Australian rural radiographers: radiographic interpretation, communication and disclosure of their radiographic opinion

Transcription

1 Australian rural radiographers: radiographic interpretation, communication and disclosure of their radiographic opinion Kathryn Squibb DipDiagRad, GradDipUltrasonography, MAppSc (MedUltrasound) Submitted in fulfilment of the requirements for the Degree of Doctor of Philosophy University of Tasmania July 2013

2 Declaration of Originality I declare that this thesis contains no material which has been accepted for a degree or diploma by the University or any other institution, except by the way of background information and duly acknowledged in the thesis. To the best of my knowledge and belief this thesis contains no material previously published or written by another person, except where due acknowledgement is made in the text of the thesis, nor does the thesis contain any material that infringes copyright. Signed Dated ii

3 Statement of Authority of Access This thesis may be made available for loan and limited copying and communication in accordance with the Copyright Act Signed Dated iii

4 Abstract Rural radiographers draw upon informally, experientially acquired knowledge in order to navigate dilemmas and activities that demonstrate complex ethical and social dimensions in their practice. Through an exploration of the social and historical world of the rural radiographer, this thesis generates a substantive theoretical insight into rural radiographers participation in radiographic interpretation, communication with referrers and disclosure of their radiographic opinion to patients, with a specific focus on plain film radiography. A two phase, exploratory interpretive study was undertaken. The first phase employed a paper based questionnaire and elicited information from Australian rural radiographers that included demographic profile, context and patterns of service delivery. The purpose of the questionnaire was not to draw statistical conclusions about the rural radiographic population, but rather to gather a demographic snapshot of rural radiographers and to determine radiographers involvement in radiographic interpretation, communication and disclosure of their radiographic opinion. To this end the quantitative component of the questionnaire data was analysed using frequency analysis. Consistent with field literature, the questionnaire data demonstrated that radiographers are engaged in radiographic interpretation, communication with referrers and disclosure of their radiographic opinion to their patients. Emerging findings from the questionnaire provided the foundation for the second stage of the study, interviews with radiographers again providing radiographic services in rural Australia. The thematic analysis of the interview data revealed that, without a clear picture of where they stand medico-legally, rural radiographers draw on an experiential collective of radiographic perception and radiographic interpretation skills as the basis for the complex decisions they make about communication and disclosure of their radiographic opinion. Furthermore, the findings show that the level and method of disclosure chosen by radiographers is governed by the diagnostic, therapeutic and emotional impact this disclosure may have on the patient. Rural radiography transcends the technical image that dominates the field literature and extends to a more humanistic endeavour: patient welfare is central to the iv

5 practice world of the rural radiographer. Utilising a social constructionist framework, theoretical explanations of radiographic practices in relation to radiographic interpretation, communication and disclosure were generated. This study shows that rural radiographers construct of their role in patient care extends beyond image acquisition into radiographic image reading, communication and disclosure of their radiographic opinion. A key finding from this study is that rural radiographers, guided by an ethic of care, navigate a complex interplay of variables as they decide the way in which to convey their radiographic opinion. Radiographers communication of their radiographic opinion with referrers is mediated by the radiographer/referrer game and tends to diagnostic accuracy, but with patients, disclosure is diagnostically vague and may be understood as filtered truth. The way in which rural radiographers convey their radiographic opinion is contextual and informed by experiential knowledge that has evolved through their shared experience of clinical practice in rural settings. This knowledge contributes as equally to an effective outcome for the patient to a radiographic examination as the radiographer s technical expertise in image acquisition; it is however not well described in the radiographic literature nor does it seem to be commonly discussed amongst radiographers and their health care colleagues. The findings from this study indicate that a mismatch in educational preparation, compounded by a lack of professional guidelines and legislative clarity, has led to the ways in which radiographers choose to convey their radiographic opinion. It is important that this implicit and tacit dimension to rural radiographic practice is understood so that it can inform professional, educational and policy decisions relating to radiographers contemporary scope of practice. v

