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The Delivery of Image Interpretation Education for Radiographers

Michael J Neep BSc MSc

submitted in fulfilment of the requirements for the degree of

Doctor of Philosophy

Institute of Health and Biomedical Innovation (IHBI) and

School of Public Health and Social Work

Faculty of Health

Queensland University of Technology

2018

The delivery of image interpretation education for radiographers ii

Abstract

Background Access to appropriate and timely medical imaging is important for the provision of

effective emergency healthcare in hospital settings. Findings from medical imaging

investigations underpin many diagnostic and treatment decisions, particularly for

people who have presented to hospital following a trauma event. The radiographic

image series remains the primary imaging modality requested for patients who may

have sustained trauma.

In emergency settings, the definitive radiology report may not be available within a

clinically relevant timeframe. This means, in many cases, that treatment decisions are

likely to have been implemented by the referring clinical team before the radiologist’s

report is available. Unfortunately, delay between radiographic image capture and the

availability of the radiologist’s report can contribute to missed, incomplete or incorrect

diagnoses.

One approach to mitigate risk and better support junior or inexperienced members of

the referring clinical team is the recording of a brief comment by the radiographer at

the time of image capture to highlight any abnormalities they may have detected. This

mechanism is known as radiographer commenting and more recently as Preliminary

Image Evaluation (PIE). Access to appropriate image interpretation training, suitable

for practicing radiographers, has been reported as a leading barrier to the

implementation of PIE. Two potential formats for delivering accessible image

interpretation education for practicing clinical radiographers may include an intensive

delivery (for example, 2-day training may be suitable for regional radiographers visiting

metropolitan areas) and non-intensive delivery (for example, short regular tutorials

over a 12-week period). To date there has been no study comparing the effectiveness

of different education delivery formats of an image interpretation education program

for radiographers.

Aims

The delivery of image interpretation education for radiographers iii

This thesis addresses six aims:

1. Explore Australian radiographers’ perceptions of potential benefits, barriers and

enablers of introducing a PIE system.

2. Describe Australian radiographers’ current image interpretation self-efficacy.

3. Investigate which (if any) format of image interpretation education

radiographers currently prefer.

4. Develop and validate a quantitative outcome measure that evaluates

radiographer image interpretation and commenting skills suitable for use in a

randomised trial.

5. Evaluate the comparative effectiveness of intensive (2-day) versus non-

intensive (90 minute x 9) formats of delivering an education program designed

to improve radiographers’ abilities to detect and comment on radiographic

abnormalities in trauma settings.

6. Investigate Australian radiographers’ experiences in completing the intensive

or non-intensive education programs and their perceived readiness for

participation in a PIE system.

As a result of this research, five manuscripts have been published in peer-reviewed

journals.

Methods To achieve the research objectives, this program of research was divided into three

consecutive studies. Before commencing the first study, a review of the pertinent

literature was undertaken to identify the current gaps in the evidence (presented in

Chapter 2). This also provided the ground work for the design of the research and the

methods employed.

The first study involved administering a cross-sectional survey to a volunteer sample

of 73 radiographers from south east Queensland (presented in Chapters 4 and 5). The

survey was a custom designed 18-item questionnaire that included a mix of Likert

scale responses and open-ended questions. It explored five domains covering self-

efficacy, benefits, barriers, enablers of implementing a PIE system and educational

preferences.

The delivery of image interpretation education for radiographers iv

The second study involved the development and validation of a quantitative outcome

measure suitable for evaluating radiographers’ ability to interpret and comment on

trauma radiographs (presented in Chapter 6). This study implemented a two-stage

process. Stage 1 involved the development of the Image Interpretation Test (IIT)

content, as well as a reference standard and item scoring. Stage 2 involved

prospective validation of the test using a cohort of radiographers.

The penultimate study of this thesis was the final study (presented in Chapter 7). It

was a multi-centre, stratified (by years of experience) two group, parallel arm, single

blind (assessor blinded), randomised controlled trial that examined two formats of

education delivery. The two formats of education delivery included an intense delivery

format (13.5 hours over 2 consecutive days) versus non-intensive training sessions of

shorter duration (90 minute tutorials, once per week over a 9-week period). The

primary outcome measure was the IIT assessment score developed in Study 2.

Participants completed assessments before education, at 1 week post-intervention

completion and at 12 weeks post-intervention completion. A secondary outcome

measure was used to examine participants’ perceptions of their ability to interpret

radiographs. This involved the development and distribution of two questionnaires.

The first was completed at the baseline assessment prior to randomisation, while the

second was completed at the 12-week post-intervention assessment. The

questionnaires were designed to determine radiographers’ perceptions regarding their

confidence and accuracy in their ability to interpret radiographs before and after the

completion of the education intervention.

Results The main findings of Study 1 identified five overarching perceived benefits of PIE,

consisting of: ‘assisting multi-disciplinary teams’, ‘patient care’, ‘radiographer ability’,

‘professional benefits’ and ‘quality of imaging’. Additionally, commonly reported

perceived barriers consisted of: ‘difficulty accessing image interpretation education’,

‘lack of time’, and ‘low confidence in interpreting radiographs’. The questionnaire also

identified that radiographers reported higher confidence and perceived accuracy to

detect traumatic abnormalities than to describe abnormalities. Radiographers

frequently reported high desirability ratings for both the intensive and non-intensive

education delivery and few respondents reported low ratings (four or less out of ten)

The delivery of image interpretation education for radiographers v

for either the 90-minute tutorials (n=10, 14%) or intensive two-day format of delivery

(n=13, 18%). A Wilcoxon signed-rank test did not detect a significant difference in

desirability ratings between these two formats (p=0.11).

The IIT developed in Study 2 consisted of 60-items consistent with the proportion of

normal and abnormal cases and distribution of anatomical regions representing a

typical adult trauma case-mix. This study has provided foundational preliminary

evidence to support the reliability and validity of the IIT among radiographers.

Specifically, case scores were internally consistent (Cronbach’s alpha=0.90).

Favourable inter-rater reliability (kappa>0.70 for 58/60 cases, Intra-class Correlation

Coefficient (ICC)>0.99 for total score) and intra-rater reliability (kappa>0.90 for all

cases, ICC>0.99 for total score) were observed. There was a positive association

between radiographers’ confidence in image interpretation and IIT score

(coefficient=1.52, r-squared=0.60, p<0.001).

Study 3 recruited a total of 48 participants (24 participants were allocated to each trial

arm;; intensive education format and non-intensive education format). The findings of

this study identified that image interpretation performance was not significantly

different between groups at baseline. A mixed effect generalized linear model

indicated that participants who received the intensive education format improved their

image interpretation performance by a greater margin than the group that received

non-intensive education at the 1 week (p=0.002) and 12-week (p<0.001) follow-up

assessments. The linear mixed models of questionnaire findings indicated that both

groups improved at the 12-week follow-up assessment when compared to the

baseline across all self-perception questionnaire ratings (p value range p≤0.001).

Conclusions The findings from this program of research have practical implications for the

healthcare field. The findings have contributed to the existing literature by describing

the potential benefits, barriers and enablers to implementing a PIE system. This

research was the first to investigate the effectiveness of two image interpretation

education delivery formats for radiographers. It also developed the first validated

quantitative outcome measure based on a typical adult emergency department case-

The delivery of image interpretation education for radiographers vi

mix, that is suitable to assess radiographers’ ability to detect and describe

abnormalities visualised on trauma radiographs. The outcome of the randomised controlled trial suggested that the intensive format of

delivery was more effective at improving radiographers’ ability to interpret trauma

radiographs, although participants demonstrated improvement in image interpretation

ability in both trial arms. This study’s results may be of great relevance to health care

providers, emergency department and medical imaging department directors seeking

to improve radiographers’ image interpretation ability and may contribute to improving

the quality of patient management in the emergency department through informing

education delivery for image interpretation training.

Further research that incorporates regional and rural sites is warranted to assess the

potential difference that might occur with radiographers working in these different

locations. To this end, the use of tele-education platform to reduce geographical

barriers associated with accessing face-to-face education may also be worthy of

investigation. Collectively, this thesis provides insight on how image interpretation

education can be effectively delivered to radiographers in hospital settings.

The delivery of image interpretation education for radiographers vii

List of Publications and Presentations

Peer reviewed journal articles in order of presentation within this thesis.

1. Neep MJ, Steffens T, Owen R, McPhail SM. Radiographer commenting of

trauma radiographs: a survey of the benefits, barriers and enablers to

participation in an Australian healthcare setting. Journal of Medical Imaging and

Radiation Oncology. 2014 Aug 1;;58(4):431-8.

2. Neep MJ, Steffens T, Owen R, McPhail SM. A survey of radiographers'

confidence and self-‐‑perceived accuracy in frontline image interpretation and

their continuing educational preferences. Journal of Medical Radiation

Sciences. 2014 Jun 1;;61(2):69-77.

3. Neep MJ, Steffens T, Riley V, Eastgate P, McPhail SM. Development of a valid

and reliable test to assess trauma radiograph interpretation performance.

Radiography. 2017 May 1;;23(2):153-8.

4. Neep MJ, Steffens T, Eastgate P, McPhail SM. Evaluating the effectiveness of

intensive versus non-‐‑intensive image interpretation education for

radiographers: a randomised control trial study protocol. Journal of Medical

Radiation Sciences. 2018 March 1;;65(1):63-70.

5. Neep MJ, Steffens T, Eastgate P, McPhail SM. Evaluating the effectiveness of

intensive versus non-intensive image interpretation education for

radiographers: a randomised controlled trial. Journal of Medical Radiation

Sciences 2018. In press.

The delivery of image interpretation education for radiographers viii

Conference Presentations

1. Development of an instrument to assess trauma radiograph interpretation

performance (United Kingdom Radiology Congress, Manchester, United

Kingdom, 2017)

Invited speaker

2. Development and validation of an image interpretation assessment instrument

(New Zealand Medical Imaging Radiation Therapy, Wellington, New Zealand,

2015)

Proffered paper

3. The delivery of image interpretation education for radiographers (Institute of

Health and Biomedical Innovation, Queensland University of Technology,

Kelvin Grove, Australia, 2014)

Invited speaker

4. Radiographer commenting: a survey of the benefits, barriers and enablers to

participation in an Australian healthcare setting (Combined Scientific Meeting,

Sydney, Australia, 2014)

Proffered paper

5. A survey of radiographers' confidence and self-‐‑perceived accuracy in frontline

image interpretation and their continuing educational preferences (Combined

Scientific Meeting, Sydney, Australia, 2014)

Proffered paper

6. Reducing image interpretation error in ED examinations by training

radiographers in frontline image interpretation and commenting

(Errors in Medical Imaging National Conference, Melbourne, Australia, 2012)

Invited speaker

The delivery of image interpretation education for radiographers ix

Keywords

Radiographers, image interpretation, education, cross sectional study, x-ray,

diagnostic errors, reliability, validity, emergency department, trauma, assessment,

intensive, non-intensive, randomised controlled trial, longitudinal study.

The delivery of image interpretation education for radiographers x

List of Figures

Figure 1.1 Structure of program of research

Figure 2.1 Thesis structure – Chapter 2



Figure 4.2 Histogram representing the proportion of cases (out of 100) that

radiographers participate in an abnormality detection system

Figure 4.3 Histogram representing radiographers’ level of agreement with six

statements about potential involvement in an image interpretation

service


Figure 5.2 Histogram representing radiographers’ confidence to participate in an

abnormality detection system

Figure 5.3 Histogram representing radiographers’ confidence to detect and

describe traumatic abnormalities

Figure 5.4 Histogram representing radiographers’ self-perceived accuracy of

detecting and describing traumatic abnormalities

Figure 5.5 Histogram representing radiographers’ desirability ratings for two

potential intensity formats of receiving image interpretation education


The delivery of image interpretation education for radiographers xi

Figure 6.2 Image Interpretation Test development flow diagram

Figure 6.3 Scatter plot with line of best fit representing the association between the

sum of Image Interpretation Test performance scores and the sum of

confidence ratings


Figure 7.2 Study design – randomised control trial

Figure 7.3 Study design – randomised control trial

Figure 7.4 Box plots of image interpretation test scores


Figure 8.2 Thesis structure – Research findings

The delivery of image interpretation education for radiographers xii

List of Tables Table 4.1 Radiographers’ perceived benefits of a radiographer commenting

system;; divided into categories within five themes

Table 4.2 Perceived barriers that radiographers believe inhibit the implementation

of a successful radiographer commenting system

Table 4.3 Perceived enablers that would assist the successful implementation of a

radiographer commenting system

Table 5.1 Perceived advantages and disadvantages of a non-intensive format of

delivery

Table 5.2 Perceived advantages and disadvantages of an intensive format of

delivery

Table 6.1 Scoring criteria for each case in the Image Interpretation Test

Table 7.1 Education intervention content outline

Table 7.2 Scoring criteria for each examination in the Image Interpretation Test

Table 7.3 Examination classifications for primary outcome measure

Table 7.4 Education intervention content outline

Table 7.5 Scoring criteria for each examination in the Image Interpretation Test

Table 7.6 Radiographers’ perceived confidence and accuracy regarding image

interpretation ability

The delivery of image interpretation education for radiographers xiii

List of Abbreviations

ASMIRT Australian Society of Medical Imaging and Radiation Therapy

CI Confidence Interval

DICOM Digital Imaging and Communications in Medicine

ED Emergency Department

F Female

ICC Intraclass Correlation Coefficient

IIT Image Interpretation Test

IQR Inter Quartile Range

M Male

MRPBA Medical Radiation Practice Board of Australia

PIE Preliminary Image Evaluation

SD Standard Deviation

RANZCR Royal Australian and New Zealand College of Radiologists

RCT Randomised Controlled Trial

UK United Kingdom

The delivery of image interpretation education for radiographers xiv

Statement of Original Authorship

The work contained in this thesis has not been previously submitted to meet

requirements for an award at this or any other higher education institution. To the best

of my knowledge and belief, the thesis contains no material previously published or

written by another person except where due reference is made.

I do declare the above statement is true and correct.

Michael Neep

03/07/2018

QUT Verified Signature

The delivery of image interpretation education for radiographers xv

Conflict of Interest Statement

Michael Neep is a Director of Egg Cup Training Pty Ltd. This company provides image

interpretation training for healthcare professionals in conjunction with two other

radiographers outside of this program of research. Michael Neep does not have a

direct financial interest in the outcomes of this research or conflicts to report. All co-

authors who have contributed to this research have confirmed that they have no

conflicts of interest to report.

The delivery of image interpretation education for radiographers xvi

Acknowledgements

Completion of this Doctoral research would not have been possible or as enjoyable

for me professionally, without the support and assistance of numerous people

throughout the research project. I would like to sincerely thank my primary supervisor

Associate Professor Steven McPhail for his guidance, enthusiasm for research,

patience, tolerance and mentoring over this seven year journey. I would also like to

acknowledge the support of Dr. Peter Lazzarini, Professor MaryLou Fleming, and Dr.

Rebecca Owen who contributed to my supervision at different stages of this program

of research.

I would like to thank all of my medical imaging directors and colleagues who have

supported me and I hope the outcome of this research improves the care given to our

patients.

Finally, I’d like to thank my wonderful wife, Gabrielle, my beautiful sons, Hugo and

Louis, and my extended family for all their support in this and all my endeavours. Their

patience and understanding throughout my doctoral research has enabled me to

complete this work.

The delivery of image interpretation education for radiographers xvii

Table of Contents

Front Matter

Abstract ii

List of Publications vii

Keywords ix

List of Figures x

List of Tables xii

List of Abbreviations xiii

Statement of Original Authorship xiv

Conflict of Interest Statement xv

Acknowledgements xvi

Contents xvii

Chapter 1: Introduction………………………………………………………………….. 1 1.1 Preamble 1

1.2 Background 2

1.3 Research Aims 6

1.4 Significance of the Thesis 7

1.5 Thesis Structure 7

1.6 References 10

Chapter 2: Literature Review………………………………………………..…………. 15 2.1 Preamble 15

2.2 Introduction 16

2.3 Healthcare Demand and Reform 16

2.3.1 Emergency Care Services 16

2.3.2 Medical Imaging Services and Reporting Times 17

2.4 Interpretation of Trauma Radiographs 18

2.4.1 Emergency Doctors 18

2.4.2 Radiographers 18

2.4.2.1 Benefits and Barriers of Image Interpretation by

Radiographers

19

2.4.3 Nurses 21

The delivery of image interpretation education for radiographers xviii

Table of Contents

Chapter 2: (cont) 2.4.4 Physiotherapists 22

2.4.5 Image Interpretation Performance 22

2.5 Education 23

2.5.1 Impact of Training for Radiographer Image Interpretation 23

2.5.2 Education Opportunities 24

2.5.2.1 Potential Education Delivery Formats 24

2.6 Standard Measure of Performance 25

2.7 Future Direction for PIE Research 27

2.8 Conclusions 28

2.9 References 28

Chapter 3: Methods………………………………………………………………............. 36 3.1 Preamble 36

3.2 Introduction 37

3.3 Study Design 37

3.3.1 Study 1 37

3.3.2 Study 2 37

3.3.3 Study 3 37

3.4 Setting and Participants 39

3.4.1 An Overview 39

3.4.2 Individual Studies 40

3.5 Procedure 41

3.5.1 Education Intervention Development 41

3.6 Ethical Approval 43

3.7 References 43

Chapter 4: Radiographer commenting of trauma radiographs: a survey of the benefits, barriers and enablers to participation in an Australian healthcare setting…………………………………………………………………………………………..

45

4.1 Preamble 47

4.2 Manuscript 1 48

4.2.1 Abstract 48

4.2.2 Introduction 49

The delivery of image interpretation education for radiographers xix

Table of Contents

Chapter 4 (cont)

4.2.3 Methods 51

4.2.4 Results 53

4.2.5 Discussion 59

4.2.6 Conclusion 62

4.2.7 References 62

4.3 Thesis Commentary 65

Chapter 5: A survey of radiographers’ confidence and self-perceived accuracy in frontline image interpretation and their continuing educational preferences…………………………………………………………………………………..

67

5.1 Preamble 69

5.2 Manuscript 2 70

5.2.1 Abstract 70


5.2.3 Methods 73

5.2.4 Results 76

5.2.5 Discussion 82

5.2.6 Conclusion 85

5.2.7 References 85


Chapter 6: Development of a valid and reliable test to assess trauma radiograph interpretation performance………………………………………………………………..

89

6.1 Preamble 91

6.2 Manuscript 3 93

6.2.1 Abstract 93


6.2.3 Methods 95

6.2.4 Results 101

6.2.5 Discussion 103

6.2.6 Conclusion 106

6.2.7 References 106


The delivery of image interpretation education for radiographers xx

Table of Contents

Chapter 7: Evaluating the effectiveness of intensive versus non-intensive image interpretation education for radiographers: a randomised controlled trial…………………………………………………………………………………………….

