiation oncology: a case study. European Journal of Oncology Nursing: The Official Journal of European Oncology Nursing Society, 19(6), 731-739. Scope and Standards of Practice: Radiologic and Imaging Nursing. (2013). Silver Spring, Maryland: American Nurses Association. Sury, M.R., Hatch, D.J., Deeley, T., Dicks-Mireaux, C., & Chong, W.K. (1999). Development of a nurse-led sedation service for paediatric magnetic resonance imaging. The Lancet, 353(9165), 1667-1671. Tuite, C., & Rosenberg, E. (2005). Sedation and analgesia in interventional radiology. Seminars in Interventional Radiology, 22(2), 114-120. Vari, A., & Gangi, A. (2017). Anesthesia practices for interventional radiology in Europe. Cardiovascular and Interventional Radiology, 40(6), 803-813.
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An Integrative Review of Outcomes and Radiology Nursing Jennifer A. Werthman, MS, MBA, RN, NE-BC * Vanderbilt University School of Nursing, Nashville, TN
a b s t r a c t Keywords: Radiology nursing Health outcomes
The primary aim of this article is to present a broad overview and to describe and analyze the existing literature related to the effect of radiology nurses on health and health outcomes. Combinations of search terms related to the role of the radiology nurse and patient outcomes were used to search three electronic databases. Of the studies reviewed, 15 met inclusion criteria. This review concludes that further work must be completed to obtain an appropriate understanding of the effect of radiology nursing on patient outcomes. Given the lack of literature on this topic, there is significant opportunity to continue research on nursing in radiology. © 2018 Association for Radiologic & Imaging Nursing. Published by Elsevier Inc. All rights reserved.
Introduction Nurses play an essential role within health care and hospital systems. There is substantial evidence from the last few decades which demonstrates the importance of nursing in achieving hospital quality and safety goals. Numerous studies and measures have directly linked nursing to quality and health services outcomes. Examples include studies that assess the impact of nursing on failure to rescue, mortality, pneumonia, urinary tract infections, and patient satisfaction (Aiken et al., 2011; Kutney-Lee et al., 2009; Needleman et al., 2002). Despite the growing body of work over the last few decades defining the roles and value of nursing, there remains limited information that describes the impact of nurses on health-care outcomes in specialized treatment areas such as radiology. Miller and Gerard first described the role of the nurse in radiology in their 1964 article The Nurse on the Radiological Team, which discussed the impact of nurses on the patient as it relates to positive outcomes and accurate diagnoses, given the “… unique position of closeness to the patient (Miller and Gerard, 1964, p. 128).” Formal nursing employment in radiology departments began in the 1970s (Goodhart and Page, 2007). Today, radiology nurses work in both diagnostic imaging and interventional treatment areas. They are responsible for promoting health, comfort, and safety during imaging procedures, patient assessment, education, monitoring of vital signs, patient positioning, and medication administration, including the administration of moderate sedation (Goodhart and Declaration of interest: none. * Corresponding author: Jennifer A. Werthman, Vanderbilt University School of Nursing, 461 21st Avenue, SouthNashville, TN 37240. E-mail address: [email protected].
Page, 2007; Scope and Standards of Practice: Radiologic and Imaging Nursing, 2013). As nurses have more contact with patients than any other provider, they have the potential to make a significant impact on patient outcomes in radiology areas (Dempsey et al., 2014). Existing literature describing the role of nursing within radiology is primarily descriptive. These articles contain information about the activities in which nurses may participate and a generalized discussion of the value of nursing in radiology (Goodhart and Page, 2007; Miller and Gerard, 1964). The extent to which literature exists which measures this value with regard to health-care outcomes is unknown. This article describes the current state of the science regarding nursing impact on patient outcomes within the radiology department.
