An Investigation of the Practices and Clinical Reporting of Radiography

Posted on February 7th, 2023.

Dr A Hisham Alkurdi. United Kingdom

ADVANCED PRACTICE AND CLINICAL REPORTING OF RADIOGRAPHERS IN THE UK AGAINST RADIOGRAPHERS IN OTHER COUNTRIES. 

This paper has adopted the case of Saudi Arabian Radiographers. Published May 2020. London UK

• Journal of Financial Reporting and Accounting
• 11(2)
• DOI:10.1108/JFRA-07-2020-003
• Author: Dr A Hisham Alkurdi. United Kingdom

ADVANCED PRACTICE AND CLINICAL REPORTING OF RADIOGRAPHERS IN THE UK AGAINST RADIOGRAPHERS IN OTHER COUNTRIES.

Introduction

Radiographers around the world are an integral part of the diagnostic approach and can provide expert advice based on radiography. In essence, the radiographer is the first healthcare professional to review all diagnostic images obtained by focusing on the patient.

Radiographers have a unique opportunity to exchange professional opinions with a treating physician in a timely manner, which significantly influences the treatment of patients. According to Elkhadiret al. (2019), the case of Saudi Arabia clearly reflects that radiographers are not allowed or given the same opportunities as those who work in UK.

Radiographers in Saudi Arabia are not allowed to provide clinical reporting and interpretation hence, a number of radiographs are often unreported or un-interpreted which raises concerns over the quality of healthcare. Saudi Arabia utilizes authorized physicians for interpretation of radiographs and this indicates that radiographers are not provided opportunities for clinical reporting and interpretation. This is due to the low level of confidence on radiographer’s skills, knowledge and expertise.

Health practitioners in Saudi Arabia are provided radiographs for interpretation and this counts as their routine practice. Currently, Saudi Arabia lacks significantly in terms of radiographer’s role and their importance and this is having a negative impact on how the country’s healthcare system functions.  Milner et al. (2016) mention that, despite the surprising acceleration in imaging technology over the past 10 years, actually sharing the responsibility of radiologists and radiographers are the biggest impact. The production of final reports by Radiographers has been part of the imaging service in the UK for over 20 years. However, over a decade ago, the expansion in advanced clinical radiological practice and consultant radiographic practice has been remarkable. Cuplan et a. (2019) states that, National statistics in England indicate that 32 percent of all diagnostic images are now reported by radiologists or sonographers. It has been driven by close collaboration between radiology teams at the local level and supported by the national health policy.

At the professional body level, the 2012 guidance published by the Royal College of Radiologists and the College of Radiographers (“Clinical Imaging Team”) was innovative. It was indicated that, in fact, the two professions could work together to better meet the growing demand for high-quality reports. Snaith et al. (2018) mentions that, radiographer reports are a solid solution only if patient care is ultimately improved and patient safety is scrupulously maintained. The precision, that is, the sensitivity and specificity, of a report by a radiographer must be equivalent to that of a consulting radiologist.

Ongoing clinical audits and a growing body of academic and clinical research indicate that this quality and accuracy criterion is met. Reference patients and physicians expect the highest quality report from their exams. Rowe et al. (2019) stated that, UK is confident that radiologists and radiographers working in teams to provide reporting services meet your expectations .radiologists and radiologists have become justifiably eager for the commercialization of our specialty, as increased capabilities and availability of images have accompanied decreased clinical diagnostic capacity among the reference community. This in turn has led to over-reliance on imaging services. Even terminology has evolved with this regression, as the term "image reference" became "request" and, ultimately, "order." Hardy and Harvey (2019) mentions that, artificial intelligence (machine learning and deep learning) technologies will enable offering enhancements such as referral support, workload management, prioritization, detection, and front-line reporting.

This will offer the opportunity to reverse the process of co-modification. With the support of these advancements, radiologists and radiologists will be able to retrieve their clinical credentials as imaging professionals, and then make the most appropriate referral in consultation with their patients and clinical colleagues. O'Mahony (2018) illustrated that, unprecedented opportunities for imaging professionals to interact directly with patients should lead to new roles in clinical leadership of patient health care pathways that facilitate efficient, rapid and person-centered care. Currently, the role of senior practitioners in radiographic reporting is limited to the United Kingdom (UK) (Paterson et al., 2004).