111

7.1 Preamble 113

7.2 Manuscript 4 115

7.2.1 Abstract 115


7.2.3 Methods 117


7.3 Manuscript 5 130

7.3.1 Abstract 130


7.3.3 Methods 132

7.3.4 Results 141


7.3.6 Conclusion 150

7.4 References 151


Chapter 8: Thesis Implications and Recommendations……………………………... 156 8.1 Preamble 156

8.2 Summary of Findings 157

8.3 Implications for Practice 159

8.3.1 A Validated Outcome Measuring Test Image Interpretation

Performance

159

8.3.2 An Education Program that improves Image Interpretation

Ability for Radiographers

160

8.3.3 Awareness of the Benefits Barriers and Enablers of

implementing PIE in Australia

161

8.3.4 Some Australian Radiographers perceive they are not ready to

participate in a PIE System

162

8.3.5 Development of PIE Nationally and Internationally since the

commencement of this Research

162

The delivery of image interpretation education for radiographers xxi

Table of Contents

Chapter 8 (cont)

8.4 Strengths and Limitations of this Research 163

8.5 Recommendations for Future Research 165

8.5.1 Modify and Validate the IIT for other Settings and

Pathology

165

8.5.2 Test other Professions’ Image Interpretation Ability using

the IIT

166

8.5.3 Educate and Test Radiographers who are working in

different Healthcare Settings using the IIT

166

8.5.4 Transfer the IIT to an Online Platform 166

8.5.5 Compare the Effectiveness of University Based Image

Interpretation Education versus an Intensive Short Course

Format

167

8.5.6 Compare the Psychometric Properties of a University

Endorsed Assessment Tool against the IIT

8.5.7 Evaluate the Cost-effectiveness of Training and

Implementing PIE

167

168

8.6 Conclusions 168

8.7 References 169

References ……………………………………………………………………………….. 171 Appendices ……………………………………………………………………………….. 185

Chapter(1:(Introduction( 1"

Chapter(1:(Introduction(!

!

1.1( Preamble(This! chapter! introduces! the! key! concepts! of! this! thesis,! radiographer! Preliminary!

Image!Evaluation!and!radiographer!image!interpretation!education.!It!also!highlights!

the!gaps!in!the!evidence!in!this!emerging!field.!This!is!followed!by!an!outline!of!the!

aims,!significance!and!structure!of!this!thesis.!

!

!

( (


1.2( Background((Contemporary!healthcare!services!are!dependent!on!medical!imaging!to!provide!key!

diagnostic!information!for!many!patient!presentations.!Plain!x@rays!are!the!most!widely!

utilised! form! of! medical! imaging.1! In! acute! hospital! settings,! such! as! Emergency!

Departments,!expeditious!access!to!x@ray!imaging!is!critical.2,!3!Patients!referred!by!

their! medical! team! for! an! x@ray! are! seen! by! a! radiographer! (skilled! allied! health!

professional)! who! is! responsible! for! acquiring! the! requested! x@rays.! The! term!

‘radiographer‘! will! be! employed! throughout! this! thesis! to! denote! those! health!

professionals!who!perform!diagnostic!radiography.!Once!an!x@ray!image!is!acquired,!

a!radiologist!(medical!specialist)!reviews!the!examination!and!produces!a!diagnostic!

report.!Radiologist!reports!provide!authoritative!diagnostic!information!to!the!referring!

clinical! team! who! can! view! the! x@ray! examination! and! consider! the! diagnostic!

radiologist! report.! This! information! is! very! valuable,! particularly! when! patients! are!

being! cared! for! by! junior! referrers,! primarily! junior! doctors,! who!may! have! limited!

experience! in! identifying! radiographic! evidence! of! pathologies! and! interpreting! the!

image!to!inform!their!treatment!choices.4@7!!

!

Unfortunately,!radiologist!reports!are!frequently!not!available!within!clinically!relevant!

time!frames.!In!many!cases,!junior!referrers!may!make!an!intervention!selection!or!a!

decision! to! discharge! a! patient! before! a! radiologist! has! viewed! important! x@ray!

imaging.3,!8@10!A!number!of!hospitals!in!Queensland!have!reported!that!only!62%!of!all!

radiologist!diagnostic! reports!were!available!within!24!hours.11!This!does!not!meet!

Australian!Healthcare!Standards!and!consequently,! it! is!possible! for!patients! to!be!

discharged!from!care!or!have!their!treatment!delivered!or!altered!before!the!radiologist!

report! is! available.! The! absence! of! a! radiologist! report! within! clinically! relevant!

timeframes!represents!ongoing!potential!risks!to!patients!through!missed!or!incorrect!

diagnosis.12,!13!This!represents!a!major!shortcoming!in!the!contemporary!clinical!model!

that!is!dependent!on!junior!emergency!doctors!for!immediate!interpretation!of!medical!

images! (such! as! x@rays)! without! a! radiologist! report.! Australian! and! international!

evidence!acknowledges!that!medical!school!curriculum!often!involves!little!radiology!

and! many! emergency! departments! do! not! have! a! structured! x@ray! interpretation!

program.14@19!Furthermore,!junior!medical!doctors!who!may!have!very!little!experience!

in! interpreting! x@rays! often! staff! emergency! departments! and! errors! are! not!

uncommon.4,!16,!20!An!additional!level!of!risk!mitigation!that!can!be!implemented!while!


the!radiologist’s!report!is!generated,!exists!in!the!form!of!a!radiographer!Preliminary!

Image!Evaluation!system.21!

!!

A! Preliminary! Image! Evaluation! (PIE)! system! or! radiographer! commenting! is! one!

method! that! has! been! employed! and! proven! to! be! an! efficient! and! succinct!

communication!mechanism!between!a!radiographer!and!the!referring!clinical!team.22,!

23! Successful! implementation! of! PIE! has! great! potential! to! improve! the! timely!

diagnosis! and! management! of! patients! in! emergency! care! settings! where! delays!

between! image! capture! and! comprehensive! radiological! reporting! occur.22@25!

Radiographer!commenting!is!not!a!substitute!for!the!definitive!radiologist!report,!but!

rather,! provides! a! timely! indication! to! the! referring! multidisciplinary! clinical! teams!

regarding!potential!absence!or!presence!of!an!acute!abnormality!along!with!a!brief!

written!description!of!the!location,!type!and!number!of!abnormalities!present.!!

!

Despite! evidence! that! PIE! systems! can! improve! medical! imaging! services! (and!

ultimately! patient! care)! by! acting! as! a! conduit! for! communication! between!

radiographers! and! the! referring! clinical! team,22,! 25! PIE! has! yet! to! be! implemented!

widely!outside!of!the!United!Kingdom.!At!present,!there!is!no!published!evidence!of!

the! practice! of! radiographer! PIEs! in! Australian! hospitals.! The! successful!

implementation!of!radiographer!commenting!systems!is!dependent!on!the!confidence!

and! ability! of! radiographers! to! detect! and! describe! abnormalities! on! trauma!

radiographs.! Undergraduate! coursework! for! entry@level! radiographers! frequently!

includes! some! image! interpretation! content.22,! 26! However,! it! is! currently! unknown!

whether! this!education!satisfactorily!prepares! radiographers! to!detect!and!describe!

abnormalities!of!the!musculoskeletal!system!in!emergency!settings.!Empirical!studies!

among!qualified!radiographers!have!demonstrated!that!their!confidence!and!accuracy!

to!interpret!radiographs!substantially!improves!following!the!completion!of!a!targeted!

education!program!designed!to!improve!image!interpretation!performance.22,!27@32!This!

may!imply!that!radiographers,!who!have!not!yet!completed!targeted!education,!lack!

confidence!and!ability!to!detect!and!describe!abnormalities!accurately.!The!provision!

of! an! effective! education! program! for! radiographers! in! a! format! amenable! to! their!

ongoing!professional!development!would!likely!assist!in!raising!their!confidence!and!

accuracy!in! interpreting!images!to!a!suitable!standard!for!participation!in!a!frontline!

PIE!service.!


!

Postgraduate!university!qualifications!incorporating!image!interpretation!coursework!

are!available!in!some!regions.28,!33,!34!Until!recently,!Australian!universities!which!

offer!postgraduate!courses!including!image!interpretation!either!at!Masters!or!

Graduate!Diploma!level!now!offer!the!course!online.!Most!students!enrolling!in!

postgraduate!degrees!in!Australia!can!apply!for!a!loan!to!cover!the!financial!cost,!but!

must!be!repaid!and!is!capped.!!An!alternative!to!formal!postgraduate!university!

qualifications!is!targeted!image!interpretation!training!delivered!in!short@course!

formats,22!for!example,!intensive!delivery!over!a!weekend!or!regular!short!tutorials!

as!part!of!ongoing!in@service!education!within!hospital!medical!imaging!departments.!!

!

While! there! is!evidence!supporting! the!use!of!education! to! increase!radiographers’!

ability! to! interpret! and! comment! on! radiographs,22,! 28! there!are! inadequate! training!

options!available!in!many!countries!including!Australia.!This!highlights!a!key@limiting!

factor! for! the! implementation! of! a! PIE! system.! Targeted! education! for! image!

interpretation!is!a!priority!for!radiographers!within!Australian!hospitals!and!elsewhere.!

While! literature! specific! to! the!Australian! context! is! lacking,! there! are! at! least! two!

potential!reasons!why!limited!training!options!may!exist.!The!first!may!relate!to!(lack!

of)! availability! of! suitably! qualified! radiographers! who! are! able! to! deliver! imaging!

interpretation! and! commenting! training.! The! second! could! be! the! difficulty! for!

radiographers,! from!diverse!Australian!geographical! locations,! to!be!able!to!access!

training!amenable! to! their! location!or! routine!work!schedule.!A!potential!solution! to!

facilitate! the! accessibility! of! training! is! to! offer! two! separate! formats! of! education!

delivery:!an! intensive!delivery!2@day! training!suitable! for! radiographers!who!require!

the! training! to! be! completed! in! a! short! amount! of! time! (for! example,! a! regional!

radiographer!visiting!a!metropolitan!centre!where!the!training!is!offered),!and!a!non@

intensive! delivery! of! short! regular! tutorials! over! a! 12@week! period! which! could! be!

incorporated!into!regular!in@service!education!within!hospital!facilities.!This!thesis!fills!

a!gap!in!the!international!literature!where!the!effectiveness!of!intensive!versus!non@

intensive!training!has!not!been!investigated.!This!has!immediate!practical!implications!

for!an!impending!roll@out!across!the!Australian!state!of!Queensland!and!other!regions.!

!

In!an!environment!undergoing!rapid!transformation,!it!is!not!surprising!that!education!

delivery! methods! have! also! been! evolving.! Intensive! teaching! or! non@traditional!


teaching! was! initially! developed! to! allow! institutions! to! deliver! content! in! an!

accelerated!format!due!to!time!constraints.!One!of!the!earliest!examples!of!intensive!

teaching!was!taught!at!Harvard!University!in!1869.35!Numerous!investigations!have!

been!conducted!in!fields!outside!of!radiography!to!examine!the!merit!of!intensive!and!

non@intensive!teaching!formats.35@37!In!summary,!these!investigations!have!indicated!

that! intensive!teaching!formats!may! lead!to!comparable!or!slightly!more!favourable!

learning! outcomes! rather! than! non@intensive! teaching! formats.35,! 36! To! date,! no!

research!has!investigated!intensive!versus!non@intensive!education!for!radiographers.!

!

Despite! the! introduction! of! PIE! systems! in! the! United! Kingdom’s! National! Health!

Service,! there! is! a! scarcity! of! empirical! research! in! this! field! internationally.! The!

successful!development!of!radiographer!commenting!in!the!United!Kingdom!has!been!

influenced! by!multiple! factors! including! chronic! national! shortage! of! radiologists,38!

radiologist! support39! and! access! to! x@ray! interpretation! education22.! Several!

preliminary! studies! have! trialled! radiographer! image! interpretation! in! Australian!

settings,! all! yielding! encouraging! results.23@25,! 28,! 32,! 40@43! A! number! of! these! studies!

found! that! radiographers’! level! of! diagnostic! accuracy! when! interpreting! trauma!

radiographs! increased! following! targeted! image! interpretation! education.23,! 32,! 40,! 41!

Smith!and!Younger’s24!study! in!2002!demonstrated! that! the!use!of!a! ‘radiographer!

opinion!form’!proved!a!useful!communication!tool!to!convey!a!radiographer’s!opinion!

of! suspected! abnormalities! to! the! referrer.! An! investigation! by! McConnell! et! al.23!

published!in!2012!demonstrated!that!radiographers!working!with!emergency!clinicians!

in!interpreting!trauma!radiographs,!can!minimise!the!potential!for!missed!or!incorrect!

injuries!in!the!pre@radiologist!phase!of!interpretation.!Internationally,!there!remains!a!

gap! in! the!knowledge!that! identifies!what! format!of!delivery! is! the!most!effective! in!

training!radiographers!to!provide!a!PIE.!

!

Several! important! gaps! remain! in! this! emerging! field! of! radiographer! image!

interpretation!education!and!PIE.!Prior! to! this!program!of! research,!no!studies!had!

examined:!Australian!radiographers’!perceptions!of!the!benefits,!barriers!and!enablers!

of!PIE!and!Australian!radiographers’!current!self@efficacy!in!image!interpretation!and!

commenting.! Additionally,! no! studies! exist! internationally! which! have! explored!

radiographers’!desire!to!receive!image!interpretation!education!delivered!via!intensive!

or!non@intensive!formats.!There!was!also!no!validated!outcome!measure!based!on!a!


typical! adult! emergency! department! case@mix,! that!was! suitable! to! quantify! image!

interpretation! and! commenting! ability! among! radiographers.! Lastly,! there! has! also!

been! no! study! internationally! comparing! education! delivery! formats! of! an! image!

interpretation!program!for!radiographers.!This!program!of!research!culminated!in!an!

assessment!of!the!comparative!merits!of!two!education!delivery!methods!(intensive!

versus! non@intensive)! for! improving! radiographers’! capability! to! provide! a! PIE! in!

relation!to!trauma!radiographs!of!the!appendicular!and!axial!musculo@skeletal!system!

of!the!adult!patient.!This!critical!evidence!will!inform!the!rollout!of!targeted!training!for!

radiographers!within!Australia!and!is!likely!to!influence!clinical!education!in!national!

and!international!healthcare!settings.!

!

1.3( Research(Aims(To!address!the!gaps!in!the!literature,!this!program!of!research!has!six!aims:!

1.! Explore!Australian!radiographers’!perceptions!of!potential!benefits,!barriers!and!

enablers!of!introducing!a!PIE!system.!

2.! Describe!Australian!radiographers’!current!image!interpretation!self@efficacy.!!

3.! Investigate! which! (if! any)! format! of! image! interpretation! education!

radiographers!currently!prefer.!

4.! Develop! and! validate! a! quantitative! outcome! measure! that! evaluates!

radiographer!image!interpretation!and!commenting!skills!suitable!for!use!in!a!

randomised!trial.!

5.! Evaluate! the! comparative! effectiveness! of! intensive! (2@day)! versus! non@

intensive!(90!minute!x!9)!formats!of!delivering!an!education!program!designed!

to! improve! radiographers’! abilities! to! detect! and! comment! on! radiographic!

abnormalities!in!trauma!settings.!!

6.! Investigate!Australian!radiographers’!experiences!in!completing!the!intensive!

or! non@intensive! education! programs! and! their! perceived! readiness! for!

participation!in!a!PIE!system.!!

!

!

!

( (


1.4( Significance(of(the(Thesis(The! findings! from! this! program! of! research! have! practical! implications! to! the!

healthcare! field.!This! research!was! the! first! to! investigate! the!effectiveness!of! two!

image! interpretation!education!delivery! formats! for! radiographers! in!Queensland.! It!

also!developed!the!first!validated!quantitative!outcome!measure!based!on!a!typical!

adult!emergency!department!case@mix,!that! is!suitable!for!assessing!radiographers’!

ability! to! provide! a! PIE! on! abnormalities! visualised! on! trauma! radiographs.!

Furthermore,! the! findings! have! contributed! to! the! existing! published! literature! by!

describing! the!potential!barriers!and!enablers! to! implementing!a!PIE!system!within!

Australia! and! by! determining! radiographers’! readiness! for! participation.! These!

advances!will! inform! subsequent! education! roll@out! strategies! for! radiographer!PIE!

education!among!practicing!radiographers!in!trauma!settings!in!Australian!facilities!(as!

well!as!internationally)!to!prepare!them!for!participation!in!PIE.!Improving!the!image!

interpretation! capabilities! of! radiographers! practicing! in! these! settings! will! likely!

minimise!the!risk!of!missed!or!incorrect!diagnosis!due!to!delay!in!radiologist!reports.!!

!

1.5( Thesis(Structure(This!thesis!is!presented!in!the!format!of!published!papers.!This!research!program!was!

divided! into! three!consecutive!studies,! investigating!six! research!aims.!The!overall!

structure!of!this!thesis!is!illustrated!in!the!Figure!1.1.!A!version!of!this!figure!is!provided!

at!the!commencement!of!each!chapter,!along!with!a!preamble,!to!familiarise!readers!

with!the!contribution!of!each!chapter!of!the!thesis.!Manuscripts!included!in!the!thesis!

are! presented! in! their! published! (or! final! submitted)! form,! with! the! exception! of!

changes! to! support! consistent! formatting! throughout! the! thesis.!As! a! result! of! this!

research,! five! manuscripts! have! been! prepared! and! submitted! to! peer@reviewed!

journals,! four! of! which! are! published,! and! the! remaining! manuscript! has! been!

submitted.


!

!Figure!1.1:! Thesis!Structure!