Methods The following questions were used to guide the literature search and analysis: (1) Are studies available in the literature describe nursing in radiology and their relation to outcomes? (2) How are the studied outcomes defined? Both nursing in radiology and outcomes were defined very broadly to include any literature that may link the two topics. The current “radiologic and imaging nurse generalist” is defined as a “licensed registered nurse who demonstrates clinical skills and knowledge in radiologic and imaging nursing and imaging technologies (American Nurses Scope and Standards of Practice: Radiologic and Imaging Nursing, (2013), p. 10).” A 2007 survey conducted by the Association for Radiologic and Imaging Nursing and the Radiologic Nursing Certification Board identified imaging and interventional/therapeutic radiology as the two major practice
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areas within radiology nursing, encompassing sixteen specific modalities (Practice Analysis of Radiology Nursing, 2010). These modalities include general diagnostic imaging, computed tomography, magnetic resonance imaging (MRI), interventional radiology, nuclear medicine, neurointerventional radiology, cardiac catheterization, breast health/women's health, ultrasound, radiation therapy, information technology, positron emission tomography, vascular ultrasound, cardiac stress testing, vascular access, and other (Practice Analysis of Radiology Nursing, 2010). Studies describing radiology nurses practicing in any of these modalities were included. Outcomes were defined as a patient, treatment, health service, or nursing-sensitive outcome that was linked in some way to the presence or practice action of a radiology nurse within any of these modalities or practice categories. Nursing-sensitive outcomes, as defined by Doran (2011) in Nursing Outcomes: The State of the Science, include functional status, selfcare, symptom management, patient safety, patient satisfaction, psychological distress, health-care utilization, and mortality (Doran, 2011). These nursing-sensitive outcomes were chosen based on their extensive study and the supporting literature defining their specificity to nursing. PubMed, CINAHL, and PsycINFO were used to obtain literature for review. Terms used in the search included combinations of the following words: radiology, imaging, nurse(s), nursing, role, nurse's role, and radiotherapy/nursing. Terms used in the search to identify literature related to patient outcomes included combinations of the following words: outcomes, patient outcomes, outcome assessment, treatment outcome, morbidity, mortality, heath services outcomes, patient functional status, patient safety, patient satisfaction, self-care, symptom management, psychological distress, and health-care utilization. Specific Boolean operators and methods to achieve variations in terms were used. Search terms for all strategies were confined to the article title or abstract to obtain the most relevant results. Studies published in the English language which described nursing as having an effect on health-care outcomes were reviewed. To achieve maximum results for all search strategies, dissertations and quality-improvement studies were included. Articles not describing primary research, articles using only author opinion, or articles that simply described the role of the radiology nurse, with no discussion of outcomes, were excluded. This review did not include a study of the potential effect of advanced practice nurses (ie, nurse practitioners) on outcomes. No limitations were placed on the geographic location or year to obtain the maximum results. All literature had to be accessible via the Vanderbilt University library systems. Results Using the described search methods, a total of 748 records were retrieved (Figure 1). A title review identified 111 articles appropriate for abstract review after duplicates were removed. Twentynine records met the inclusion criteria and underwent full-text review. Of these 29, 15 met inclusion criteria (Table 1) (Applegate et al., 2016; Bluemke and Breiter, 2000; Crego, 2014; Crego et al., 2017; Dong et al., 2016; Faithfull et al., 2001; Gamulka et al., 2005; Gonzales and Rutledge, 2015; Janjan et al., 1992; Johnson et al., 1997; Lang and Berbaum, 1997; Mason et al., 2002; Ochonma et al., 2015; Rose and Yates, 2015; Sury et al., 1999).
PubMed (n = 597)
CINAHL (n=118)
PsycINFO (n = 33)
Title and/or abstract review after duplicates removed (n=559)
Full text review (n=29)
Two additional articles added as a result of abstract review (n = 2)
Included in review (n = 15)
Figure 1. Search strategy.
