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Diagnostic radiography: A study in distancing
Radiography 18 (2012) 78e83
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Radiography journal homepage: www.elsevier.com/locate/radi
Diagnostic radiography: A study in distancing Pauline J. Reeves a, *, Sola Decker b a b
Faculty of Health & Wellbeing, Sheffield Hallam University, Sheffield S10 2BP, UK School of Healthcare Sciences, Bangor University, Technology Park, Wrexham LL13 7YP, UK
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a b s t r a c t
Article history: Received 31 August 2011 Received in revised form 15 December 2011 Accepted 22 January 2012 Available online 14 February 2012
Aims: This article aims to explore the ways in which diagnostic radiographers use distancing as a tool for emotional management in radiography practice. Methods: This review utilises data from oral history interviews undertaken as part of a larger study documenting the oral history of the diagnostic radiography profession in the United Kingdom as recounted by 24 participants. Results: The results are presented as illustrative of various aspects of the role of the diagnostic radiographer including the initial choice of diagnostic radiography as a profession, the endemic use of particular terminology, the nature of the encounter in diagnostic radiography (including that of sectional imaging) and whether the role is really patient-centred. Conclusions: The article concludes by suggesting that distancing from the patient is mediated by the need for physical touch in order to position the patient for radiography and also makes the suggestion that those opting for diagnostic radiography as a career may do so because they want a profession which is more distanced from the patient and that, even where this is not the case initially, individuals are socialised into adopting the ‘feeling rules’ of the profession. The article concludes by outlining potential areas for further research. Ó 2012 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Keywords: Distancing Emotion work Touch Oral history Models
Introduction Diagnostic radiography is classed as one of the allied health professions. In previous research groups of radiographers were asked to state what they felt differentiated diagnostic radiography from other healthcare professions in order to produce a definition of the role; The role of the diagnostic radiographer is a technical one, aiding the diagnosis of disease. It is a specialised role, offering both responsibility (in the use of radiation) and variety. It is a caring role, but tends to be characterised by less time or close involvement with patients, when compared to other professions.1 In addition, in contrast to other allied health professions such as physiotherapy, speech and language therapy, occupational therapy-even therapy radiography, diagnostic radiography is often conducted before the patient is diagnosed rather than after.
* Corresponding author. Sheffield Hallam University, Diagnostic Radiography, Faculty of Health & Wellbeing, Robert Winston Building, Broomhall Rd, Sheffield S10 2BP, UK. Tel.: þ44 (0) 1142 255447. E-mail address: [email protected] (P.J. Reeves).
Organizational, technological and economic changes have resulted in further investigation and understanding of the healthcare professional and client relationship.2e4 In the following critical analysis of the radiography profession, oral historical interviews of diagnostic radiographers who were eyewitnesses to changes that have occurred in the profession are revisited.2 The interview data are utilised in exploring the concept of distancing in the radiographer e patient relationship. It is argued that the work of the diagnostic radiographer differs from that of other allied health professionals in that it is characterised by distancing from the patient as suggested by literature and by the oral historical accounts of radiographers who trained and practised between the period 1945 and 1995 before the advent of graduate radiographers and evolution of radiography to diagnostic radiography and imaging.
Oral history as research method Oral history research method is interdisciplinary, drawing on history, sociology and social sciences.5 It can be used in illuminating the social, political and economic context of healthcare delivery.6 Oral history is one method of gathering evidence for aspects of professional practice hidden or left unexplored by the profession7
1078-8174/$ e see front matter Ó 2012 The College of Radiographers. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.radi.2012.01.001
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and is thus a valuable method for the profession and other researchers seeking to investigate the evolving nature of radiography practice.2 Oral history interviews are carried out to preserve the perspective of an individual or individuals. The purpose of oral history, therefore, ‘is to interview individuals in order to capture and preserve their spoken perspectives, judgements, and recollections’.8 Oral history interview is therefore an information gathering, connective or discovery tool.9 It shares characteristics with other forms of narrative research but with some unique characteristics of its own.10 Subjectivity is a key characteristic of oral history and reliability and credibility of informants’ memory are also considered as part of its weakness.10 To compensate for its weaknesses, the method may be combined with other qualitative research methodologies.11 The role of oral history in radiography2,8,12 and other professions6,13e15 are well established. The contextual nature of history involves both facts and fiction as its reconstruction and interpretation are of presently understood past, experienced present and anticipated future.7,10 This makes oral historical data valuable for the sociological analysis of the profession. It is such data that has been revisited in exploring the concept of distancing in diagnostic radiography and imaging. Original research from which the oral history interview was obtained The oral history interview collection used in exploring the concept of distancing in diagnostic radiography and imaging utilised the raw data used in the doctoral thesis of one of the authors,2 which investigated the changes that had occurred in the profession from 1945e1995. Among the aims of the original research was to document the history of the profession from the perspectives of diagnostic radiographers who had witnessed, lived and experienced the changes that had occurred in the profession in its second half-century since the discovery of X-rays; much had been documented about the fifty year period from 1895 to 1945 but not necessarily since. Coincidentally, this period was also largely before the introduction of degree education. The research was deemed to be part of the social history of the profession, enabling sociological analysis of the profession using the narratives generated from the career history of the radiographers interviewed. The key methodological frameworks used in the original study were hermeneutic phenomenology and oral history together with phenomenological scholarship, ‘a principled form of inquiry that neither simply rejects or ignores tradition, nor slavishly follows or kneels in front of it ’16 underpinning the structure, conduct, interpretation and writing of the research report. It is this philosophy that was deemed as most appropriate in order to understand the nature of radiography practice from the perspectives of its practitioners’ lived experiences in preference to the well established positivist tradition predominant in radiography research. Interpretive phenomenology embraces the a priori knowledge of the researcher in the conduct of interpretive/hermeneutic phenomenological research but demands that the researcher engages in reflexivity throughout the conduct and writing of the research. Through phenomenological questioning, we come to understand the life-world of the subject (the radiographers’ lived experiences). The objectivity of the researcher draws the researcher into describing and interpreting the phenomenon (radiography) as it appears from the lived experiences of the radiographers. This resulted in the generation of verbatim data. Oral history interview method was employed as the interview tool with focus on the career history of the radiographers. The radiographers were asked to talk about their careers in radiography and were given the scope