Four%of%these%manuscripts%have%been%included%as%consecutive%chapters%in%this%thesis%

(Chapters%4%to%7).%One%of%the%manuscripts%is%a%description%of%the%randomised%controlled%

trail% protocol% adhered% to% in%Study% 3% and% is% presented% as% part% of%Chapter% 7.% These%

chapters%will%be%inserted%after%the%introduction%to%the%thesis%(Chapter%1),%a% literature%

review%of%relevant%topics%(Chapter%2)%and%an%outline%of%methods%used%for%each%study%

within%this%doctoral%program%of%research%(Chapter%3).%A%small%degree%of%repetition%of%

background%concepts,%may%therefore%occur%in%the%introduction%of%manuscript%chapters.%

This% repetition% is% necessary% to% allow% the% chapters% to% be% read% as% standGalone%

manuscripts,%and%to%concisely%demonstrate%the%contribution%to%the%literature%at%each%

stage% of% the% research% program.% The% PhD% program% was% a% result% of% an% emergent%

process,%where%the%development%of%each%study%was%based%on%previous%chapters.%As%a%

result,%independent%chapters%are%linked%and%demonstrate%progression.%

%

Before% the% commencement% of% Study% 1,% an% extensive% review% of% literature% was%

conducted.%Based%on%that,%the%most%pressing%gaps%in%the%literature%were%identified%and%

research% questions% were% developed% accordingly.% % It% also% established% the% research%

methodology%employed%for%subsequent%studies.%The%first%study%addressed%Aims%1%to%

3.%Chapter%4%reports%the%findings%of%Aim%1%whereas%Chapter%5%presents%the%results%of%

Aims%2%and%3.%This%study%involved%administering%a%crossGsectional%survey%to%a%volunteer%

sample% of% 73% radiographers% from% south% east% Queensland.% This% study% explored%

radiographers’%opinions%regarding%selfGefficacy%of%their%image%interpretation%skills,%the%

major% benefits,% barriers% and% enablers% of% introducing% a% radiographer% commenting%

system%and%finally%which%method%of%education%delivery%radiographers%prefer.%Results%

from%this%study%informed%the%formats%of%education%delivery%for%use%in%Study%3.%

%

The% second% study% addressed% Aim% 4.% This% study% involved% the% development% and%

validation%of%a%quantitative%outcome%measure%suitable% for%evaluating% radiographers’%

ability%to%interpret%and%comment%on%trauma%radiographs%(presented%in%Chapter%6).%This%

study% implemented%a% twoGstage%process.%Stage%1% involved% the% development% of% the%

Image% Interpretation% Test% (IIT)% content,% as% well% as% a% reference% standard% and% item%

scoring.% Stage% 2% involved% prospective% validation% of% the% test% using% a% cohort% of%

radiographers.%%The%findings%suggest%that%it%is%possible%to%assess%image%interpretation%

performance%of%adult%trauma%radiographs%with%this%test.%This%outcome%measure%was%

used%in%Study%3%to%evaluate%change%in%radiographers’%image%interpretation%ability.%%


%

The%third%and%final%study%addressed%Aims%5%and%6%(reported%in%Chapter%7).%This%study%

was%informed%by%the%outcomes%of%Study%1%and%Study%2.%Chapter%7%includes%a%published%

trial% protocol% and% the% associated% findings% of% a% multiGcentre,% stratified% (by% years% of%

experience)% two% group% parallel% arm% single% blind% (assessor% blinded)% randomised%

controlled%trial% that%examined%two%formats%of%education%delivery.%The%two%formats%of%

education% delivery% included% an% intense% delivery% format% (two% consecutive% days% of%

training)%versus%nonGintensive%training%sessions%of%shorter%duration%(90%minute%tutorials,%

once%per%week%over% a%9Gweek%period).%The%primary%outcome%measure%was% the% IIT%

assessment% score.% Participants% completed% assessments% before% education,% at% one%

week%postGintervention%completion%and%at%12%weeks%postGintervention%completion.%A%

secondary% outcome%measure% included% examining% participants’% perceptions% of% their%

ability% to% interpret% radiographs.%This% involved% the%distribution%of% two%questionnaires.%

The% first% questionnaire% was% completed% at% the% baseline% assessment% prior% to%

randomisation,% while% the% second% was% completed% at% the% 12Gweek% postGintervention%

assessment.% The% questionnaires% were% designed% to% examine% radiographers’%

perceptions% regarding% their% confidence% and% accuracy% in% their% ability% to% interpret%

radiographs% following% completion% of% the% education% intervention.% Findings% from% this%

study%will%be%of% relevance%to%radiographers%seeking% image% interpretation% training%as%

well%as%organisations%providing%image%interpretation%education%to%prepare%clinical%staff%

for%participation%in%a%PIE%system.%

%

Chapter% 8% aims% to% draw% together% the% findings% of% the% program% of% research% and% to%

describe% the% implications% and% application% of% those% findings% to% clinical% practice.% The%

limitations%of%the%research%and%recommendations%for%further%research%are%discussed%in%

this%final%chapter.%

%

1.6$ References$for$Chapter$1$1% Pinto%A,%Reginelli%A,%Pinto%F,(et(al.%Errors%in%imaging%patients%in%the%emergency%

setting.%British(Journal(of(Radiology.%2016X%89:%20150914.%

2% WalshGKelly% CM,% MelzerGLange% MD,% Hennes% HM,( et( al.% Clinical% impact% of%

radiograph%misinterpretation%in%a%pediatric%ED%and%the%effect%of%physician%training%level.%

The(American(Journal(of(Emergency(Medicine.%1995X%13:%262G264.%


3% Eastgate%P,%Davidson%R,%McPhail%SM.%Radiographic%imaging%for%traumatic%ankle%

injuries:%a%demand%profile%and%investigation%of%radiological%reporting%timeframes%from%

an%Australian%tertiary%facility.%Journal(of(Foot(and(Ankle(Research.%2014X%7:%25.%

4% Guly% H.% Diagnostic% errors% in% an% accident% and% emergency% department.%

Emergency(Medicine(Journal.%2001X%18:%263G269.%

5% Nyhsen%CM,%Lawson%C,%Higginson%J.%Radiology%teaching%for%junior%doctors:%their%

expectations,%preferences%and%suggestions% for% improvement.% Insights( Into( Imaging.%

2011X%2:%261G266.%

6% Free%B,%Lee%GA,%Bystrzycki%A.%Literature%review%of%studies%on%the%effectiveness%

of% nurses% ability% to% order% and% interpret% XGrays.% Australasian( Emergency( Nursing(

Journal.%2009X%12:%8G15.%

7% Ball% ST,% Walton% K,% Hawes% S.% Do% emergency% department% physiotherapy%

Practitioner’s,%emergency%nurse%practitioners%and%doctors%investigate,%treat%and%refer%

patients% with% closed% musculoskeletal% injuries% differently?% Emergency( Medicine(

Journal.%2007X%24:%185G188.%

8% Kane% C,% Wilson% C.% XGray% failure:% Queensland% Health% reveals% thousands% of%

patients% lacked% proper% review.% % 2014% [cited% 26% September% 2014].% Available% from%

http://www.abc.net.au/news/2014G07G14/queenslandGhealthGrevealsGthousandsGofGxG

raysGlackedGreview/5595162.%

9% Patty%A.%Reviews%needed%on%mountain%of%backlogged%XGrays,%says%professor.%

Sydney(Morning(Herald.%May%16%ed,%Sydney,%Australia,%2012X%5.%

10% Clinical%Excellence%Commission%New%South%Wales.%Recommendations%of%the%

Clinical% Advisory% Committee:% Plain% XGRay% Image% Reporting% Backlog.% New% South%

Wales%Government,%Sydney,%New%South%Wales,%2014.%

11% Queensland%Govenment.%Queensland%Health%Radiology%Services%Profile%2016G

2017.%Queensland%Health,%2018.%

12% Kachalia%A,%Gandhi%TK,%Puopolo%AL,(et(al.%Missed%and%delayed%diagnoses%in%

the% emergency% department:% a% study% of% closed% malpractice% claims% from% 4% liability%

insurers.%Annals(of(Emergency(Medicine.%2007X%49:%196G205.%

13% Devaney%C,%Gordon%M.%Radiography%abnormality%description%project:%project%

completion%report.%Queensland%Health,%2010.%

14% Holt%NF.%Medical%students%need%more%radiology%education.%Academic(Medicine.%

2001X%76:%1.%


15% Gunderman% RB,% Siddiqui% AR,% Heitkamp% DE,% Kipfer% HD.% The% vital% role% of%

radiology%in%the%medical%school%curriculum.%American(Journal(of(Roentgenology.%2003X%

180:%1239G1242.%

16% McLauchlan%C,%Jones%K,%Guly%H.%Interpretation%of%trauma%radiographs%by%junior%

doctors% in% accident% and% emergency% departments:% a% cause% for% concern?% Journal( of(

Accident(and(Emergency(Medicine.%1997X%14:%295G298.%

17% Subramaniam% R,% Kim% C,% Scally% P.% Medical% student% radiology% teaching% in%

Australia%and%New%Zealand.%Australasian(radiology.%2007X%51:%358G361.%

18% Subramaniam%RM,%Kim%C,%Scally%P,%Tress%B.%Medical%student%radiology%training:%

What% are% the% objectives% for% contemporary%medical% practice?%Academic( Radiology.%

2003X%10:%295G300.%

19% Salajegheh%A,% Jahangiri%A,%DolanGEvans%E,%Pakneshan%S.%A% combination%of%

traditional%learning%and%eGlearning%can%be%more%effective%on%radiological%interpretation%

skills%in%medical%students:%a%preGand%postGintervention%study.%BMC(Medical(Education.%

2016X%16:%46.%

20% Vincent%C,%Driscoll%P,%Audley%R,%Grant%D.%Accuracy%of%detection%of%radiographic%

abnormalities%by%junior%doctors.%Archives(of(Emergency(Medicine.%1988X%5:%101G109.%

21% Neep%MJ.%Is%radiographer%commenting%the%answer?%Journal(of(Medical(Imaging(

and(Radiation(Oncology.%2013X%57:%206G206.%

22% Hardy%M,%Culpan%G.%Accident%and%emergency% radiography:%a%comparison%of%

radiographer%commenting%and%‘red%dotting’.%Radiography.%2007X%13:%65G71.%

23% McConnell% J,% Devaney% C,% Gordon% M.% Queensland% radiographer% clinical%

descriptions% of% adult% appendicular%musculoGskeletal% trauma% following% a% condensed%

education%programme.%Radiography.%2012X%19:%48G55.%

24% Smith%T,%Younger%C.%Accident%and%emergency%radiological%interpretation%using%

the%radiographer%opinion%form%(ROF).%The(Radiographer.%2002X%49:%27.%

25% McConnell% J,% Baird% M.% Could% musculoGskeletal% radiograph% interpretation% by%

radiographers% be% a% source% of% support% to% Australian%medical% interns:% a% quantitative%

evaluation.%Radiography.%2017X%23:%321G329.%

26% Medical%Radiation%Practitioner%Board% of%Australia.%Medical% radiation% practice%

accreditation% guidance%material.% Australian% Health% Practitioner% Regulation% Agency,%

Melbourne,%Victoria,%2016.%


27% McConnell%J,%Webster%A.%Improving%radiographer%highlighting%of%trauma%films%in%

the%accident%and%emergency%department%with%a%short%course%of%study%G%an%evaluation.%

British(Journal(of(Radiology.%2000X%73:%608G612.%

28% McConnell% J,%Devaney%C,%Gordon%M,%Goodwin%M,%Strahan%R,%Baird%M.%The%

impact% of% a% pilot% education% programme% on% Queensland% radiographer% abnormality%

description%of% adult% appendicular%musculoGskeletal% trauma.%Radiography.% 2012X% 18:%

184G190.%

29% Loughran%C.%Reporting%of%fracture%radiographs%by%radiographers:%the%impact%of%

a%training%programme.%British(Journal(of(Radiology.%1994X%67:%945G950.%

30% Hargreaves%J,%Mackay%S.%The%accuracy%of%the%red%dot%system:%can%it%improve%

with%training?%Radiography.%2003X%9:%283G289.%

31% Mackay% S.% The% impact% of% a% short% course% of% study% on% the% performance% of%

radiographers% when% highlighting% fractures% on% trauma% radiographs:“The% Red% Dot%

System”.%British(Journal(of(Radiology.%2006X%79:%468G472.%

32% Smith%T,%Traise%P,%Cook%A.%The%influence%of%a%continuing%education%program%on%

the%image%interpretation%accuracy%of%rural%radiographers.%Rural(and(Remote(Health.%

2009X%9:%1145.%

33% Buskov% L,% Abild% A,% Christensen% A,% Holm% O,% Hansen% C,% Christensen% H.%

Radiographers%and%trainee%radiologists%reporting%accident%radiographs:%a%comparative%

plain%filmGreading%performance%study.%Clinical(radiology.%2013X%68:%55G58.%

34% Hardy%M,%Snaith%B.%Radiographer%interpretation%of%trauma%radiographs:%issues%

for%radiography%education%providers.%Radiography.%2009X%15:%101G105.%

35% Seamon% M.% ShortGand% longGterm% differences% in% instructional% effectiveness%

between% intensive% and% semesterGlength% courses.%Teachers( College( Record.% 2004X%

106:%635G650.%

36% Davies% WM.% Intensive% teaching% formats:% a% review.% Issues( in( Educational(

Research.%2006X%16:%1G20.%

37% Hinger%B.%The%distribution%of%instructional%time%and%its%effect%on%group%cohesion%

in% the% foreign% language%classroom:%a% comparison%of% intensive%and%standard% format%

courses.%System.%2006X%34:%97G118.%

38% TorresGMejía%G,%Smith%RA,%de%la%Luz%CarranzaGFlores%M,(et(al.%Radiographers%

supporting% radiologists% in% the% interpretation% of% screening% mammography:% a% viable%

strategy%to%meet%the%shortage%in%the%number%of%radiologists.%Biomed(Central(Cancer.%

2015X%15:%410.%


39% The% Royal% College% of% Radiologists% and% the% Society% and% College% of%

Radiographers.%Team%working%in%clinical%imaging.%The%Royal%College%of%Radiologists%

and%the%Society%and%College%of%Radiographers,%London,%2012.%

40% Jane% S,% Hall% R,% Egan% I.% The% red% dot% system:% the% outback% experience.% The(

Radiographer.%1999X%46:%11.%

41% Cook% AP,% Oliver% T,% Ramsay% L.% Radiographer% reporting:% discussion% and%

Australian%workplace%trial.%The(Radiographer.%2004X%51:%61G66.%

42% Orames% C.% Emergency% department% XGray% diagnosisGhow% do% radiographers%

compare?%The(Radiographer.%1997X%44:%52.%

43% Kelly%B,%Rainford%L,%Gray% J,%McEntee%M.%Collaboration%between% radiological%

technologists%(radiographers)%and%junior%doctors%during%image%interpretation%improves%

the%accuracy%of%diagnostic%decisions.%Radiography.%2012X%18:%90G95.%

%

Chapter 2: Literature Review 15

Chapter 2: Literature Review

2.1 Preamble The aim of this chaper is to provide a review of literature to establish the national and

international evidence relating to radiographer preliminary image evaluation

performance and the effectiveness of radiographer image interpretation education.

This review will provide current knowledge of best evidence surrounding radiographer

preliminary image evaluation and lays the foundation for research undertaken in this

PhD (see Figure 2.1 below).



2.2 Introduction This review will provide an overview of contemporary radiographer image

interpretation research through a brief summary of current demands on the Australian

healthcare setting, a review of the development of radiographer image interpretation

and a concise review of image interpretation education. The review will then conclude

with a discussion on priorities for future research.

2.3 Healthcare Demand and Reform Many healthcare settings around the globe are under growing pressure to reduce

costs and improve quality of care. Australia has an ageing and increasing population

that is contributing to the strain on the health system.1 Health expenditure in Australia

is growing faster than economic growth.1 For the first time Australia’s health

expenditure in 2007-08 exceeded $100 billion.2 Health Workforce Australia proposed

that to address the growing strain on the health workforce, the answer is not simply to

produce more workers but to improve competencies, change skills mix and enhance

productivity.2 This report suggested that a paradigm shift in thinking about health

reform is required to meet these challenges. In particular, one that works backwards

from outcomes for communities versus the current thinking of working forward from

the base of existing professions, skills demarcations and responsibilities.2

2.3.1 Emergency Care Services

Demand for emergency healthcare is consistently growing across Australia with the

number of presentations to emergency departments increasing on average 3.7% each

year between 2012-13 and 2016-17.3 Emergency departments’ performance can be

compromised by increases in patient activity. The consequences of increases in

patient activity can include: increased waiting times and increased emergency

department length of stay. Subsequently, patient safety may be threatened. In addition

to these pressures, and in response to the potential risks to patient safety, the

Australian Government in 2010 introduced the National Emergency Access Target.

The goal of this target is to increase the proportion of emergency department patients

who leave the emergency department (for hospital admission, referral to another

hospital or discharged) within four hours.2 The combination of demand for emergency

care and introduction of this target has health services looking for innovative initiatives

to improve service delivery.


2.3.2 Medical Imaging Services and Reporting Times

Medical imaging is critical to patient care in almost all high-demand and high-risk

settings in contemporary healthcare environments including hospital emergency

departments. The most common and fundamental medical imaging is a plain

radiograph (x-ray).4 Health professionals from multiple disciplines depend on plain

radiographs for diagnoses, intervention planning and monitoring of disease

progression for patients with a broad range of clinical presentations (both traumatic

and non-traumatic). It is not surprising that major metropolitan hospitals (with >500

beds) in Queensland such as the Princess Alexandra Hospital and Royal Brisbane

and Womens’ Hospital each perform more than 90,000 X-rays per annum.5

Contemporary healthcare standards indicate that non-urgent radiological studies must

have a report provided to the referring doctor within 24 hours of imaging in order to

influence patient management.6 This may be problematic in public healthcare settings

with high demand and limited resourcing. Internationally, there have been attempts to

improve the radiology reporting time-frames but delays of up to 30 days have been

reported before a definitive report is available to an emergency department referrer.7-

10 In emergency settings, delay in availability of a radiologist report often leads to

patients being discharged from care or having their clinical management occurring

without the referring clinical team being informed by the definitive report. The absence

of a definitive report or radiographer comment within clinically relevant time-frames is

a potential risk to patients accessing healthcare services through increased likelihood

of missed or incorrect diagnosis.11, 12 Without a definitive report, a major shortcoming

occurs in the existing clinical model which is dependent on junior doctors making an

immediate interpretation of medical images.

In response to the National Health Reform, government departments are promoting

flexible and innovative use of healthcare professionals.2 Radiographers are well

positioned to respond to these pressures by contributing to enhancing the patient care

continuum in the emergency care setting by the implementation of radiographer

commeting or Preliminary Image Evaluation (PIE) systems. Despite the expanding

evidence of the benefits of a PIE system and its uptake in the United Kingdom,13, 14

Australian healthcare services are yet to widely implement such a system. At the time


of writing this thesis, anecdotally only three public hospitals out of a potential 701 in

Australia were known to have implemented a PIE system.