radiotherapy, peripherally inserted central catheter (PICC) services, and diagnostic imaging. Sample sizes ranged from 19 to 36,352 patients. The majority of studies were completed or used data from a single hospital or clinic setting, whereas two studies used data from the Pediatric Sedation Research Consortium (PSRC) database that collects data from >30 individual facilities in and outside of the United States (Crego, 2014; Crego et al., 2017). Most studies reported a combination of the male and female adult population (>18), with one focusing on men receiving radiotherapy for prostate and bladder cancer (Faithfull et al., 2001). Five studies reported an entirely pediatric population (Crego, 2014; Crego et al., 2017; Gamulka et al., 2005; Mason et al., 2002; Sury et al., 1999). Six studies were completed in China, the United Kingdom, Canada, Nigeria, and Australia (Dong et al., 2016; Faithfull et al., 2001; Gamulka et al., 2005; Ochonma et al., 2015; Rose and Yates, 2015; Sury et al., 1999). The remaining studies were completed in the United States (Applegate et al., 2016; Bluemke and Breiter, 2000; Crego, 2014; Crego et al., 2017; Gonzales and Rutledge, 2015; Janjan et al., 1992; Johnson et al., 1997; Lang and Berbaum, 1997; Mason et al., 2002). All studies used quantitative research methods with a variety of design approaches including, descriptive, quasi-experimental, and experimental. Three studies used single-group designs, whereas the rest reported the use of two or more groups (Gamulka et al., 2005; Gonzales and Rutledge, 2015; Sury et al., 1999). Two studies reported the use of random assignment to study the effectiveness of their intervention (Dong et al., 2016; Faithfull et al., 2001). Most studies describe primary research using prospective data collection, whereas three studies were retrospective reviews of databases (Bluemke and Breiter, 2000; Crego, 2014; Crego et al., 2017). These retrospective reviews focused on sedation administration and divided their samples into groups based on provider characteristics to study their outcomes of interest. The range of outcome measures identified in these studies include sedationrelated adverse events, successful MRI images, morbidity, patient satisfaction, successful PICC insertion, procedural anxiety, pain, continuance of life activities, mood, and responses to nursing care in accordance with the broad scope of search terms.
Sedation and Outcomes Study Details Subjects in the studies reviewed included patients seen in multiple radiology services, including interventional radiology, magnetic resonance imaging (MRI), computed tomography,
Six of the 15 studies focused on aspects of procedural sedation in relation to sedation-related adverse events (Applegate et al., 2016; Bluemke and Breiter, 2000; Crego, 2014; Crego et al., 2017; Mason et al., 2002; Sury et al., 1999). Bluemke and Breiter (2000) used
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Table 1 Articles included in the review Authors
Aim/purpose
Setting
Outcomes
Key findings related to nurses
Applegate et al. (2016)
Determine incidences of alarm events and number of alarm events with advanced monitoring Describe safety and effectiveness of conscious sedation and efficiency of sedation in MRI Describe the characteristics, sedation practice, and nurse outcomes in MRI, CT scan, and ultrasound procedures Describe differences in sedation-related adverse events by provider type
Gastroenterology and interventional radiology procedures at hospital in the United States MRI at hospital in the United States
Fewer alarm events in advanced vs. standard monitoring
Unable to determine the influence of the procedural sedation nurse
Sedation is safe and effective and specialized nurses are beneficial
Data obtained from the Pediatric Sedation Research Consortium Database
Adverse sedation event totaled 727 (5.78%)
Decreased sedation time and lower costs are associated with the use of specialized sedation nurses Challenging to compare complication rates due to limited literature
Data obtained from the Pediatric Sedation Research Consortium Database
RN þ MD sedation teams higher odds of adverse events
Dong et al. (2016)
Examine the effect of nursing intervention in MRI
MRI at hospitals in China
Faithfull et al. (2001)
Evaluate the effectiveness of nurse-led vs. conventional follow-up on morbidity and patient satisfaction for patients receiving pelvic radiotherapy Evaluate nurse-inserted PICC program (insertion rate success and periprocedural and long-term procedural complications) Describe patient-reported pain and anxiety levels at preprocedural, intraprocedural, and postprocedural steps Describe response to oral care and analgesic treatment protocol for patients with head and neck cancer
Radiotherapy services at hospital in the United Kingdom
Success rate of MRI and quality image is higher in the group receiving nursing intervention No difference in symptom score between the two groups. Higher levels of satisfaction in nurse-led group and additional cost reduction 69 PICCs successfully inserted by nurse (71.1%); no insertion complications, 13.4% required removal before therapy completion Pain (>4) noted by small number of participants; preprocedural anxiety noted by a range of patients (22%68%). Patients with daily nursing intervention, defined oral care, and pain protocol showed improved pain management Patients receiving intervention reported less disruption in life activities and more positive mood