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to do so as they wished with any questions largely taking the form of prompts to facilitate recollection. Each respondent was, however, specifically asked what made them select radiography as a career choice and, later in the interview, about the impact of technology on practice. The subjectivity of the research requires that the researcher interpret the phenomenon (radiography) from different perspectives in order to gain in-depth understanding of the profession and its practice. Interpretive phenomenology16 facilitated both the description (verbatim text describing aspects of the phenomenon) and the interpretation of the meaning of such text in the context of the researcher(s) ‘a priori’ knowledge by engaging in individual and cross case analysis of data. Population/sample Following approval from the relevant NHS Trust ethics committee, purposive sampling identified 24 informants who had trained and qualified before the profession became a graduate programme. All the informants were accorded a gender specific pseudonym in conformance with the ethics committee approval requirements and were advised that data gathered might subsequently be used in both published and conference papers. The number included five retired radiographers however 21 were still in service as at 2006 when the interviews were completed. Of the 24 informants, six were male and 18 female; 17 were clinical radiographers, two were managers and five were radiography educators. The sample size was considered to have validity as data collected in the field had reached the point of saturation when no new information was generated.17 Qualitative research makes no attempt at generalisation from the chosen sample. The study was designed to explore the changes that had occurred in the profession following the rapid socio-political, technological and economic changes that have taken place in society, healthcare sector and the profession following World War II and how these had impacted on the profession and its practice.18e20 As is characteristic of interpretive phenomenological research, the texts generated from the original study are open for further revelations left hidden in the texts.21 It is the texts generated from the transcripts from the oral history interviews that the authors (both radiographers with qualitative research background) have revisited and employed in this critical analysis. The responses recorded and discussed in this article arose from detailed immersion and manual analysis of the interview data. The themes used below arose both from the literature and from scrutiny of the transcripts. The responses are used illustratively as is usual in qualitative research. Distancing: a tool in emotion management Literature in other fields of healthcare suggests that distancing is a technique adopted by healthcare professionals when handling difficult situations as part of their daily role22,23 as the professionals strive to meet the demands placed on safety, efficiency and effectiveness. The shift from task oriented care to patient focused care has precipitated renewed interest in the concept of distancing as a coping strategy in emotion work and emotional labour4; “Emotion work is the process of handling our daily, personal emotions; emotional labour involves invoking, performing, and managing emotions that are a required aspect of a job or occupation”.24 Much of the work of the diagnostic radiographer is involved with the Accident and Emergency (A&E) department, examining patients who have undergone some form of trauma. Other patients
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may have been admitted with serious, often life-threatening, illness. Such work is often undertaken at night or at weekends when the radiographer may be working alone or with minimal support from colleagues. Patient injuries may be the result of violence, falls or road traffic accidents and thus constitute traumatic events for the radiographer who has to position them for their X-ray examinations and who may, inadvertently, cause further pain to the patient in doing so. In order to deal with such trauma the radiographer may use distancing as a strategy to detach from the pain of these events,25 an activity that may be perceived as situating the profession in the technologyehumanism dualism26 as greater focus is placed on technology rather than the humanistic aspect of caring.27 It is argued that the exposure of a radiographer to traumatic events and complex disease processes in the course of their daily routine work challenges both the individual’s personal identity and their world view as they struggle to achieve a balance between emotion work (personal) and emotional labour (professional) in the course of performing their role as a radiographer. Emotion work and emotional labour constitute impression management and this has been a well established coping strategy in such work places as education,24 General Practitioner surgeries, air flight services, manual labour28 and different disciplines in nursing.23,29 This article aims to explore the ways in which diagnostic radiographers use distancing as a tool for impression management in radiography practice. The following section presents the themes and related responses derived from the analysis of the oral history transcripts. Initial selection of diagnostic radiography over other health professions A number of respondents made comments relating to their choice of radiography which suggested that they may have (consciously or otherwise) opted for a profession whose practice was slightly more distanced from patients than other allied health professions; I just felt that I didn’t think I could do long-term nursing duties (Anne line 18). I couldn’t have been a physiotherapist because I wouldn’t have wanted to get to know people so well.The chances of you seeing your patient ‘Mr Smith’ who you X-rayed last night for fractured femur is remote and that suited me. I wouldn’t have wanted to get involved with people (Becky lines 656e663). None of us wanted to be nurses and I’m sure the nurses probably didn’t want to be us!’ (Collette lines 258e9). ‘So I was deciding I might do nursing but I wasn’t really a bedpan sort of person (Rose lines 67e8). I think I might have been a bit frightened at just total patientorientated thing like nursing.When I went to see a physio I went to one of the chest places and I thought “oh I can’t do with all this coughing and spitting and all this phlegm kind of thing”. So I think that put me off physio in a way.more the dirty side of it that I didn’t want the patient contact with (Ruth lines 206e15). The radiographic encounter ‘You are presented with a patient for X-ray, you do them, you send them off and never actually hear again what happened.’ (James lines 626e7). James also refers to radiography being ‘a 10 min and bites (sic) job unlike nursing’ (lines 48e52). You’re not holding on to them long enough for them to realise who you are, what you do. (Jenny lines 892e3).
