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Can skeletal image reporting be taught online: Perspectives of experienced reporting radiographers?
Radiography 19 (2013) 104e112
Contents lists available at SciVerse ScienceDirect
Radiography journal homepage: www.elsevier.com/locate/radi
Can skeletal image reporting be taught online: Perspectives of experienced reporting radiographers? Lesley Leishman* School of Health Sciences, Faculty of Health & Social Care, Robert Gordon University, Aberdeen, AB10 7QG, UK
a r t i c l e i n f o
a b s t r a c t
Article history: Received 8 August 2012 Received in revised form 5 December 2012 Accepted 9 December 2012 Available online 29 December 2012
Background: Image interpretation relies upon expert clinical skill and comprehensive knowledge and understanding of the theories and concepts that underpin clinical practices. Traditionally, radiographer reporting education has been delivered using a blend of classroom based learning combined with workplace clinical practice. The direct and indirect costs of staff development and maintenance of the service has seen the incorporation of e-learning into courses in other health professions. Yet, despite its proven success, in the UK radiography has been resistant to progression into e-learning for reporting. This study aims to explore the perceptions of reporting radiographers to interactive online delivery of skeletal image reporting education. Method: Invitations to participate in the study were sent to 80 radiology departments in the UK. Reporting radiographers were asked to complete an online questionnaire to detail their reporting education experiences and to consider whether online delivery was a viable option. Results: A total of 86 radiographers participated in the study. They could see potential benefits of online delivery but agreed it would only be suitable for delivery of theoretical subjects, and that development of practical/clinical skills required interaction with experts in the field to enhance learning. Conclusion: Image reporting education is not suitable for entirely online delivery, and a blended learning solution, where online classroom based learning is combined with work based learning is more appropriate as it allows for interaction with experts in the field of reporting to facilitate the development of reporting skills enhance the overall learning experience. Ó 2012 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Keywords: E-learning Course delivery Interactive Health professions
Introduction The analysis, interpretation and diagnostic reporting of skeletal radiographic images is a complex, multifactorial process that relies upon both expert clinical skill and comprehensive knowledge and understanding of the theories and concepts that underpin clinical practices. Traditionally, interpretation and reporting has been taught using a blend of classroom based learning combined with workplace clinical practice. The direct and indirect costs of staff development are widely reported,1 with implications for service sustainability a particular feature of geographically distant locations.2 A nationally recognised shortage of radiologists3 to supervise workplace experience and support classroom based academic learning has challenged health professionals to investigate alternative mechanisms to deliver image reporting programmes.4 In response, in 2005 a joint venture by the Department of Health and the Royal College of Radiologists introduced the e-Learning for * Tel.: þ44 (0) 1224 263262; fax:þ044 (0)1224 263290. E-mail address: [email protected].
Health: Radiology e Integrated Training Initiative (R-ITI), a blended learning solution, combining traditional teaching models with elearning techniques, which delivers the entire radiology core curriculum through an interactive electronic learning platform.5 According to its curriculum guide, the purpose of the R-ITI is to supplement the learning of ST1-3 specialist registrars on the 5-year radiology training scheme and increase training capacity without putting any additional strain on current resources. A critical review of literature showed that distance and e-learning formats are also being used more widely in other healthcare professions, both at undergraduate and postgraduate level, including nursing6e8 and dentistry.9,10 Whilst the literature did highlight the issues of lack of interactivity with tutors and peers to enhance the learning experience6,8,9 and the difficulties faced in teaching clinical/practical skills,7 the literature also highlighted the many potential benefits, namely the flexibility for the students to fit study around personal and professional commitments1,2,6,8,9 and the potential for the Higher Education Institutions (HEI) to attract larger student numbers from a wider geographical area.6,11 The authors also discussed possible solutions to the negative issues by embracing
1078-8174/$ e see front matter Ó 2012 The College of Radiographers. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.radi.2012.12.003
L. Leishman / Radiography 19 (2013) 104e112
new technologies such as discussion forums6,8 to promote interactivity, and the use of simulation software9,10 for the development of practical skills. In the radiography profession, the value of blended learning, incorporating e-learning techniques, has been studied12,13 and, despite highlighting the same potential drawbacks as the other healthcare professions previously discussed,6e10 it has been shown to be beneficial. Yet, despite this proven success and a growing demand for online and distance learning provision, in the United Kingdom (UK) radiography has been resistant to progression into elearning for diagnostic reporting. Radiographer reporting continues to be necessary for the provision of timely reports and effective patient care,14 and easier access to flexible training which would minimise the effects on personal and professional commitments would be beneficial to the radiographers, their employers and ultimately the service users. Analysis of all radiographic reporting programmes across the UK in 200911 failed to identify any that delivered in an interactive electronic format. Similar to the R-ITI electronic learning platform for radiology, e-Learning for Healthcare (e-LfH): Image Interpretation is a joint venture by the Department of Health and the College of Radiographers, an interactive e-learning resource supporting the development of image interpretation skills. Launched in 2010, its focus is on enabling development of basic image interpretation skills required across the range of National Health Service (NHS) healthcare professions who perform image interpretation as part of their clinical role, including radiographers. The level of image interpretation skills to be gained from participation will enable individuals to give an informed opinion on images, but it does not extend to those of the interpretation and diagnostic reporting processes undertaken by skilled reporting radiographers, nor is the resource available to HEIs. Given the progress reported by the R-ITI15 and the slow pace of change for radiographic image reporting courses, this study aims to explore the perceptions of experienced reporting radiographers of interactive online delivery of skeletal image reporting education. Method Whilst the study was designed to obtain predominantly qualitative data, some investigation of the demographics of the participants and frequency of the responses was considered beneficial, given that much of the previous literature had highlighted similar potential benefits/drawbacks of online course delivery, and it would be interesting to establish if the participants of this study had similar opinions. A combination of question types was incorporated into the questionnaire; closed-response questions16 were devised from the