6 Acknowledgements This thesis could not have begun nor been completed without the support and encouragement of many individuals. So to those people who provided me with not only the impetus to begin but also the courage to continue, I thank you. To my mother Shirley Squibb ( ), for introducing me to the value of research, who in reply to my requests as a child for information on human anatomy or the birds and the bees would send me to her nursing anatomy text book, euphemistically referred to as the arms and legs book. And to my father Barrie for his love, support and for saying ask your mother. To all the rural radiographers who generously gave their time to participate in this study. To my supervisors, Professor Rosalind Bull, Professor Judi Walker, Dr Lisa Dalton and Dr Lindsay Smith for their guidance and support and Associate Professor Tony Smith for his invaluable input. Thank you to Tina Pinkard who provided editorial services limited to copyediting and proofreading as set out in standards D and E of the Australian Standards of Editing Practice. To the University of Tasmania, School of Nursing and Midwifery and the University Department of Rural Health for graduate research support. Also to the UDRH and Graduate Research Unit for both their support and for providing a co-funded Tasmanian Postgraduate Research Scholarship (TPRS). Finally, thank you to my family and friends, especially John, Ryan and William, for their love, understanding and patience, as they endured yet more school work. vi

7 Contents Declaration of Originality... ii Statement of Authority of Access... iii Abstract... iv Acknowledgements... vi Contents... vii List of Figures... xii List of Tables... xii Abbreviations and Acronyms... xiii Publications arising from this thesis... xiv Chapter 1: Introduction to the study In t roduct io n Sect io n 1: In t roduct ion t o t h e st ud y Research Problem Purpose of the study Aims of the study Research questions Research design Significance of the study Sect io n 2: Background t o t h e st ud y Problems with framing radiography as a technical endeavour Radiography: A complex, specialised and humanistic profession Hospital to undergraduate education and radiographic qualification The evolution of radiography as support for medical diagnostics Image production, interpretation and communication: interprofessional role overlap Communicating the results of radiographic interpretation Legal and ethical challenges of rural radiographic practice Overview of t h e t h esis Summary Chapter 2: Literature Review Introduction Literature review method vii

8 Radiologists reports - delays and absences Radiographic interpretation Diagnostic Error in Radiographic Interpretation Multidisciplinary Radiographic Interpretation Communication with referring clinicians: limitations and management Radiographer Abnormality Detection Schemes Disclosure to patients: difficulties and ethical implications Summary Chapter 3: Theoretical Perspectives Introduction Establishing the need for a humanistic theoretical framework A theoretical framework for examining the social and cultural nature of rural radiographic practice The social construction of rural radiographic practice The use and value of ethical theories for examining rural radiography Summary Chapter 4: Research Methods Introduction Research Design Study set up Ethical considerations Study Setting Study Participants Determining population size Data Collection and Analysis First Data Collection Phase The Questionnaire Development of the questionnaire Ensuring rigor in the questionnaire Validity of the questionnaire Construct Validity Content validity Piloting the questionnaire through expert evaluation Distribution of the questionnaire Managing the questionnaire data viii

9 Analysis of the questionnaire data Demographic Profile of Questionnaire Respondents Second Data Collection Phase The Interviews Recording rural radiographers experiences of practice through interviews Interview structure Piloting the interview Inviting the participants to interview Sampling strategies Recording and transcribing the interview Data Analysis Techniques Preparing qualitative data as text for analysis Analysis of the qualitative data set Reflective Journal The researcher as a rural radiographer Establishing trustworthiness of the study Confirmability Transferability Dependability Credibility Summary Chapter 5: Radiographic interpretation, communication and disclosure of radiographic opinion: the pre-conditions Introduction Beyond the Technical The Diagnostic Gap (i) Delay in Reporting (ii) Perceived health professional inadequacies in image interpretation (iii) Radiographers triaging patients based on their radiographic images Strategies radiographers employ for responding to the diagnostic gap The strategies that radiographers employ to alert the radiologist The strategies that radiographers employ to alert the referring clinician Factors that inhibit radiographers actions to close the diagnostic gap (i) Informally acquired radiographic interpretation skills (ii) Radiographers are not always confident in their radiographic interpretation ix