A radiographer is.I think they’re someone that looks after people, even be it for a short length of time.We might only meet them for a short time but we’re still a big part (Ruth lines 803e13). In a way, there is a difference between radiography and physiotherapy. In some instances the physiotherapist has to be cruel to be kind. So there you’ve got a different caring approach. They also have lots more of physical hands-on caring approach to patient as well. Compared to nurses, nurses are quite different, because they’ve got to care for the feelings all the time. Also with the relatives of the patients, they have to care and cope with them. They have to have much more empathy with the patients and families much more than general radiography because it is not a conveyor belt system where the person goes through radiography then you may not see them again. In radiotherapy again, you get to see the person more than once and you got to be able to use your caring skills but not to be over sympathetic. There is difficulty in the way you have to approach the situation (Tina, lines 706e719). Use of reductionist language .Within 4 or 5 months.you were starting to X-ray hands and fingers and to some degree or lesser degree chest (Becky lines 25e6). The world record we did was 14 pacemakers in one day which is amazing (Angela line 267e8). ‘I enjoyed the abdominal work but I didn’t really enjoy the pregnancies’ (Anne line 119-talking about ultrasound). So, of course, the skull, sinuses and mastoids were then done in the room where the IVU used to be done (Becky lines 151e2). Task-orientation: the centrality of the image And I still like to see an aesthetically beautiful film. I actually think .there is beauty in the way you can set it out and things.it pleased my eye as well as the other senses (Vanessa lines 101e5). And then you’d feel quite proud of putting the film up, “That’s my film, that is!” (Wills lines 629e30). You know, sometimes you get so bugged up with technology, you forget there is a patient there, that it is a whole person that we’re dealing with (Vanessa lines 1222e1224). Technical skills vs patient care We’ve always been a cross between quite scientific and nursing. We still need to keep those patient care skills’ (Angela lines 782e4). ‘I do get a kick out of getting a difficult patient and getting a wonderful film, which sounds really pathetically sad (Collette lines 734e6). I suppose it is just the different types of patients and the satisfaction you get out of producing good set of films isn’t it? .like trauma views or trauma obliques on a C spine when the patient is strapped on a trolley and the challenge of producing a nice film, yeah. (Denise lines 694e698). .With the advent of technological advances the actual skills of a radiographer who will position for complex radiographic techniques has diminished. Now the skills are changed, it’s how you can manipulate equipment as opposed to patient (Judy, lines 950e965). The scanning room e behind the glass; CT & MRI There’s too much pressure on throughput.I know in CT I do very little patient care, much less than I used to. I used to be the one giving the preps, I used to be the one explaining the procedure, putting the patient at their rest; don’t do that now, very rare (Judy lines 902e7).
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Otherwise you really will have divisions then won’t you? That people.in MR and CT absolutely hate being drawn into the department, don’t like it at all. Not all, but most of them. Because.no, we don’t do this (Kate lines 833e6). Mediation of distancing through touch You know it is literally a hands-on (sic). You can’t do radiography standing with your hands behind your back, saying do you mind moving down. You’ve got to make contact, you are really handling. So you have to be able to get them to trust you enough to allow you to do that (Vanessa lines 1150e1155). I remember watching somebody doing a lumbar spine and they were rubbing their hands up and down the lumbar spine (Angela lines 147e8). That then suggested that if we couldn’t do physical contact that we shouldn’t really be there (James lines 36e7). Discussion In a study of how nurses dealt with emotions,30 it was suggested that a community of staff may have ‘implicit feeling rules’ regarding the management of emotions within encounters and that these ‘feeling rules’ act as a framework for social interaction for its members.31 This framework has its own coping mechanisms for dealing with the emotional aspects of the work; we may postulate that diagnostic radiography has its own set of these rules, which are subtly different from nursing and other allied health professionals, and which incorporate a greater degree of distancing from the patient. These rules may, or may not, include aspects of the technology as a mediating factor.32 The concepts presented in this nursing article30 are derived from the work of Goffman33 and presents the nurses in the study as being “accomplished social actors and multiskilled emotion managers”.30 At one stage the author refers to nurses presenting their ‘smiley faces’ to patients; a need felt to result from changes in management style and the prevailing political ethos. This has recently been echoed in an article exploring the possible existence of a ‘blame culture’ in radiography in which radiographers expressed the need to apologise to patients to avoid being blamed for long waiting times and other technological factors over which they actually had little or no control.34 When potential employees investigate their chosen professions they subconsciously include aspects of the ‘feeling rules’ for that profession and decide whether or not these are a good ‘fit’ for them personally before committing to that profession.31 The definition of diagnostic radiography presented in the introduction was developed by asking practising radiographers to identify what was unique about the role of the diagnostic radiographer.1 The resultant definition highlighted the limited duration of the radiographic encounter. The phrase ‘hit and run carer’ was also derived to characterise, not only the short length of time that radiographers spend with patients, but also (and something not picked up by the definition) the fact that most diagnostic radiographers will never encounter that same patient again, making the encounter particularly transient.1,35 Radiotherapy radiographers have similarly short encounters with patients but these are repeated, often up to 25 times in the course of the treatment period, allowing for the development of a relationship with the patient over several weeks. The diagnostic radiographer rarely has that opportunity. It has been argued elsewhere that brevity in encounters is not unique to radiography but, indeed, typifies healthcare in the UK National Health Service (NHS).31 The term ‘blip culture’ is used as broadly analogous to the ‘hit and run’ carer.1,31 It is claimed that this ‘fleeting encounter’ helps to characterise diagnostic radiographers