Bluemke and Breiter (2000)
Crego (2014)
Crego et al. (2017)
Gamulka et al. (2005)
Gonzales and Rutledge (2015)
Janjan et al. (1992)
Johnson et al. (1997)
Lang and Berbaum (1997)
Evaluate nurse-provided intervention based on the self-regulation theory on patient QOL during and after radiation therapy Patients' perception of pain after education intervention for IR staff
PICC services at hospital in Canada
IR at hospitals in the United States
Radiotherapy services at hospitals in the United States
Radiotherapy services at hospitals in the United States
IR at hospitals in the United States
Patients pain scores were lower after training than baseline conditions
Mason et al. (2002)
Multiphase study to develop a ketamine sedation program
IR at hospital in the United States
No sedation failures or significant adverse events occurred
Ochonma et al. (2015)
Assess ethical conduct of radiographers and radiology nurses on patient satisfaction
One public and one private hospital in Nigeria
Radiographers high professional service delivery. Satisfaction higher in favor of private hospitals
Rose and Yates (2015)
Describe patient responses to nursing care after implementation of the person-centered care model Safety and efficacy of nurseled sedation for MRI
Outpatient radiotherapy canters in Australia
Patients satisfied with nursing care despite changes in well-being throughout radiation therapy course 5% failure rate of sedation and no adverse airway events
Sury et al. (1999)
Hospital in the United Kingdom
Sedation provider type (RN alone, MD alone, RN þ MD team) has implications for adverse events Nursing intervention aided in the success of MRI and image quality Nurse-led follow-up effective in increasing patient satisfaction and decreasing cost
Nurse-led PICC insertion program showed high success rate and low complications
Radiology nurses should be aware of pain levels and potential need for nonpharmacologic strategies Daily intervention by radiation therapy nurse aided in more effective pain management Radiation therapy nurses can use self-regulation theory ebased interventions for patients undergoing radiation therapy Radiology personnel trained in nonpharmacologic strategies can effectively help lower patients' pain during procedures Radiologist-supervised nurse-administered ketamine administration program successful for patients who may otherwise require general anesthesia Nursing is accountable to radiographers in the hospitals; unable to determine the specific impact of nurses in radiology Patient-centered nursing care can improve patient care in radiation therapy Nurse-led sedation service for pediatric MRI is successful in this hospital
CT ¼ computed tomography; MRI ¼ magnetic resonance imaging; PICC ¼ peripherally inserted central catheter; RN = registered nurse; MD = medical doctor; IR = interventional radiology; QOL = quality of life.
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an internal hospital sedation database, whereas Crego (2014) and Crego et al. (2017) used secondary data from the PSRC. Each of these studies specifically noted the contribution of the radiology sedation nurse. For example, Crego et al. (2017) used the PSRC database to examine the differences in adverse events based on provider type. Out of 36,352 cases reviewed, the lowest odds of adverse events were found in individual provider teams (registered nurse alone [odds ratio, 0.46] or medical doctor alone [odds ratio, 0.53]) when compared with the registered nurse þ medical doctor sedation teams in MRI procedures (Crego et al., 2017). Crego (2014) reviewed sedation practice and outcomes of sedation administered for a pediatric population of 12,584 cases sampled from the PSRC. Registered nurses administered sedation and monitored the patients in all these cases. The author found 727 (5.78%) adverse events occurred in this population, with the most common being inadequate sedation (n ¼ 196) and desaturation (n ¼ 138) (Crego, 2014). However, the author noted the significant challenges interpreting these results given the lack of published data on adverse events related to nurse-administered sedation. Bluemke and Breiter (2000) analyzed a sample of 4,761 sedation records over the course of 8 years to study the safety, effectiveness, quality, and efficiency of moderate sedation for MRI examinations. Of the 4,761 patients requiring sedation during the study period (March 1991 to November 1998), 4,453 (93.5%) received successfully, with 20 recorded adverse events (0.42%). Sedation times were compared among a group of four radiology nurses who performed 76% of the total sedations, other radiology nurses who performed sedation less often, and inpatient nurses from the hospital units of the individual patients. Among all three groups, the four radiology nurses who routinely performed sedation had the shortest sedation time and least variability (23.6 ± 15.2 minutes) compared with the other radiology nurses (26.8 ± 20.1 minutes) (p < .001) and the inpatient nurses (47.3 ± 36.6 minutes) (Bluemke and Breiter, 2000). The remaining three studies describing adverse sedation events were reports of the development of new sedation programs and procedures. Applegate et al. (2016) addressed advanced (addition of acoustic respiratory monitoring