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Radiographers' Experience of Work Performance After Attending a Postgraduate Course in Appendicular Reporting—A Qualitative Study
Journal of Radiology Nursing xxx (2020) 1e5
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Radiographers' Experience of Work Performance After Attending a Postgraduate Course in Appendicular ReportingdA Qualitative Study Berit Møller Christensen, PhD, RRN a,*, Roland Bendroth, MSc, RRN b, Bodil T. Andersson, PhD, RNT b a b
€nko €ping University, Jo €nko €ping, Sweden Department of Natural Science and Biomedicine, School of Health and Welfare, Jo Faculty of Medicine, Department of Health Sciences, Lund University, Lund, Sweden
a b s t r a c t Keywords: Radiographer Education Reporting Qualitative content analysis Work performance
The radiography profession in Sweden is young but has been rapidly changing over the recent years. The developing profession has led to radiographers facing various challenges related to responsibility for both the technical equipment and patient care in the periradiographic process. Further education is urgent to keep up with the arising level of competence required. The study aimed to explore radiographer’s experience of their work performance and contribution to the clinic after accomplishing a 7.5 ECTS postgraduate course in appendicular reporting. The study has a qualitative design, based on individual and semistructured interviews with 34 registered radiographers from all parts of Sweden. The results revealed that the course led to “Breadth and depth in the professional practice.” This was seen by a perceived increased knowledge, more professional recognition, and a perceived increased work satisfaction. The postgraduate course in reporting was a valuable experience for the attending radiographers and contributed both to their personal and professional development. © 2019 Association for Radiologic & Imaging Nursing. Published by Elsevier Inc. All rights reserved.
Introduction The radiography profession is young, being recognized as recently as 1963, and the number of professionals and the level of scientific activity in the educational institutions are limited. The most recent statistics from 2016, regarding number of radiographers in Sweden, registered by National Board of Health and Welfare is 3921 (National Board of Health and Welfare, 2016). To become a registered radiographer in Sweden, a bachelor degree containing 180 ECTS is required. The professional title is protected by the (National Board of Health and Welfare, 2016). As of today, there is no formal education in reporting radiography in Sweden. However, in Sweden, the academic field of radiography has grown since 2001 (Andersson, 2012). This may be related to more progressive education in a number of universities, which now offer academic degrees in radiography, opening up opportunities for higher academic studies. The competencies for the radiographer include care for the patient throughout the whole * Corresponding author: Berit Møller Christensen, Department of Natural Science €nko €ping University, Box 1026, Sand Biomedicine, School of Health and Welfare, Jo € nko € ping, Sweden. Tel.: þ46 36 101297. 551 11 Jo E-mail address: [email protected] (B. Møller Christensen).
proceduredbefore, during and after the examination. The scope of practice includes, apart from patient care, radiation protection and patient safety as well as the responsibilities in carrying out the ex€ amination (Andersson, 2012; Ornberg & Andersson, 2012). Regarding the medical image, the radiographer should have the ability to assess and optimize image quality as well as making the primary assessment € related to the referral (Ornberg & Andersson, 2012). Furthermore, digitalization of diagnostic radiology departments throughout Sweden in the 1980s has resulted in greater responsibility falling on the profession (Fridell, 2007; Larsson et al., 2007). For example, the radiographer has become responsible for approving diagnostic image quality and subsequently discharging the patient. This extended responsibility and additional workload have not been facilitated by academic training, however, but rather by in-service training at the clinic (Selim, 2016). As a consequence of the development of the profession, the radiographer faces various challenges as he/she is responsible for the technical equipment, performing radiographic examinations, and patient care in the peri-radiographic process (Andersson et al., 2008; Andersson, 2012). The technical equipment has become more nuanced with more possibilities to perform advanced examinations, and more patients with complex medical conditions are seen
https://doi.org/10.1016/j.jradnu.2019.12.010 1546-0843/$36.00/© 2019 Association for Radiologic & Imaging Nursing. Published by Elsevier Inc. All rights reserved.
Please cite this article in press as: Møller Christensen B et al., Radiographers' Experience of Work Performance After Attending a Postgraduate Course in Appendicular ReportingdA Qualitative Study, Journal of Radiology Nursing, https://doi.org/10.1016/j.jradnu.2019.12.010
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B. Møller Christensen et al. / Journal of Radiology Nursing xxx (2020) 1e5
in the radiology departments. Consequently, the radiographer is taking on more responsibility for the technical areas of professional practice and encountering patients with more complex medical conditions (Henderson et al., 2016). This progression within the profession seen in Sweden over the past 20 years is a trend that previously permeated the profession in the United Kingdom (Hardy & Snaith, 2006; Henderson et al., 2016). The starting point for the development of the profession in these contexts was the Radiographers Abnormality Detection Schemes (RADS), called red dot system. The red dot system implies that when the radiographer recognizes any abnormality, this is highlighted in the image by a red dot, for the radiologist to be aware of. This particular development of the radiographer profession has been followed by role extension (Hardy & Snaith, 2006). In 1997, the College of Radiographers published a vision paper regarding reporting by radiographers, which was followed by guidelines to assist radiographers undertaking radiographic reporting (College of Radiographers, 2003). The trends within the profession that were previously seen in the United Kingdom of embracing role extension and more in-depth education (Hardy & Snaith, 2006) have also been predicted for the Swedish context (Andersson et al., 2017; Bjorkman et al., 2017). The scenario seen in the Swedish context suggests that radiology departments throughout the country struggle with a shortage of both radiologists and radiographers. The lack of radiologists has led to extensive use of tele-radiology to interpret radiographs, and radiographers have at times been in charge on emergency duty when no radiologist was on location. This work situation has led to radiographers taking on additional responsibility