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as ‘non-persons’ in the eyes of the patient36; this was backed up by one of the interviewees (‘Jenny’). This concept has been recognised and termed ‘the Tardis encounter’31 since, like Dr Who’s Tardis, the radiographic examination is potentially bigger on the inside than it might appear from the outside; for example the magnitude of the communication skills required to successfully manage such short encounters may well be underestimated. Members of the public are often unclear as to the identity of the professional who is carrying out the examination. In a study of the patient experience in magnetic resonance imaging (MRI) and computed tomography (CT) the respondents consistently referred to radiographers as nurses.27 The radiographerepatient encounter was further compared to other allied health professions and highlighted variation in the role of emotional management in a healthcare setting. Tina’s experiences, related above, further highlight the potential for depersonalisation of the patient; the perception that you have to be ‘cruel to be kind’ to aid the patient’s recovery as suggested in the role of the physiotherapist and the short encounter with the radiographer as depicted in the comparison with the conveyor belt system.35 Reductionist language, whereby patients are referred to as body parts, is endemic within the profession. Its use stems from the biomedical model and is characterised by the referral process whereby doctors fill in request forms with terms such as ‘chest Xray please’, ‘X-ray lumbar spine’.37,38 Radiographer clinical education also tends to be organised by body parts, with students being encouraged to undertake examinations of hands and feet at the start of their training; students are therefore very quickly socialised into using the same terminology. In an article exploring the concept of emotional intelligence, Mackay et al. cite a study in which a statistically significant inverse relationship was found between reductionism/distancing from the patient and high emotional intelligence38,39; in other words those with high emotional intelligence were more likely to display caring, patient-centred attitudes. Unlike nursing and other professions, there have been few attempts to develop theories or models of the practice of diagnostic radiography.1,37,40 Previous research resulted in the development of a patient-centred model of radiography as illustrated in Fig. 1. However other researchers35 have noted that, whilst diagnostic radiographers claim to be patient-centred, this claim is not borne out by the reality. In fact we may argue that it is the image, not the patient, that is, in fact, at the centre of diagnostic radiography practice. Radiography differs from the other allied health professions (including therapy radiography) in that there is an actual product at the end of the radiographic process; that is an image or set of images. Diagnostic radiographers produce images, often in very difficult situations. Radiography practice sees the production
Figure 1. Patient-centred model of patient care in radiography.
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of a quality diagnostic image as the long-term goal of the radiographer whilst the humanistic interaction constitutes the short term goal required to achieve the end product.41 Radiographers often experience pride in being able to achieve a good set of images in areas such as theatre, resuscitation rooms or intensive care units; until recently this product was actually tangible, in the form of a film. Now the images are on computer systems. In both cases the images provide distancing from the patient and their suffering.30 Sociologists have commented on the extent to which medical imaging technology strips away the patient’s sense of self and allows professionals to objectify their patients.32,42e44 It has also been argued that such images take on a reality of their own.45 A recent study of diagnostic radiography students argued that there is a dichotomy between technological competence and patient care and that the process of socialisation of students into the profession encouraged the prioritisation of technical competence.46 This can, in part, be traced back to the early days of the profession. Many individuals (predominantly female) came into radiography from nursing and gained hospital positions over male radiographers. This provoked a backlash on the part of male radiographers whereby they actively denigrated nursing qualifications and patient care skills in radiography and sought to elevate technical skills (as being typically male), defining the radiographer’s role in relation to the technical apparatus, not the patient.47 This level of technical skill was seen as being undermined by technological developments in the radiographic equipment itself. The focus on equipment manipulation may therefore be seen as constituting an emotional shield while the radiographer demonstrates technical skill and efficiency. Murphy27,36 has made an extended study of the role of the radiographer and the reaction of the patient in computed tomography (CT) and magnetic resonance scanning (MR). Cross sectional imaging technologies, when compared to general radiography, represent further distancing from the patient since there is actual physical separation by means of a lead glass wall-the patient is in one room in the scanner, whilst the operating controls (and thus the radiographers) are located in an adjacent room. As indicated by one of the respondents, pressures on throughput mean that helpers often undertake patient care roles previously undertaken by radiographers. Some respondents commented on the fact that this separation from the patient also led to the scanning radiographers separating themselves off from other colleagues elsewhere in the imaging department. This separation of staff in modalities such as CT from other areas of practice is reiterated in a study of the development of specialisation within diagnostic radiography.12 It is argued that ‘exclusivity’ whereby certain members of staff work with only one modality (such as MRI) detracts from patient-centred care, whilst recognising that physical boundaries are a means of acknowledging the existence of specialisation. The one aspect of a radiographer’s work that acts as a mediator to emotional distancing and the technology of medical imaging is that the radiographer has to use physical touch in order to position patients and determine surface markings. In one study the use of touch was described as a strategy for handling difficult situations,22 suggesting that, for some individuals, the use of touch to connect with individual patients may be a preferable alternative to emotional investment. Conclusions Critical review of the profession suggests that diagnostic radiographers are distanced from their patients by technology, by taskfocussing on the production of an image and by the ‘blip culture’ or ‘hit and run’ aspects of the role whereby short examination times
are coupled with a high likelihood that the encounter with any individual patient will never be repeated. It has been argued elsewhere that diagnostic radiographers use lack of emotional investment in their patients as a coping strategy and to reduce the stress of the job.35 The authors would go further than that and suggest that the fact that the profession is characterised by distancing from the patient may possibly be a factor which attracts certain types of personalities to become diagnostic radiographers; when they look at X-ray departments they perceive a profession that will allow them to serve the patient without becoming, for the most part, emotionally involved.22 They are subconsciously attracted to radiography because they can control the extent to which they become emotionally entangled with patients and thus are able to fulfil their desire to work in an allied health profession. Even where this is not the case initially, participants are socialised into the profession’s ‘feeling rules’30 which, it is argued, require distancing from the patient, although this emotional distancing is partly mediated by the requirement to touch the patient when positioning them for their images. There has been little research done on the reasons why diagnostic radiography is selected as a profession and this may be a fruitful area for further investigation. Equally, the authors accept that the views expressed by the respondents above may possibly differ from those who have entered the profession more recently and, again, a study of the characteristics of the graduate entrants to the profession may also be a valid topic for further research. It is also anticipated that the current research which is being done into the area of the ‘emotional intelligence’ of radiographers may well throw further light onto the issues raised in this article.