10 (iii) Referrers may ignore radiographers radiographic interpretation Navigating the diagnostic gap with referrers (i) Referrers Seeking Radiographers Opinions (ii) Patient s treatment initiated on rural radiographer radiographic interpretation (iii) Communicating radiographic opinion to the referring clinician (iv) Language games for communicating radiographic opinion to the referrer Summary Chapter 6: Rural Radiographers and Disclosure of their Radiographic Opinion to Patients Introduction Disclosure of radiographic opinion to patients Radiographers understanding about responsibility to disclosure information Factors that modify radiographers level of disclosure to patients (i) Radiographer s assessment of the patient (ii) Legal Considerations (iii) The perceived significance of the pathology identified on the radiographic image (iv) Wanting to avoid causing the patient to worry Filtered Truth (i) Language of full Disclosure (ii) Language to minimise disclosure (iia) White lies (iib) Amorphous language (iic) Radiographer s whisper (iii) Language to avoid disclosure Summary Chapter 7: Discussion of the Findings Introduction Diagnostic Gap Discussion Understanding disclosure to patients, truth telling and lies Radiographers filtering the truth The hierarchical nature of Australian radiology Radiographer-Referrer Game Ethics and perception of diagnostic duty Ethics of Care x

11 Summary Chapter 8: Conclusion Introduction Summary of the thesis Achieving the research aims Answering the guiding questions Answering the overarching research questions Significant contributions Limitations Recommendations Concluding statement References Appendices xi

12 List of Figures Figure 1 Radiographic qualification List of Tables Table 1 Table 2 Table 3 Table 4 Table 5 Table 6 Table 7 Table 8 Diagnostic Radiography Courses offered in Australia RRMA classification Inclusion/Exclusion criteria Questionnaire return rates Gender Distribution Facility for training and preparation for rural practice Relationships between coded data and theme diagnostic gap Porter s Interactions compared with radiographers actions xii

13 Abbreviations and Acronyms ABS Australian Bureau of Statistics AHP Allied Health Professional AHPRA Australian Health Practitioner Regulation Agency AIR Australian Institute of Radiography ALARA As Low As Reasonably Achievable APWG Advanced Practice Working Group ARIA Accessibility/Remoteness Index of Australia ASGC Australian Standard Geographical Classification CINAHL Cumulative Index to Nursing and Allied Health Literature COAG Council of Australian Governments CPD Continuing Professional Development CR Computed Radiography CT Computed Tomography ED Emergency Department ESP Expanded Scope of Practice FTE Full Time Equivalent FRANZCR Fellow of the Royal Australian and New Zealand College of Radiologists GP General Practitioner kv kilovolts IPP Interprofessional Practice ISRRT International Society of Radiographers and Radiologic Technologists LHMU Liquor, Hospitality and Miscellaneous Workers Union ma milliamperes MIU Minor Injuries Unit MRI Magnetic Resonance Imaging MRTRBWA Medical Radiation Technologists Board of Western Australia ms milliseconds NPDP National Professional Development Program PACS Picture Archiving and Communication Systems PDY Professional Development Year RANZCR Royal Australian and New Zealand College of Radiologists RAD Radiographer Abnormality Description RADS Radiographer Abnormality Detection Scheme RIS Radiological Information Systems RMIT Royal Melbourne Institute of Technology ROF Radiographers Opinion Form RRMA Rural, Remote and Metropolitan Areas RRPAB Rural and Remote Practitioners Advisory Board SHO Senior House Officer SoA Statement of Accreditation SoR Society of Radiographers UK United Kingdom USA United States of America VSoA Validated Statement of Accreditation WACHS Western Australian Country Health Service xiii

14 Publications arising from this thesis Papers Squibb, K, (2007) Rural Radiography, not so much black and white as shades of grey. In Le Q, (ed) Graduate Research Papers in Rural Health, Launceston, Tasmania. University of Tasmania. Conferences and Seminar Presentations Squibb, K. White Lies. University of Tasmania Collaborative Graduate Research Symposium. Hobart. (2008). Agudera, M, Knight, K, Lodhia, J, Owen, R, Squibb, K. Research, Life Balance How to do a PhD and live to tell the tale. AIR Graduate Research Symposium. Melbourne. (2008). Smith, T, Smylie, J, Andrews, J, Blyth, J, Squibb, K. Rural and Remote Diagnosis and Treatment. AIR Fellowship Session. 5th ASMMIRT. Melbourne (2008). Squibb, KA, Rural Radiographer Survey. Graduate Research Conference. University of Tasmania. Launceston, (2007). Squibb, KA, 'Bioethics and Rural Radiography'. University of Tasmania UDRH Graduate Research Retreat. Launceston, (2005). xiv