and, consequently, needing and requesting more in-depth knowledge (Andersson et al., 2017; Bjorkman et al., 2017). Therefore, there is a need for postgraduate courses to meet the demand for sound and advanced reporting knowledge. There is also a lack of knowledge about radiographers' experience of interpreting radiographs. Previous studies (Paterson & et al., 2004; Piper et al., 2005; Wareing et al., 2017) have shown that there is an urgent need for postgraduate education to keep up with the rising level of competence required. A postgraduate course in appendicular reporting was launched. The radiographers' experience of this course and the way it has influenced their work performance and individual perspectives then needed to be explored. The aim was to explore radiographers' experience of their work performance and contribution to the clinical work after the completion of a 7.5 ECTS postgraduate course in appendicular reporting. Methods The study has a qualitative design based on individual and semistructured interviews with 34 registered radiographers from all parts of Sweden. The inclusion criterion was radiographers who had completed a 7.5 ECTS postgraduate course in appendicular reporting. The exclusion criterion was radiographers who had not completed the course. Context The appendicular reporting program was a 7.5 ECTS post€nko €ping University. The course was graduate course offered by Jo organized as a distance-learning course with three campus meetings during a 10-week period. The course was offered once each autumn 2013, 2014, and 2015. The theoretical part of the course comprised assignments and lectures on normal anatomical variations and pathology within the appendicular skeleton, differential diagnosis, assessment of image quality and reflections on the peri-radiographic process. During the
campus meetings, the students conducted diagnostic tests, seminars, and examinations. The practical part of the course comprised training in workshops during campus meetings and clinical practice assessing a number of cases with regard to image quality and reporting on conventional Xray examinations on the appendicular skeleton. The reporting followed a structured procedure, and a minimum of 160 reports, equally divided in the upper and lower limb, were documented in a logbook based on established forms, where the sensitivity and specificity was measured. A specialist in musculoskeletal radiography evaluated the logbooks. The curriculum stated certain goals that students should achieve: demonstrate in-depth knowledge of normal anatomical variations in the appendicular and axial skeleton of conventional Xray examination demonstrate in-depth knowledge of common pathological changes in acute injuries within the appendicular and axial skeleton demonstrate in-depth knowledge of basic radiographic image reconstruction methods optimized for the appendicular and axial skeleton assess and analyze image quality adapted for the appendicular and axial skeleton within conventional X-ray examination identify and describe pathological changes in acute injuries within the appendicular and axial skeleton by conventional Xray examination clarify the interaction with other professions in the periradiographic process evaluation ability and approach critically review and evaluate own efforts and identify what needs to be developed evaluate collaboration with other professions. The students were examined through attendance and achievement under mandatory conditions, individual assignments and oral presentations, and a final OSCE examination. Sample A total of 44 radiographers attended the course and received a letter of invitation to participate in the study. Participation meant being interviewed by one of the three authors by phone or in person. The interviews were conducted based on an interview guide consisting of ten questions on the reason for applying to the course and the experience of changed work performance and increased contribution to the diagnostic radiology department after the course. There was a dropout of ten potential informants. During spring 2016, 34 interviews were conducted. The sample consisted of 10 (29%) men and 24 (71%) women. The average level of the radiographers' performance within the course was a sensitivity of 97% and a specificity of 92%. The interviews were transcribed verbatim and analyzed using qualitative content analysis (Graneheim & Lundman, 2004; Krippendorff, 2013). The analysis process consisted of six steps. First, the transcribed interviews were read and crosschecked for correctness by all three authors. Second, the transcripts were read several times to search for statements describing experiences related to the aim of the study and then these were extracted into meaning units. Third, the meaning units were condensed with the aim of maintaining the essential content. Fourth, the analysis process continued abstracting the meaning units and labeling them with a code. Fifth, the codes were compared based on differences and similarities and sorted into subcategories and categories, which constitute the manifest content. All the steps in the analysis process
Please cite this article in press as: Møller Christensen B et al., Radiographers' Experience of Work Performance After Attending a Postgraduate Course in Appendicular ReportingdA Qualitative Study, Journal of Radiology Nursing, https://doi.org/10.1016/j.jradnu.2019.12.010
B. Møller Christensen et al. / Journal of Radiology Nursing xxx (2020) 1e5
were performed by the researchers together and discussed until consensus was reached. Sixth, the researchers felt that an underlying meaning could be seen in the material and, therefore, a theme was discussed as a latent final step of the analysis (Krippendorff, 2013). All the researchers were involved in the interviews, recordings, and transcriptions as well as the data analyses.
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understanding of pathology and diagnostics and, consequently, improved performance in everyday work procedures and interpreting and discussing the radiographs. “I use my new knowledge in my everyday work.” “I am more critical when scrutinising the image quality… have a deeper understanding of the criteria for a good image.”
Ethical Considerations The study only included staff, and therefore, no formal ethics committee approval was required which is in line with the Swedish national ethical requirements (General Assembly of the World Medical Association World Medical Association Declaration of Helsinki, 2014). Ethical considerations were made according to the Declaration of Helsinki (2014) (Codex Rules and Guidelines for Research, n.d.). The participants received detailed written information about the study and implications of participation. In addition, verbal information was given at the beginning of each interview, stressing the voluntary nature of participation and the right to withdraw at any time. Participants were assured of confidentiality through secure access to the data and anonymous presentation of the results.