issues that had arisen in the review of previous literature. Some did however allow the participant to add their own comments to the list of answers offered; this was felt to be more appropriate as closed-response questions have the potential to introduce bias16 and the purpose of the research was to elicit the personal opinions of the radiographers taking part. Open-ended questions were also incorporated to allow more detailed responses to be given. Given the high costs and poor response rate of postal questionnaires17 an online format was adopted. The whole of the UK was targeted to ensure a sizeable sample of participants. It was also felt that the issue of geographical location would always be raised by reporting radiographers in Scotland, and targeting the whole of the UK would enrich the data gathered. There is currently no national database of reporting radiographers. Previous research requiring similar participants identified them by targeting hospitals throughout the UK that had both an Accident and Emergency (A&E) department onsite and a radiography service.18 Some sites (Trusts) had more than one hospital fitting the inclusion criteria, although it was impossible to establish from these
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sources how many, if any, reporting radiographers were employed at each. The decision was made to work on the assumption that there would be one reporting radiographer at each of the hospitals, although the researcher was aware that some would have more than one and some would have none at all, giving a potential recruitment figure of 240 participants. There is no agreed standard for the acceptable minimum response rate, but it seems to be generally agreed that below 60% (n ¼ 144) is sub-optimal.19 Approval to carry out the study was granted by the School of Health Sciences Research Review Group (SRRG) at the Robert Gordon University. An application was subsequently made for approval of the project proposal by the NHS Research Ethical Committee (REC) and the NHS Research and Development (R&D) offices. Approval was granted for Scotland but correspondence received from the National Institute for Health Research Coordinated System for gaining NHS Permission (NIHR CSP) Unit in England stated that the study was not eligible for inclusion in the NIHR Clinical Research Network (NIHR CRN) Portfolio, because it was a student project with no external funding. The letter did state, however, that this decision did not mean that the researcher was prevented from gaining NHS permission outside the CSP. Communication with the local NHS Research Scotland Coordinating Centre (NRSCC) confirmed that this refusal would mean the researcher contacting the REC of each individual site (Trust) where permission to carry out the research was being sought. Further information on the process was sought from the NHS R&D Forum Website (http://www.rdforum.nhs.uk/ 001.asp) and this provided the researcher with contact information for the individual R&D offices throughout the United Kingdom. Four months later a cut-off date was set for receiving approvals and letters and participation packs were sent to the sites who had by then approved the project (n ¼ 80). Initial contact was made with the radiology managers, asking them to act as gatekeepers for the project, only passing on participation information to the relevant staff member(s) if they felt it appropriate. Informed consent was gained from participants through a check box at the start of the online questionnaire. The time frame set for data collection was 4 weeks. Where previous studies have sought to explore participants’ perceptions by questionnaire, where open questions are incorporated to elicit unique individual responses, data analysis has been in the form of coding/categorisation of responses and identification of themes.13,20 Given the purpose of the research, this was felt the most appropriate method for this study. Frequency of responses to the questions was analysed using the Statistical Package for Social Sciences (SPSS v.19.0) statistical package. Results By the end of the specified data collection period, 86 participants had completed the online questionnaire. As this was above the set minimum 60% response rate, the data collection period was terminated. Of the 86 participants who completed the online questionnaire, 72.1% (n ¼ 62) were female, which was to be expected in a female dominated profession; 81.3% of all qualified diagnostic radiography staff in the UK in 2007 were female.21 The majority of participants were either in the 36e45 years age range (34.9%; n ¼ 30) or the 46e55 years age range (37.2%; n ¼ 32). The results of this question were as expected and, given that radiographer reporting is an advanced skill practiced by experienced clinicians, it was not surprising to see only 2.3% of participants (n ¼ 2) in the 20e25 years age group (Fig. 1). Geographical location of current place of employment Participants were asked for the geographical location of their current place of employment to establish whether or not the
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Figure 1. Graph representing age range of participants.
questionnaire had been distributed widely throughout the UK. It had already been decided that the entire UK ought to be targeted, rather than just Scotland (the researcher’s own home country/place of work) in order to reduce the bias that might have been introduced due to remote geographical location. Targeting the UK as a whole would also allow for a larger sample size.
Given the issues surrounding the R&D approvals process out with Scotland, and given that the arrival of the deadline date saw approval from only 68 of the 146 sites approached, the spread of participants is encouraging (Fig. 2). What is interesting is that of the 12 participants in the “All Other Responses” category, 2 stated that their place of work was in Wales (1 North; 1 South West), despite
Figure 2. Graph representing geographical location of current place of employment.
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the researcher having had no contact with the central coordinating office there. It was suggested that these participants had possibly worked in England at the time the study details were issued, and then moved to a new post in Wales before completing the online questionnaire, but this seemed very unlikely. The only other alternative solution was that the central office had passed on the information to individual sites as part of the R&D approval process and that the study had been accessed by staff at the two sites before the approval process had been completed. Time since qualification Participants were asked how long it had been since they had studied for their reporting qualification in order to establish whether advances in IT systems in use in HEIs could erase some of the issues previously highlighted as barriers to online education.6,9,12,13 That said, only 29.1% (n ¼ 25) of respondents had studied recently, within the previous 2 years (Fig. 3). Course delivery A previous study11 had highlighted the fact that, at that time, no HEIs delivered radiographer reporting education in an online distance learning format, and the results from the question regarding how the courses had been delivered confirmed that this was still the case, with the 88.4% (n ¼ 76) majority following the blended learning approach, with a combination of block release and work based learning, and none offering online course delivery (Fig. 4). One individual comment on a subsequent question in the survey did however suggest that online education was being employed, albeit unsuccessfully: “On line was tried during my course but was abandoned because of poor quality image transfer or unavailability of appropriate quality viewing hardware and access for all of the cohort.”
