Julie Nightingale

Clinical practice at an advanced level: an introduction

The way that healthcare is developing in Great Britain is unique because of the way the advanced clinical practice of the so-called ‘non-medical’ professions (e.g. nursing, radiography, physiotherapy etc.) has advanced at a phenomenal rate. At a local (hospital) level, radiographers are being encouraged to take on new roles; although in some sub-specialties of radiography, the rate of change has been more sedate. For example Holmes and Hogg [1] and also Huggett and McClellan [2] nicely illustrate this on the subject of image interpretation by non-medical staff or personnel in nuclear medicine. Nonetheless, it is well recognised that local variations exist, but the overall ambition (both politically and professionally) is for a greater engagement in advanced practice to improve patient care and management. One must accept that, for a variety of reasons, there will always be resistance to change; and perhaps in a future article, this topic could be the subject of a debate. On examination of the literature, onewill findmany articles and comments in journals, professional magazines and conference abstracts books on the various aspects of advanced practice. However, there is a lack of systematic documentary evidence that takes into account the current and future states of practice. Many of the publications and presentations on the advanced practice are often specific in nature—addressing a focused aspect, and often such valuable work adds to the general body of knowledge. In this series of articles, an attempt will be made to summarise and document generic (e.g. legal issues) and specific (e.g. the role of the gastro-intestinal (GI) specialist) themes on the advanced clinical practice. There is a dual purpose to this exercise: to formally record summary information for historical record; and to address more contemporary issues—such as the sharing of experience and knowledge in a bid to help meet common educational needs. Although most articles on the advanced practice are specific in nature, it is important to note that some review and debate articles do exist. In particular, we draw the attention to Hay’s [3] article. This article gives an excellent overview of skill mix and advanced practice in 1998. Then there is the more specific work of Price [4], a seminal piece, documenting how reporting for radiographers evolved throughout the ages. The work of Paterson [5] helps us to understand the need for publications addressing not only the current situation, but also the future development of the profession. This article commences with a review of the current position of advanced radiographic practice, which is followed by an examination of some catalysts that (Received 6 January 2003; accepted 17 January 2003)

The gastrointestinal advanced practitioner: an emerging role for the modern radiology service

Radiographer role development in the field of gastrointestinal (GI) imaging is a flourishing sub-speciality, with radiographers in many National Health Service (NHS) Trust hospitals performing a range of examinations that were formerly in the province of the radiologist. The emergence of this advanced role has been rapid and sustained, with practitioners continually pushing the traditional practice boundaries within this speciality. The purpose of this article is threefold. Firstly, it is important to document the historical context and justification for this change in practice; secondly, to provide an overview of the scope of practice currently seen across the UK; and finally, to consider the potential opportunities afforded to GI practitioners and their patients in the future.

'I thought it was just an x-ray': a qualitative investigation of patient experiences in cardiac SPECT-CT imaging.

BackgroundPatients attending for complex imaging examinations may experience anxiety and discomfort with associated poor satisfaction and reduced compliance. This may lead to poor quality imaging, repeat scans and nonattendance. Analysing and understanding patient experience to improve the quality of care is of paramount importance within the National Health Service; yet, little published evidence of patient experience research exists within nuclear medicine. This qualitative study aimed to explore the experience of patients referred for cardiac single-photon emission computed tomography–computed tomography (SPECT-CT) in two different clinical environments. Methods and resultsTwenty-two patients (13 women, nine men; mean age 63.9 years) were interviewed before and after the procedure to determine their prior knowledge, concerns, expectations and experiences. Thematic analysis demonstrated seven recurring themes: justification, validity of patient information, fear (of their condition, of harm and of the procedure), compliance, role of significant others, mitigation of anxiety, and coping strategies. In most cases an expectation–reality divide was apparent, with the actual experiences of the procedure being in some cases a pleasant surprise, or in other cases a shock. ConclusionCardiac SPECT-CT patients are often poorly informed and present with a range of anxieties that may ultimately affect examination quality. The imaging team requires an awareness of potential expectation–reality divides, even when there are no overt signs of worry and distress. Written patient information is undoubtedly helpful, but there is no substitute for ongoing and repeated explanations and reassurance by staff. These findings are likely to have implications for other complex nuclear medicine procedures, including noncardiac SPECT-CT examinations and emerging PET-CT applications.