The qualitative content analysis of the interviews resulted in a comprehensive theme: breadth and depth in professional practice. Three categories and a total of 16 unique subcategories identified the radiographers' experience of their work performance and contribution to the clinic after completion of a postgraduate course in reporting. The three categories were perceived increased knowledge, professional recognition, and work satisfaction (Table 1). Breadth and depth in professional practice was extracted from the data analysis as a comprehensive theme. The theme was unfolded through latent abstraction based on a manifest analysis of the radiographers' experience of their work performance after completing the postgraduate course in appendicular reporting. Perceived Increased Knowledge The radiographers expressed that they had acquired greater knowledge, which, for some, was part of higher university education. The knowledge gained from the course had led to increased Table 1 Results from the analysis of 34 interviews, showing categories and subcategories Categories
Subcategories
Perceived increased knowledge
Increased understanding of diagnostics and pathology Better equipped as supervisor Increased patient safety Improved performance in everyday work procedures, interpreting and discussing the radiographs Improved safety on emergency duty Discharge patients
Work satisfaction
“The new knowledge helps a lot, especially on emergency duty, when there is no radiologist in place after 10 pm.” “I am now able to discharge patients who previously had to wait for the radiologist report to the Emergency Department if the injury has caused a fracture because I am more secure and reliable in my knowledge.” For most of the radiographers, daily work would at times involve supervising students, and attending the course had helped them to become better equipped as supervisors.
Results
Professional recognition
There were times in most radiology departments when the radiographers were in charge on emergency duty when no radiologist was on location. The increased knowledge implied improved safety on emergency duty and increased patient safety, which, for example, implied an ability to discharge patients.
Recognition from colleagues Self-assurance in professional competence Colleagues request expertise Improved interprofessional communication Inspirational and motivational towards colleagues More fun to work Perform on a higher level Improved self-esteem Increased stimulation in work-related tasks Comfortable in the professional role
“Working with the students, I am better equipped and skilled to explain the structures seen in the images.” Professional Recognition After completing the postgraduate course in appendicular reporting, the radiographers experienced more professional recognition. They felt confident in their professional role and consequently were able to improve interprofessional communication. “I am more confident in my professional role as a radiographer.” The radiographers learned recognition from colleagues, which was eventually seen by colleagues requesting expertise. “We discuss the images more often now, and colleagues request my opinion.” In addition, the radiographers felt they could be a source of inspiration and motivation for colleagues, which may be an expression of greater self-assurance in their competence. “I feel confident sharing my knowledge with colleagues.” “I know what I am doing and what I am capable of.” Perceived Increased Work Satisfaction Everyday work after completion of the course implied work satisfaction in a different way to before. The radiographers felt increased stimulation in tasks and consequently that it was more fun to work. “My work has become more interesting.” “It's much more fun to look at the images now.” The radiographers experienced improved self-esteem and now performed on a higher level. Consequently, they were more comfortable in the professional role.
Please cite this article in press as: Møller Christensen B et al., Radiographers' Experience of Work Performance After Attending a Postgraduate Course in Appendicular ReportingdA Qualitative Study, Journal of Radiology Nursing, https://doi.org/10.1016/j.jradnu.2019.12.010
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“I feel that I am valuable to the department.” “I am more competent as a radiographer, which is beneficial for the department.” Discussion The results showed a comprehensive view of breadth and depth in professional practice by the radiographers who had attended the specific course in appendicular reporting. The study revealed that the course in reporting was a valuable experience for the radiographers in terms of identifying and developing professional knowledge, competence, and understanding. This result supports the assumption that initiated the study: that there is a high demand for postgraduate courses to increase radiographers' professional development, especially when undertaking extensive responsibilities with more advanced and greater scope in the profession. In addition, studies among radiographers in the United Kingdom and Scotland have highlighted the need for courses for radiographers to develop in their professional role (Henderson et al., 2016; Milner & Snaith, 2017). The radiographers expressed extended and more in-depth knowledge with regard to understanding diagnostics and pathology and improved their performance within the profession. A previous study undertaken in Australia showed that radiographers have the knowledge to improve their performance, for example, to assist junior doctors. This particular study showed that radiographers perform at a high level with regard to sensitivity and specificity in reporting, suggesting that they may be used to assisting junior doctors (McConnell & Baird, 2017). The increased knowledge that the radiographers had gained was seen in their improved ability to interpret and discuss the radiographs, as well as in improved safety on emergency duty and interaction with patients. McConnel and Baird (2017) also found in a recent study that radiographers have the knowledge to assist in interpreting radiographs, and they suggested that radiographers could contribute to the training of junior doctors in their early years. A study undertaken in the United Kingdom not only suggested but expected radiographers who had knowledge of interpreting radiographs to participate in staff training (General Assembly of the World Medical Association World Medical Association Declaration of Helsinki, 2014). The radiographers in the study work in radiology departments where they have radiographer students in clinical practice who they are expected to supervise in basic radiography. The results showed that the radiographers considered themselves better equipped as supervisors after attending the course in appendicular reporting. A recent study by Milner & Snaith (2017) showed that about half of radiographers with advanced knowledge in reporting take on the role of mentor and support the development of others.20 The radiographers said that the increased knowledge improved patient safety and allowed them to discharge the patient when no radiologist was on location, for example, on emergency duty. This result is supported by a study of radiographers in Australia, which shows that with the appropriate knowledge, radiographers are able to contribute more widely to the multidisciplinary team (McConnell & Baird, 2017). A study by Howard (2013) also showed that radiographers understood the radiographs in a way that allowed them to comment on them, which had impact on the patient care pathway. It also showed that radiographers as a group are motivated to embrace lifelong learning for the benefit of the patient (Howard, 2013). Interpreting and discussing the radiographs with radiologists has been reported as difficult because radiologists can obstruct the development of the radiographers' role (Henderson et al., 2016) or