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Further investigation of this participant’s other responses to the questions revealed that the time since study was 3e10 years previously, and the question of advances in technology ironing out such issues must again be considered. The participants were asked to report on any problems they had encountered during their studies, the list of responses to the question having been derived from the common themes which had arisen during the review of literature (Fig. 5). Almost half of the participants (n ¼ 42; 48.8%) reported having no difficulties, despite the fact that the majority of courses (n ¼ 76; 88.4%) had been delivered by block release. That said, the responses to the next question (Fig. 6) will demonstrate that 68.6% (n ¼ 69) of participants lived within 100 miles, i.e. daily commuting distance, of the HEI so the difficulties around course availability, personal commitments and professional commitments would not have been an issue. Distance from HEI to home/place of employment The previously highlighted issues concerning geographical location of the HEI in relation to the student’s home, and the flexibility that online education could bring in relation to fitting studies around personal and professional commitments,1,2,6,8,9,12,13,22 formed the basis for this question. Given the current geographical location of the participants (Fig. 2), it is not surprising that the majority of participants (n ¼ 59; 68.6%) were based within 100 miles of the HEI, thus making it easier for these individuals to attend on a day-to-day basis and alleviating some of the problems previously discussed with reference to personal and professional commitments (Fig. 6). Given the geographical location of the participants at the time of study, it is not surprising that when asked if the course would have been more appealing had they not had to attend the HEI, 88.4% said no. Further to this, when asked what their preferred delivery method would be, they were very much in favour of a blended learning approach, where work based learning was combined with
Figure 3. Graph representing time since qualification.
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Figure 4. Graph representing course delivery method.
attendance at the HEI, either on a block-release (n ¼ 58; 67.4%) or day-release (n ¼ 16; 18.6%) basis (Fig. 7). It was encouraging to note that 11.6% (n ¼ 10) of the participants did consider blended learning an option, combining work based
learning and an online virtual classroom, however none of the participants thought that radiographer reporting could be delivered fully online, echoing potential problems previous studies have highlighted with regard to teaching practical/clinical skills.7,12,13
Figure 5. Graph representing difficulties encountered during enrolment on course.
L. Leishman / Radiography 19 (2013) 104e112
Figure 6. Graph representing distance from home/place of work to HEI where reporting qualification obtained.
Figure 7. Graph representing preferred method of course delivery.
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When asked specific reasons, the top three responses were those highlighted in previous studies, namely lack of face-to-face contact with peers (n ¼ 78; 90.7%), tutors (n ¼ 70, 81.4%) and lack of expert contact for lectures (n ¼ 72, 83.7%) (Fig. 8). Expanded responses to this question echo the findings, including the value of face-to-face contact: “I don’t think that anything could actually replace sitting in a group, with a radiologist or other expert and viewing/discussing images. We got to know our group and tutors really well and the visits to the university were really enjoyable.” “I think that it is good to be in a group where you meet other professionals who are going through the same study as you are. It can be a real help and ideas etc can all be shared.” The issue of contact with experts in the same field (radiologists; reporting radiographers) was also discussed and it was apparent that much of the learning of practical reporting skills is work based: “I felt most of my reporting skills were provided by my mentor- the specialist knowledge delivered at uni was intense but being able to speak to my peers and discuss/discovery most were experiencing the same difficulties was important to me - confidence levels were low!” This relates back to previous studies where the ability to develop clinical skills in an online environment was questioned.7,12,13 One participant also commented favourably on the blockrelease method of delivery, in relation to the issue of protected study time,6 although a possible solution could be in the form of a Learning Contract between the employer and student: “The ability to leave your normal working environment to allow complete focus on your study is essential especially in busy radiography departments where study time could become disrupted affecting the consistency and quality of any learning activity.”
Which topics could/could not be delivered online? The participants were provided with a list of topics which were likely to be included in a postgraduate radiographer reporting course and asked which they considered were/were not suitable for online delivery, as shown in Table 1. This process highlighted the fact that many participants thought it could be successful in the delivery of theoretical modules, including pattern recognition, where online delivery was considered appropriate by 73.9% (n ¼ 51) participants: “simple, factual content sits well with e-learning” On radiological anatomy/osteology; online delivery considered appropriate by 63.8% (n ¼ 44) participants:
was
“well established e-learning tools available” However, online delivery was not considered appropriate for the development of reporting (i.e. clinical) skills: On image viewing principles, evaluation and diagnosis; online delivery was not considered appropriate by 55.1% (n ¼ 38) participants: “Experience and knowledge of Consultant Radiologists in their field of expertise is of paramount importance in learning what is classed as a "hands-on" part of the job. Experience of reporting all quality of images is important and I don’t feel that this would be performed accurately online.” On diagnostic accuracy; online delivery was not considered appropriate by 58% (n ¼ 40) participants: “There are lots of factors involved in reaching a final report for a series of images and this varies from one patient to the next even with the same or similar set of images. Again, talking and discussing
Figure 8. Graph representing potential problems encountered in an online learning environment.