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Contents lists available at SciVerse ScienceDirect
Radiography journal homepage: www.elsevier.com/locate/radi
Diagnostic radiography: A study in distancing Pauline J. Reeves a, *, Sola Decker b a b
Faculty of Health & Wellbeing, Sheffield Hallam University, Sheffield S10 2BP, UK School of Healthcare Sciences, Bangor University, Technology Park, Wrexham LL13 7YP, UK
a r t i c l e i n f o
a b s t r a c t
Article history: Received 31 August 2011 Received in revised form 15 December 2011 Accepted 22 January 2012 Available online 14 February 2012
Aims: This article aims to explore the ways in which diagnostic radiographers use distancing as a tool for emotional management in radiography practice. Methods: This review utilises data from oral history interviews undertaken as part of a larger study documenting the oral history of the diagnostic radiography profession in the United Kingdom as recounted by 24 participants. Results: The results are presented as illustrative of various aspects of the role of the diagnostic radiographer including the initial choice of diagnostic radiography as a profession, the endemic use of particular terminology, the nature of the encounter in diagnostic radiography (including that of sectional imaging) and whether the role is really patient-centred. Conclusions: The article concludes by suggesting that distancing from the patient is mediated by the need for physical touch in order to position the patient for radiography and also makes the suggestion that those opting for diagnostic radiography as a career may do so because they want a profession which is more distanced from the patient and that, even where this is not the case initially, individuals are socialised into adopting the ‘feeling rules’ of the profession. The article concludes by outlining potential areas for further research. Ó 2012 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Keywords: Distancing Emotion work Touch Oral history Models
Introduction Diagnostic radiography is classed as one of the allied health professions. In previous research groups of radiographers were asked to state what they felt differentiated diagnostic radiography from other healthcare professions in order to produce a definition of the role; The role of the diagnostic radiographer is a technical one, aiding the diagnosis of disease. It is a specialised role, offering both responsibility (in the use of radiation) and variety. It is a caring role, but tends to be characterised by less time or close involvement with patients, when compared to other professions.1 In addition, in contrast to other allied health professions such as physiotherapy, speech and language therapy, occupational therapy-even therapy radiography, diagnostic radiography is often conducted before the patient is diagnosed rather than after.
* Corresponding author. Sheffield Hallam University, Diagnostic Radiography, Faculty of Health & Wellbeing, Robert Winston Building, Broomhall Rd, Sheffield S10 2BP, UK. Tel.: þ44 (0) 1142 255447. E-mail address: [email protected] (P.J. Reeves).
Organizational, technological and economic changes have resulted in further investigation and understanding of the healthcare professional and client relationship.2e4 In the following critical analysis of the radiography profession, oral historical interviews of diagnostic radiographers who were eyewitnesses to changes that have occurred in the profession are revisited.2 The interview data are utilised in exploring the concept of distancing in the radiographer e patient relationship. It is argued that the work of the diagnostic radiographer differs from that of other allied health professionals in that it is characterised by distancing from the patient as suggested by literature and by the oral historical accounts of radiographers who trained and practised between the period 1945 and 1995 before the advent of graduate radiographers and evolution of radiography to diagnostic radiography and imaging.
Oral history as research method Oral history research method is interdisciplinary, drawing on history, sociology and social sciences.5 It can be used in illuminating the social, political and economic context of healthcare delivery.6 Oral history is one method of gathering evidence for aspects of professional practice hidden or left unexplored by the profession7
1078-8174/$ e see front matter Ó 2012 The College of Radiographers. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.radi.2012.01.001
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and is thus a valuable method for the profession and other researchers seeking to investigate the evolving nature of radiography practice.2 Oral history interviews are carried out to preserve the perspective of an individual or individuals. The purpose of oral history, therefore, ‘is to interview individuals in order to capture and preserve their spoken perspectives, judgements, and recollections’.8 Oral history interview is therefore an information gathering, connective or discovery tool.9 It shares characteristics with other forms of narrative research but with some unique characteristics of its own.10 Subjectivity is a key characteristic of oral history and reliability and credibility of informants’ memory are also considered as part of its weakness.10 To compensate for its weaknesses, the method may be combined with other qualitative research methodologies.11 The role of oral history in radiography2,8,12 and other professions6,13e15 are well established. The contextual nature of history involves both facts and fiction as its reconstruction and interpretation are of presently understood past, experienced present and anticipated future.7,10 This makes oral historical data valuable for the sociological analysis of the profession. It is such data that has been revisited in exploring the concept of distancing in diagnostic radiography and imaging. Original research from which the oral history interview was obtained The oral history interview collection used in exploring the concept of distancing in diagnostic radiography and imaging utilised the raw data used in the doctoral thesis of one of the authors,2 which investigated the changes that had occurred in the profession from 1945e1995. Among the aims of the original research was to document the history of the profession from the perspectives of diagnostic radiographers who had witnessed, lived and experienced the changes that had occurred in the profession in its second half-century since the discovery of X-rays; much had been documented about the fifty year period from 1895 to 1945 but not necessarily since. Coincidentally, this period was also largely before the introduction of degree education. The research was deemed to be part of the social history of the profession, enabling sociological analysis of the profession using the narratives generated from the career history of the radiographers interviewed. The key methodological frameworks used in the original study were hermeneutic phenomenology and oral history together with phenomenological scholarship, ‘a principled form of inquiry that neither simply rejects or ignores tradition, nor slavishly follows or kneels in front of it ’16 underpinning the structure, conduct, interpretation and writing of the research report. It is this philosophy that was deemed as most appropriate in order to understand the nature of radiography practice from the perspectives of its practitioners’ lived experiences in preference to the well established positivist tradition predominant in radiography research. Interpretive phenomenology embraces the a priori knowledge of the researcher in the conduct of interpretive/hermeneutic phenomenological research but demands that the researcher engages in reflexivity throughout the conduct and writing of the research. Through phenomenological questioning, we come to understand the life-world of the subject (the radiographers’ lived experiences). The objectivity of the researcher draws the researcher into describing and interpreting the phenomenon (radiography) as it appears from the lived experiences of the radiographers. This resulted in the generation of verbatim data. Oral history interview method was employed as the interview tool with focus on the career history of the radiographers. The radiographers were asked to talk about their careers in radiography and were given the scope