2.4 Interpretation of Trauma Radiographs Interpretation of trauma radiographs is a complex clinical skill that requires a broad

knowledge base. A number of professional groups, medical and non-medical, are

involved, to some degree, in medical image interpretation. Radiologists form the

majority who undertake this task and are considered the ‘gold standard’ expert.15

Emergency doctors, nurse practitioners, physiotherapists and radiographers also play

an active role in interpreting medical images in Australia.16-18

2.4.1 Emergency Doctors

Australian medical school programs typically include on average 85 hours of

specifically devoted radiology training and many emergency departments do not have

a structured image interpretation training program for junior doctors.19, 20 An Australian

study undertaken as part of McConnell’s doctoral research investigated final year

medical students’ opinions on the radiology education they received at medical

school.21 The results indicated that a majority of respondents believed they had not

received sufficient education in image interpretation. This quantity of radiology

teaching is not too dissimilar when compared to medical programs in the UK and

United States.22-25

Recognising the current delay in availability of a radiologist report in many healthcare

facilities,7, 8, 26 junior doctors with little experience in interpreting radiographs, are often

required to diagnose and subsequently treat patients. Not surprisingly, given the

demanding shifts junior doctors work in emergency departments, errors do occur.22, 27-

30 Previous studies have demonstrated that between approximately 2% and 8% of all radiographs interpreted by emergency doctors are misdiagnosed.23, 31

2.4.2 Radiographers

The potential for radiographers to interpret radiographs is well recognised.32-34 It was

Swinburne, who in 1971, first suggested that a radiographer could be utilised to identify

whether a radiographic examination in the emergency setting was normal or

abnormal.32 This concept was initially intended to alleviate radiologist workload.


However, its future use would primarily assist emergency doctors in frontline

diagnosis.

It was not until the early 1980s in the United Kingdom (UK) that radiographers in some

emergency settings began participating in an abnormality detection system.33 An

abnormality detection system (commonly known as ‘red dot’) was first introduced in

the UK to alert the referring emergency doctor to the possible presence of a traumatic

abnormality.35 This system involved the radiographer simply marking the radiograph

with a small red sticker after the radiographer detected a possible abnormality.33

Interest in radiographers contributing to frontline image interpretation in the

emergency setting continued into the 1990’s. Numerous studies have since

demonstrated the effectiveness of this system.34, 36, 37 However, the simplicity of the

‘red dot’ system is not without pitfalls.13, 38 The ‘red dot’ system is voluntary and only

distinguishes between normal and abnormal pathology. It offers no opportunity to

indicate the location or severity of the abnormality, presence of a normal variant or the

number of abnormalities present.

An evolution of a detection-only system has been the development of radiographer

commenting or Preliminary Clinical Evaluation or PIE systems. PIE systems not only

indicate the possible presence of a traumatic pathology but also provide the

radiographer with opportunity to include a brief written comment on the nature and

location of possible abnormalities present.

2.4.2.1 Benefits and Barriers of Image Interpretation by Radiographers

Radiographer abnormality detection and commenting is not intended to replace the

role of radiologist reports but to assist multidisciplinary clinical teams and radiologists

when viewing and interpreting radiographs. Previous research has indicated

radiographer commenting systems which highlight and describe acute abnormalities

at the point of care, can expedite service delivery and improve the accuracy of

diagnoses by emergency referrers and radiologists which, in turn, enhances patient

outcomes in emergency settings.13, 16, 38 Further research from the UK has

demonstrated that radiographers who are actively involved in radiographer

commenting feel an enhancement of their professional pride and job satisfaction.14, 39


Despite the evidence of benefit of a radiographer commenting system, the

implementation of such a system has been relatively slow in the UK.37 In Australia,

there is no published evidence of a radiographer commenting system in operation. A

number of barriers have been suggested that have led to the slow implementation of

radiographer commenting in the UK include: radiographer confidence and skills,

medico-legal status, time constraints to interpret radiographs and access to targeted

training.14, 39 These findings were not dissimilar to the barriers identified in McConnell’s

doctoral research.21 It is noteworthy to consider the concern expressed by some

radiographers in these studies regarding their medico-legal responsibility when

providing a PIE. Although the radiologist report is the final stage in the imaging

pathway, legal ramifications are possible for aspects of the acquisition of images

component (for example, poor quality imaging) in addition to the interpretive

component, whether it be a radiologist report or a radiographer PIE. This highlights

that legal responsibility could be carried by the radiographer during acquisition of

images in the first instance, as the radiologist may argue that their interpretation was

influenced by the quality of imaging provided. In Australia, the Medical Radiation

Practice Board of Australia’s statement on professional capabilities for medical

radiation practice recommends that radiographers are to communicate results of

diagnostic tests to the referrer when they identify significant abnormal findings.40 This

recommendation should alleviate radiographers concerns regarding the provision of a

PIE. Furthermore, it could be argued that a radiographer who does not provide a PIE

is in breach of their professional registration. Two coroner’s inquest findings in Victoria

in 200941 and 201342 serve to illustrate that had radiographers played a more integral

role by communicating findings to the referrer at an earlier stage, then it is likely the

deaths of these two patients could have been avoided.

A further potential barrier reported by radiographers is that they feel a lack of support

from radiologists.14 Evidence from the UK proposes that this lack of support may be

due to radiologists’ resistance towards frontline radiographer image interpretation due

to a concern relating to loss of professional demarcation between the role of

radiologists and radiographers and concern that a patient may receive a lesser quality

of care.14, 43 Research evidence questioning the implementation of radiographer

participation in a frontline image interpretation service is generally lacking. However,

a study published in 2012 questioned the benefit of the ‘red dot’ radiographer


abnormality detection system in tertiary hospitals.44 This study set out to investigate

the accuracy (sensitivity and specificity) of the ‘red dot’ system utilising a retrospective

review of radiographic examinations at a single facility. Due to their retrospective study

design and the voluntary nature of participation in the ‘red dot’ system, this did not

allow the investigators to distinguish between ‘no abnormality detected’ (no red dot)

and ‘radiographer did not participate in the ‘red dot’ system for this radiograph’ (also

no red dot). Thus, it is likely that a large proportion of the ‘false negative’ cases

reported in this previous study were a result of radiographer non-participation,

rendering the accuracy values reported in that study, erroneous. Therefore, only one

low quality study has investigated this potential negative impact of radiographer

frontline image interpretation.

Australian radiologists currently reject interpretation of radiographs by radiographers.

This type of interpretation includes a PIE or formal reporting by radiographers. This

view is held as the radiologist report is perceived to be the medical component to

patient management. In May 2018, the professional body for radiologists the Royal

Australian and New Zealand College of Radiologists (RANZCR), published a position

statement via their official website titled ‘Image Interpretation by Radiographers – not

the right solution’.45 In this statement RANZCR argues that radiographers lack the

experience and training to properly interpret imaging examinations despite published

evidence. RANZCR does not consider radiographer PIE to be within the current scope

of practice of a radiographer. This opinion is in direct opposition with the regulatory

body governing radiographers (i.e., Medical Radiation Practice Board of Australia). In

July 2012, Medical Radiation Practice Board of Australia published a document titled

‘Professional capabilities for medical radiation practice’.40 This document clearly states

that radiographers are expected to communicate significant findings to the referrer and

clarify this by providing a list of pathologies that radiographers should be able to

identify on completion of an undergraduate degree.46 It is noteworthy to mention that

during the consultation phase of developing the capability framework, strong

opposition to a radiographer’s interpretive position was made by the RANZCR.

2.4.3 Nurses

Similar to the radiographer’s role, Australian emergency department nurse practitioner

roles have been evolving towards a more autonomous position where interpreting


radiographs has been established. The evolving nature of this role has occurred in

response to emergency departments’ necessity to discover innovative ways to

improve service delivery. The nurse practitioner’s role involves the assessment,

treatment and discharge of patients in the emergency setting. In this context, nurse

practitioners may request and interpret radiographs.47, 48 Previous studies have

highlighted that there is no formalised training program in place for nurse practitioners

to gain vital knowledge and qualifications in interpreting medical images in many

healthcare settings internationally.48, 49

2.4.4 Physiotherapists

Physiotherapy practitioners in some Australian emergency departments have been

introduced more recently in an attempt to provide care for patients with

musculoskeletal problems. Their role is to assess patients, diagnose injuries which

includes interpreting medical imaging and to manage patients independently, without

the need to be seen by an emergency doctor.18, 50, 51 This innovative model has been

acknowledged as being a positive addition to the emergency department team

impacting on the reduction of patient wait times.51

2.4.5 Image Interpretation Performance

Numerous studies have investigated the performance of radiographers, emergency

doctors and nurses in image interpretation of radiographs in the emergency setting.

Since the inception of ‘red dot’ systems in the 1980’s, several studies have been

conducted considering radiographer performance.33, 36, 52 More recently, there has

been a transition in the research towards investigating the performance of

radiographers in providing a radiographer comment on trauma radiographs.13, 16, 38, 53-

55 One of the early studies that compared the image interpretation ability of

radiographers and emergency doctors found a similar diagnostic accuracy between

the two professions, 87.4% and 88.9% respectively.33 A salient investigation in

Australia, undertaken in 2010 (published in 2012), aimed to measure radiographers’

descriptive ability in interpreting adult appendicular musculoskeletal trauma

radiographs against emergency doctors and radiologists.16 The study involved 10

radiographers who had completed a short course on image interpretation of the

appendicular adult skeleton. 653 examinations were included in the analysis.

Radiographer image descriptions were compared against the emergency doctors and


radiologist reports. The results demonstrated that with appropriate education and

clinical contact, no significant difference between the radiographers and emergency

clinicians was noted. The authors concluded that radiographers working with

emergency doctors could minimize the potential for missed or incorrect injuries in the

pre-radiologist phase of interpretation. It is interesting to note that this study also found

that errors made by radiographers when interpreting radiographs were different to

those made by emergency doctors. A study conducted in Ireland in 2012 found a

similar outcome.56 It proposed that the clinical decisions made by junior doctors were

positively impacted after combining their interpretation of a radiograph with the opinion

of the radiographer.56

The majority of research comparing the performance of radiographers interpreting

radiographs, compared their performance either independently or in comparison with

radiologists,34 although there have been a few studies which have compared the

image interpretation ability of radiographers with nurses.55, 57 Two investigations from

the UK found that radiographers achieved a better overall performance in the

interpretation of radiographs when compared with nurses.55, 58 The literature regarding

the interpretive performance of emergency department physiotherapist practitioners is

somewhat sparse. The majority of the research in this field has been centred around

patient satisfaction regarding the quality of the assessment they received.51

2.5 Education 2.5.1 Impact of Training for Radiographer Image Interpretation

Image interpretation education and training improves the ability of radiographers to

interpret radiographs in the emergency setting.13, 21, 36, 59, 60 Despite evidence that

radiographer commenting systems can improve medical imaging services (and

ultimately patient care) by acting as a conduit for communication between

radiographers and the referring clinical team,13, 16 radiographer commenting has yet

to be implemented widely outside of the UK. The development of radiographer

commenting in the UK has been influenced by multiple factors including a chronic

national shortage of radiologists61 and widespread unreported x-rays.7 The successful

implementation of radiographer commenting systems is dependent on the confidence

and ability of radiographers to detect and describe abnormalities on trauma

radiographs. Universities delivering undergraduate degrees in radiography within


Australia are required to work within the expectations of the MRPBA ‘Medical radiation

practice accreditation guidance material’.46 This includes incorporating image

interpretation training into the curriculum. In clinical practice, it is currently unknown

whether this education satisfactorily prepares radiographers to detect and describe

abnormalities of the musculoskeletal system in emergency settings. Empirical studies

amongst qualified diagnostic radiographers have demonstrated that their confidence

and accuracy to interpret radiographs substantially improves following the completion

of a targeted image interpretation education program.13, 36, 52, 53, 59, 62, 63 Loughran59

reported that radiographers’ diagnostic accuracy in interpreting radiographs

significantly increased (p<0.001) following a six-month training program consisting of

weekly tutorials and written assignments. This may imply that radiographers, who

have not yet completed targeted image interpretation education, may lack confidence

and skills to detect and describe abnormalities accurately. The provision of an effective

image interpretation education program for radiographers in a format amenable with

their ongoing professional development would likely assist in raising their confidence

and accuracy in interpreting images to a suitable standard for participation in a frontline

image interpretation service.

2.5.2 Education Opportunities

Postgraduate university qualifications incorporating image interpretation coursework

are available in some regions. In Australia, several universities offer postgraduate

study in image interpretation involving a commitment of between 12 and 24 months

full-time equivalent study.64 Radiographers may find this formal university coursework

inaccessible due to large time requirement and a substantial financial commitment.65

Most students enrolling in postgraduate degrees in Australia can apply for a loan to

cover the financial cost, but this must be repaid and is capped. An alternative to formal

postgraduate university qualifications is targeted image interpretation training

delivered in short-course formats13, 63 either via an intensive delivery format or regular

short tutorials. In Australia, there is no evidence of accredited short courses available

to radiographers in image interpretation.

2.5.2.1 Potential Education Delivery Formats

Radiographers’ preferences for receiving short course targeted image interpretation

education has not been investigated. While intensive short courses delivered over


consecutive days may be convenient for some attendees, regular tutorials

incorporated into existing in-service programs may be preferable to others. Similarly,

some people may prefer to receive education in an intensive format to minimise

information forgotten between sessions, whilst others may prefer to consolidate

learning between regular tutorial sessions before moving on to new education

material. Intensive teaching or non-traditional teaching was initially developed to allow

institutions to deliver content in an accelerated format due to time constraints. One of

the earliest examples of intensive teaching was taught at Harvard University in 1869.66

Prior research has been conducted in other fields to examine the merit of intensive

and non-intensive teaching formats.66-70 In summary, these investigations indicate that

intensive teaching formats may lead to comparable or slightly more favourable

learning outcomes rather than non-intensive teaching formats. Such positive findings

for students in intensive programs may be due to a higher level of motivation,71 and

concentration.72

Traditionally, university based education has been delivered face to face (i.e. in the

classroom). However, more recently, the use of e-learning has provided an appealing

alternative. E-learning is being used in several health professions including

radiography, both at undergraduate and postgraduate level.73-75 The literature has

acknowledged a number of benefits of e-learning. E-learning provides students with a

flexible learning environment, allowing the student to work through the content at their

own pace and at a time that suits their personal and professional commitments.76

Despite these benefits, the literature has acknowledged several limitations of e-

learning that include lack of interactivity with teachers and peers,73, 77 and the

challenges faced with teaching a practical skill such as interpreting radiographs.74, 76

To date, no research has investigated intensive versus non-intensive education

(classroom based or e-learning) for radiographers

2.6 Standard Measure of Performance With the evolution of radiographers providing a brief description of radiographic

abnormalities (a radiographer PIE) in the emergency setting, the question of how to

test clinical competence is an important consideration. The reliability and validity

assessments for clinical competence have become a particularly interesting area of

research within healthcare and medical education. Any profession that provides a


service to the public has a responsibility to ensure that its professional members are

competent to practice. Multiple choice questions, short response essays and oral

examinations, can be used to test factual knowledge.78 However, more refined

methods are required to assess clinical performance including observed cases,

objective structured clinical examinations and standardized assessments.78

Several image interpretation tests have been reported in the literature.17, 27, 36, 79-83

However, there is a paucity of data describing the validity and reliability of these image

tests. Furthermore, it is unclear whether the content of prior image tests represents

the image case-mix that a clinician may expect to see in the context of their clinical

practice. Unfortunately, most research addressing radiographer image interpretation

performance has included methodological limitations.84-88 For example, Brealey et al88

reported that a number of studies introduced case selection bias (bias in selecting the

sample of radiographs for the test bank) by utilising methodology which did not

develop a test bank that accurately represented typical clinical practice. In

McConnell’s doctoral research,21 he addressed many of the bias’s that Brealey

acknowledged88 and subsequently developed an image test bank that was balanced

according to injury prevalence, rates of injury according to anatomical region, age and

gender. Unfortunately, McConnell did not conduct any validity or reliability tests prior

to use. Consequently, it is not possible to determine whether the image bank

McConnell developed was a valid and reliable measure of image interpretation

performance.

There remains contention in the literature as to whether manufactured image tests

(i.e., hand-picked cases) are an accurate indicator of interpretive performance in

comparison to image test banks which represent clinical practice. A typical

manufactured test bank has an abnormality prevalence of 70%,55, 58 in comparison to

a lower reported abnormality prevalence of 20-30% in image banks that represent

clinical practice.89, 90 A salient study by Hardy et al91 in 2016 examined the influence

of abnormality prevalence bias on the accuracy of interpretation of radiographs by

investigating radiographers’ performance on manufactured high abnormality

prevalence image banks versus clinical practice image banks. The results indicated

that the manufactured high abnormality prevalence test banks may overestimate

abnormality detection ability.


If studies are designed to evaluate whether healthcare professionals can accurately

interpret radiographs in clinical practice, there is a requirement to be able to access a

validated and reliable standard measure. Unfortunately, there was no widely available

standardised assessment instrument for measuring the competence of radiographers

or other professionals to interpret trauma radiographs of the appendicular and axial

musculoskeletal system.

2.7 Future Direction for PIE Research Current service delivery targets are focused on reducing patient waiting times.

However, with the demand for medical imaging services growing rapidly, current

service delivery models are likely to struggle to maintain efficiencies. One suggestion

to manage this escalating demand for service is to implement a frontline radiographer

commenting service in emergency departments. Despite the development and

implementation of radiographer commenting systems in the UK, there is a scarcity of

published research in this field internationally. Several preliminary studies have trialled

radiographer image interpretation in Australian settings, all yielding encouraging

results.15, 16, 38, 53, 54, 63, 65, 92 For radiographer commenting to develop further in the

Australian healthcare setting, a number of research priorities need to be addressed.

Priorities for research include exploration of Australian radiographers’ perceptions of

the benefits, barriers and enablers of PIE and Australian radiographers’ current self-

efficacy in image interpretation and commenting. Additionally, no studies exist

internationally which have explored radiographers’ desire to receive image

interpretation education delivered via intensive or non-intensive formats. There is also

currently no validated outcome measure based on a typical adult emergency

department case-mix, that is suitable to quantify image interpretation and commenting

ability among radiographers. Lastly, there has also been no study internationally

comparing education delivery formats of an image interpretation program for

radiographers. Exploring these factors will contribute to the development of a valuable

body of empirical work to inform radiographer commenting education which is likely to

improve service delivery in emergency healthcare settings and enhance patient

management.


2.8 Conclusions Increasing workloads and demand on healthcare services in Australia are inevitable.

In order to meet government and patient expectations of imaging services, healthcare

providers need to be innovative and improve the current medical imaging service

delivery model. Radiographers are well-positioned to contribute to improving service

delivery by participating in a PIE system. A plethora of evidence exists outisde of

Australia which demonstrates the benefits and barriers of implementing a radiographer

PIE system. However, further research is warranted, as outlined in this review, in the

Australian healthcare setting.