L. Leishman / Radiography 19 (2013) 104e112 Table 1 Topics for delivery. Theory of pattern recognition Principles of image viewing, evaluation and diagnosis Diagnostic accuracy Report writing Clinical audit Current research and medico-legal aspects of reporting Radiological anatomy/osteology Skeletal pathology Joint disease Normal variants Other(s), please specify
the factors with an expert in the field is important and a valuable learning experience.” One topic where the responses were very evenly distributed was in the delivery of pathology. Despite the majority of participants being in favour of online delivery of radiological anatomy/osteology, joint disease and normal variants, only 50.7% (n ¼ 35) considered this method appropriate for this particular topic area, compared to 49.3% (n ¼ 34) who did not. Comments from those who favoured the online delivery method included: “Good quality images can be viewed online for teaching purposes.” “As long as there is a forum for discussion and private questioning of areas that are not understood initially.” The second comment highlights the fact that online delivery would be suitable to a certain extent, but that further support would also be required, and this a common thread which was apparent in many of the responses, including those given for the final question on other topics that had not been included in the list: “Probably could be taught online, however it is far more interesting if interaction is possible. Lecturers often bring their own interesting cases to discuss.” “This needs interaction with lecturer and peer discussion. Often glean other useful information perhaps not relevant to particular pathology being discussed or just helpful hints. Would need much more base support if no interactive teaching on course.” Emerging themes The key themes which emerged from the coding/categorisation of the responses are shown in Table 2. Discussion In considering online delivery of courses, the greatest advantage is its flexibility to enable the students to combine study with personal and professional commitments. Yet, when asked if the course would have been more appealing had HEI attendance not been a requirement, the majority (88.4%) said no. This could have been due to a large proportion (68.6%) of participants living within 100 miles, i.e. daily commuting distance, of the HEI, thus negating
Table 2 Key themes. Online delivery suitable for theoretical modules only Need face-to-face interaction with peers Need face-to-face interaction with tutors Reporting skills learned by interacting with experts in the field Most learning of reporting skills happens in clinical environment
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any such issues. Indeed, the participants favoured the blended learning approach of course delivery, combining attendance at the HEI with work-based learning. The previously documented individual comment in justification for this preferred method alluded to protected study time, an issue previously highlighted in the literature review6 but it is suggested that a learning contract23 be in place to define requirements and support mechanisms. What is more apparent is that the participants preferred the time spent on campus, as it allowed them to interact with their tutors and peers, thus enhancing the overall learning experience and allowing for feedback, questioning and discussion. This was a common theme highlighted in the review of literature6,8,9,12,13,22,24 and one which continually featured throughout the responses to the questionnaire in this study. Another common theme to emerge was that of the suitability of online delivery of practical/clinical skills, such as image reporting. This had been previously discussed in the literature7,12,13 and again appeared throughout the questionnaire responses. Two sub-themes emerged; that of the need for interaction with experts and colleagues in reporting to learn such skills; and that most of this learning happens in the clinical environment. The first of these sub-themes relates back to the previous issue of interaction to promote learning, whilst the second supports the blended learning approach to reporting education. This is further supported by the participants’ responses when asked to consider topics suitable for online delivery; again, any topic considered to be development of clinical/practical skills was deemed not suitable, and the same reasons were given as justification. That said, the participants considered some of the theoretical modules suitable for this delivery method, and a small minority (11.6%) did select the combination of work based learning with an online virtual classroom as their preferred course delivery method. Despite all of the potential advantages to online learning, none of the participants thought that radiographer reporting could be delivered fully online. Conclusion None of the experienced reporting radiographers who participated in the study considered reporting education suitable for entirely online delivery, although a small minority did consider a blended learning solution, where online classes would be combined with work based learning. The participants continually highlighted the need for interaction with experts in the field of reporting to enhance their learning, particularly in the clinical environment. The majority of participants did consider online education an option for theoretical/academic topics but not for learning practical/clinical skills; again the input from experts in the field was seen as essential to the learning process and development of reporting skills. Interaction with peers and tutors to enhance the learning experience was also an extremely important factor in course delivery method. Whilst the majority considered this in a face-to-face scenario, a small number did recognise that there were means of virtual interaction which could be employed and be just as beneficial. Radiographer reporting continues to be necessary in the provision of effective patient care.14 Easier access to more flexible education which would minimise the effects on personal and professional commitments would be beneficial to the radiographers, their employers and ultimately the service users. Conflict of interest statement This study was completed as part of a student MSc research project. No external funding was received and there are no conflicts of interest.
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Acknowledgements The author would like to thank Dr Mandy Plumb, Oxford Brookes University, for her guidance and support as academic supervisor, and the staff of the School of Health Sciences, Robert Gordon University Aberdeen, for their continued encouragement. References 1. National Health Service Education for Scotland. Role development for radiographers, and radiography support staff within Scotland. Edinburgh: NHS Education for Scotland; 2006. 2. Scottish Government. Delivering for remote and rural healthcare. Edinburgh: Scottish Government; 2007. 3. Royal College of Radiologists. Clinical radiology: a workforce in crisis. London: Royal College of Radiologists; 2002. 4. Gourtsoyiannis N, McCall I, Reiser M, Silberman B, Bischof Delaloye A, Carrió I, et al. White paper of the European Society of Radiology (ESR) and the European Association of Nuclear Medicine (EANM) on multimodality imaging. European Radiology 2007;17(8):1926e30. 5. Scarsbrook AF, Foley PT, Perriss RW, Graham RNJ. Radiological digital teaching file development: an overview. Clinical Radiology 2005;60(8):831e7. 6. Wilkinson A, Forbes A, Bloomfield J, Fincham Gee C. An exploration of four web-based open and flexible learning modules in post-registration nurse education. International Journal of Nursing Studies 2004;41:411e24. 7. Bloomfield J, Roberts J, While A. The effect of computer-assisted learning versus conventional teaching methods on the acquisition and retention of handwashing theory and skills in pre-qualification nursing students: a randomised control trial. International Journal of Nursing Studies 2010;47(3):287e94. 8. Jonas D, Burns B. The transition to blended e-learning. Changing the focus of educational delivery in children’s pain management. Nurse Education in Practice 2010;10(1):1e7.