An evaluation of radiographer performed and interpreted barium swallows and meals.

AIM To determine whether radiographers are able to perform and interpret barium swallows and meals (BSM) to an acceptable standard. MATERIALS AND METHODS A retrospective audit was performed of all radiographer-managed BSMs over a 4-year period in an acute hospital. Descriptive statistics were used to analyse patient demographics, radiation doses, referral sources, and imaging findings. Radiographer reports were compared with radiologist reports assumed to be the reference standard, and correlated with patient outcomes via electronic record searches and case note scrutiny. Reporting accuracy, sensitivity, and specificity were calculated. RESULTS Three radiographers performed a total of 962 BSMs in the 4-year audit period, including a varied and complex case-mix. Only 13 (0.01%) cases were abandoned due to technical reasons, with all other examinations of diagnostic quality. Although radiation dose levels were initially variable, following the installation of modern fluoroscopy equipment they remained comfortably within the national and regional diagnostic reference levels. Consultant radiologists verified the majority of the radiographer reports, with the most experienced radiographer independently reporting 230 cases (24%). Follow-up of patient outcome was possible in 935 cases. The overall radiographer accuracy based on the 935 cases was 98.9%, sensitivity 98%, and specificity 98.9%. CONCLUSIONS Appropriately trained radiographers are able to perform and interpret BSM examinations to a very high standard.

The Role of 18F-Sodium Fluoride PET/CT Bone Scans in the Diagnosis of Metastatic Bone Disease from Breast and Prostate Cancer

We describe the role of 18F-sodium fluoride (18F-NaF) PET/CT bone scanning in the staging of breast and prostate cancer. 18F-NaF PET was initially utilized as a bone scanning agent in the 1960s and early 1970s, however, its use was restricted by the then-available γ-cameras. The advent of hybrid PET/CT cameras in the late 1990s has shown a resurgence of interest in its use and role. After a brief introduction, this paper describes the radiopharmaceutical properties, dosimetry, pharmacokinetics, and mechanism of uptake of 18F-NaF. The performance of 18F-NaF PET/CT is then compared with that of conventional bone scintigraphy using current evidence from the literature. Strengths and weaknesses of 18F-NaF PET/CT imaging are highlighted. Clinical examples of improved accuracy of diagnosis and impact on patient management are illustrated. Limitations of 18F-NaF PET/CT imaging are outlined.

A qualitative analysis of staff-client interactions within a breast cancer assessment clinic

OBJECTIVES Breast screening clients recalled to an assessment clinic experience high levels of anxiety. The culture of the assessment clinic may impact upon client experience, which may influence their future re-engagement in screening. This study aimed to explore the culture of staff-client interactions within a breast cancer assessment clinic. MATERIALS AND METHODS Following an ethnographic approach, twenty-three client journeys were observed, followed by semi-structured interviews with the clients. The observation and interview data were analysed to produce research themes, which were then explored within two focus groups to add a practitioner perspective. RESULTS Multiple staff-client interaction events were observed over a period of several weeks. Client interview feedback was overwhelmingly positive. Three recurrent and sequential themes emerged: breaking down barriers, preparing the ground and sign-posting. These themes outline the changing focus of staff-client interactions during the clients clinic journey, encompassing how anxieties were expressed by clients, and responded to by practitioners. CONCLUSION This study was the first to explore in depth the staff-client interaction culture within a breast assessment clinic using an ethnographic approach. A new perspective on professional values and behaviours has been demonstrated via a model of staff-client interaction. The model documents the process of guiding the client from initial confusion and distress to an enhanced clarity of understanding. A recommendation most likely to have a positive impact on the client experience is the introduction of a client navigator role to guide the clients through what is often a lengthy, stressful and confusing process.

The academic radiography workforce: Age profile, succession planning and academic development.