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55 Piper KJ, Paterson A. Initial image interpretation of appendicular skeletal

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56 Kelly B, Rainford L, Gray J, McEntee M. Collaboration between radiological

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the accuracy of diagnostic decisions. Radiography. 2012;; 18: 90-95.

57 Hardy M, Barrett C. Interpretation of trauma radiographs by radiographers and

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58 Coleman L, Piper K. Radiographic interpretation of the appendicular skeleton:

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59 Loughran C. Reporting of fracture radiographs by radiographers: the impact of

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60 Tay Y, Wright C. Image interpretation: Experiences from a Singapore in-house

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61 Torres-Mejía G, Smith RA, de la Luz Carranza-Flores M, et al. Radiographers

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62 Mackay S. The impact of a short course of study on the performance of

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System”. British Journal of Radiology. 2006;; 79: 468-472.

63 Smith T, Traise P, Cook A. The influence of a continuing education program on

the image interpretation accuracy of rural radiographers. Rural and Remote Health.

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64 Smith TN, Baird M. Radiographers' role in radiological reporting: a model to

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65 Jane S, Hall R, Egan I. The red dot system: the outback experience. The

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67 Davies WM. Intensive teaching formats: a review. Issues in Educational

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68 Hinger B. The distribution of instructional time and its effect on group cohesion

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77 White P, Cheung AK. E-learning in an undergraduate radiography programme:

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80 Boutis K, Pecaric M, Seeto B, Pusic M. Using signal detection theory to model

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81 Tudor G, Finlay D. Is there an improvement in performance when radiographs

are re-reported at 24 hours? British Journal of Radiology. 1999;; 72: 465-468.

82 Minnes BG, Sutcliffe T, Klassen TP. Agreement in the interpretation of

extremity radiographs of injured children and adolescents. Academic Emergency

Medicine. 1995;; 2: 826-830.


83 Piper K, Paterson A, Godfrey R. Accuracy of radiographers' reports in the

interpretation of radiographic examinations of the skeletal system: a review of 6796

cases. Radiography. 2005;; 11: 27-34.

84 Brealey S, Scally A, Thomas N. Methodological standards in radiographer plain

film reading performance studies. British Journal of Radiology. 2002;; 75: 107-113.

85 Brealey S, Scally A. Bias in plain film reading performance studies. British

Journal of Radiology. 2001;; 74: 307-316.

86 Brealey S, Scally A, Hahn S, Godfrey C. Evidence of reference standard related

bias in studies of plain radiograph reading performance: a meta-regression. British

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87 Brealey S, Scally A. Methodological approaches to evaluating the practice of

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88 Brealey S, Scally A, Thomas N. Presence of bias in radiographer plain film

reading performance studies. Radiography. 2002;; 8: 203-210.

89 Robinson P, Culpan G, Wiggins M. Interpretation of selected accident and

emergency radiographic examinations by radiographers: a review of 11000 cases.


90 Hardy M, Snaith B, Scally A. The impact of immediate reporting on interpretive

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20120112.

91 Hardy M, Flintham K, Snaith B, Lewis EF. The impact of image test bank

construction on radiographic interpretation outcomes: a comparison study.

Radiography. 2016;; 22: 166-170.

92 Orames C. Emergency department X-ray diagnosis-how do radiographers compare? The Radiographer. 1997;; 44: 52.

Chapter 3: Methods 36

Chapter 3: Methods

3.1 Preamble This chapter will provide a summary of the salient features of the methods used in this

thesis (see Figure 3.1 below) and will provide greater detail of contextual information

to further support this thesis than could have been provided in each manuscript. The

methodological processes for each study have been described in detail in the

manuscripts presented in Chapters 4-7.

Figure 3.1 Thesis Structure – Chapter 3


3.2 Introduction This thesis comprises three discrete yet inter-related studies, using different methods

to answer the respective research questions. The first study used both qualitative and

quantitative research methods to identify and measure radiographers’ image

interpretation ability, confidence, perceived accuracy and education preferences. This

design allowed the researcher to develop a thorough understanding of the gaps in the

evidence before embarking on Study 2 and 3. The second study was the development

and validation of a quantitative measure of image interpretation ability suitable for use

in the final study evaluating two formats of image interpretation education. The overall

program of research reflects a sequential exploratory research design.

3.3 Study Design 3.3.1 Study 1

Study 1 was a cross-sectional survey administered via a web-based platform to

address Aims 1 to 3. This study explored Queensland radiographers’ opinions

regarding self-efficacy of their image interpretation skills, the major benefits, barriers

and enablers of introducing a PIE system and finally which format of education delivery

radiographers prefer. Chapter 4 reports the findings of Aim 1 and Chapter 5 presents

the results of Aims 2 and 3. A detailed description of the questionnaire content and

development is provided in Chapters 4 and 5.

3.3.2 Study 2

Study 2 involved the development and validation of a quantitative outcome measure

suitable for evaluating radiographers’ ability to interpret and comment on trauma

radiographs. This study addressed Aim 4 and implemented a two-stage process.

Stage 1 involved the development of the Image Interpretation Test (IIT) content, as

well as a reference standard and item scoring. Stage 2 involved prospective validation

of the test using a cohort of radiographers. A detailed description of the methods

employed in both stages is provided in Chapter 6.

3.3.3 Study 3

A detailed description of methods used in Study 3 are presented in Chapter 7 as a

published trial protocol. This protocol is positioned in the first part of Chapter 7. Study


3 was a multi-centre, stratified (by years of experience) two group parallel arm, single

blind, randomised controlled trial that examined two formats of education delivery

(intensive versus non-intensive) to address the research aims (Aims 5 and 6). A

randomised controlled trial (RCT) design was chosen as it is considered to generate

a high level of evidence in research. Participants in this study were allocated to one of

two groups: 1) intensive format of education or 2) non-intensive format of education in

a 1:1 ratio to examine whether either education delivery approach is superior to the

other.

The primary outcome measure was the IIT assessment score developed and validated

in Study 2. Participants completed assessments before education, at one week post-

intervention completion and at 12 weeks post-intervention completion. A secondary

outcome measure was used to determine participants’ perceptions of their ability to

interpret radiographs. This involved the development and distribution of two

questionnaires. The first questionnaire was completed at the baseline assessment

prior to randomisation, while the second was completed at the 12-week post-

intervention assessment. The questionnaires were designed to determine

radiographers’ perceptions regarding their confidence and accuracy in their ability to interpret radiographs following completion of the education intervention.

When designing the RCT, the decision to not include a third arm as a control (i.e., a

no education intervention arm) was carefully considered. There were two pertinent

factors that influenced this decision. Firstly, existing evidence already acknowledged

that image interpretation education delivered to radiographers such as the intervention

used in this RCT does improve image interpretation ability. Demonstrating that

receiving education improved image interpretation ability more than not receiving

education would not have been adding any particularly valuable new information to

the field.1-6 Second, each participant’s own baseline assessment (prior to commencing

education) represented their own ability having not (yet) received education, these

baseline assessments offered a useful point of comparison to be made within each

group in addition to the between group comparisons. Thus, the research team

considered that the two arm randomised trial design was the best balance of

methodological rigour, scientific merit and feasibility. In addition, it may have been

more difficult to recruit participants if it were possible that they may have been


randomised to a group that did not (immediately) receive any image interpretation education.

3.4 Setting and Participants 3.4.1 An overview

This program of research was conducted within Metro South Hospital and Health

Service which is situated in south east Queensland, Australia. Queensland is the

second largest state by area and third largest state by population in Australia.7 Metro

South Hospital and Health Service is one of 16 hospital and health services in

Queensland and serves an estimated population of 1.6 million.8 The health service’s

catchment spans 3,856 square kilometres.8 It provides services through a network of

five major hospitals and a number of community health centres. The primary

participating site involved in this research was the Princess Alexandra Hospital.

Princess Alexandra Hospital is a tertiary healthcare centre with approximately 780

beds, providing care in all major adult specialties including tramua.9 The hospital is

deemed as being a Level 1 trauma service by the Royal Australasian College of

Surgeons trauma verification process.10 The Princess Alexandra Hospital Medical

Imaging Department is one of the largest medical imaging departments in

Queensland. It offers emergency imaging 24 hours/day, 7 days/week, 365 days/year.

The emergency imaging division works closely with emergency physicians and plays

an integral role in providing care to patients presenting to the emergency department.

The emergency imaging team is predominantly staffed by two groups of professionals;;

radiographers and radiologists.

Radiographers are health professionals who employ a range of complex equipment to

produce high quality radiographic images that are used to diagnose pathology.

Radiographers in Australia are required to be registered with the Medical Radiation

Practice Board of Australia. Since 1992, all graduate radiographers are required to

have completed a university bachelor degree level in radiography.11 Diagnostic

radiography courses are offered by universities in Queensland, New South Wales,

Victoria, South Australia and Western Australia. Two education models currently exist

in Australia. One is a three-year undergraduate degree plus an intern or clinical year,

termed the Supervised Practice Program (SPP), the second is a four-year program


that incorporates the additional clinical time.12 All Australian universities offering a

radiography program are required to integrate curriculum that prepares radiographers

to identify and communicate significant findings to appropriate members of the health

care team (i.e. providing a radiographer PIE).13

Radiologists are registered medical practitioners who possess a fellowship of the

Royal Australian and New Zealand College of Radiologists awarded upon successful

completion of a five-year traineeship in an accredited clinical radiology department.14

The term ‘radiologist’ employed throughout this thesis is used to denote a radiology

registrar (in training), fellow (completing fellowship year) or consultant radiologist. A

radiologist’s role involves the provision of a high-quality interpretation of radiographic

images that have been produced by a radiographer. This interpretation facilitates diagnosis.

3.4.2 Individual studies

In Study 1, participants were radiographers from four public hospitals in south east

Queensland where radiographer participation in abnormality detection systems was

voluntary. Radiographers were considered eligible for inclusion if they had at least 12

months clinical experience immediately following completion of a 48 week period of

supervised practice and had worked in an emergency setting. This volunteer sampling

approach was undertaken to ensure the sample adequately represented

radiographers who have some understanding of the implementation of a radiographer

abnormality detection system in a public hospital emergency setting.

Participation in Study 2 and Study 3 was available to radiographers from three

metropolitan public hospital medical imaging departments in south east Queensland.

These hospitals were chosen as they each have a dedicated emergency-imaging

department and the management at each site provided approval for potential

participants to be contacted. Radiographers eligible for inclusion in these studies must

have been currently working in an emergency-imaging department and were willing to

undertake either intensive or non-intensive image interpretation training.

Radiographers were excluded from the study if they: had previously completed formal

postgraduate education in image interpretation or commenting (e.g., a master’s


degree that included image interpretation coursework);; were not available to attend

training at the potential scheduled times;; or did not hold full registration as a radiographer with the national board.

For all three studies, radiographers at the participating sites were invited to participate

via email invitation. This was achieved by sending the radiographer clinical educator

at each of the sites an email asking them to forward the invitation to participate to all their radiographers who rotate through their emergency-imaging department.

3.5 Procedure The procedures for the three studies have been outlined in detail in their respective

manuscripts. In addition to content described in Chapter 7, the following education

intervention details for Study 3 are provided in Section 3.5.1.

3.5.1 Education intervention development

Over the past half century, educators have acknowledged multiple learning styles and

techniques used to effectively educate a learner. In 1946, Edgar Dale described the

Learning Pyramid.15 The Pyramid was designed to represent the importance of varying

teaching methods in relation to knowledge retention. The Pyramid suggests the least

effective learning method involves learning through passive information presented

through verbal symbols (i.e., listening to spoken words) which is, in fact, the style of

traditional lectures, while the most effective learning method involves the student

actively participating in learning activities. The Learning Pyramid illustrates the

average retention rates for different teaching strategies, where the traditional lecture

was found to provide the least retention (5%), and more active methods such as

workshops and teaching others, were found to provide the most retention (75-90%).15,

16

The educational intervention employed in this study was originally developed to

enhance junior emergency doctors’ skills in interpreting trauma radiographs,

particularly, appendicular and axial skeletal trauma. This program was refined to suit

radiographers by the original authors. To cater for multiple learning styles and to

adhere to the Learning Pyramid, a blended learning environment was developed

combining two distinct strategies;; passive traditional classroom with an interactive

practical component. The traditional approach consisted of power point presentations


presented by expert instructors which allowed the learner to gain the knowledge

required to improve their image interpretation skills. The interactive practical approach

involved the learner actively participating in interpreting several trauma radiographs.

This allowed the learner the opportunity to practice this skill and to build self-

confidence for transfer outside of the classroom. Combing these two strategies of

learning maximised the;; flexibility of learning, the learner’s engagement, group cohesion and the retention rate for learning.

Hermann Ebbinghaus in 1885 was involved in studies investigating the human

memory.17 Ebbinghaus found that the stronger the memory, the longer period of time

a person is able to recall it.17 He also found that humans tend to halve their memory

of newly learned knowledge in a matter of days or weeks unless they consciously

review the learned material.17 With this knowledge of the importance of a strong

memory this education program incorporated and developed a number of original

acronyms and mnemonics to assist the learner with memory retention. These aids for

memory retention were utilised regularly throughout the interactive practical activities

where each repetition in learning increases the retention rate to support students

practising the skills learnt to build capability.

A range of educational research has also indicated that the factors determining student

learning are wide ranging, and include the level of student motivation, the expertise of

the instructors, the relevance of the learning material, instructor enthusiasm, active

learning, relaxed learning environment, well-planned and structured activities and the

use of different teaching strategies.18-20 To achieve these objectives, the education

program delivered in this program of research used a variety of learning strategies

which included multi-sense (use of more than one of the five senses), psychomotor

(the development of hands-on skills to promote memory retention) and affective

(change in attitude to learning) strategies. An example of the use of multiple sense

learning is evidence in one of the interactive practicals where the learner uses their

image interpretation skills in front of the class with the use of a variety of magnetic

words and with assistance from their peers. Here the student utilises the senses of

sight, sound and touch. The continuous use of interactive practical activities allows the

learner to hone their psychomotor skills to the level where they don’t have to think so

hard about how to interpret an x-ray while they are interpreting their radiographic

images. Finally, affective learning involves reaching the emotional and belief system


aspects of those who participate in it. This style of learning is demonstrated by the

facilitators promoting a safe and open learner-centred environment. It was hoped that

such an environment would be a welcome contrast to the high-pressure environment

in which junior doctors usually find themselves. Mezirow’s (1990) research described

these ideal conditions of affective learning which this education program adheres to and how more complex learning occurs when an affective change has occurred.21

3.6 Ethical Approval Ethical approval for all three studies was granted by the Human Research Ethics

Committees of both the Metro South Hospital and Health Service

(HREC/11/QPAH/172) and the Queensland University of Technology (1200000061).

3.7 References for Chapter 3 1 McConnell J, Devaney C, Gordon M, Goodwin M, Strahan R, Baird M. The



184-190.













2009;; 9: 1145.

7 Queensland Government [homepage on the internet]. Brisbane, Queensland

[updated 2000 January 1;; cited April 9 2018]. Available from

https://www.qld.gov.au/about/about-queensland/statistics-facts/facts.


8 Queensland Govenment. Metro South Hospital and Health Service Annual

Report 2016–2017. Queensland Health, Brisbane, Queensland, 2017.

9 Queensland Government [homepage on the internet]. Brisbane, Queensland

[updated 2018 January 3;; cited April 9 2018]. Available from

https://metrosouth.health.qld.gov.au/radiology?provider=66.

10 Royal Australasian College of Surgeons [homepage on the internet]. Kangaroo

Point, Queensland [cited April 9 2018]. Available from https://www.surgeons.org/for-

hospitals/trauma-verification/.

11 Australian Society of Medical Imaging and Radiation Therapy [homepage on

the internet]. Melbourne, Victoria [cited May 25 2018]. Available from

https://www.asmirt.org/careers-and-employment/overseas-assessments.

12 Australian Institute of Radiography. Review of the Professional Development

Year. Melbourne, Victoria, 2009.

13 Medical Radiation Practitioner Board of Australia. Medical radiation practice

accreditation guidance material. Australian Health Practitioner Regulation Agency,


14 The Royal Australian and New Zealand College of Radiologists [homepage on

the internet]. Sydney, New South Wales [cited April 9 2018]. Available from

https://www.ranzcr.com/trainees/clinical-radiology/training-program.

15 Dale E. Audiovisual methods in teaching. Holt, Reinhart & Winston, New York,

1946.

16 Masters K. Edgar Dale's pyramid of learning in medical education: a literature

review. Medical Teacher. 2013;; 35: 1584-1593.

17 Ebbinghaus H. Memory: a contribution to experimental psychology. Annals of

Neurosciences. 2013;; 20: 155.

18 Conrad P. Attributes of high-quality intensive course learning experiences:

Student voices and experiences. College Student Journal. 1996;; 30: 69-77.

19 Daniel EL. A review of time-shortened courses across disciplines. College

Student Journal. 2000;; 34: 298-308.

20 Wlodkowski RJ. Accelerated learning in colleges and universities. New

Directions for Adult and Continuing Education. 2003;; 2003: 5-16.

21 Mezirow J. Transformative dimensions of adult learning. Jossey-Bass, San Francisco, 1991

Chapter(4:(Survey(of(the(benefits,(barriers(and(enablers(of(PIE( 45#

Chapter( 4:( Radiographer( commenting(

of(trauma(radiographs:(a(survey(of(the(

benefits,( barriers( and( enablers( to(

participation(in(an(Australian(healthcare(

setting(!

!

!

!

!

!

!

!

!

!

!

!

!

!

!

!

This!chapter!contains!the!content!of!Manuscript!1:!

Neep( MJ,( Steffens( T,( Owen( R,( McPhail( SM.( Radiographer( commenting( of(

trauma( radiographs:( a( survey( of( the( benefits,( barriers( and( enablers( to(

participation(in(an(Australian(healthcare(setting.(Journal(of(Medical(Imaging(and(

Radiation(Oncology.(2014(Aug(1J58(4):431P8.

!

This!chapter!is!presented!as!it!was!published,!with!the!exception!of!changes!to!

support!consistent!chapter!formatting!throughout!the!thesis.!


!

Statement(of(Contribution(of(Co=Authors(for(Thesis(by(Published(Paper(

The!authors!listed!below!have!certified!that:!1.! they!meet!the!criteria!for!authorship!in!that!they!have!participated!in!the!

conception,!execution,!or!interpretation,!of!at!least!that!part!of!the!publication!in!their!field!of!expertise>!!

2.! they!take!public!responsibility!for!their!part!of!the!publication,!except!for!the!responsible!author!who!accepts!overall!responsibility!for!the!publication>!

3.! there!are!no!other!authors!of!the!publication!according!to!these!criteria>!!4.! potential!conflicts!of! interest!have!been!disclosed!to!(a)!granting!bodies,!