9. Grimes EB. Student perceptions of an online dental terminology course. Journal of Dental Education 2002;66(1):100e7. 10. Meckfessel S, Stühmer C, Bormann KH, Kupka T, Behrends M, Matthies H, et al. Introduction of e-learning in dental radiology reveals significantly improved results in final examination. Journal of Cranio-maxillo-facial Surgery 2011;39: 40e8. 11. Hardy M, Snaith B. Radiographer interpretation of trauma radiographs: issues for radiography education providers. Radiography 2009;15:101e5. 12. White P, Cheung AKY. E-learning in an undergraduate radiography programme: example of an interactive website. Radiography 2006;12:244e52. 13. Rosenkoetter LE. Moving toward online courses. Radiography 2007;13:271e5. 14. College of Radiographers. Medical image interpretation by radiographers: definitive guidance. London: SCoR; 2010. 15. Dixon A. Current thoughts about academic radiology. Clinical Radiology 2008;63(2):115e7. 16. Polgar S, Thomas SA. Introduction to research in the health sciences. 5th ed. Edinburgh: Churchill Livingstone Elsevier; 2008. 17. Hicks CM. Research methods for clinical therapists. 4th ed. Edinburgh: Churchill Livingstone; 2004. 18. Snaith B, Hardy M. Radiographer abnormality detection schemes in the trauma environment e as assessment of current practice. Radiography 2008;14:277e81. 19. Groves RM, Couper MP. Nonresponse in household interview surveys. New York: Wiley Blackwell; 1998. 20. Poulos A, Llewellyn G. Mammography discomfort: a holistic perspective derived from women’s experiences. Radiography 2005;11:17e25. 21. Bogg J, Hussain Z. Equality, diversity and career progression: perceptions of radiographers working in the National Health Service. Radiography 2010;16: 262e7. 22. Henwood SM, Huggett SM. Radiographic CPD requirements e a regional study. Radiography 1999;5:3e10. 23. Brambleby P, Coates R. Learning contracts in higher professional training: a user’s guide. Postgraduate Medical Journal 1997;73:279e82. 24. Kiteley RJ, Ormrod G. Towards a team-based, collaborative approach to embedding e-learning within undergraduate nursing programmes. Nurse Education Today 2009;29:623e9.
Contents lists available at SciVerse ScienceDirect
Radiography journal homepage: www.elsevier.com/locate/radi
Can skeletal image reporting be taught online: Perspectives of experienced reporting radiographers? Lesley Leishman* School of Health Sciences, Faculty of Health & Social Care, Robert Gordon University, Aberdeen, AB10 7QG, UK
a r t i c l e i n f o
a b s t r a c t
Article history: Received 8 August 2012 Received in revised form 5 December 2012 Accepted 9 December 2012 Available online 29 December 2012
Background: Image interpretation relies upon expert clinical skill and comprehensive knowledge and understanding of the theories and concepts that underpin clinical practices. Traditionally, radiographer reporting education has been delivered using a blend of classroom based learning combined with workplace clinical practice. The direct and indirect costs of staff development and maintenance of the service has seen the incorporation of e-learning into courses in other health professions. Yet, despite its proven success, in the UK radiography has been resistant to progression into e-learning for reporting. This study aims to explore the perceptions of reporting radiographers to interactive online delivery of skeletal image reporting education. Method: Invitations to participate in the study were sent to 80 radiology departments in the UK. Reporting radiographers were asked to complete an online questionnaire to detail their reporting education experiences and to consider whether online delivery was a viable option. Results: A total of 86 radiographers participated in the study. They could see potential benefits of online delivery but agreed it would only be suitable for delivery of theoretical subjects, and that development of practical/clinical skills required interaction with experts in the field to enhance learning. Conclusion: Image reporting education is not suitable for entirely online delivery, and a blended learning solution, where online classroom based learning is combined with work based learning is more appropriate as it allows for interaction with experts in the field of reporting to facilitate the development of reporting skills enhance the overall learning experience. Ó 2012 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Keywords: E-learning Course delivery Interactive Health professions
Introduction The analysis, interpretation and diagnostic reporting of skeletal radiographic images is a complex, multifactorial process that relies upon both expert clinical skill and comprehensive knowledge and understanding of the theories and concepts that underpin clinical practices. Traditionally, interpretation and reporting has been taught using a blend of classroom based learning combined with workplace clinical practice. The direct and indirect costs of staff development are widely reported,1 with implications for service sustainability a particular feature of geographically distant locations.2 A nationally recognised shortage of radiologists3 to supervise workplace experience and support classroom based academic learning has challenged health professionals to investigate alternative mechanisms to deliver image reporting programmes.4 In response, in 2005 a joint venture by the Department of Health and the Royal College of Radiologists introduced the e-Learning for * Tel.: þ44 (0) 1224 263262; fax:þ044 (0)1224 263290. E-mail address: [email protected].