The changing nature of global health care has enabled many countries, including Canada (Canadian Association of Medical Radiation Technologists, 2014), Australia, Norway (Hofmann &Vikestad, 2013) and Denmark (Buskov et al., (2013) to develop more advanced models of radiology practice, including deterministic clinical reporting.

However, Saudi Arabia currently lacks far behind in this regard as radiographers aren’t provided an opportunity to showcase their skills, expertise and knowledge as they are only allowed to be part of performing radiography and aren’t provided an opportunity to analyse or perform assessment which can be handed over to the doctor. In summary, the practice of patients returning to their doctor, surgeon, or general practitioner for radiological results could become a thing of the past.

Rapid progression along the most appropriate path of care, facilitated by expert advice and support from the imaging team, will benefit everyone. The objective of this project is to identify how UK’s radiographer’s role can help in improving the overall healthcare structure within Saudi Arabia. In this regard, this project focuses on advanced practice and clinical reporting of radiographers and how the UK’s approach can help in improving the healthcare in Saudi Arabia. This will be accomplished by first identifying internal and external change drivers using SWOT and PESTLE analysis technique. Furthermore, leadership style will be evaluated for effective change management and lastly, Lewin’s change management model will be explained with its justification for application. The last section will provide a reflection regarding understanding concerning the entire assignment.

Discussion

Internal and External Change

In terms of internal and external change, it is important to analyse that the proposed change will be heavily impacted by the external environment of the country (Hagos&2010).Saudi Arabia’s political factors illustrate stability, however, these factors are not directly associated with the change under discussion hence, the impact of political factors will be minimal to none. In addition, economic factors will have an impact upon radiographer’s role in clinical reporting as it will provide a positive impact on healthcare industry and will benefit the country’s economic position. Hence, this factor can positively influence the change. In terms of social factors, it can be identified that, individuals are interested in progressing and patients would like to receive quality healthcare facilities which are similar to European standards. Hence, it can be identified that UK’s healthcare is among the best in the world and Saudi Arabian social factors would encourage a change which replicates UK’s model of radiographer’s inclusion in reporting practices.

Technological factors will not have a major impact on this change whereas; legal factors will definitely have a huge impact as Saudi Arabia’s legal environment will have to accept the incorporation of radiographers and their changing role. Environmental factors will not be having any impact on the change management process under discussion (Hammad, 2015). In terms of internal change, it is important to conduct SWOT analysis to find out about the strengths, weaknesses, opportunities and threats associated (Williams & Sir, 2017).

In terms of strengths, it can be identified that, there are a number of positives associated with changing Saudi Arabia’s current role for radiographers. According to Milner et al. (2016), these X-ray specialists can improve their reporting capabilities and reduce the number of workstations where radiographers and radiologists work with a multidisciplinary reporting team. Study published by Woznitza et al. (2014) illustrated that, although the time for overall radiographic report preparation increased during the study, there was a significant reduction in waiting and reporting time for CT and MR patients, but the incidence increased by 22.8% and 43.7%, respectively. This evidence demonstrates the value of radiographers 'report on radiologists' release for CT and MRI and the need to monitor for possible (unexpected) consequences of service changes that exceed the expected change.

The research illustrates how radiographers can contribute positively towards decreasing patient’s waiting time and how it can positively impact the healthcare system within the country. Radiographer’s reports appear to have a positive impact on radiographer’s personal and professional life. Furthermore, it reflects positively on the motivation and confidence level of multidisciplinary medical team (Rimes et al., 2015).

By reviewing and reporting their findings, radiographers involved in image interpretation and reporting participate in clinical decision-making to provide treatment for patients. In these roles, the radiographer defined high clinical team job satisfaction (84%), pride, motivation, trust, and value (Kilburn et al., 2018). In the current NHS environment, the increased morale associated with better interpretation and reporting of the radiography image may have a positive impact on the recruitment, retention and recovery of radiologists and radiographers among cancer patients. Lack of such opportunities in Saudi Arabia illustrates that the level of job satisfaction and motivation must be low and this would negatively impact upon the country’s healthcare system and on the performance of radiographers working within Saudi Arabian healthcare system. Concerning the opportunities, it is important to identify that, all existing UK colleges have quality assurance, both internally and externally, including the Higher Education Quality Assurance Agency (QAA) and the Scientific Committee.