(b)!the!editor!or!publisher!of!journals!or!other!publications,!and!(c)!the!head!of!the!responsible!academic!unit,!and!!

5.! they!agree!to!the!use!of!the!publication!in!the!student’s!thesis!and!its!publication!on!the!QUT’s!ePrints!site!consistent!with!any!limitations!set!by!publisher!requirements.!

!In!the!case!of!this!chapter:!!Chapter!4!–!Manuscript!1.!Neep!MJ,!Steffens!T,!Owen!R,!McPhail!SM.!Radiographer!commenting!of!trauma!radiographs:!a!survey!of!the!benefits,!barriers!and!enablers!to!participation!in!an!Australian!healthcare!setting.!Journal!of!medical!imaging!and!radiation!oncology.!2014!Aug!1>58(4):431W8.!!

Contributor( Statement(of(contribution*(Michael!Neep! !

Study!conception!and!experimental!design,!data!collection!and!management,!analyses!of!data,!principal!manuscript!writing!and!preparation,!manuscript!appraisal!and!editing.!

29.05.18! !Tom!Steffens!!

Aided!experimental!design,!manuscript!appraisal!and!editing.!!

Dr!Rebecca!Owen!!

Aided!manuscript!appraisal!and!editing.!!

Assoc,!Prof.!Steven!McPhail!

Aided!study!conception!and!experimental!design,!primary!support!for!data!analyses!and!manuscript!appraisal!and!editing.!

Principal(Supervisor(Confirmation(I!have!sighted!email!or!other!correspondence!from!all!CoWauthors!confirming!their!certifying!authorship.!(If!the!Co!Wauthors!are!not!able!to!sign!the!form!please!forward!their!email!or!other!correspondence!confirming!the!certifying!authorship!to!the!RSC).!

Assoc.!Prof.!Steven!McPhail!Name! Signature! Date!!



4.1( Preamble!

The!review!of!literature!presented!in!Chapter!2!identified!that!no!prior!studies!

had!examined!Australian! radiographers’!perceptions!of! the!benefits,!barriers!

and! enablers! of! participating! in! a! radiographer! commenting! system.! This!

chapter!describes!Study!1,!a!crossWsectional!survey!that!addressed!Aim!1!(see!

Figure!4.1!below).!The!findings!of!this!chapter!helped!inform!the!design!of!the!

Study! 3! which! explored! the! effectiveness! of! two! different! formats! of! image!

interpretation! education! for! radiographers.! Furthermore,! the! results! of! this!

chapter! are! likely! to! prove! valuable! to! the! Australian! healthcare! setting! in!

planning!for!the!implementation!of!frontline!radiographer!image!interpretation!

services.!!

!

!Figure!4.1! Thesis!Structure!–!Chapter!4!

!


4.2( Radiographer(commenting(of(trauma(radiographs:(a(survey(of(the(

benefits,(barriers(and(enablers(to(participation(in(an(Australian(

healthcare(setting(

(

4.2.1!Abstract!!

Introduction:!!

Radiographer! abnormality! detection! systems! that! highlight! abnormalities! on!

trauma!radiographs!(‘red!dot’!system)!have!been!operating!for!more!than!30!

years.! Recently! a! number! of! pitfalls! have! been! identified.! These! limitations!

initiated! the! evolution! of! a! radiographer! commenting! system,! whereby! a!

radiographer! provides! a! brief! description! of! abnormalities! identified! in!

emergency! healthcare! settings.! This! study! investigated! radiographers'!

participation! in! abnormality! detection! systems,! their! perceptions! of! benefits,!

barriers!and!enablers!to!radiographer!commenting,!and!perceptions!of!potential!

radiographer!image!interpretation!services!for!emergency!settings.!

!

Methods:!!

A! crossWsectional! survey! was! implemented.! Participants! included!

radiographers! from! four! metropolitan! hospitals! in! Queensland,! Australia.!

Conventional! descriptive! statistics,! histograms! and! thematic! analysis! were!

undertaken.!!

!

Results:!!

SeventyWthree! surveys! were! completed! and! included! in! the! analysis! (68%!

response!rate)>!30(41%)!of!respondents!reported!participating! in!abnormality!

detection!in!20%!or!less!of!examinations,!26(36%)!reported!participating!in!80%!

or!more!of!examinations.!Five!overarching!perceived!benefits!of!radiographer!

commenting! were! identified>! assisting!multiWdisciplinary! teams,! patient! care,!

radiographer!ability,! professional! benefits! and!quality! of! imaging.!Frequently!

reported!perceived!barriers! included!‘difficulty!accessing!image!interpretation!

education’,! ‘lack! of! time’,! and! ‘low! confidence! in! interpreting! radiographs’.!

Perceived! enablers! included! ‘access! to! image! interpretation! education’! and!

‘support!from!radiologist!colleagues’.!!

!


Conclusions:!!

A!range!of!factors!are!likely!to!contribute!to!the!successful!implementation!of!

radiographer! commenting! in! addition! to! abnormality! detection! in! emergency!

settings.!Effective! image! interpretation!education!amenable! to!completion!by!

radiographers! would! likely! prove! valuable! in! preparing! radiographers! for!

participation!in!abnormality!detection!and!commenting!systems!in!emergency!

settings.!!

(

Key(words!!

Education,!Image!interpretation,!healthcare,!radiographer!

!

4.2.2(Introduction(

Radiographers! in! some! emergency! settings! began! participating! in! an!

abnormality! detection! system! in! the! early! 1980s.1! An! abnormality! detection!

system! (commonly! known! as! ‘red! dot’)! was! first! introduced! in! the! United!

Kingdom! (UK)! to! alert! the! referring! emergency! clinician! to! the! possible!

presence!of! a! traumatic! abnormality.! This! system! involved! the! radiographer!

simply!marking!the!radiograph!with!a!small!red!sticker!when!the!radiographer!

detected!a!possible!abnormality1.!Numerous!studies!have!since!demonstrated!

the! effectiveness! of! this! system.2,! 3! However,! the! simplicity! of! the! ‘red! dot’!

system! is! not! without! pitfalls.4,! 5! The! ‘red! dot’! system! is! voluntary! and! only!

distinguishes!between!normal!and!abnormal!pathology.!It!offers!no!opportunity!

to! indicate! the! location!or! severity!of! the!abnormality,! presence!of!a!normal!

variant!or!the!number!of!abnormalities!present.!!

!

An! evolution! of! a! detection! only! system! has! been! the! development! of!

radiographer! commenting! systems.! Radiographer! commenting! systems! not!

only!indicate!the!possible!presence!of!a!traumatic!pathology,!but!also!provide!

the!radiographer!with!opportunity!to!include!a!brief!comment!on!the!nature!and!

location!of!possible!abnormalities!present.!!!

!

Radiographer!abnormality!detection!and!commenting!is!not!intended!to!replace!

radiologist! reports,!but!assist!multidisciplinary!clinical! teams!and! radiologists!

when! viewing! and! interpreting! radiographs.! Benefits! of! frontline! image!


interpretation! integrated!within! radiographer!services!have!been!reported.4W11!

Previous! research! has! indicated! radiographer! commenting! systems! that!

highlight!and!describe!acute!abnormalities!at! the!point!of! care!can!expedite!

service! delivery! and! improve! the! accuracy! of! diagnoses! to! enhance! patient!

outcomes! in! emergency! settings.4,! 5,! 11,! 12! Similarly,! previous! research! has!

suggested! that! nurse! practitioners! may! also! be! able! to! contribute! towards!

improving! the! service! in! the! emergency! department! by! interpreting!

radiographs.13! A! literature! review! conducted! by! Australian! researchers!

acknowledged!that!further!research!is!necessary!to!establish!the!clinical!utility!

of!nurses!to!interpret!radiographs.14!

!

Contemporary! healthcare! standards! indicate! that! nonWurgent! radiological!

studies!must!have!a!report!provided!to!the!referring!doctor!within!24!hours!of!

imaging!in!order!to!influence!patient!management1.5!This!may!be!problematic!

in! public! healthcare! settings! with! high! demand! and! limited! resourcing.! For!

example,! the! 2011W12! Radiology! Services! Profile! for! public! hospitals! in!

Queensland,! highlighted! only! 56%! of! all! radiologist! diagnostic! reports! were!

available!within!24!hours.16!!

!

In! emergency! departments,! a! delay! in! availability! of! radiologist! reports! can!

mean!that!decisions!regarding!clinical!management!or!discharge!may!be!made!

by!the!referring!clinical!team!without!consideration!of!the!radiologist!report.!The!

absence! of! a! radiologist! report! or! radiographer! comment! within! clinically!

relevant!timeframes!is!a!potential!risk!to!patients!accessing!health!care!services!

through! increased! likelihood! of! missed! or! incorrect! diagnosis.17,! 18! This!

represents! a! major! shortcoming! in! the! contemporary! clinical! model! that! is!

dependent! on! junior!medical! officers! for! immediate! interpretation!of!medical!

images!without!a!radiologist!report.!International!evidence!acknowledges!that!

medical! school! curriculum! often! incorporates! little! radiology! and! many!

emergency! departments! do! not! have! a! structured! image! interpretation!

education!program!for!junior!doctors.19,!20!Furthermore,!junior!doctors!with!little!

experience! in! interpreting! radiographs! often! work! demanding! shifts! in!

emergency! departments! and! errors! do! occur.20W24! Similar! to! junior! doctors,!

radiographers! also! make! incorrect! interpretations! of! trauma! radiographs.! A!


study! in!Brisbane!in!2012!indicated!that!errors!made!by!radiographers!when!

interpreting!radiographs!are!different! to! those!made!by! junior!doctors.25!This!

study! acknowledged! that! when! an! emergency! doctor! and! radiographer’s!

interpretation!of!a! radiograph! is!combined! the!overall!diagnostic!accuracy! is!

enhanced!compared!to!the!accuracy!of!emergency!doctors!alone.25!!

!

Despite! the! development! of! radiographer! commenting! systems! in! the! UK!

National!Health!Service,! there! is!a!scarcity!of!peerWreviewed!research! in!this!

field! conducted! outside! the! UK.! Several! preliminary! studies! have! trialled!

radiographer! image! interpretation! in! Australian! settings,! all! yielding!

encouraging!results.5,!6,!8,!9,!25W27!The!purpose!of! this!study!was! to! investigate!

radiographers'!current!participation!in!abnormality!detection!systems,!and!their!

perceptions! of! the! benefits! of! radiographer! commenting>! the! barriers! and!

enablers! to! radiographer! commenting>! and! the! level! of! radiographer! image!

interpretation! service! that! they! consider! appropriate! for! public! hospital!

emergency!settings.!

!

4.2.3(Methods(

Design!

A!crossWsectional!webWbased!survey!was!implemented.!!

!

Ethics!

The!Human!Research!Ethics!Committees!of! the!Metropolitan!South!Hospital!

and! Health! Service! District! and! the! Queensland! University! of! Technology!

approved!this! investigation.!Potential!participants!were!provided!with!a!study!

information! sheet! as! part! of! the! email! invitation>! choosing! to! complete! the!

survey!was! taken! as! consent! to! participate.!Participation!was! voluntary.!No!

personal!identifying!information!was!attached!to!the!survey!responses.!

!

Participants!and!setting!

A!total!of!108!radiographers!were!identified!as!eligible!for!participation!and!were!

invited!to!complete!the!survey.!Participants! included!radiographers!from!four!

metropolitan! hospitals! in! Queensland! where! radiographer! participation! in!

abnormality! detection! systems! is! currently! voluntary.! Radiographers! were!


considered! eligible! for! inclusion! if! they! had! at! least! 12! months! clinical!

experience!immediately!following!completion!of!a!48!week!period!of!supervised!

practice! and! had! worked! in! an! emergency! setting.! This! volunteer! sampling!

approach! was! undertaken! to! ensure! the! sample! adequately! represented!

radiographers! who! have! some! understanding! of! the! implementation! of! a!

radiographer! abnormality! detection! system! in! a! public! hospital! emergency!

setting.!The!current!radiographer!abnormality!detection!systems!that!operate!in!

the!four!participating!facilities!encourage!(but!do!not!mandate)!radiographers!

to!flag!abnormalities!on!trauma!radiographs.!Within!the!participating!settings,!

radiographers! are! encouraged! to! highlight! trauma! abnormalities! of! the!

appendicular! and! axial! musculoskeletal! system! as! well! as! a! suspected!

pneumothorax.!!

!

Survey!content!and!procedure!

The!custom!designed!questionnaire!consisted!of!five!sections!(see!Appendix!

A).! The! first! contained! questions! about! demographic! information! including!

years!of!clinical!experience!and!gender,!whilst!the!second!asked!respondents!

whether!they!participate!in!an!abnormality!detection!system!(yes!or!no)!and!the!

estimated!proportion!of!cases!in!which!they!participate.!Respondents!were!then!

asked! to! identify!benefits!of!a! radiographer!commenting!system! in! their!own!

words.!The! fourth! section!asked! respondents! to!describe!perceived!barriers!

and!enablers! to! implementing!a! front! line! image! interpretation!service!again!

using! openWended! responses.! The! questionnaire! concluded! by! asking!

respondents! to! nominate! the! level! of! a! radiographer! image! interpretation!

service! they! considered! appropriate! for! implementation! in! public! hospital!

emergency!settings!on!a!Likert!scale.!The!questionnaire!was!piloted!among!

radiographers!with!experience!using!abnormality!detection!systems!that!were!

not!from!the!participating!hospitals.!During!the!piloting!of!the!survey!instrument,!

cognitive!pretesting!methods!were!used!to!ensure!the!questions!were!easy!to!

understand,! were! interpreted! as! intended,! and! that! response! options! were!

clearly! understood.28! This! resulted! in! an! amendment! of! one! of! the! original!

questions!due!to!potentially!misleading!terminology.!

!


Eligible!radiographers!from!the!four!facilities!were!invited!to!participate!via!an!

email!containing!a!hyperlink! to! the!webWbased!survey!platform.!This!allowed!

respondents!to!complete!the!questionnaire!at!their!convenience!and!submit!it!

online.!A!reminder!email!was!sent!one!week!before!the!closure!of!the!4Wweek!

data! collection! period! to! maximise! the! response! rate.! The! time! required! to!

complete!the!questionnaire!was!approximately!15!minutes.!!

!

Analysis!

Conventional!descriptive!statistics!(number,!percentage>!median,!interquartile!

range! (IQR)! and! range)! were! used! to! describe! participants’! demographic!

information!and!participation!in!an!abnormality!detection!system.!OpenWended!

responses!were!independently!coded!by!two!researchers!who!then!consulted!

with! each! other! to! derive! a! set! of! agreed! data! categories.! These! similar!

categories! were! then! considered! as! an! overarching! theme.! The! number! of!

responses! coded! into! each! category! were! recorded! and! expressed! as! a!

percentage! of! total! responses.! Response! frequency! was! also! used! to!

determine!the!primary!emerging!categories!for!perceived!barriers!and!enablers.!!

!!

4.2.4(Results(

A! total!of!73! (68%!response! rate)!completed! the!survey.!The!median! (interW

quartile!range)!years!of!radiographer!experience!was!5!(2!to10).!The!range!of!

experience!was!from!1!to!36!years.!FortyWnine!(67%)!respondents!were!female.!

Sixty! (82%)! respondents! reported! that! they! currently! participate! in! an!

abnormality! detection! system.! The! proportion! of! cases! that! radiographers!

reported!participating!in!an!abnormality!detection!system!is!displayed!in!Figure!

4.2.!The!pattern!of!responses!indicated!a!biWmodal!distribution!with!two!focal!

maxima! at! either! end! of! the! participation! range!with! 30! (41%)! respondents!

reporting!levels!of!participation!in!the!0W20%!range!and!26!(36%)!respondents!

reporting!participating!in!an!abnormality!detection!system!for!80W100%!of!cases.!

!


(

Figure!4.2! Histogram!representing!the!proportion!of!cases!(out!of!100)!that!

radiographers!participate!in!an!abnormality!detection!system!

!

Radiographers! reported! a! variety! of! perceived! benefits! from! potential!

participation!in!a!radiographer!commenting!system!(Table!4.1).!Some!of!most!

frequent! responses! referred! to! “assisting( junior( medical( staff( in( identifying(

traumatic( pathologies”! (Participant! 28)! as! they! “are( not( well( trained( (or(

experienced)( in( xPray( interpretation”! (Participant! 12),! enhancing!

“communication(and(teamwork(within(the(emergency(department”!(Participant!