Health: Radiology e Integrated Training Initiative (R-ITI), a blended learning solution, combining traditional teaching models with elearning techniques, which delivers the entire radiology core curriculum through an interactive electronic learning platform.5 According to its curriculum guide, the purpose of the R-ITI is to supplement the learning of ST1-3 specialist registrars on the 5-year radiology training scheme and increase training capacity without putting any additional strain on current resources. A critical review of literature showed that distance and e-learning formats are also being used more widely in other healthcare professions, both at undergraduate and postgraduate level, including nursing6e8 and dentistry.9,10 Whilst the literature did highlight the issues of lack of interactivity with tutors and peers to enhance the learning experience6,8,9 and the difficulties faced in teaching clinical/practical skills,7 the literature also highlighted the many potential benefits, namely the flexibility for the students to fit study around personal and professional commitments1,2,6,8,9 and the potential for the Higher Education Institutions (HEI) to attract larger student numbers from a wider geographical area.6,11 The authors also discussed possible solutions to the negative issues by embracing
1078-8174/$ e see front matter Ó 2012 The College of Radiographers. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.radi.2012.12.003
L. Leishman / Radiography 19 (2013) 104e112
new technologies such as discussion forums6,8 to promote interactivity, and the use of simulation software9,10 for the development of practical skills. In the radiography profession, the value of blended learning, incorporating e-learning techniques, has been studied12,13 and, despite highlighting the same potential drawbacks as the other healthcare professions previously discussed,6e10 it has been shown to be beneficial. Yet, despite this proven success and a growing demand for online and distance learning provision, in the United Kingdom (UK) radiography has been resistant to progression into elearning for diagnostic reporting. Radiographer reporting continues to be necessary for the provision of timely reports and effective patient care,14 and easier access to flexible training which would minimise the effects on personal and professional commitments would be beneficial to the radiographers, their employers and ultimately the service users. Analysis of all radiographic reporting programmes across the UK in 200911 failed to identify any that delivered in an interactive electronic format. Similar to the R-ITI electronic learning platform for radiology, e-Learning for Healthcare (e-LfH): Image Interpretation is a joint venture by the Department of Health and the College of Radiographers, an interactive e-learning resource supporting the development of image interpretation skills. Launched in 2010, its focus is on enabling development of basic image interpretation skills required across the range of National Health Service (NHS) healthcare professions who perform image interpretation as part of their clinical role, including radiographers. The level of image interpretation skills to be gained from participation will enable individuals to give an informed opinion on images, but it does not extend to those of the interpretation and diagnostic reporting processes undertaken by skilled reporting radiographers, nor is the resource available to HEIs. Given the progress reported by the R-ITI15 and the slow pace of change for radiographic image reporting courses, this study aims to explore the perceptions of experienced reporting radiographers of interactive online delivery of skeletal image reporting education. Method Whilst the study was designed to obtain predominantly qualitative data, some investigation of the demographics of the participants and frequency of the responses was considered beneficial, given that much of the previous literature had highlighted similar potential benefits/drawbacks of online course delivery, and it would be interesting to establish if the participants of this study had similar opinions. A combination of question types was incorporated into the questionnaire; closed-response questions16 were devised from the issues that had arisen in the review of previous literature. Some did however allow the participant to add their own comments to the list of answers offered; this was felt to be more appropriate as closed-response questions have the potential to introduce bias16 and the purpose of the research was to elicit the personal opinions of the radiographers taking part. Open-ended questions were also incorporated to allow more detailed responses to be given. Given the high costs and poor response rate of postal questionnaires17 an online format was adopted. The whole of the UK was targeted to ensure a sizeable sample of participants. It was also felt that the issue of geographical location would always be raised by reporting radiographers in Scotland, and targeting the whole of the UK would enrich the data gathered. There is currently no national database of reporting radiographers. Previous research requiring similar participants identified them by targeting hospitals throughout the UK that had both an Accident and Emergency (A&E) department onsite and a radiography service.18 Some sites (Trusts) had more than one hospital fitting the inclusion criteria, although it was impossible to establish from these
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sources how many, if any, reporting radiographers were employed at each. The decision was made to work on the assumption that there would be one reporting radiographer at each of the hospitals, although the researcher was aware that some would have more than one and some would have none at all, giving a potential recruitment figure of 240 participants. There is no agreed standard for the acceptable minimum response rate, but it seems to be generally agreed that below 60% (n ¼ 144) is sub-optimal.19 Approval to carry out the study was granted by the School of Health Sciences Research Review Group (SRRG) at the Robert Gordon University. An application was subsequently made for approval of the project proposal by the NHS Research Ethical Committee (REC) and the NHS Research and Development (R&D) offices. Approval was granted for Scotland but correspondence received from the National Institute for Health Research Coordinated System for gaining NHS Permission (NIHR CSP) Unit in England stated that the study was not eligible for inclusion in the NIHR Clinical Research Network (NIHR CRN) Portfolio, because it was a student project with no external funding. The letter did state, however, that this decision did not mean that the researcher was prevented from gaining NHS permission outside the CSP. Communication with the local NHS Research Scotland Coordinating Centre (NRSCC) confirmed that this refusal would mean the researcher contacting the REC of each individual site (Trust) where permission to carry out the research was being sought. Further information on the process was sought from the NHS R&D Forum Website (http://www.rdforum.nhs.uk/ 001.asp) and this provided the researcher with contact information for the individual R&D offices throughout the United Kingdom. Four months later a cut-off date was set for receiving approvals and letters and participation packs were sent to the sites who had by then approved the project (n ¼ 80). Initial contact was made with the radiology managers, asking them to act as gatekeepers for the project, only passing on participation information to the relevant staff member(s) if they felt it appropriate. Informed consent was gained from participants through a check box at the start of the online questionnaire. The time frame set for data collection was 4 weeks. Where previous studies have sought to explore participants’ perceptions by questionnaire, where open questions are incorporated to elicit unique individual responses, data analysis has been in the form of coding/categorisation of responses and identification of themes.13,20 Given the purpose of the research, this was felt the most appropriate method for this study. Frequency of responses to the questions was analysed using the Statistical Package for Social Sciences (SPSS v.19.0) statistical package. Results By the end of the specified data collection period, 86 participants had completed the online questionnaire. As this was above the set minimum 60% response rate, the data collection period was terminated. Of the 86 participants who completed the online questionnaire, 72.1% (n ¼ 62) were female, which was to be expected in a female dominated profession; 81.3% of all qualified diagnostic radiography staff in the UK in 2007 were female.21 The majority of participants were either in the 36e45 years age range (34.9%; n ¼ 30) or the 46e55 years age range (37.2%; n ¼ 32). The results of this question were as expected and, given that radiographer reporting is an advanced skill practiced by experienced clinicians, it was not surprising to see only 2.3% of participants (n ¼ 2) in the 20e25 years age group (Fig. 1). Geographical location of current place of employment Participants were asked for the geographical location of their current place of employment to establish whether or not the
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Figure 1. Graph representing age range of participants.
questionnaire had been distributed widely throughout the UK. It had already been decided that the entire UK ought to be targeted, rather than just Scotland (the researcher’s own home country/place of work) in order to reduce the bias that might have been introduced due to remote geographical location. Targeting the UK as a whole would also allow for a larger sample size.