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to do so as they wished with any questions largely taking the form of prompts to facilitate recollection. Each respondent was, however, specifically asked what made them select radiography as a career choice and, later in the interview, about the impact of technology on practice. The subjectivity of the research requires that the researcher interpret the phenomenon (radiography) from different perspectives in order to gain in-depth understanding of the profession and its practice. Interpretive phenomenology16 facilitated both the description (verbatim text describing aspects of the phenomenon) and the interpretation of the meaning of such text in the context of the researcher(s) ‘a priori’ knowledge by engaging in individual and cross case analysis of data. Population/sample Following approval from the relevant NHS Trust ethics committee, purposive sampling identified 24 informants who had trained and qualified before the profession became a graduate programme. All the informants were accorded a gender specific pseudonym in conformance with the ethics committee approval requirements and were advised that data gathered might subsequently be used in both published and conference papers. The number included five retired radiographers however 21 were still in service as at 2006 when the interviews were completed. Of the 24 informants, six were male and 18 female; 17 were clinical radiographers, two were managers and five were radiography educators. The sample size was considered to have validity as data collected in the field had reached the point of saturation when no new information was generated.17 Qualitative research makes no attempt at generalisation from the chosen sample. The study was designed to explore the changes that had occurred in the profession following the rapid socio-political, technological and economic changes that have taken place in society, healthcare sector and the profession following World War II and how these had impacted on the profession and its practice.18e20 As is characteristic of interpretive phenomenological research, the texts generated from the original study are open for further revelations left hidden in the texts.21 It is the texts generated from the transcripts from the oral history interviews that the authors (both radiographers with qualitative research background) have revisited and employed in this critical analysis. The responses recorded and discussed in this article arose from detailed immersion and manual analysis of the interview data. The themes used below arose both from the literature and from scrutiny of the transcripts. The responses are used illustratively as is usual in qualitative research. Distancing: a tool in emotion management Literature in other fields of healthcare suggests that distancing is a technique adopted by healthcare professionals when handling difficult situations as part of their daily role22,23 as the professionals strive to meet the demands placed on safety, efficiency and effectiveness. The shift from task oriented care to patient focused care has precipitated renewed interest in the concept of distancing as a coping strategy in emotion work and emotional labour4; “Emotion work is the process of handling our daily, personal emotions; emotional labour involves invoking, performing, and managing emotions that are a required aspect of a job or occupation”.24 Much of the work of the diagnostic radiographer is involved with the Accident and Emergency (A&E) department, examining patients who have undergone some form of trauma. Other patients
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may have been admitted with serious, often life-threatening, illness. Such work is often undertaken at night or at weekends when the radiographer may be working alone or with minimal support from colleagues. Patient injuries may be the result of violence, falls or road traffic accidents and thus constitute traumatic events for the radiographer who has to position them for their X-ray examinations and who may, inadvertently, cause further pain to the patient in doing so. In order to deal with such trauma the radiographer may use distancing as a strategy to detach from the pain of these events,25 an activity that may be perceived as situating the profession in the technologyehumanism dualism26 as greater focus is placed on technology rather than the humanistic aspect of caring.27 It is argued that the exposure of a radiographer to traumatic events and complex disease processes in the course of their daily routine work challenges both the individual’s personal identity and their world view as they struggle to achieve a balance between emotion work (personal) and emotional labour (professional) in the course of performing their role as a radiographer. Emotion work and emotional labour constitute impression management and this has been a well established coping strategy in such work places as education,24 General Practitioner surgeries, air flight services, manual labour28 and different disciplines in nursing.23,29 This article aims to explore the ways in which diagnostic radiographers use distancing as a tool for impression management in radiography practice. The following section presents the themes and related responses derived from the analysis of the oral history transcripts. Initial selection of diagnostic radiography over other health professions A number of respondents made comments relating to their choice of radiography which suggested that they may have (consciously or otherwise) opted for a profession whose practice was slightly more distanced from patients than other allied health professions; I just felt that I didn’t think I could do long-term nursing duties (Anne line 18). I couldn’t have been a physiotherapist because I wouldn’t have wanted to get to know people so well.The chances of you seeing your patient ‘Mr Smith’ who you X-rayed last night for fractured femur is remote and that suited me. I wouldn’t have wanted to get involved with people (Becky lines 656e663). None of us wanted to be nurses and I’m sure the nurses probably didn’t want to be us!’ (Collette lines 258e9). ‘So I was deciding I might do nursing but I wasn’t really a bedpan sort of person (Rose lines 67e8). I think I might have been a bit frightened at just total patientorientated thing like nursing.When I went to see a physio I went to one of the chest places and I thought “oh I can’t do with all this coughing and spitting and all this phlegm kind of thing”. So I think that put me off physio in a way.more the dirty side of it that I didn’t want the patient contact with (Ruth lines 206e15). The radiographic encounter ‘You are presented with a patient for X-ray, you do them, you send them off and never actually hear again what happened.’ (James lines 626e7). James also refers to radiography being ‘a 10 min and bites (sic) job unlike nursing’ (lines 48e52). You’re not holding on to them long enough for them to realise who you are, what you do. (Jenny lines 892e3).