and processed electroencephalography) vs. standard monitoring, finding fewer alarm events in advanced, monitored patients. Mason et al. (2002) described the development of a nurse-administered ketamine program for pediatric patients undergoing interventional radiology procedures, and Sury et al. (1999) described the development of a nurse-led sedation service for pediatric MRI patients. All authors concluded that their respective programs were safe and effective options for nurseled sedation programs. Nursing Intervention and Outcomes Five studies described the success of specific nursing interventions on patient outcomes (Dong et al., 2016; Faithfull et al., 2001; Janjan et al., 1992; Johnson et al., 1997). Three of the four of these studies describe interventions for patients receiving radiation therapy (Faithfull et al., 2001; Janjan et al., 1992; Johnson et al., 1997). Dong et al. (2016) tested a nursing-specific intervention on 60 patients undergoing MRI to determine the completion rate and quality of the image. The intervention group was taught during the preprocedural, intraprocedural, and postprocedural steps of the MRI, resulting in a completion rate of 96.67% in the intervention group vs. 66.67% in control and a ‘diagnosable’ image in 96.67% vs. control (76.67%) (Dong et al., 2016). Faithfull et al. (2001) describe a nurseled intervention based on the participant's comprehensive understanding of their cancer diagnosis for men undergoing pelvic radiotherapy. Although there was no difference in the overall symptom score between intervention and control groups, there was an associated cost reduction of 31% (p < .001) in the intervention
group vs. control group and higher reported satisfaction levels in the intervention group vs. control group (p < .002) (Faithfull et al., 2001). Janjan et al. (1992) describe the use of a tailored nursing intervention for patients undergoing radiation therapy for head and neck cancer. In this study, the patients were seen daily by a radiation therapy nurse who assessed pain level via a 15-question survey, and if necessary, the nurse immediately adjusted the analgesic regimen. Patients receiving this intervention reported a reduction in moderate to severe pain compared with the control group (Janjan et al., 1992). Johnson et al. (1997) described an education intervention based on self-regulation theory for patients receiving radiation therapy. The four-part intervention resulted in the intervention group experiencing less disruption in activities and a more positive mood over controls (Johnson et al., 1997). The final article by Rose and Yates (2015) described responses to nursing care after the implementation of a person-centered care model for patients receiving radiotherapy treatments. This intervention focused on support provided to the family and patient by the radiation oncology nurse. The authors reported no significant difference in measured aspects of quality of life, patient satisfaction, anxiety, and depression; however, patients identified the nurse as an important source of information (Rose and Yates, 2015). Program Implementation Two studies reviewed the implementation of new hospital programs and their impact on patient outcomes. Gamulka et al. (2005) evaluated a nurse-led PICC program for pediatric patients to address the need for timely long-term intravenous access for their patient population (Gamulka et al., 2005). Sixty-nine PICC lines were successfully placed by the nursing team, out of 97 attempts (71.1%). Lang and Berbaum (1997) tested an educational intervention for nonpharmacologic methods on radiology personnel to determine the effects on patients’ perception of pain during interventional radiology procedures (Lang and Berbaum, 1997). Staff training resulted in lower reported pain scores for patients than baseline condition (1.48 vs. 2.54 [p ¼ .001]), emphasizing the importance of nonpharmacologic options for pain control (Lang and Berbaum, 1997). Survey Methodology The final two studies were descriptive studies using survey methodology to describe outcomes including pain, anxiety, and patient satisfaction (Gonzales and Rutledge, 2015; Ochonma et al., 2015). Gonzales and Rutledge (2015) surveyed the preprocedural, intraprocedural, and postprocedural pain levels using an 11-item numeric rating scale (0 to 10 scale) for 53 patients undergoing arteriovenous fistulogram, arteriovenous declotting, chest/arm port placement, or tunneled catheter placement. Anxiety was seen in a wide range of patients (22-68%), whereas pain greater than a score of four (0-10 scale) was seen in a small number of participants (11/ 53) (Gonzales and Rutledge, 2015). The study completed by Ochonma et al. (2015) assessed patient satisfaction among 300 patients receiving treatment in the radiology departments of two hospitals in Nigeria. The authors used a cross-sectional design with review of ethical conduct of both the radiographers and radiology nurses and its impact on patient satisfaction in this setting (Ochonma et al., 2015). The authors concluded that specifics of conduct such as obtaining informed consent before treatment and explanation of the procedure, equipment, or experience had an impact on the satisfaction levels of the patients. There was no mention of the influence of nurses aside from their accountability to the radiographers (Ochonma et al., 2015).