Given the issues surrounding the R&D approvals process out with Scotland, and given that the arrival of the deadline date saw approval from only 68 of the 146 sites approached, the spread of participants is encouraging (Fig. 2). What is interesting is that of the 12 participants in the “All Other Responses” category, 2 stated that their place of work was in Wales (1 North; 1 South West), despite
Figure 2. Graph representing geographical location of current place of employment.
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the researcher having had no contact with the central coordinating office there. It was suggested that these participants had possibly worked in England at the time the study details were issued, and then moved to a new post in Wales before completing the online questionnaire, but this seemed very unlikely. The only other alternative solution was that the central office had passed on the information to individual sites as part of the R&D approval process and that the study had been accessed by staff at the two sites before the approval process had been completed. Time since qualification Participants were asked how long it had been since they had studied for their reporting qualification in order to establish whether advances in IT systems in use in HEIs could erase some of the issues previously highlighted as barriers to online education.6,9,12,13 That said, only 29.1% (n ¼ 25) of respondents had studied recently, within the previous 2 years (Fig. 3). Course delivery A previous study11 had highlighted the fact that, at that time, no HEIs delivered radiographer reporting education in an online distance learning format, and the results from the question regarding how the courses had been delivered confirmed that this was still the case, with the 88.4% (n ¼ 76) majority following the blended learning approach, with a combination of block release and work based learning, and none offering online course delivery (Fig. 4). One individual comment on a subsequent question in the survey did however suggest that online education was being employed, albeit unsuccessfully: “On line was tried during my course but was abandoned because of poor quality image transfer or unavailability of appropriate quality viewing hardware and access for all of the cohort.”
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Further investigation of this participant’s other responses to the questions revealed that the time since study was 3e10 years previously, and the question of advances in technology ironing out such issues must again be considered. The participants were asked to report on any problems they had encountered during their studies, the list of responses to the question having been derived from the common themes which had arisen during the review of literature (Fig. 5). Almost half of the participants (n ¼ 42; 48.8%) reported having no difficulties, despite the fact that the majority of courses (n ¼ 76; 88.4%) had been delivered by block release. That said, the responses to the next question (Fig. 6) will demonstrate that 68.6% (n ¼ 69) of participants lived within 100 miles, i.e. daily commuting distance, of the HEI so the difficulties around course availability, personal commitments and professional commitments would not have been an issue. Distance from HEI to home/place of employment The previously highlighted issues concerning geographical location of the HEI in relation to the student’s home, and the flexibility that online education could bring in relation to fitting studies around personal and professional commitments,1,2,6,8,9,12,13,22 formed the basis for this question. Given the current geographical location of the participants (Fig. 2), it is not surprising that the majority of participants (n ¼ 59; 68.6%) were based within 100 miles of the HEI, thus making it easier for these individuals to attend on a day-to-day basis and alleviating some of the problems previously discussed with reference to personal and professional commitments (Fig. 6). Given the geographical location of the participants at the time of study, it is not surprising that when asked if the course would have been more appealing had they not had to attend the HEI, 88.4% said no. Further to this, when asked what their preferred delivery method would be, they were very much in favour of a blended learning approach, where work based learning was combined with
Figure 3. Graph representing time since qualification.
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Figure 4. Graph representing course delivery method.
attendance at the HEI, either on a block-release (n ¼ 58; 67.4%) or day-release (n ¼ 16; 18.6%) basis (Fig. 7). It was encouraging to note that 11.6% (n ¼ 10) of the participants did consider blended learning an option, combining work based
learning and an online virtual classroom, however none of the participants thought that radiographer reporting could be delivered fully online, echoing potential problems previous studies have highlighted with regard to teaching practical/clinical skills.7,12,13
Figure 5. Graph representing difficulties encountered during enrolment on course.
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Figure 6. Graph representing distance from home/place of work to HEI where reporting qualification obtained.
Figure 7. Graph representing preferred method of course delivery.
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When asked specific reasons, the top three responses were those highlighted in previous studies, namely lack of face-to-face contact with peers (n ¼ 78; 90.7%), tutors (n ¼ 70, 81.4%) and lack of expert contact for lectures (n ¼ 72, 83.7%) (Fig. 8). Expanded responses to this question echo the findings, including the value of face-to-face contact: “I don’t think that anything could actually replace sitting in a group, with a radiologist or other expert and viewing/discussing images. We got to know our group and tutors really well and the visits to the university were really enjoyable.” “I think that it is good to be in a group where you meet other professionals who are going through the same study as you are. It can be a real help and ideas etc can all be shared.” The issue of contact with experts in the same field (radiologists; reporting radiographers) was also discussed and it was apparent that much of the learning of practical reporting skills is work based: “I felt most of my reporting skills were provided by my mentor- the specialist knowledge delivered at uni was intense but being able to speak to my peers and discuss/discovery most were experiencing the same difficulties was important to me - confidence levels were low!” This relates back to previous studies where the ability to develop clinical skills in an online environment was questioned.7,12,13 One participant also commented favourably on the blockrelease method of delivery, in relation to the issue of protected study time,6 although a possible solution could be in the form of a Learning Contract between the employer and student: “The ability to leave your normal working environment to allow complete focus on your study is essential especially in busy radiography departments where study time could become disrupted affecting the consistency and quality of any learning activity.”