A radiographer is.I think they’re someone that looks after people, even be it for a short length of time.We might only meet them for a short time but we’re still a big part (Ruth lines 803e13). In a way, there is a difference between radiography and physiotherapy. In some instances the physiotherapist has to be cruel to be kind. So there you’ve got a different caring approach. They also have lots more of physical hands-on caring approach to patient as well. Compared to nurses, nurses are quite different, because they’ve got to care for the feelings all the time. Also with the relatives of the patients, they have to care and cope with them. They have to have much more empathy with the patients and families much more than general radiography because it is not a conveyor belt system where the person goes through radiography then you may not see them again. In radiotherapy again, you get to see the person more than once and you got to be able to use your caring skills but not to be over sympathetic. There is difficulty in the way you have to approach the situation (Tina, lines 706e719). Use of reductionist language .Within 4 or 5 months.you were starting to X-ray hands and fingers and to some degree or lesser degree chest (Becky lines 25e6). The world record we did was 14 pacemakers in one day which is amazing (Angela line 267e8). ‘I enjoyed the abdominal work but I didn’t really enjoy the pregnancies’ (Anne line 119-talking about ultrasound). So, of course, the skull, sinuses and mastoids were then done in the room where the IVU used to be done (Becky lines 151e2). Task-orientation: the centrality of the image And I still like to see an aesthetically beautiful film. I actually think .there is beauty in the way you can set it out and things.it pleased my eye as well as the other senses (Vanessa lines 101e5). And then you’d feel quite proud of putting the film up, “That’s my film, that is!” (Wills lines 629e30). You know, sometimes you get so bugged up with technology, you forget there is a patient there, that it is a whole person that we’re dealing with (Vanessa lines 1222e1224). Technical skills vs patient care We’ve always been a cross between quite scientific and nursing. We still need to keep those patient care skills’ (Angela lines 782e4). ‘I do get a kick out of getting a difficult patient and getting a wonderful film, which sounds really pathetically sad (Collette lines 734e6). I suppose it is just the different types of patients and the satisfaction you get out of producing good set of films isn’t it? .like trauma views or trauma obliques on a C spine when the patient is strapped on a trolley and the challenge of producing a nice film, yeah. (Denise lines 694e698). .With the advent of technological advances the actual skills of a radiographer who will position for complex radiographic techniques has diminished. Now the skills are changed, it’s how you can manipulate equipment as opposed to patient (Judy, lines 950e965). The scanning room e behind the glass; CT & MRI There’s too much pressure on throughput.I know in CT I do very little patient care, much less than I used to. I used to be the one giving the preps, I used to be the one explaining the procedure, putting the patient at their rest; don’t do that now, very rare (Judy lines 902e7).
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Otherwise you really will have divisions then won’t you? That people.in MR and CT absolutely hate being drawn into the department, don’t like it at all. Not all, but most of them. Because.no, we don’t do this (Kate lines 833e6). Mediation of distancing through touch You know it is literally a hands-on (sic). You can’t do radiography standing with your hands behind your back, saying do you mind moving down. You’ve got to make contact, you are really handling. So you have to be able to get them to trust you enough to allow you to do that (Vanessa lines 1150e1155). I remember watching somebody doing a lumbar spine and they were rubbing their hands up and down the lumbar spine (Angela lines 147e8). That then suggested that if we couldn’t do physical contact that we shouldn’t really be there (James lines 36e7). Discussion In a study of how nurses dealt with emotions,30 it was suggested that a community of staff may have ‘implicit feeling rules’ regarding the management of emotions within encounters and that these ‘feeling rules’ act as a framework for social interaction for its members.31 This framework has its own coping mechanisms for dealing with the emotional aspects of the work; we may postulate that diagnostic radiography has its own set of these rules, which are subtly different from nursing and other allied health professionals, and which incorporate a greater degree of distancing from the patient. These rules may, or may not, include aspects of the technology as a mediating factor.32 The concepts presented in this nursing article30 are derived from the work of Goffman33 and presents the nurses in the study as being “accomplished social actors and multiskilled emotion managers”.30 At one stage the author refers to nurses presenting their ‘smiley faces’ to patients; a need felt to result from changes in management style and the prevailing political ethos. This has recently been echoed in an article exploring the possible existence of a ‘blame culture’ in radiography in which radiographers expressed the need to apologise to patients to avoid being blamed for long waiting times and other technological factors over which they actually had little or no control.34 When potential employees investigate their chosen professions they subconsciously include aspects of the ‘feeling rules’ for that profession and decide whether or not these are a good ‘fit’ for them personally before committing to that profession.31 The definition of diagnostic radiography presented in the introduction was developed by asking practising radiographers to identify what was unique about the role of the diagnostic radiographer.1 The resultant definition highlighted the limited duration of the radiographic encounter. The phrase ‘hit and run carer’ was also derived to characterise, not only the short length of time that radiographers spend with patients, but also (and something not picked up by the definition) the fact that most diagnostic radiographers will never encounter that same patient again, making the encounter particularly transient.1,35 Radiotherapy radiographers have similarly short encounters with patients but these are repeated, often up to 25 times in the course of the treatment period, allowing for the development of a relationship with the patient over several weeks. The diagnostic radiographer rarely has that opportunity. It has been argued elsewhere that brevity in encounters is not unique to radiography but, indeed, typifies healthcare in the UK National Health Service (NHS).31 The term ‘blip culture’ is used as broadly analogous to the ‘hit and run’ carer.1,31 It is claimed that this ‘fleeting encounter’ helps to characterise diagnostic radiographers