not support the discussion through feedback (McConnell & Baird, 2017). However, a previous study has shown that radiographers who contribute to interpreting radiographs are not doing so solely to increase service productivity but to contribute to cost-effective service development (Hardy et al., 2013). After taking the course, the radiographers felt more confident in their professional role and consequently were able to improve their interprofessional communication. A previous study by Henderson et al. (2016) also showed that confidence in advanced skills increases professional standing in hospitals. The perception of increased recognition from colleagues when, for example, they requested expertise is in line with the study by Henderson et al. (2016) in which radiographers who possessed advanced knowledge felt respected by colleagues when they discussed radiographs together (Henderson et al., 2016). The radiographers felt more confident in their professional role when colleagues requested their expertise, and they felt better equipped as supervisors. Previous research has also showed professional pride as a result of more in-depth knowledge within the radiography area (Bjorkman et al., 2017; Howard, 2013). Coleman and Piper (2009) argue that professional recognition is seen as recognition of the value of radiographic knowledge and consequently provides stimulus for education and development. When they acquired more in-depth knowledge in appendicular reporting, the radiographers felt more comfortable in their professional role and enjoyed work more, which increased overall work satisfaction. This result corresponds to a study conducted in the United Kingdom showing that the practice of reporting led to greater job satisfaction and professional pride among radiographers (Howard, 2013), which was seen as a result of extended responsibilities. Coleman and Piper (2009) also suggest that maximizing the role of the radiographer would lead to improved job satisfaction. Methodological consideration The trustworthiness of qualitative research relies heavily on the captured and described richness of the participants' experiences, feelings and thoughts under study (Kazdin, 2003). Credibility, dependability, confirmability, and transferability are used to judge trustworthiness (Lincoln & Guba, 1985). Credibility is based on the connection between the aim and the chosen methods and is achieved when the researchers' interpretation of the data is truthful. The researchers had prior experience of qualitative research as well as radiography and education. Credibility was obtained by means of the researchers discussing the analysis in general and, in particular, the categories and final theme until consensus was reached. Dependability refers to the stability of data, where similar findings would be obtained if the study were repeated with the same kind of participants in a similar context. This was achieved by the variety of informants included in the study. Confirmability was obtained using open-ended questions to help the participants share their experiences of the investigated subject and strengthened by descriptions of categories reinforced with quotations. Confirmability was further obtained through the description of each step in the analysis process. Altogether, confirmability can be seen in the researchers' ability to bring out the core of the data when striving for objectivity and accuracy. Transferability refers to the generalizability of the findings. This was obtained based on the variation of sociodemographic characteristics among the participants and the number of diagnostic radiology departments represented in the study (Coleman & Piper, 2009). Limitations in the study may be the limited information regarding demographic data of the participants, that is, age, workplace, years within the profession, etc.
Please cite this article in press as: Møller Christensen B et al., Radiographers' Experience of Work Performance After Attending a Postgraduate Course in Appendicular ReportingdA Qualitative Study, Journal of Radiology Nursing, https://doi.org/10.1016/j.jradnu.2019.12.010
B. Møller Christensen et al. / Journal of Radiology Nursing xxx (2020) 1e5
Conclusion The study revealed that the postgraduate course in reporting was a valuable experience for the attending radiographers and contributed to their clinical work. It was valuable in terms of identifying and developing the radiographers' professional knowledge, which led to them experiencing greater professional recognition and increased their personal work satisfaction.
Acknowledgments The authors would like to thank the radiographers who contributed in interviews with valuable viewpoints to the study. No financial contribution was granted. References Andersson, B.T. (2012). Radiographers’ Professional Competence. Development of a € nko €ping: School of Health contextspecific instrument (Doctoral Dissertation). Jo Sciences. n, C., & Axelsson, Å.B. (2008). Radiographers’ area Andersson, B.T., Fridlund, B., Elga of professional competence related to good nursing care. Scandinavian Journal of Caring Sciences, 22, 401-409. n, M. (2017). Trends that have influenced Andersson, B.T., Lundgren, S.M., & Lunde the Swedish radiography profession over the last four decades. Radiography, 23, 292-297. Bjorkman, B., Fridell, K., & Tavakol Olofsson, P. (2017). Plausible scenarios for the radiography profession in Sweden in 2025. Radiography, 23, 314-320. Codex Rules and Guidelines for Research. n.d.. Retrieved from http://www.codex.vr. se/en/index.shtml. Accessed July 7, 2019. Coleman, L., & Piper, K. (2009). Radiographic interpretation of the appendicular skeleton; A comparison between casualty officers, nurse practitioners and radiographers. Radiography, 15, 196-202. College of Radiographers. (2003). Role development revisited e the research evidence (pp. 1-65). London: College of Radiographers. Fridell, K. (2007). Individuals change when technology change. Department of Clinical Science, Intervention and Technology. (Licentiate Dissertation). Stockholm: Karolinska Institutet.