Which topics could/could not be delivered online? The participants were provided with a list of topics which were likely to be included in a postgraduate radiographer reporting course and asked which they considered were/were not suitable for online delivery, as shown in Table 1. This process highlighted the fact that many participants thought it could be successful in the delivery of theoretical modules, including pattern recognition, where online delivery was considered appropriate by 73.9% (n ¼ 51) participants: “simple, factual content sits well with e-learning” On radiological anatomy/osteology; online delivery considered appropriate by 63.8% (n ¼ 44) participants:
was
“well established e-learning tools available” However, online delivery was not considered appropriate for the development of reporting (i.e. clinical) skills: On image viewing principles, evaluation and diagnosis; online delivery was not considered appropriate by 55.1% (n ¼ 38) participants: “Experience and knowledge of Consultant Radiologists in their field of expertise is of paramount importance in learning what is classed as a "hands-on" part of the job. Experience of reporting all quality of images is important and I don’t feel that this would be performed accurately online.” On diagnostic accuracy; online delivery was not considered appropriate by 58% (n ¼ 40) participants: “There are lots of factors involved in reaching a final report for a series of images and this varies from one patient to the next even with the same or similar set of images. Again, talking and discussing
Figure 8. Graph representing potential problems encountered in an online learning environment.
L. Leishman / Radiography 19 (2013) 104e112 Table 1 Topics for delivery. Theory of pattern recognition Principles of image viewing, evaluation and diagnosis Diagnostic accuracy Report writing Clinical audit Current research and medico-legal aspects of reporting Radiological anatomy/osteology Skeletal pathology Joint disease Normal variants Other(s), please specify
the factors with an expert in the field is important and a valuable learning experience.” One topic where the responses were very evenly distributed was in the delivery of pathology. Despite the majority of participants being in favour of online delivery of radiological anatomy/osteology, joint disease and normal variants, only 50.7% (n ¼ 35) considered this method appropriate for this particular topic area, compared to 49.3% (n ¼ 34) who did not. Comments from those who favoured the online delivery method included: “Good quality images can be viewed online for teaching purposes.” “As long as there is a forum for discussion and private questioning of areas that are not understood initially.” The second comment highlights the fact that online delivery would be suitable to a certain extent, but that further support would also be required, and this a common thread which was apparent in many of the responses, including those given for the final question on other topics that had not been included in the list: “Probably could be taught online, however it is far more interesting if interaction is possible. Lecturers often bring their own interesting cases to discuss.” “This needs interaction with lecturer and peer discussion. Often glean other useful information perhaps not relevant to particular pathology being discussed or just helpful hints. Would need much more base support if no interactive teaching on course.” Emerging themes The key themes which emerged from the coding/categorisation of the responses are shown in Table 2. Discussion In considering online delivery of courses, the greatest advantage is its flexibility to enable the students to combine study with personal and professional commitments. Yet, when asked if the course would have been more appealing had HEI attendance not been a requirement, the majority (88.4%) said no. This could have been due to a large proportion (68.6%) of participants living within 100 miles, i.e. daily commuting distance, of the HEI, thus negating
Table 2 Key themes. Online delivery suitable for theoretical modules only Need face-to-face interaction with peers Need face-to-face interaction with tutors Reporting skills learned by interacting with experts in the field Most learning of reporting skills happens in clinical environment
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any such issues. Indeed, the participants favoured the blended learning approach of course delivery, combining attendance at the HEI with work-based learning. The previously documented individual comment in justification for this preferred method alluded to protected study time, an issue previously highlighted in the literature review6 but it is suggested that a learning contract23 be in place to define requirements and support mechanisms. What is more apparent is that the participants preferred the time spent on campus, as it allowed them to interact with their tutors and peers, thus enhancing the overall learning experience and allowing for feedback, questioning and discussion. This was a common theme highlighted in the review of literature6,8,9,12,13,22,24 and one which continually featured throughout the responses to the questionnaire in this study. Another common theme to emerge was that of the suitability of online delivery of practical/clinical skills, such as image reporting. This had been previously discussed in the literature7,12,13 and again appeared throughout the questionnaire responses. Two sub-themes emerged; that of the need for interaction with experts and colleagues in reporting to learn such skills; and that most of this learning happens in the clinical environment. The first of these sub-themes relates back to the previous issue of interaction to promote learning, whilst the second supports the blended learning approach to reporting education. This is further supported by the participants’ responses when asked to consider topics suitable for online delivery; again, any topic considered to be development of clinical/practical skills was deemed not suitable, and the same reasons were given as justification. That said, the participants considered some of the theoretical modules suitable for this delivery method, and a small minority (11.6%) did select the combination of work based learning with an online virtual classroom as their preferred course delivery method. Despite all of the potential advantages to online learning, none of the participants thought that radiographer reporting could be delivered fully online. Conclusion None of the experienced reporting radiographers who participated in the study considered reporting education suitable for entirely online delivery, although a small minority did consider a blended learning solution, where online classes would be combined with work based learning. The participants continually highlighted the need for interaction with experts in the field of reporting to enhance their learning, particularly in the clinical environment. The majority of participants did consider online education an option for theoretical/academic topics but not for learning practical/clinical skills; again the input from experts in the field was seen as essential to the learning process and development of reporting skills. Interaction with peers and tutors to enhance the learning experience was also an extremely important factor in course delivery method. Whilst the majority considered this in a face-to-face scenario, a small number did recognise that there were means of virtual interaction which could be employed and be just as beneficial. Radiographer reporting continues to be necessary in the provision of effective patient care.14 Easier access to more flexible education which would minimise the effects on personal and professional commitments would be beneficial to the radiographers, their employers and ultimately the service users. Conflict of interest statement This study was completed as part of a student MSc research project. No external funding was received and there are no conflicts of interest.
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