Chapter(4:(Survey(of(the(benefits,(barriers(and(enablers(of(PIE( 55"

19)$ leading$ to$ “improved(patient(care”( (Participant$73)$and$promoting$ “an(efficient(and(streamlined(patient( treatment( /(diagnosis”(

(Participant$66).$$

$

Table$4.1$Radiographers’$perceived$benefits$of$a$radiographer$commenting$systemC$divided$into$categories$within$five$themes$$Radiographer+ability+Benefits(relating(to(the(skills(and(knowledge(of(

radiographers+

Patient+care+Benefits(associated(with(improved(care(and(patient(outcomes+

Assisting+multi7discipline+teams+

Benefits(that(assists(the(team(in(their(clinical(roles+

Quality+of+imaging+Benefits(to(the(profession((and(individuals(working(within(the(profession)+

Profession+Benefits(to(the(profession((and(individuals(working(within(the(profession)+

1.$Knowledge$of$abnormal$and$normal$pathology$n$=$22$(30%)+

1.$Less$abnormalities$missed$n$=$25$(34%)$

1.$Support$junior$medical$officers$n$=$36$(49%)$

1.$Enhanced$understanding$of$required$image$quality$n$=$24$(33%)$

1.$Improve$job$satisfaction$n$=$20$(27%)$

$2.$Skill$in$detecting$and$describing$pathology$n$=$9$(12%)+

$2.$Expedited$service$delivery$n$=$24$(33%)$

$2.$Enhanced$communication$n$=$20$(27%)$

$ $2.$Improve$awareness$of$the$radiographer$profession$n$=$7$(9%)$

$3.$Confidence$in$their$ability$to$detect$and$describe$pathology$n$=$12$(16%)$

$ $ $ $3.$Opportunity$for$career$advancement$n$=$6$(8%)$

$


The$ summary$ of$ radiographers’$ perceived$ barriers$ to$ the$ implementation$ of$

successful$ radiographer$ commenting$ systems$ are$ presented$ in$ Table$ 4.2.$

Responses$were$coded$into$thirteen$categories$of$barriers.$The$most$frequent$

potential$barriers$to$implementing$a$radiographer$commenting$system$included$

access$to$targeted$image$interpretation$education$(n=32,$43%),$lack$of$time$to$

review$radiographs$(n=30,$41%)$and$radiographers’$low$confidence$to$interpret$

radiographs$(n=24,$33%).$$

$

Table$4.2$ Perceived$ barriers$ that$ radiographers$ believe$ inhibit$ the$

implementation$of$a$successful$radiographer$commenting$system$

$

Perceived(barriers( N((%)(Access$to$targeted$image$interpretation$education$ 32$(43%)$

Lack$of$time$to$review$radiographs$ 30$(41%)$

Radiographers’$low$confidence$to$interpret$radiographs$ 24$(33%)$

Inconsistency$in$use$and$absence$of$guidelines$ 17$(23%)$

Resistance$to$participate$by$radiographers$ 11$(15%)$

Radiologists$resistance$to$change$ 10$(14%)$

Radiographers$fear$that$they$could$be$wrong$ 9$(12%)$

Junior$medical$officers’$awareness$of$such$a$system$ 8$(11%)$

Emergency$departments$lack$of$trust$in$the$system$ 5$(6%)$

Medico$legal$issues$ 4$(5%)$

Resistance$from$other$professions$ 3$(4%)$

Scope$of$practice$concerns$ 2$(3%)$

Deficient$emergency$department$communication$ 2$(3%)$

$

( $


The$ potential$ enablers$ for$ the$ implementation$ of$ successful$ radiographer$

commenting$ systems$ are$ presented$ in$ Table$ 4.3.$ A$ total$ of$ 14$ perceived$

enablers$were$identified.$Access$to$image$interpretation$education$(n=65,$89)$

was$ identified$ as$ an$ enabler$ five$ times$more$ frequently$ than$ the$ next$most$

common$ response.$ The$ two$ next$ most$ frequently$ identified$ enablers$ were$

support$from$radiologists$(n=13,$18%)$and$junior$doctors$being$aware$that$the$

system$ was$ in$ place$ in$ order$ to$ utilise$ the$ radiographer$ comments$ in$ their$

clinical$practice$(n=13,$18%).$

$

Table$4.3$ Perceived$ enablers$ that$ would$ assist$ the$ successful$

implementation$of$a$radiographer$commenting$system$

$

Perceived(enablers( N((%)(Access$to$image$interpretation$education$ 65$(89%)$

Support$from$Radiologists$ 13$(18%)$

Awareness$of$radiographer$commenting$system$by$junior$medical$officers$ 13$(18%)$

Improved$communication$with$emergency$department$$ 10$(14%)$

Clear$guidelines$(radiographer$commenting$role$clearly$defined)$ 8$(11%)$

Consistent$rostering$of$competent$radiographers$ 6$(8%)$

Support$from$radiography$management$ 5$(7%)$

Allowing$time$to$review$radiographs$ 5$(7%)$

Continuous$audit$on$quality$of$the$radiographer$comment$ 5$(7%)$

Support$from$national$governing$body$ 4$(5%)$

Evidence$that$such$a$system$works$ 4$(5%)$

Willing$participation$from$radiographers$ 4$(5%)$

Implementation$of$a$standardised$radiographer$comment$worksheet$ 2$(2%)$

Medico$legal$cover$ 1$(1%)$

$

Radiographers’$ ratings$on$a$ five$point$Likert$ scale$of$agreement$ (1=strongly$

disagree,$ 5=strongly$ agree)$ with$ six$ statements$ about$ radiographers’$

involvement$ in$ an$ integrated$ image$ interpretation$ service$ are$ presented$ in$

Figure$4.3.$The$pattern$of$responses$varied$across$the$six$statements.$Strong$

disagreement$with$the$statement$that$‘radiographers$should$never$provide$an$


image$interpretation$opinion$was$evident$(Figure$4.3a).$This$matched$the$strong$

agreement$ with$ the$ statement$ that$ radiographers$ should$ participate$ in$ an$

abnormality$ detection$ system$ (Figure$ 4.3d).$ Radiographers$ had$ differing$

opinions$on$whether$a$written$description$(radiographer$comment)$should$be$

provided$for$each$case$(Figure$4.3e),$but$most$disagreed$or$strongly$disagreed$

that$ a$ complete$ diagnostic$ report$ should$ be$ provided$ by$ the$ radiographer$

(Figure$4.3f).$$$

$$

$$

Figure$4.3$ $Histogram$ representing$ radiographers’$ level$ of$ agreement$

(1=strongly$disagree,$5=strongly$agree)$with$ six$ statements$ (“Radiographers$

should…”)$about$potential$involvement$in$an$image$interpretation$service(


$

4.2.5(Discussion(This$has$been$the$first$study$to$report$the$perceptions$of$Australian$radiographers$with$

respect$ to$ participation$ in$ voluntary$ abnormality$ detection$ systems_$ their$ perceived$

benefits,$ barriers$ and$enablers$ to$ the$ successful$ implementation$of$ a$ radiographer$

commenting$system$in$emergency$care$settings.$A$large$proportion$of$radiographers$

reported$ participating$ in$ abnormality$ detection$ systems.$ However,$ the$ level$ of$

participation$was$not$consistent$with$some$radiographers$ taking$part$ in$abnormality$

detection$for$almost$all$examinations,$while$others$rarely$contributed$to$abnormality$

detection.$This$inconsistent$participation$may$be$attributed$to$several$factors$including$

the$ voluntary$ nature$ of$ participation,$ mixed$ confidence$ levels$ in$ interpreting$

radiographs,$inconsistent$implementation$of$abnormality$detection$systems$or$variable$

time$availability$(to$review$each$radiograph)$across$emergency$care$settings.$

$

The$ Medical$ Radiation$ Practice$ Board$ of$ Australia’s$ statement$ on$ professional$

capabilities$ for$medical$ radiation$practice,29$ recommends$ that$ radiographers$ are$ to$

communicate$ results$ of$ diagnostic$ tests$ to$ referring$ doctors$ when$ they$ identify$

significant$ abnormal$ findings.$ This$ investigation$ has$ demonstrated$ some$

radiographers$ in$ Australian$ emergency$ settings$ may$ not$ be$ following$ this$

recommendation.$Perhaps$ this$should$be$a$point$of$concern$among$radiographers,$

managers$of$medical$imaging$departments$or$to$the$Medical$Radiation$Practice$Board$

of$Australia.$

$

Despite$the$evidence$of$benefit,$some$resistance$to$radiographer$image$interpretation$

has$ been$ reported.8,$ 30$Research$ evidence$ questioning$ the$ benefit$ of$ radiographer$

participation$in$a$frontline$image$interpretation$service$is$generally$lacking.$However,$

one$study$has$recently$questioned$the$benefit$of$the$‘red$dot’$radiographer$abnormality$

detection$system$in$tertiary$hospitals.31$This$study$set$out$to$investigate$the$accuracy$

(sensitivity$and$specificity)$of$ the$ ‘red$dot’$system$utilising$a$retrospective$review$of$

radiographic$examinations$at$a$single$facility.$Due$to$their$retrospective$study$design$

and$the$voluntary$nature$of$participation$in$the$‘red$dot’$system,$this$did$not$allow$the$

investigators$ to$ distinguish$ between$ ‘no$ abnormality$ detected’$ (no$ red$ dot)$ and$

‘radiographer$did$not$participate$in$the$red$dot$system$for$this$radiograph’$(also$no$red$

dot).$ Findings$ from$ the$ current$ study$ highlighted$ that$ a$ substantial$ proportion$ of$


radiographers$choose$ to$participate$ in$voluntary$ ‘red$dot’$systems$ less$ than$ twenty$

percent$of$the$time.$It$is$likely$that$a$large$proportion$of$the$‘false$negative’$cases$in$

this$previous$study$were$a$result$of$radiographer$nonaparticipation.$$

$

Perhaps$ more$ importantly,$ this$ highlights$ a$ key$ pitfall$ of$ voluntary$ radiographer$

abnormality$ detection$ systems$ for$ clinical$ care.$ When$ radiographer$ abnormality$

detection$ is$ voluntary,$other$members$of$ the$multidisciplinary$ team$may$be$unsure$

whether$the$radiographer$did$not$detect$an$abnormality,$or$was$not$participating$in$the$

abnormality$detection$system.$It$may$also$lead$to$radiographer$participation$in$cases$

where$ an$ abnormality$ is$ overtly$ evident,$ for$ example,$ a$ joint$ dislocation,$ and$ nona

participation$in$cases$where$abnormality$detection$would$require$closer$consideration$

and$possibly$greater$skill,$confidence$and$time$commitment$to$the$task,$for$example,$

an$avulsion$fracture$of$the$triquetral$carpal$bone.$

$

The$ five$ themes$ of$ radiographer$ perceived$ benefits$ from$ the$ successful$

implementation$of$a$radiographer$commenting$system$were$congruent$with$previous$

research$ investigating$ radiographer$ image$ interpretation$ internationally.4a6,$ 11,$ 12$ A$

number$of$previous$reports$have$highlighted$that$junior$emergency$doctors$have$little$

experience$ in$ interpreting$radiographs$and$ that$errors$ in$ interpretation$occur.19,$21a24$

Previous$ studies$ have$ shown$ that$ between$ 1%$ and$ 7%$ of$ radiographs$ are$

misinterpreted$by$emergency$doctors.23,$32$The$most$commonly$missed$findings$were$

fractures$and$pulmonary$nodules.$$

$

The$ perceived$ potential$ benefits$ reported$ by$ respondents$ in$ this$ study$ extended$

beyond$ those$ related$ to$ improved$patient$care$and$assisting$other$members$of$ the$

multiadisciplinary$team.$The$respondents$also$indicated$that$radiographer$commenting$

might$ lead$ to$ improved$ skills,$ career$ advancement$ opportunities$ and$ improved$ job$

satisfaction.$This$finding$is$consistent$with$research$in$this$field$from$the$UK.33,$34$

$

The$realisation$of$any$benefit$from$a$radiographer$commenting$system$hinges$on$its$

successful$implementation.$Interestingly,$both$the$most$frequently$identified$barrier$to$

and$enabler$of$the$successful$implementation$of$a$radiographer$commenting$system$

centred$on$the$importance$of$access$to$image$interpretation$education.$While$some$

postgraduate$university$qualifications$(for$example,$a$masters$degree)$involving$image$


interpretation$coursework$are$available,$clinical$radiographers$are$likely$to$find$formal$

university$coursework$of$this$nature$inaccessible.$This$inaccessibility$may$be$due$to$

large$(often$inflexible)$time$requirements$and$a$substantial$financial$commitment.$The$

financial$ cost$ is$ not$ limited$ to$ tuition$ fees,$ but$ may$ also$ include$ leaving$ current$

employment$ (or$ taking$ extended$ leave)$ during$ semester$ to$ attend$ coursework$

activities.$$$

$

An$alternative$to$regimented$postgraduate$university$qualifications$is$targeted$image$

interpretation$ training$ for$ radiographers.$ Targeted$ image$ interpretation$ training$

programs$in$shortacourse$formats$exist$in$the$UK.4$However,$lack$of$access$to$suitable$

shortacourse$ image$ interpretation$education$ for$diagnostic$ radiographers$ remains$a$

barrier$ to$ the$ successful$ implementation$ of$ a$ radiographer$ commenting$ system$ in$

regions$ where$ image$ interpretation$ education$ is$ not$ readily$ available.$ Initial$

radiographer$ image$interpretation$training$seems$a$critical$ first$step$to$radiographer$

involvement$in$an$integrated$image$interpretation$service$in$emergency$settings.$Initial$

research$in$this$field$has$indicated$that$short$course$training$enhances$radiographers’$

confidence$and$ability$to$interpret$plain$radiographs.2,$4,$25,$26,$35a37$

$

Another$ important$ topic$ that$ was$ raised$ as$ both$ an$ enabler$ of$ and$ barrier$ to$ the$

successful$ implementation$ of$ an$ image$ interpretation$ service$ was$ the$ support$ or$

potential$ lack$of$support$from$radiologists$ in$healthcare$services.$It$ is$not$surprising$

that$radiographers$consider$the$support$of$radiologists$as$an$important$facilitator$to$the$

successful$implementation$of$a$radiographer$commenting$system.$This$may$be$due$to$

the$interarelated$and$interadependent$roles$that$radiologists$and$radiographers$provide$

in$diagnostic$imaging$services,$as$well$as$their$longstanding$history$of$working$together$

for$ the$ common$ good$ of$ their$ patients$ receiving$ medical$ imaging$ services.$ One$

potential$ concern$ that$ has$ been$ raised$ is$ the$ potential$ for$ loss$ of$ professional$

demarcation$between$the$role$of$radiologists$and$radiographers.33,$38$The$data$from$

the$current$study$may$dampen$these$concerns$with$radiographers$clearly$indicating$

they$did$not$see$their$role$in$a$successful$image$interpretation$service$to$include$the$

provision$of$a$diagnostic$report_$the$primary$role$of$their$radiologist$colleagues.$

$

$

$


Strengths$and$limitations$

This$ investigation$ has$ several$ strengths$ and$ limitations.$ First,$ the$ investigation$

included$a$sample$of$participants$from$four$metropolitan$hospitals.$This$enabled$the$

study$ to$ address$ the$ intended$ research$ aim.$ However,$ radiographers$ working$ in$

dissimilar$settings,$or$regional$and$rural$locations$may$have$had$different$perceptions$

regarding$ the$ implementation$ of$ a$ radiographer$ commenting$ system$ than$ those$

radiographers$ who$ participated$ in$ this$ investigation.$ Similarly,$ radiographers’$

foundation$of$knowledge$is$shaped$by$their$undergraduate$or$postagraduate$education.$

This$investigation$did$not$capture$details$of$participants’$educational$qualifications$or$

location$of$training.$A$further$limitation,$that$is$always$a$risk$when$conducting$voluntary$

survey$research,$was$the$possibility$of$response$bias.$Radiographers$who$responded$

to$ the$ survey$may$ have$ a$ greater$ interest$ in$ radiographer$ commenting$ than$ nona

responders.$

(4.2.6(Conclusion(This$ investigation$ has$ addressed$ the$ research$ aims$ and$ highlighted$ that$ many$

radiographers$do$no$participate$in$existing$abnormality$detection$systems$for$a$large$

proportion$of$their$trauma$cases.$A$leading$perceived$(and$modifiable)$barrier$to$the$

implementation$ of$ radiographer$ interpretation$ and$ commenting$ in$ Australian$

emergency$ care$ settings$ is$ access$ to$ effective$ image$ interpretation$ education$ for$

radiographers.$ For$ abnormality$ detection$ and$ commenting$ by$ radiographers$ to$

advance$within$Australian$healthcare$settings,$ it$ is$pertinent$ that$ radiographers$are$

appropriately$ skilled$ in$ interpreting$ trauma$ radiographs.$ The$evaluation$ of$ targeted$

radiographer$ image$ interpretation$ education$ programs$ amenable$ to$ completion$ by$

clinical$radiographers$is$a$key$priority$for$future$research$in$this$field.$

$

4.2.7(References(for(Chapter(4(1$ Berman$L,$de$Lacey$G,$Twomey$E,$Twomey$B,$Welch$T,$Eban$R.$Reducing$

errors$ in$ the$ accident$ department:$ a$ simple$ method$ using$ radiographers.$ British(

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7$ Smith$ L.$ The$Redadot$ system$ in$medical$ imaging:$ ethical,$ legal$ and$ human$

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24$ Willis$BH,$Sur$SD.$How$good$are$emergency$department$senior$House$officers$

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Medicine.$2007_$14:$6a13.$

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descriptions$ of$ adult$ appendicular$musculoaskeletal$ trauma$ following$ a$ condensed$

education$programme.$Radiography.$2012_$19:$48a55.$

26$ McConnell$ J,$Devaney$C,$Gordon$M,$Goodwin$M,$Strahan$R,$Baird$M.$The$

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184a190.$

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medical$radiation$practice.$Melbourne,$Victoria,$2013.$


30$ Kenny$ LM,$ Andrews$ MW.$ Addressing$ radiology$ workforce$ issues.$Medical(

Journal(of(Australia.$2007_$186:$615.$

31$ Brown$N,$Leschke$P.$Evaluating$the$true$clinical$utility$of$the$red$dot$system$in$

radiograph$interpretation.$Journal(of(Medical(Imaging(and(Radiation(Oncology.$2012_$

56:$510a513.$

32$ Wardrope$J,$Chennells$P.$Should$all$casualty$radiographs$be$reviewed?$British(

Medical(Journal((Clinical(Research(ed).$1985_$290:$1638.$

33$ Howard$ML.$An$exploratory$study$of$radiographer's$perceptions$of$radiographer$

commenting$on$musculoaskeletal$trauma$images$in$rural$community$based$hospitals.$

Radiography.$2013_$19:$137a141.$

34$ Lancaster$A,$Hardy$M.$An$investigation$ into$the$opportunities$and$barriers$to$

participation$ in$ a$ radiographer$ comment$ scheme,$ in$ a$ multiacentre$ NHS$ trust.$

Radiography.$2012_$18:$105a108.$

35$ Loughran$C.$Reporting$of$fracture$radiographs$by$radiographers:$the$impact$of$

a$training$programme.$British(Journal(of(Radiology.$1994_$67:$945a950.$

36$ Hargreaves$J,$Mackay$S.$The$accuracy$of$the$red$dot$system:$can$it$improve$

with$training?$Radiography.$2003_$9:$283a289.$

37$ Mackay$ S.$ The$ impact$ of$ a$ short$ course$ of$ study$ on$ the$ performance$ of$

radiographers$ when$ highlighting$ fractures$ on$ trauma$ radiographs:“The$ Red$ Dot$

System”.$British(Journal(of(Radiology.$2006_$79:$468a472.$

38$ Johansen$ LW,$ Brodersen$ J.$ Reading$ screening$ mammograms$ –$ attitudes$

among$radiologists$and$radiographers$about$skill$mix.$European(Journal(of(Radiology.$

2011_$80:$325a330.$

$

4.3$ Thesis$Commentary(This$ chapter$ identified$ five$ overaarching$ perceived$ benefits$ of$ radiographer$

commenting,$ comprised$ of:$ ‘assisting$ multiadisciplinary$ teams’,$ ‘patient$ care’,$

‘radiographer$ ability’,$ ‘professional$ benefits’$ and$ ‘quality$ of$ imaging’.$ Frequently$

reported$ perceived$ barriers$ included$ ‘difficulty$ accessing$ image$ interpretation$

education’,$‘lack$of$time’,$and$‘low$confidence$in$interpreting$radiographs’.$Perceived$

enablers$ included$ ‘access$ to$ image$ interpretation$ education’$ and$ ‘support$ from$

radiologist$colleagues’.$The$findings$of$ this$chapter$helped$ inform$the$design$of$ the$

penultimate$study$in$this$thesis,$Study$3.$To$refine$the$research$methodology$to$be$

employed$ in$ Study$ 3,$ it$ was$ imperative$ to$ ascertain$ Australian$ radiographers’$


perceptions$of$their$image$interpretation$confidence$and$accuracy$and$which$method$

of$education$delivery$they$preferred.$This$was$the$purpose$of$the$next$chapter.$

Chapter 5: Survey of radiographers’ confidence and accuracy in providing a PIE 67

Chapter 5: A survey of radiographers' confidence and self-‐‑perceived accuracy in frontline image interpretation and their continuing educational preferences

This chapter contains the content of Manuscript 2:

Neep MJ, Steffens T, Owen R, McPhail SM. A survey of radiographers' confidence

and self-‐‑perceived accuracy in frontline image interpretation and their continuing

educational preferences. Journal of Medical Radiation Sciences. 2014 Jun

1;;61(2):69-77

This chapter is presented as it was published, with the exception of changes to

support consistent chapter formatting throughout the thesis.