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General Assembly of the World Medical Association World Medical Association Declaration of Helsinki. (2014). Ethical principles for medical research involving human subjects. Journal of the American College of Dentists, 81(3), 14-18. Graneheim, U.H., & Lundman, B. (2004). Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Education Today, 24(2), 105-112. Hardy, M., Hutton, J., & Snaith, B. (2013). Is a radiographer led immediate reporting service for emergency department referrals a cost effective initiative? Radiography, 19, 23-27. Hardy, M., & Snaith, B. (2006). Role extension and role advancement e Is there a difference? A discussion paper. Radiography, 12, 327-331. Henderson, I., Mathers, S.A., McConnell, J., & Minnoch, D. (2016). Advanced and extended scope practice of radiographers: The Scottish perspective. Radiography, 22, 185-193. Howard, M.L. (2013). An exploratory study of radiographer’s perception of radiographer commenting on musculo-skeletal trauma images in rural community based hospitals. Radiography, 19, 137-141. Kazdin, A.E. (2003). Research design in clinical psychology. Boston, MA: Allyn and Bacon. Krippendorff, K. (2013). Content analysis: An introduction to its methodology. Thousand Oaks, Calif: SAGE. € ld, L., Larsson, W., Aspelin, P., Bergqvist, M., Hillergård, K., Jacobsson, B., Lindsko Wallberg, J., & Lundberg, N. (2007). The effects of PACS on radiographer’s work practice. Radiography, 13(3), 235-240. Lincoln, Y.S., & Guba, E.G. (1985). Naturalistic inquiry. Beverly Hills. California: Sage. McConnell, J.R., & Baird, M.A. (2017). Could musculo-skeletal radiograph interpretation by radiographers be a source of support to Australian medical interns: A quantitative evaluation. Radiography, 23, 321-329. Milner, R.C., & Snaith, B. (2017). Are reporting radiographers fulfilling the role of advanced practitioner? Radiography, 23, 48-54. National Board of Health and Welfare. (2016) Statistical Database, health Care Practitioners. Retrieved from http://www.socialstyrelsen.se/en/statistics-anddata/statistics/statisticaldatabase/. Accessed April 30, 2019. € The Swedish Society of Radiographers, Ornberg, G., & Andersson, B.T. (2012). The competency standards for Registered Radiographers. Stockholm: TMG. Paterson, A.M., et al. (2004). Reporting by radiographers: A policy and practice guide. Radiography, 10(3), 205-212. Piper, K.J., Paterson, A., & Godfrey, R. (2005). Accuracy of radiographers’ reports in the interpretation of radiographic examinations of the skeletal system: A review of 6796 cases. Radiography, 11(1), 27-34. Selim, M. (2016). Från analogt till digitalt e digitaliseringen av svensk radiologi i ett € produktions- och organisationsperspektiv (Licentiate Dissertation). Orebro University: Department of Health Sciences. Wareing, A., Buissink, C., Harper, D., Gellert Olesen, M., Soto, M., Braico, S., Van Laer, P., Gremion, I., & Rainford, L. (2017). Radiography, 23, 558-563.
Please cite this article in press as: Møller Christensen B et al., Radiographers' Experience of Work Performance After Attending a Postgraduate Course in Appendicular ReportingdA Qualitative Study, Journal of Radiology Nursing, https://doi.org/10.1016/j.jradnu.2019.12.010
Contents lists available at ScienceDirect
Journal of Radiology Nursing journal homepage: www.sciencedirect.com/journal/ journal-of-radiology-nursing
Radiographers' Experience of Work Performance After Attending a Postgraduate Course in Appendicular ReportingdA Qualitative Study Berit Møller Christensen, PhD, RRN a,*, Roland Bendroth, MSc, RRN b, Bodil T. Andersson, PhD, RNT b a b
€nko €ping University, Jo €nko €ping, Sweden Department of Natural Science and Biomedicine, School of Health and Welfare, Jo Faculty of Medicine, Department of Health Sciences, Lund University, Lund, Sweden
a b s t r a c t Keywords: Radiographer Education Reporting Qualitative content analysis Work performance
The radiography profession in Sweden is young but has been rapidly changing over the recent years. The developing profession has led to radiographers facing various challenges related to responsibility for both the technical equipment and patient care in the periradiographic process. Further education is urgent to keep up with the arising level of competence required. The study aimed to explore radiographer’s experience of their work performance and contribution to the clinic after accomplishing a 7.5 ECTS postgraduate course in appendicular reporting. The study has a qualitative design, based on individual and semistructured interviews with 34 registered radiographers from all parts of Sweden. The results revealed that the course led to “Breadth and depth in the professional practice.” This was seen by a perceived increased knowledge, more professional recognition, and a perceived increased work satisfaction. The postgraduate course in reporting was a valuable experience for the attending radiographers and contributed both to their personal and professional development. © 2019 Association for Radiologic & Imaging Nursing. Published by Elsevier Inc. All rights reserved.
Introduction The radiography profession is young, being recognized as recently as 1963, and the number of professionals and the level of scientific activity in the educational institutions are limited. The most recent statistics from 2016, regarding number of radiographers in Sweden, registered by National Board of Health and Welfare is 3921 (National Board of Health and Welfare, 2016). To become a registered radiographer in Sweden, a bachelor degree containing 180 ECTS is required. The professional title is protected by the (National Board of Health and Welfare, 2016). As of today, there is no formal education in reporting radiography in Sweden. However, in Sweden, the academic field of radiography has grown since 2001 (Andersson, 2012). This may be related to more progressive education in a number of universities, which now offer academic degrees in radiography, opening up opportunities for higher academic studies. The competencies for the radiographer include care for the patient throughout the whole * Corresponding author: Berit Møller Christensen, Department of Natural Science €nko €ping University, Box 1026, Sand Biomedicine, School of Health and Welfare, Jo € nko € ping, Sweden. Tel.: þ46 36 101297. 551 11 Jo E-mail address: [email protected] (B. Møller Christensen).
proceduredbefore, during and after the examination. The scope of practice includes, apart from patient care, radiation protection and patient safety as well as the responsibilities in carrying out the ex€ amination (Andersson, 2012; Ornberg & Andersson, 2012). Regarding the medical image, the radiographer should have the ability to assess and optimize image quality as well as making the primary assessment € related to the referral (Ornberg & Andersson, 2012). Furthermore, digitalization of diagnostic radiology departments throughout Sweden in the 1980s has resulted in greater responsibility falling on the profession (Fridell, 2007; Larsson et al., 2007). For example, the radiographer has become responsible for approving diagnostic image quality and subsequently discharging the patient. This extended responsibility and additional workload have not been facilitated by academic training, however, but rather by in-service training at the clinic (Selim, 2016). As a consequence of the development of the profession, the radiographer faces various challenges as he/she is responsible for the technical equipment, performing radiographic examinations, and patient care in the peri-radiographic process (Andersson et al., 2008; Andersson, 2012). The technical equipment has become more nuanced with more possibilities to perform advanced examinations, and more patients with complex medical conditions are seen
https://doi.org/10.1016/j.jradnu.2019.12.010 1546-0843/$36.00/© 2019 Association for Radiologic & Imaging Nursing. Published by Elsevier Inc. All rights reserved.