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Discussion
Limitations
This review identified significant opportunities for the continued study of radiology nursing. A synthesis of the available literature shows an overall lack of studies that examine the role and impact of radiology nursing on patient outcomes. The range of literature represents a time period of approximately 25 years, with the earliest identified study completed by Janjan et al. in 1992. Given the fact that radiology nursing, as a formal employment specialty, is described as early as the 1970s, 15 publications studying radiology nursing and outcomes over a period of approximately 50 years represents a significant dearth of evidence (Goodhart and Page, 2007). This deficiency is especially poignant in the era of health-care reform and ‘value,’ within which understanding the work and contribution of the nursing profession becomes vital. Notably, nurse-administered sedation is a major component of many radiologic procedures, yet the study of sedation outcomes is limited (Patatas and Koukkoulli, 2009). Crego (2015) published a general overview of the current state of nursing standards for procedural sedation, calling regulation in the United States “fragmented and poorly documented (Crego, 2015, p. 55).” As described, only six studies focused on aspects of procedural sedation in relation to adverse sedation-related events (Applegate et al., 2016; Bluemke and Breiter, 2000; Crego, 2014; Crego et al., 2017; Mason et al., 2002; Sury et al., 1999). Unfortunately, the generalizability of these studies is limited based on their use of only pediatric populations, internal hospital databases, and individualized single-site program implementation and development. The small number and limits of these studies is certainly due in part to the lack of large-scale available sedation outcomes data. Sedation continues to be a priority for the radiologic population, and various surveys have attempted to assess its use within radiology. A 1997 survey of radiologic practices queried the 1,713 members of the Society of Cardiovascular and Interventional Radiology (Mueller et al., 1997). Of the 634 that responded (37% response rate), a reported 90% of therapeutic procedures used a “drowsy/arousable” level of sedation, whereas 87% reported the presence of a full-time radiology nurse (Mueller et al., 1997). Korzewski et al. (2016) described practices during the endovascular therapy for acute ischemic stroke. Although the authors note that a certified registered nurse anesthetist or anesthesiologist was typically responsible for sedation management in these patients, 51.69% of the hospitals indicated that sedation may be provided by the registered nurse (Korzewski et al., 2016). Vari and Gangi (2017) described a survey of sedation practice throughout Europe, noting that the current state of the literature indicates varying practice patterns and levels of sedation for similar procedures (Vari and Gangi, 2017). Their respondents describe sedation administration by an anesthesiologist (48.3%), followed by the nurse (43.2%) and the interventional radiologist (~30%) (Vari and Gangi, 2017). As more procedures are completed within radiology which require sedation administration, nurses in these areas will be called upon to use this specialized skill (Murphy, 2013; Tuite and Rosenberg, 2005). Buerhaus et al. (2017) recently identified health-care reform as one of the four top challenges faced by the current nursing workforce in the United States (Buerhaus et al., 2017). In their view, the shift from fee-for-service to value-based purchasing could be beneficial for nurses as organizations begin to focus on providing the best possible outcomes at the lowest cost (Buerhaus et al., 2017). However, this perceived benefit is dependent on nursing being influential on these best possible outcomes. More research is needed to further define nursing's role.