The use of high-quality external study programs provided by colleges will help raise awareness among NHS Trust employers of the practical skills of senior radiographers. National implementation standards and radiologist best practice recommendations, screening tools, and appointment meetings provide radiologists with quality assurance of clinical practice reporting (Lockwood, 2017). Radiographer reporting and assessment can also be integrated into practice by Saudi Arabian colleges and universities which can adapt a similar style of teaching and assessment for radiography students. Once the students are able to successfully pass the assessment process, they can be integrated into practice where they can serve better in terms of their role and contribute towards improving the quality of healthcare and service delivery for the patients.

Implementation of Proposed Plan of Change

With more reason, change management involves learning to produce a process of permanent innovation in the action of organizations (Allen, 2016). With this philosophical basis of support, management paradigms must make health professionals co-responsible in order to generate a consensus on the commitment of the human factor to the processes of continuous improvement of health systems. In order for effective change management, it is necessary to work upon the identified areas and focus on change management model. In addition, leadership style plays a big role as well. Hospital or healthcare institute staff asks a number of questions about the change and its need. It is important for the hospital leader to be well prepared to answer their questions (Sutherland, 2013).

A leader must be innovative, inspiring, charismatic and can help in improving performance of the team as well as the entire organization. Concerning the leadership style, it can be identified that transformational leadership style is highly effective in change management as the change under discussion is a complete shift from the traditional practice used within Saudi Arabia. An effective leader must allow participation from employees and improves their level of satisfaction and association with change management process (Cummings et al., 2010).

Concerning the change management process under discussion, stakeholders identified includes radiographers and other staff within the healthcare institute as well as educational institutes responsible for radiographer’s training and education. It is important to analyze and discuss different leadership styles and identify the style’s applicability by discussing its strengths. Authoritarian leadership is useful in crisis and bewilderment situations (Giltinane, 2013). If it is prolonged in time, it causes demotivation and a flight of talent. In democratic or participatory leadership, before making a decision, the leader asks for the opinion of all those involved, listens to it and takes it into account. Let employees decide more about their roles and have enough decision-making powers. This system makes it easy to create flexible and responsible teams, but it is poorly suited to the character of professionals who expect the boss to set the tone. Transactional Leadership responds to the classical conception, before the idea of emotional intelligence was disclosed. The motivational elements are reward and punishment: it is an exchange of material benefits (Cummings et al., 2018) whereas transformational leadership focuses on people. The leader believes that the transformation of the company is only possible through people. It encourages the creative participation of workers, trusts them, cares about them, motivates and inspires them. In this approach, leader is a risk taker (Schreuder et al., 2011).

Lewin Model

Concerning the change management process, it is important to identify model of change which needs to be implemented and work upon the change management process by successfully integrating and incorporating change management model (Antwi & Kale, 2014).In addition, it can be identified that, change management model of Lewin can be used as it is easy to integrate and apply in a change management scenario. In this model, it is established that to achieve effective changes, individuals face two major obstacles: first, they are not willing (or cannot) modify long-established behaviours, and second, that change usually lasts little time. The model is applied following a series of 3 steps, which must be fully complied with to achieve effective changes, these steps or phases are the following: Defrost, Change or Movement and Refreezing.

The author of this model (Kurt Lewin) promulgated that changes passed from one state to another with respect to their different behaviours, thus developing new values, habits and behaviours (Dickson et al., 2012). The phases proposed in the model can only be achieved if the problem is determined, the current situation is identified and the goal to be achieved is established. In addition, the negative and positive forces that affect change in the organization are identified (Payne, 2013). According to the force field analysis, it can be identified that the factors that can positively influence change management are more than the negative forces. This is because of the factors associated with the change and the positive impact it can bring on Saudi Arabian healthcare industry.

The Unfreeze phase

This first step is essential when preparing for a change. Of course, it is important to talk about a planned change here and not a change that occurs following an unexpected event. The objective is to make teams aware that a transformation to state B is inevitable and to convince them of this change. As a result, resistance appears from this first stage. Leaving state may seem very difficult or impossible for some people (Huryk, 2010). In this regard, effective leadership style such as transformational leadership can be beneficial. Furthermore, involved stakeholders and healthcare management can be provided evidence based research findings which will allow analysing importance of adopting a similar style of radiographer’s practice in UK.