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as ‘non-persons’ in the eyes of the patient36; this was backed up by one of the interviewees (‘Jenny’). This concept has been recognised and termed ‘the Tardis encounter’31 since, like Dr Who’s Tardis, the radiographic examination is potentially bigger on the inside than it might appear from the outside; for example the magnitude of the communication skills required to successfully manage such short encounters may well be underestimated. Members of the public are often unclear as to the identity of the professional who is carrying out the examination. In a study of the patient experience in magnetic resonance imaging (MRI) and computed tomography (CT) the respondents consistently referred to radiographers as nurses.27 The radiographerepatient encounter was further compared to other allied health professions and highlighted variation in the role of emotional management in a healthcare setting. Tina’s experiences, related above, further highlight the potential for depersonalisation of the patient; the perception that you have to be ‘cruel to be kind’ to aid the patient’s recovery as suggested in the role of the physiotherapist and the short encounter with the radiographer as depicted in the comparison with the conveyor belt system.35 Reductionist language, whereby patients are referred to as body parts, is endemic within the profession. Its use stems from the biomedical model and is characterised by the referral process whereby doctors fill in request forms with terms such as ‘chest Xray please’, ‘X-ray lumbar spine’.37,38 Radiographer clinical education also tends to be organised by body parts, with students being encouraged to undertake examinations of hands and feet at the start of their training; students are therefore very quickly socialised into using the same terminology. In an article exploring the concept of emotional intelligence, Mackay et al. cite a study in which a statistically significant inverse relationship was found between reductionism/distancing from the patient and high emotional intelligence38,39; in other words those with high emotional intelligence were more likely to display caring, patient-centred attitudes. Unlike nursing and other professions, there have been few attempts to develop theories or models of the practice of diagnostic radiography.1,37,40 Previous research resulted in the development of a patient-centred model of radiography as illustrated in Fig. 1. However other researchers35 have noted that, whilst diagnostic radiographers claim to be patient-centred, this claim is not borne out by the reality. In fact we may argue that it is the image, not the patient, that is, in fact, at the centre of diagnostic radiography practice. Radiography differs from the other allied health professions (including therapy radiography) in that there is an actual product at the end of the radiographic process; that is an image or set of images. Diagnostic radiographers produce images, often in very difficult situations. Radiography practice sees the production
Figure 1. Patient-centred model of patient care in radiography.
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of a quality diagnostic image as the long-term goal of the radiographer whilst the humanistic interaction constitutes the short term goal required to achieve the end product.41 Radiographers often experience pride in being able to achieve a good set of images in areas such as theatre, resuscitation rooms or intensive care units; until recently this product was actually tangible, in the form of a film. Now the images are on computer systems. In both cases the images provide distancing from the patient and their suffering.30 Sociologists have commented on the extent to which medical imaging technology strips away the patient’s sense of self and allows professionals to objectify their patients.32,42e44 It has also been argued that such images take on a reality of their own.45 A recent study of diagnostic radiography students argued that there is a dichotomy between technological competence and patient care and that the process of socialisation of students into the profession encouraged the prioritisation of technical competence.46 This can, in part, be traced back to the early days of the profession. Many individuals (predominantly female) came into radiography from nursing and gained hospital positions over male radiographers. This provoked a backlash on the part of male radiographers whereby they actively denigrated nursing qualifications and patient care skills in radiography and sought to elevate technical skills (as being typically male), defining the radiographer’s role in relation to the technical apparatus, not the patient.47 This level of technical skill was seen as being undermined by technological developments in the radiographic equipment itself. The focus on equipment manipulation may therefore be seen as constituting an emotional shield while the radiographer demonstrates technical skill and efficiency. Murphy27,36 has made an extended study of the role of the radiographer and the reaction of the patient in computed tomography (CT) and magnetic resonance scanning (MR). Cross sectional imaging technologies, when compared to general radiography, represent further distancing from the patient since there is actual physical separation by means of a lead glass wall-the patient is in one room in the scanner, whilst the operating controls (and thus the radiographers) are located in an adjacent room. As indicated by one of the respondents, pressures on throughput mean that helpers often undertake patient care roles previously undertaken by radiographers. Some respondents commented on the fact that this separation from the patient also led to the scanning radiographers separating themselves off from other colleagues elsewhere in the imaging department. This separation of staff in modalities such as CT from other areas of practice is reiterated in a study of the development of specialisation within diagnostic radiography.12 It is argued that ‘exclusivity’ whereby certain members of staff work with only one modality (such as MRI) detracts from patient-centred care, whilst recognising that physical boundaries are a means of acknowledging the existence of specialisation. The one aspect of a radiographer’s work that acts as a mediator to emotional distancing and the technology of medical imaging is that the radiographer has to use physical touch in order to position patients and determine surface markings. In one study the use of touch was described as a strategy for handling difficult situations,22 suggesting that, for some individuals, the use of touch to connect with individual patients may be a preferable alternative to emotional investment. Conclusions Critical review of the profession suggests that diagnostic radiographers are distanced from their patients by technology, by taskfocussing on the production of an image and by the ‘blip culture’ or ‘hit and run’ aspects of the role whereby short examination times
are coupled with a high likelihood that the encounter with any individual patient will never be repeated. It has been argued elsewhere that diagnostic radiographers use lack of emotional investment in their patients as a coping strategy and to reduce the stress of the job.35 The authors would go further than that and suggest that the fact that the profession is characterised by distancing from the patient may possibly be a factor which attracts certain types of personalities to become diagnostic radiographers; when they look at X-ray departments they perceive a profession that will allow them to serve the patient without becoming, for the most part, emotionally involved.22 They are subconsciously attracted to radiography because they can control the extent to which they become emotionally entangled with patients and thus are able to fulfil their desire to work in an allied health profession. Even where this is not the case initially, participants are socialised into the profession’s ‘feeling rules’30 which, it is argued, require distancing from the patient, although this emotional distancing is partly mediated by the requirement to touch the patient when positioning them for their images. There has been little research done on the reasons why diagnostic radiography is selected as a profession and this may be a fruitful area for further investigation. Equally, the authors accept that the views expressed by the respondents above may possibly differ from those who have entered the profession more recently and, again, a study of the characteristics of the graduate entrants to the profession may also be a valid topic for further research. It is also anticipated that the current research which is being done into the area of the ‘emotional intelligence’ of radiographers may well throw further light onto the issues raised in this article.
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