Potential sources of bias include the use of English language studies only and a single author review of each article for inclusion/ exclusion criteria. The wide search and the range of outcomes in the identified studies made comparing and contrasting studies challenging. It is additionally difficult to generalize the results of studies completed outside of the United States to hospitals within the United States given the potential for differences in hospital and radiology structure and the radiology nursing role. This review focused on direct care radiology nursing and did not include the impact of advanced practice nurses such as nurse practitioners that may be used in different practice models. It is additionally possible that radiology nurses are involved in performance-improvement activities within their institutions that may not be commonly published in peer-reviewed literature. Conclusion Radiology nurses participate in a rapidly advancing technological field and have the opportunity to make substantial impacts. Potential areas for exploration include radiology nursing and sedation administration, the role of advanced practice nurses, greater exploration into nurse-led programs and procedures, and the general impact of radiology nurses on specific outcomes such as patient satisfaction and other quality and safety metrics. This review describes a sizable lack of evidence but also significant opportunity to study these nurses and document their essential role on health-care outcomes for the patients they serve. References Aiken, L.H., Cimiotti, J.P., Sloane, D.M., Smith, H.L., Flynn, L., & Neff, D.F. (2011). The effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Medical Care, 49(12), 1047-1053. Applegate, R.L., 2nd, Lenart, J., Malkin, M., Meineke, M.N., Qoshlli, S., Neumann, M., et al. (2016). Advanced monitoring is associated with fewer alarm events during planned moderate procedure-related sedation: a 2-part pilot trial. Anesthesia and Analgesia, 122(4), 1070-1078. Bluemke, D.A., & Breiter, S.N. (2000). Sedation procedures in MR imaging: safety, effectiveness, and nursing effect on examinations. Radiology, 216(3), 645-652. Buerhaus, P.I., Skinner, L.E., Auerbach, D.I., & Staiger, D.O. (2017). Four challenges facing the nursing workforce in the United States. Journal of Nursing Regulation, 8(2), 40-46. Crego, N. (2014). Pediatric sedation: using secondary data to describe registered nurse practice in radiology. Journal of Radiology Nursing, 33(4), 166-180. Crego, N. (2015). Procedural sedation practice: a review of current nursing standards. Journal of Nursing Regulation, 6(1), 50-56. Crego, N., Baernholdt, M., & Merwin, E. (2017). Differences in pediatric noninterventional radiology procedural sedation practices and adverse events by registered nurses and physicians. Journal of Pediatric Nursing, 35, 129-133. Dempsey, C., Reilly, B., & Buhlman, N. (2014). Improving the patient experience: real-world strategies for engaging nurses. The Journal of Nursing Administration, 44(3), 142-151. Dong, G.Q., Wang, W.W., Deng, K., & Wang, G.L. (2016). The pilot study of radiology nursing intervention in abdominal 3-T Magnetic Resonance examination. Revista da Escola de Enfermagem da U S P, 50(6), 961-964. Doran, D. (2011). Nursing outcomes the state of the science (2nd ed.). Sudbury, MA: Jones & Bartlett Learning. Faithfull, S., Corner, J., Meyer, L., Huddart, R., & Dearnaley, D. (2001). Evaluation of nurse-led follow up for patients undergoing pelvic radiotherapy. British Journal of Cancer, 85(12), 1853-1864. Gamulka, B., Mendoza, C., & Connolly, B. (2005). Evaluation of a unique, nurseinserted, peripherally inserted central catheter program. Pediatrics, 115(6), 1602-1606. Gonzales, M., & Rutledge, D.N. (2015). Pain and anxiety during less invasive interventional radiology procedures. Journal of Radiology Nursing, 34(2), 88-93. Goodhart, J., & Page, J. (2007). Radiology nursing. Orthopedic Nursing, 26(1), 36-39. Janjan, N.A., Weissman, D.E., & Pahule, A. (1992). Improved pain management with daily nursing intervention during radiation therapy for head and neck carcinoma. International Journal of Radiation Oncology, Biology, Physics, 23(3), 647652. Johnson, J.E., Fieler, V.K., Wlasowicz, G.S., Mitchell, M.L., & Jones, L.S. (1997). The effects of nursing care guided by self-regulation theory on coping with radiation therapy. Oncology Nursing Forum, 24(6), 1041-1050.
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