Radiographers are also concerned that contradictions in the training of experts and the skills of consultants (case competition) could undermine the expansion of radiographers' reports. The burden on the latter can be reduced through multidisciplinary shared learning methods. The increased imaging needs and the increasing number of cases reported by the official radiology department suggest that radiographers and radiology students should have many cases. Many radiologist and radiographers are supporting the need for training as it is an integral element for improving the quality of assessment and reporting (Snaith et al., 2018). In this regard, leadership and management style can help in overcoming identified barriers and implement change positively.

Change phase

The second phase is the actual change. At this stage, workforce members are ready for novelty thanks to the feeling of importance created by the previous step. However, resistance can sabotage the project. It is therefore very important to pay attention to it, in order to accompany them with flexibility, benevolence and indulgence (Ledger et al., 2013).

In the second phase, it is important to carry out the change. The change proposed needs to incorporate training style similar to that of UK so that radiographers are well equipped to be involved in reporting. College of Radiographers and Health and Care Professions Council ordered the image interpretation training to be part of the pre-registration (Paterson et al., 2004). At the national level, national resources have been developed that include X-ray interpretations of the bones to support licenses and practitioners in providing X-ray for adults and children (England, N. H. S. & Care Quality Commission, 2014). A recent report highlights the example of Australian educated radiographers, senior practitioners / radiographers in the UK, with appropriate training and support (Smith et al., 2009).

This reflects the development potential of radiography reports in Australia. Similar training is required in Saudi Arabia as it will allow developing the level of confidence and will help in improving the overall assessment quality of radiographers and will allow radiographers to be part of clinical assessment. Since 1990s, UK’s education system provides a number of opportunities to medical professionals and radiographers to learn about image interpretation and its reporting. Post graduate courses provide an opportunity to successfully develop advanced skills which are required for successful recognition of patterns and also for pre-clinical evaluation.

These procedures prepare X-rays for the interpretation of accurate images and produce their own interpretable, executable reports. NHS UK's national strategy for developing the role of a full-time medical professional emphasizes the growing value of "advanced practice," especially case studies, which include X-rays with formal image interpretation and reporting (Culpan et al., 2019). Such training methods and courses can be a huge help in successfully establishing similar practice and learning standards within Saudi Arabia where, radiographers can be offered training and teaching by their local healthcare universities and education institutes and upon passing those tests successfully, they can be allowed to work along with doctors for report assessment procedures.

Refreeze Phase

Finally, once the changes implemented, this phase can stabilize and consolidate the new situation. State B needs stabilization time: new rules and methods, new organization, etc. Ignoring or neglecting this phase can cause the project to fail with a return to the old state A (Allen, 2016). In this regard, it means that once the change is implemented it is important to take into account how the change is currently practiced and whether there are any modifications required. Furthermore, it is important for the change management process to constantly monitor for the changed practice and its resultant outcomes. In this regard, radiographers training programs are required to be accessed and their performance within clinical reporting needs to be analysed. This can be done by getting reviews or feedbacks from other staff members within the hospital and also from patients.

The radiographer’s program evaluation strategy incorporates a number of approaches, including written case studies, structured reviews including case reviews and reporting, and portfolio-based clinical case studies throughout the study period within UK (Snaith et al., 2016). Piper et al. (2014) indicates that it illustrates how UK-accredited graduate students use OSE total assessment to ensure that students are able to recognize normal chest X-rays, including anatomical differences, and report abnormal views, including random findings (Woznitza et al., 2014). Similar changes if made in Saudi Arabia context can help the country’s healthcare system to improve.

Over time, the application of radiographers in the UK has evolved to include dual layer reports. This means that the radiologist prepares a "first report" before submitting the second report.  The role of state-of-the-art reporting radiography in the UK now involves giving second-hand opinions and controls to inexperienced medical and non-medical colleagues and answering questions from doctors (Robinson, 1996). In certain UK’s hospitals, the radiographer is responsible for making independent clinical decisions, such as removal of displaced naso-gastric tubes, more imaging or referral, and advice on further treatment or abandonment of patients (Lancaster& Hardy, 2012). This indicates that radiographers in certain UK’s healthcare institutes are an integral part of medical intervention.

Given the role of radiographers in service delivery, the ability to cross-report and participate in clinical decisions and attend multidisciplinary meetings is also important (Hardy et al., 2013). In addition, the above mentioned reporting responsibility can also be established within Saudi Arabia to successfully improve the standard of radiographers and give them more importance within the industry. Once the changes are made, they will be constantly monitored to analyse the impact and sustainability of practice.