Please cite this article in press as: Møller Christensen B et al., Radiographers' Experience of Work Performance After Attending a Postgraduate Course in Appendicular ReportingdA Qualitative Study, Journal of Radiology Nursing, https://doi.org/10.1016/j.jradnu.2019.12.010
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in the radiology departments. Consequently, the radiographer is taking on more responsibility for the technical areas of professional practice and encountering patients with more complex medical conditions (Henderson et al., 2016). This progression within the profession seen in Sweden over the past 20 years is a trend that previously permeated the profession in the United Kingdom (Hardy & Snaith, 2006; Henderson et al., 2016). The starting point for the development of the profession in these contexts was the Radiographers Abnormality Detection Schemes (RADS), called red dot system. The red dot system implies that when the radiographer recognizes any abnormality, this is highlighted in the image by a red dot, for the radiologist to be aware of. This particular development of the radiographer profession has been followed by role extension (Hardy & Snaith, 2006). In 1997, the College of Radiographers published a vision paper regarding reporting by radiographers, which was followed by guidelines to assist radiographers undertaking radiographic reporting (College of Radiographers, 2003). The trends within the profession that were previously seen in the United Kingdom of embracing role extension and more in-depth education (Hardy & Snaith, 2006) have also been predicted for the Swedish context (Andersson et al., 2017; Bjorkman et al., 2017). The scenario seen in the Swedish context suggests that radiology departments throughout the country struggle with a shortage of both radiologists and radiographers. The lack of radiologists has led to extensive use of tele-radiology to interpret radiographs, and radiographers have at times been in charge on emergency duty when no radiologist was on location. This work situation has led to radiographers taking on additional responsibility and, consequently, needing and requesting more in-depth knowledge (Andersson et al., 2017; Bjorkman et al., 2017). Therefore, there is a need for postgraduate courses to meet the demand for sound and advanced reporting knowledge. There is also a lack of knowledge about radiographers' experience of interpreting radiographs. Previous studies (Paterson & et al., 2004; Piper et al., 2005; Wareing et al., 2017) have shown that there is an urgent need for postgraduate education to keep up with the rising level of competence required. A postgraduate course in appendicular reporting was launched. The radiographers' experience of this course and the way it has influenced their work performance and individual perspectives then needed to be explored. The aim was to explore radiographers' experience of their work performance and contribution to the clinical work after the completion of a 7.5 ECTS postgraduate course in appendicular reporting. Methods The study has a qualitative design based on individual and semistructured interviews with 34 registered radiographers from all parts of Sweden. The inclusion criterion was radiographers who had completed a 7.5 ECTS postgraduate course in appendicular reporting. The exclusion criterion was radiographers who had not completed the course. Context The appendicular reporting program was a 7.5 ECTS post€nko €ping University. The course was graduate course offered by Jo organized as a distance-learning course with three campus meetings during a 10-week period. The course was offered once each autumn 2013, 2014, and 2015. The theoretical part of the course comprised assignments and lectures on normal anatomical variations and pathology within the appendicular skeleton, differential diagnosis, assessment of image quality and reflections on the peri-radiographic process. During the
campus meetings, the students conducted diagnostic tests, seminars, and examinations. The practical part of the course comprised training in workshops during campus meetings and clinical practice assessing a number of cases with regard to image quality and reporting on conventional Xray examinations on the appendicular skeleton. The reporting followed a structured procedure, and a minimum of 160 reports, equally divided in the upper and lower limb, were documented in a logbook based on established forms, where the sensitivity and specificity was measured. A specialist in musculoskeletal radiography evaluated the logbooks. The curriculum stated certain goals that students should achieve: demonstrate in-depth knowledge of normal anatomical variations in the appendicular and axial skeleton of conventional Xray examination demonstrate in-depth knowledge of common pathological changes in acute injuries within the appendicular and axial skeleton demonstrate in-depth knowledge of basic radiographic image reconstruction methods optimized for the appendicular and axial skeleton assess and analyze image quality adapted for the appendicular and axial skeleton within conventional X-ray examination identify and describe pathological changes in acute injuries within the appendicular and axial skeleton by conventional Xray examination clarify the interaction with other professions in the periradiographic process evaluation ability and approach critically review and evaluate own efforts and identify what needs to be developed evaluate collaboration with other professions. The students were examined through attendance and achievement under mandatory conditions, individual assignments and oral presentations, and a final OSCE examination. Sample A total of 44 radiographers attended the course and received a letter of invitation to participate in the study. Participation meant being interviewed by one of the three authors by phone or in person. The interviews were conducted based on an interview guide consisting of ten questions on the reason for applying to the course and the experience of changed work performance and increased contribution to the diagnostic radiology department after the course. There was a dropout of ten potential informants. During spring 2016, 34 interviews were conducted. The sample consisted of 10 (29%) men and 24 (71%) women. The average level of the radiographers' performance within the course was a sensitivity of 97% and a specificity of 92%. The interviews were transcribed verbatim and analyzed using qualitative content analysis (Graneheim & Lundman, 2004; Krippendorff, 2013). The analysis process consisted of six steps. First, the transcribed interviews were read and crosschecked for correctness by all three authors. Second, the transcripts were read several times to search for statements describing experiences related to the aim of the study and then these were extracted into meaning units. Third, the meaning units were condensed with the aim of maintaining the essential content. Fourth, the analysis process continued abstracting the meaning units and labeling them with a code. Fifth, the codes were compared based on differences and similarities and sorted into subcategories and categories, which constitute the manifest content. All the steps in the analysis process
Please cite this article in press as: Møller Christensen B et al., Radiographers' Experience of Work Performance After Attending a Postgraduate Course in Appendicular ReportingdA Qualitative Study, Journal of Radiology Nursing, https://doi.org/10.1016/j.jradnu.2019.12.010
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were performed by the researchers together and discussed until consensus was reached. Sixth, the researchers felt that an underlying meaning could be seen in the material and, therefore, a theme was discussed as a latent final step of the analysis (Krippendorff, 2013). All the researchers were involved in the interviews, recordings, and transcriptions as well as the data analyses.