INTRODUCTION Academia is one area of practice in which radiographers can specialise; they compile approximately 2% of the total radiography profession in the UK, but are highly influential and essential for the education and development of the workforce in addition to undertaking research. However, the academic environment is very different to clinical practice and a period of transition is required. METHODS Data were collated to explore the age and retirement profile of the academic radiography workforce in the UK; to understand the research time allocated to this workforce; the time required to develop a clinical radiographer into an academic and the mentorship and succession planning provisions nationally. An online UK wide survey was conducted and sent to all 24 Universities delivering radiography education within the UK. RESULTS Eighteen out of 24 Universities in the UK responded to the survey. Approximately 30% of radiography academics are due to retire over the next 10 years, with over 25% of radiographers who currently hold a doctorate qualification included within this figure. Those entering academia have notably lower qualifications as a group than those who are due to retire. Developing clinical radiographers into academics was thought to take 1-3 years on average, or longer if they are required to undertake research. CONCLUSION There is vulnerability in the academic radiography workforce. Higher education institutions need to invest in developing the academic workforce to maintain research and educational expertise, which is underpinned by masters and doctorate level qualifications.

Review of Radiography in 2016 (Volume 22)

2016 was an important year for the Radiography journal for many reasons. We commenced the year by welcoming three new Associate Editors to our editorial team as well as several new Editorial Board members and reviewers. In my editorial in Issue 11 we announced that Radiography had been recognised as the official journal of the European Federation of Radiographer Societies (EFRS), an innovative affiliationwhich is already producing tangible benefits. The journal also moved to five issues in 2016, building on our quarterly regular issues with a Special Issue on Patient Safety guest edited by Consultant Radiographer and Editorial Board member Dr Beverley Snaith. Both manuscript submission numbers and rejection rates for 2016 remained in line with the previous year, and we continued our increasing international reach withmore than 50% of published papers having a non-UK corresponding author. The most common countries of origin outside the UK last year were Australia, Ireland, Nigeria and Malta, though many papers have a multi-national authorship, reflecting strengthening international collaborations. Analysis of over 100 published papers within Volume 22 (2016) demonstrates that research is being undertaken across many of the branches of our profession. Fig. 1 indicates that our 2016 published articles most commonly focussed upon radiography education, general radiography, therapeutic radiography, CT and mammography, though many articles cut across one or more topics (e.g. education for advanced practice). The ‘other’ category is extremely diverse and includes arguably some of the most current topical

The Clinical Dilemma of Incidental Findings on the Low-Resolution CT Images from SPECT/CT MPI Studies

Incidental findings are common in medical imaging. There is a particularly high prevalence of incidental findings within the thorax, the most frequent being pulmonary nodules. Although pulmonary nodules have the potential to be malignant, most are benign, resulting in a high number of false-positive findings. Low-resolution CT images produced for attenuation correction of SPECT images are essentially a by-product of the imaging process. The high number of false-positive incidental findings detected on these attenuation-correction images causes a reporting dilemma. Early detection of cancer can be beneficial, but false-positive findings and overdiagnosis can be detrimental to the patient. Attenuation-correction CT images are not of diagnostic quality, and further diagnostic tests are usually necessary for a definitive diagnosis to be reached. Given the high number of false-positive findings, the psychologic effect on the patient should be considered. This review recommends caution when the findings on attenuation-correction CT images are routinely reported.

Client-practitioner interactions within breast care services

United Kingdom (UK) breast care services are delivered within one of two models. Clients presenting with breast symptoms (symptomatic) are assessed within a ‘one stop’ (all done at one hospital attendance) out-patient setting whilst asymptomatic clients currently aged 50–70 (screening) are invited for 3 yearly breast screening by the National Health Service Breast Screening Programme (NHSBSP). A proportion of the latter are recalled for further assessment should a mammographic abnormality be suspected (assessment clients). Many other health care systems around the world also offer these three breast care approaches (symptomatic, screening and assessment services), though the timeframe between screening invitations and the age range of clients varies within the screening services (see Chap. 8).