Reflection

The Borton’s reflective model have been used herein, where my experience will be defined in three categories, “What”, “So What” and “Now What” (Chalkright& Nurse, 2017).

Description (What)

I think that the Lewin Model will allow successful change management process as I believe that the model has several advantages. Kurt Lewin's model makes it possible to identify the problems that we must face, when we want to make a change and the main moments that we must go through. Furthermore, this model establishes a new rebirth of an organization, renewing the values, missions, habits and behaviors of the individuals that make up this organization, which lead to a level of balance, entrepreneurship and new organizational cultures. From the study of Woznitza et al. (2014), I learnt that, multidisciplinary teamwork is an essential part of providing modern clinical imaging services.

The overall scope (individual or community) of a radiologist's report is narrower than that of a radiologist, and consensus and decisions have been reached at institutional and individual levels. A combination of radiation technician / radiation technician reporting skills can maximize their respective expertise and two types of knowledge to modify nursing services and show patients clinical benefits and provide service providers with logistical and economic benefits. The lack of adequate training facilities and the inability to complete images can also hinder the expansion of radiographic reports (Snaith& Hardy, 2008). Restructuring and supporting the workforce of support staff with the skills and motivation to work as professionals can alleviate the problem of performing picture-taking roles. It is often easier for support staff procurement channels to recruit radiography technicians of their choice in radiography. International practitioners' recruitment positions are also a suitable source of supply with the help of radiographers.

Analysis (So What)

By analysing Neep et al. (2014), I found out that a large number of valuable findings have been produced, and with the evidence provided by the UK, it probably suggests that Australian radiographs can make a positive contribution to the diagnosis of trauma. With proper education and training, the accuracy of radiographer image interpretation and confidence and deterministic reporting in participation in clinical practice will increase. This project illustrates that training is required to improve the quality of radiographers and to increase their level of confidence. Pre-registered radiography courses in the UK have a long history, including pattern identification, discrepancies and / or preliminary clinical evaluation (notes), and are used by the clinical department to determine the first job of capacity at this application level. This can also be implemented in Saudi Arabia to successfully improve the level of radiographers and ultimately reflect positively on their performance within healthcare systems within the country (Culpan et al., 2019).

Action Plan (Now What)

I think that Lewin’s model of change needs to be implemented in Saudi Arabia and the country needs to incorporate UK’s footsteps for radiographer’s induction and participation into clinical reporting. UK’s progress in this regard illustrates the importance of radiographers in clinical reporting and assessment and illustrates how other countries can incorporate similar structure and get the best out of radiography professionals (Brealey et al., 2005). Cancer Workforce Plan recognizes that increasing radiography reporting can relieve radiologists' stress and increase early diagnosis. Expanding the circle of radiologists should ensure that NHS services use radiologists more effectively, use their expertise in difficult situations, and enable them to participate in a multidisciplinary team case discussion (MDT).

Increased use of reporting radiographs may also reduce the number of imaging studies without formal clinical reports (Piper et al., 2014). Saudi Arabia can benefit from this approach and utilize radiographers in a similar capacity. Currently, Saudi Arabian system doesn’t provide radiographers the same level of trust and authority as UK. Hence, the above mentioned strategies need to be incorporated into Saudi Arabian system to successfully implement the change. I plan on implementing this change by taking into account the information that I have learnt during this report.

Professional Learning and SMART Goals for Future Development

In terms of professional learning I believe that the project will allow me to learn how to successfully apply change management techniques and will provide me with an opportunity to grow as a professional in healthcare. I believe that making the above mentioned changes will help me in establishing a better healthcare system in Saudi Arabia and improve healthcare efficiency. In terms of professional learning, management, time management, communication and planning skills are learnt. In terms of future development, I have set some goals for myself, which includes the following:

• Participate in radiographer training program similar to UK standards in Saudi Arabia by 2021.
• Successfully implementing change management project in Saudi Arabia by the year 2022

Conclusion

This research clearly demonstrates effectiveness and importance of radiographers and how their presence in clinical reporting and interpretation is creating a difference in UK’s healthcare system. Furthermore, it also illustrates the need for similar practice to be adopted around the globe. Saudi Arabian healthcare system can definitely learn from radiographer’s role advancement in UK considering the benefits it serves for the patients, healthcare system and the country. The research clearly illustrates the need for Saudi Arabia to allow clinical reporting opportunities for radiographers within the country. In this regard, training methods from UK can be replicated and applied within the country.

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