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understanding of pathology and diagnostics and, consequently, improved performance in everyday work procedures and interpreting and discussing the radiographs. “I use my new knowledge in my everyday work.” “I am more critical when scrutinising the image quality… have a deeper understanding of the criteria for a good image.”
Ethical Considerations The study only included staff, and therefore, no formal ethics committee approval was required which is in line with the Swedish national ethical requirements (General Assembly of the World Medical Association World Medical Association Declaration of Helsinki, 2014). Ethical considerations were made according to the Declaration of Helsinki (2014) (Codex Rules and Guidelines for Research, n.d.). The participants received detailed written information about the study and implications of participation. In addition, verbal information was given at the beginning of each interview, stressing the voluntary nature of participation and the right to withdraw at any time. Participants were assured of confidentiality through secure access to the data and anonymous presentation of the results.
The qualitative content analysis of the interviews resulted in a comprehensive theme: breadth and depth in professional practice. Three categories and a total of 16 unique subcategories identified the radiographers' experience of their work performance and contribution to the clinic after completion of a postgraduate course in reporting. The three categories were perceived increased knowledge, professional recognition, and work satisfaction (Table 1). Breadth and depth in professional practice was extracted from the data analysis as a comprehensive theme. The theme was unfolded through latent abstraction based on a manifest analysis of the radiographers' experience of their work performance after completing the postgraduate course in appendicular reporting. Perceived Increased Knowledge The radiographers expressed that they had acquired greater knowledge, which, for some, was part of higher university education. The knowledge gained from the course had led to increased Table 1 Results from the analysis of 34 interviews, showing categories and subcategories Categories
Subcategories
Perceived increased knowledge
Increased understanding of diagnostics and pathology Better equipped as supervisor Increased patient safety Improved performance in everyday work procedures, interpreting and discussing the radiographs Improved safety on emergency duty Discharge patients
Work satisfaction
“The new knowledge helps a lot, especially on emergency duty, when there is no radiologist in place after 10 pm.” “I am now able to discharge patients who previously had to wait for the radiologist report to the Emergency Department if the injury has caused a fracture because I am more secure and reliable in my knowledge.” For most of the radiographers, daily work would at times involve supervising students, and attending the course had helped them to become better equipped as supervisors.
Results
Professional recognition
There were times in most radiology departments when the radiographers were in charge on emergency duty when no radiologist was on location. The increased knowledge implied improved safety on emergency duty and increased patient safety, which, for example, implied an ability to discharge patients.
Recognition from colleagues Self-assurance in professional competence Colleagues request expertise Improved interprofessional communication Inspirational and motivational towards colleagues More fun to work Perform on a higher level Improved self-esteem Increased stimulation in work-related tasks Comfortable in the professional role
“Working with the students, I am better equipped and skilled to explain the structures seen in the images.” Professional Recognition After completing the postgraduate course in appendicular reporting, the radiographers experienced more professional recognition. They felt confident in their professional role and consequently were able to improve interprofessional communication. “I am more confident in my professional role as a radiographer.” The radiographers learned recognition from colleagues, which was eventually seen by colleagues requesting expertise. “We discuss the images more often now, and colleagues request my opinion.” In addition, the radiographers felt they could be a source of inspiration and motivation for colleagues, which may be an expression of greater self-assurance in their competence. “I feel confident sharing my knowledge with colleagues.” “I know what I am doing and what I am capable of.” Perceived Increased Work Satisfaction Everyday work after completion of the course implied work satisfaction in a different way to before. The radiographers felt increased stimulation in tasks and consequently that it was more fun to work. “My work has become more interesting.” “It's much more fun to look at the images now.” The radiographers experienced improved self-esteem and now performed on a higher level. Consequently, they were more comfortable in the professional role.
Please cite this article in press as: Møller Christensen B et al., Radiographers' Experience of Work Performance After Attending a Postgraduate Course in Appendicular ReportingdA Qualitative Study, Journal of Radiology Nursing, https://doi.org/10.1016/j.jradnu.2019.12.010
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“I feel that I am valuable to the department.” “I am more competent as a radiographer, which is beneficial for the department.” Discussion The results showed a comprehensive view of breadth and depth in professional practice by the radiographers who had attended the specific course in appendicular reporting. The study revealed that the course in reporting was a valuable experience for the radiographers in terms of identifying and developing professional knowledge, competence, and understanding. This result supports the assumption that initiated the study: that there is a high demand for postgraduate courses to increase radiographers' professional development, especially when undertaking extensive responsibilities with more advanced and greater scope in the profession. In addition, studies among radiographers in the United Kingdom and Scotland have highlighted the need for courses for radiographers to develop in their professional role (Henderson et al., 2016; Milner & Snaith, 2017). The radiographers expressed extended and more in-depth knowledge with regard to understanding diagnostics and pathology and improved their performance within the profession. A previous study undertaken in Australia showed that radiographers have the knowledge to improve their performance, for example, to assist junior doctors. This particular study showed that radiographers perform at a high level with regard to sensitivity and specificity in reporting, suggesting that they may be used to assisting junior doctors (McConnell & Baird, 2017). The increased knowledge that the radiographers had gained was seen in their improved ability to interpret and discuss the radiographs, as well as in improved safety on emergency duty and interaction with patients. McConnel and Baird (2017) also found in a recent study that radiographers have the knowledge to assist in interpreting radiographs, and they suggested that radiographers could contribute to the training of junior doctors in their early years. A study undertaken in the United Kingdom not only suggested but expected radiographers who had knowledge of interpreting radiographs to participate in staff training (General Assembly of the World Medical Association World Medical Association Declaration of Helsinki, 2014). The radiographers in the study work in radiology departments where they have radiographer students in clinical practice who they are expected to supervise in basic radiography. The results showed that the radiographers considered themselves better equipped as supervisors after attending the course in appendicular reporting. A recent study by Milner & Snaith (2017) showed that about half of radiographers with advanced knowledge in reporting take on the role of mentor and support the development of others.20 The radiographers said that the increased knowledge improved patient safety and allowed them to discharge the patient when no radiologist was on location, for example, on emergency duty. This result is supported by a study of radiographers in Australia, which shows that with the appropriate knowledge, radiographers are able to contribute more widely to the multidisciplinary team (McConnell & Baird, 2017). A study by Howard (2013) also showed that radiographers understood the radiographs in a way that allowed them to comment on them, which had impact on the patient care pathway. It also showed that radiographers as a group are motivated to embrace lifelong learning for the benefit of the patient (Howard, 2013). Interpreting and discussing the radiographs with radiologists has been reported as difficult because radiologists can obstruct the development of the radiographers' role (Henderson et al., 2016) or
not support the discussion through feedback (McConnell & Baird, 2017). However, a previous study has shown that radiographers who contribute to interpreting radiographs are not doing so solely to increase service productivity but to contribute to cost-effective service development (Hardy et al., 2013). After taking the course, the radiographers felt more confident in their professional role and consequently were able to improve their interprofessional communication. A previous study by Henderson et al. (2016) also showed that confidence in advanced skills increases professional standing in hospitals. The perception of increased recognition from colleagues when, for example, they requested expertise is in line with the study by Henderson et al. (2016) in which radiographers who possessed advanced knowledge felt respected by colleagues when they discussed radiographs together (Henderson et al., 2016). The radiographers felt more confident in their professional role when colleagues requested their expertise, and they felt better equipped as supervisors. Previous research has also showed professional pride as a result of more in-depth knowledge within the radiography area (Bjorkman et al., 2017; Howard, 2013). Coleman and Piper (2009) argue that professional recognition is seen as recognition of the value of radiographic knowledge and consequently provides stimulus for education and development. When they acquired more in-depth knowledge in appendicular reporting, the radiographers felt more comfortable in their professional role and enjoyed work more, which increased overall work satisfaction. This result corresponds to a study conducted in the United Kingdom showing that the practice of reporting led to greater job satisfaction and professional pride among radiographers (Howard, 2013), which was seen as a result of extended responsibilities. Coleman and Piper (2009) also suggest that maximizing the role of the radiographer would lead to improved job satisfaction. Methodological consideration The trustworthiness of qualitative research relies heavily on the captured and described richness of the participants' experiences, feelings and thoughts under study (Kazdin, 2003). Credibility, dependability, confirmability, and transferability are used to judge trustworthiness (Lincoln & Guba, 1985). Credibility is based on the connection between the aim and the chosen methods and is achieved when the researchers' interpretation of the data is truthful. The researchers had prior experience of qualitative research as well as radiography and education. Credibility was obtained by means of the researchers discussing the analysis in general and, in particular, the categories and final theme until consensus was reached. Dependability refers to the stability of data, where similar findings would be obtained if the study were repeated with the same kind of participants in a similar context. This was achieved by the variety of informants included in the study. Confirmability was obtained using open-ended questions to help the participants share their experiences of the investigated subject and strengthened by descriptions of categories reinforced with quotations. Confirmability was further obtained through the description of each step in the analysis process. Altogether, confirmability can be seen in the researchers' ability to bring out the core of the data when striving for objectivity and accuracy. Transferability refers to the generalizability of the findings. This was obtained based on the variation of sociodemographic characteristics among the participants and the number of diagnostic radiology departments represented in the study (Coleman & Piper, 2009). Limitations in the study may be the limited information regarding demographic data of the participants, that is, age, workplace, years within the profession, etc.
Please cite this article in press as: Møller Christensen B et al., Radiographers' Experience of Work Performance After Attending a Postgraduate Course in Appendicular ReportingdA Qualitative Study, Journal of Radiology Nursing, https://doi.org/10.1016/j.jradnu.2019.12.010
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Conclusion The study revealed that the postgraduate course in reporting was a valuable experience for the attending radiographers and contributed to their clinical work. It was valuable in terms of identifying and developing the radiographers' professional knowledge, which led to them experiencing greater professional recognition and increased their personal work satisfaction.
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Please cite this article in press as: Møller Christensen B et al., Radiographers' Experience of Work Performance After Attending a Postgraduate Course in Appendicular ReportingdA Qualitative Study, Journal of Radiology Nursing, https://doi.org/10.1016/j.jradnu.2019.12.010