Statement of Contribution of Co-Authors for Thesis by Published Paper

The authors listed below have certified that: 1. they meet the criteria for authorship in that they have participated in the

conception, execution, or interpretation, of at least that part of the publication in their field of expertise;;

2. they take public responsibility for their part of the publication, except for theresponsible author who accepts overall responsibility for the publication;;

3. there are no other authors of the publication according to these criteria;;4. potential conflicts of interest have been disclosed to (a) granting bodies, (b) the

editor or publisher of journals or other publications, and (c) the head of theresponsible academic unit, and

5. they agree to the use of the publication in the student’s thesis and its publicationon the QUT’s ePrints site consistent with any limitations set by publisherrequirements.

In the case of this chapter:

Chapter 5 – Manuscript 2. Neep MJ, Steffens T, Owen R, McPhail SM. A survey of radiographers' confidence and self-‐‑perceived accuracy in frontline image interpretation and their continuing educational preferences. Journal of Medical Radiation Sciences. 2014 Jun 1;;61(2):69-77.

Contributor Statement of contribution* Michael Neep

Study conception and experimental design, data collection and management, analyses of data, principal manuscript writing and preparation, manuscript appraisal and editing.

29.05.18 Tom Steffens Aided experimental design, manuscript appraisal and editing.

Dr Rebecca Owen Aided manuscript appraisal and editing.

Assoc, Prof. Steven McPhail

Aided study conception and experimental design, primary support for data analyses and manuscript appraisal and editing.

Principal Supervisor Confirmation I have sighted email or other correspondence from all Co-authors confirming their certifying authorship. (If the Co -authors are not able to sign the form please forward their email or other correspondence confirming the certifying authorship to the RSC).

Assoc. Prof. Steven McPhail Name Signature Date



5.1 Preamble The previous chapter presented part of the results from Study 1 which involved the

distribution of a cross-sectional questionnaire that was completed by 73

radiographers. This chapter identified the major benefits, barriers and enablers of

introducing a radiographer commenting system. To expand on this previous chapter

and the literature in the field, this chapter addressed Aims 2 and 3 (i.e. to describe

radiographers’ current image interpretation self-efficacy and to determine which (if

any) format of image interpretation education radiographers prefer) (see Figure 5.1

below). Results from this chapter informed the formats of education delivery for use in

Study 3 as well assist in the refinement of the research methodology.

Figure 5.1 Thesis Structure – Chapter 5


5.2 A survey of radiographers' confidence and self-‐‑perceived accuracy in frontline image interpretation and their continuing educational preferences 5.2.1 Abstract Introduction: The provision of a written comment on traumatic abnormalities of the musculoskeletal

system detected by radiographers can assist referrers and may improve patient

management;; but the practice has not been widely adopted outside the United

Kingdom. The purpose of this study was to investigate Australian radiographers’

perceptions of their readiness for practice in a radiographer commenting system and

their educational preferences in relation to two different delivery formats of image

interpretation education;; intensive and non-intensive.

Methods: A cross-sectional web-based questionnaire was implemented between August and

September 2012. Participants included radiographers with experience working in

emergency settings at four Australian metropolitan hospitals. Conventional descriptive

statistics, frequency histograms, and thematic analysis were undertaken. A Wilcoxon

signed-rank test examined whether a difference in preference ratings between

intensive and non-intensive education delivery was evident.

Results: The questionnaire was completed by 73 radiographers (68% response rate).

Radiographers reported higher confidence and self-perceived accuracy to detect

traumatic abnormalities than to describe traumatic abnormalities of the

musculoskeletal system. Radiographers frequently reported high desirability ratings

for both the intensive and non-intensive education delivery;; no difference in desirability

ratings for these two formats was evident (z=1.66, p=0.11).

Conclusions: Some Australian radiographers perceive they are not ready to practise in a frontline

radiographer commenting system. Overall, radiographers indicated mixed

preferences for image interpretation education delivered via intensive and non-

intensive formats. Further research, preferably randomised trials, investigating the


effectiveness of intensive and non-intensive education formats of image interpretation

education for radiographers is warranted.

Key words Education, image interpretation, radiographers, emergency

5.2.2 Introduction Healthcare settings are under growing pressure to care for patients, reduce costs and

improve quality. The Australian population is ageing and health expenditure is

increasing faster than economic growth.1 In response to the need for health reform in

Australia, government departments are promoting flexible and innovative use of allied

health professionals, as well as greater interprofessional teamwork.2 Radiographers

are well positioned to respond to these pressures by contributing to image

interpretation in emergency care settings.3

Radiographers in the United Kingdom (UK) began highlighting abnormalities on

radiographs in the emergency setting by affixing a red dot sticker to the radiograph

more than 30 years ago.4 This ‘red dot’ indicated to the referring doctor that the

radiographer had identified a potential traumatic abnormality. This type of system

simply detects an abnormality. Studies in the UK have acknowledged benefits of the

red dot and subsequent radiographer abnormality detection systems.5, 6 While

radiographer abnormality detection systems can aid emergency doctors in their

diagnosis of trauma, it does have its failings.7, 8 First, the ‘red dot’ system is voluntary

in nature and does not distinguish between occasions where a radiographer has not

detected an abnormality (no red dot) or has not participated in the detection system

for the specific examination (also no red dot). Second, a red dot alone does not provide

the referring doctor with any indication of the nature and location(s) of abnormality

detected. This ambiguity substantially diminishes the potential benefit to the referrer

and their patients. Consequently, evolution from radiographer abnormality detection

systems to abnormality description systems is underway.7, 8

Radiographer detection and description is commonly referred to as radiographer

commenting. Radiographer commenting systems not only identify whether an

abnormality is present, they also include the provision of a written comment for


consideration by the referrer and reporting radiologist. This written comment succinctly

describes the location and nature of potential pathology. Radiographer commenting

systems should not be confused with radiographer reporting. Radiographer reporting

is quite different and involves a radiographer who has completed formal postgraduate

tertiary qualifications. Radiographer reporters generate a formal written report in the

same way radiologists traditionally report on radiographs. The present study focuses

on radiographer abnormality detection and description in the context of radiographer

commenting systems;; not radiographer reporting which is beyond the scope of this

discussion.

Radiographer commenting is not a replacement for the definitive radiologist report, but

rather provides a timely indication to the referrer regarding potential absence or

presence of an acute abnormality along with a succinct written description of the

location, type and number of the abnormalities present. Inexperienced junior doctors

staffing emergency departments may be supported by this system, in what is often

considered the complex task of interpreting radiographs.9-11 Radiographer

commenting has potential to improve timely diagnosis and management of patients in

emergency care settings where delays between image capture and comprehensive

radiological reporting occur.7, 8, 12

Radiographer commenting has yet to be implemented widely outside of the UK despite

evidence that it may improve medical imaging services (and ultimately patient care)

by acting as a conduit for communication between radiographers and the referring

doctor.7, 12 The successful implementation of radiographer commenting systems is

dependent on radiographers’ readiness for practice in this role. This involves the

necessary confidence and ability of radiographers to detect and describe

abnormalities on trauma radiographs. Undergraduate coursework for entry-level

radiographers frequently includes some image interpretation content.7 However, it is

currently unknown whether this education satisfactorily prepares radiographers to

detect and describe abnormalities of the musculoskeletal system in emergency

settings.

Previous studies among radiographers have demonstrated their confidence and

accuracy to interpret radiographs improves after completing targeted image


interpretation education.5, 12-16 Effective targeted image interpretation education

program for radiographers delivered in a format amenable to their ongoing

professional development will likely assist in enhancing their readiness for practice in

radiographer commenting systems. Postgraduate university qualifications

incorporating image interpretation coursework are available in some countries

including Denmark, United Kingdom and Australia. However, radiographers may find

this formal university coursework inaccessible due to large time requirements and a

substantial financial commitment.

An alternative to formal postgraduate university programs is targeted image

interpretation training delivered in short-course formats7 either via an intensive

delivery format or regular short tutorials. Intensive delivery is where a regular or non-

intensive course (for example, 90-minute weekly tutorials conducted over two months)

is compressed into an intensive delivery format (for example, two consecutive 8-hour

days). In this context, both programs could contain the same content, structure and

total delivery time;; however one is delivered in an intensive format.

Prior research has been conducted in other fields to examine the merit of intensive

and non-intensive teaching formats.17, 18 In summary, these investigations have

indicated that intensive teaching formats may lead to comparable or slightly more

favourable learning outcomes than non-intensive teaching formats. However, no

research has investigated radiographers’ perceived readiness to practice in a

radiographer commenting system, their preferences for receiving intensive and non-

intensive education, or whether either format leads to better learning outcomes. The

purpose of this study was to investigate radiographers’ perceptions of their readiness

for practice in a radiographer commenting system, as well as their educational

preferences for receiving intensive and non-intensive image interpretation education.

5.2.3 Methods Design

A cross-sectional survey was administered via a web-based platform between August

and September 2012. The questions were designed to investigate radiographers’

confidence, self-perceived accuracy in trauma image interpretation and their


educational preference for radiographer commenting education. The questionnaire

included eight closed-ended questions and four open-ended questions.

Participants and setting

Diagnostic radiographers from four metropolitan medical imaging departments in

Queensland, Australia were invited to participate. Radiographers were considered

eligible for inclusion if they worked in the emergency setting of a medical imaging

department, had no previous experience of participating in a radiographer commenting

service and had at least completed a 48-week period of supervised practice. An overall

sample of 108 diagnostic radiographers was identified as meeting the inclusion

criteria.

Questionnaire content and procedure

The initial questionnaire was prepared by a study working group consisting of medical

imaging professionals (n=3) and health service researchers experienced in the

development evaluation and implementation of web-based questionnaires (n=3). The

survey content was first developed by the medical imaging professionals. The health

service researchers then linked the content of each item to the stated objectives of the

study to ensure the item content was valid for addressing the study aims. Items not

directly addressing the study objectives were removed. The questionnaire was then

piloted using radiographers external to the study sample that had exposure to using

abnormality detection systems. During the piloting phase of the survey instrument,

cognitive pretesting methods were used to ensure the questions were easy to

understand, were interpreted as intended, and that response options were clearly

understood.19 This resulted in amendments to two items due to potentially misleading

language.

The final questionnaire had four sections (See Appendix A). The first section

requested demographic information including years of clinical experience and gender.

The second section asked respondents to rate their confidence in participating in an

abnormality detection system, as well as their confidence in detecting and describing

traumatic abnormalities of the musculoskeletal system. Eleven-point rating scales

were used to rate confidence;; where 0 and 10 represented ‘not at all confident’ and

‘very confident’ respectively. In the third section, respondents provided ratings of their


perceived level of accuracy in detecting and describing acute traumatic abnormalities

of the appendicular and axial skeleton. For example, “What is your perceived level of

accuracy in describing acute traumatic abnormalities of the axial skeleton?”. Ratings

of perceived accuracy were recorded on 11-point scales where 0 and 10 represented

‘not at all accurate’ and ‘very accurate’ respectively.

The fourth section asked respondents to identify their perceived desirability for two

formats of receiving 12 hours of image interpretation education (eight 90-minute

sessions and two-day intensive delivery). Desirability was rated on 11-point rating

scales where 0 and 10 represented ‘very undesirable’ and ‘very desirable’

respectively. Section four also asked respondents about their perceptions of potential

advantages and disadvantages of the differing formats of education. For example,

after being provided with a description of the intensive education delivery format,

respondents were asked “What do you perceive are the advantages of an intensive

education delivery format?”.

An email containing a hyperlink to the web-based platform was distributed to all eligible

radiographers. Respondents anonymously completed the questionnaire at their

convenience. An email reminder was sent out one week before the closure of the 4-

week data collection period to maximise the response rate. Approximately 15 minutes

was required to complete the survey.

Analysis

Conventional descriptive statistics were used to describe the sample. This included

the number of respondents (and percentage response rate), median (interquartile

range) and total range years of radiographer experience of respondents, as well as

the number (and percentage) of radiographers who were female. Prior to analyses,

Chronbach’s alpha20 was used to confirm the internal consistency reliability of the

rating scales used by respondents to rate their confidence (coefficient=0.77) and

perceived accuracy (coefficient=0.86), which were in the desirable range (0.70-0.90)

for indicating ‘good’ internal consistency. Mean (standard deviation) was used to

describe radiographers’ confidence ratings for detecting and describing traumatic

radiographic abnormalities. Frequency histograms were used to describe response

distributions for radiographers’ confidence in participating in a radiographer


commenting system, self-perceived accuracy in detecting and describing traumatic

radiographic abnormalities of the appendicular and axial skeleton, and radiographers’

desirability ratings for the two potential formats of receiving image interpretation

education. A Wilcoxon signed-ranked test21 (with a significant level of 0.05) was used

to examine whether a difference in preference rating for the two potential intensity

formats of education delivery existed. This non-parametric test was selected, as these

preference ratings did not closely follow a normal distribution curve. Statistical analysis

was undertaken using Stata/IC-(StataCorp, Version 11.2).

Thematic content analysis was undertaken for responses to the perceived advantages

and disadvantages of the two potential formats of delivery of radiographer commenting

education. This was completed by two researchers who coded similar responses

together into emerging categories, independent of one another, before meeting to

reach a consensus about any differing categories. A third independent researcher was

available to mediate any unresolved coding disagreement between the two primary

coders;; however, no such disagreement occurred. The number of responses coded

into each category was also recorded and expressed as a percentage of total

responses. To determine the primary emerging categories of perceived advantages

and disadvantages of the non-intensive format of delivery and intensive format of

delivery categories were presented in order of response prevalence.

Ethics

This investigation was approved by the Human Research Ethics Committees of Metro

South Health and the Queensland University of Technology. Eligible participants were

provided with a study information sheet as part of the email invitation. Completing the

survey implied consent. Participation was voluntary.

5.2.4 Results The questionnaire was completed by 73 radiographers (68% response rate). The

median (inter-quartile range) years of radiographer experience was 5 (2 to 10). The

number of years experience working as a radiographer ranged from 1 to 36. Forty-

nine (67%) respondents were female. Respondents’ confidence ratings for

participating in an abnormality detection system are displayed in Figure 5.2. The


pattern of responses indicated that most respondents felt confident to participate in an

abnormality detection system.

Figure 5.2 Histogram representing radiographers’ confidence (0=not at all

confident, 10=very confident) to participate in an abnormality detection system

Respondents’ confidence ratings to detect and describe abnormalities on trauma

radiographs of the musculoskeletal system are presented in Figure 5.3. The pattern of

responses varied between the two skills. Respondents’ reported a mean (SD)

confidence rating of 6.7 (1.6) to detect abnormalities. A total of 66 (90%) respondents

rated their confidence to detect abnormalities at the mid-point or higher on the rating

scale. Whereas, the mean (SD) confidence of respondents to describe pathology was

5.2 (1.9) on the rating scale, and 51 (70%) respondents rated their confidence at the

mid-point or higher on the rating scale.


Figure 5.3 Histogram representing radiographers’ confidence to detect and

describe traumatic abnormalities (0=not at all confident, 10=very confident)

Respondents’ self-perceived accuracy ratings for detecting and describing traumatic

abnormalities of the appendicular and axial musculoskeletal system are presented in

Figure 5.4. The number of respondents reporting low levels of self-perceived accuracy

varied across these four accuracy ratings. The number of respondents reporting low


levels of self-perceived accuracy (rating of less than 5 out of 10) in detecting traumatic

abnormalities of the appendicular and axial skeleton in emergency settings were 1

(1%) and 9 (12%) respectively. The number of respondents reporting low levels of

self-perceived accuracy (rating less than 5 out of 10) in describing traumatic

abnormalities of the appendicular and axial skeleton were 13 (18%) and 25 (34%)

respectively.

Figure 5.4 Histogram representing radiographers’ self-perceived accuracy of

detecting and describing traumatic abnormalities (0=not at all accurate, 10=very

accurate)

Respondents’ desirability ratings for two different intensity formats of receiving image

interpretation education are presented in Figure 5.5. The pattern of desirability ratings

varied between the two potential education intensity formats. The Wilcoxon signed-

rank test did not indicate that one intensity format had higher overall desirability ratings

than the other (z=1.66, p=0.11). The number of respondents who reported ratings of

eight out of ten or higher for the 90-minute tutorials over 2 months and intensive two-

day mode of delivery being 40 (55%) and 25 (34%) respectively. Few respondents

reported low ratings (four or less out of ten) for either the 90-minute tutorials (n=10,

14%) or intensive two-day format of delivery (n=13, 18%).


Figure 5.5 Histogram representing radiographers’ desirability ratings for two

potential intensity formats of receiving image interpretation education (0=very

undesirable, 10=very desirable)


The summary of respondents’ perceived advantages and disadvantages of eight 90-

minute education sessions as a non-intensive format for receiving radiographer

commenting education are presented in Table 5.1. A total of four perceived

advantages were identified. The most frequently reported perceived advantages were

opportunity to consolidate the new information and skills between sessions (n=27,

37%), a gradual learning curve conducive to long-term acquisition of knowledge and

skill (n=16, 22%) and ability to maintain concentration and enthusiasm for 90-minute

sessions (n=16, 22%). Responses were also coded into three categories of

disadvantages. The most frequent perceived disadvantage was the long length of time

commitment (n=49, 67%) required to complete an eight-week education program.

Table 5.1 Perceived advantages and disadvantages of a non-intensive format of

delivery (eight 90 minute education sessions, 12 hours total)

Categories N (%) Advantages

Opportunity to consolidate learning between

sessions 27 (37%)

Gradual learning curve conducive to long term

acquisition of knowledge and skill 26 (36%)

Able to maintain concentration and enthusiasm

for 90 minute sessions 16 (22%)

Easy to organise around normal life and work 4 (5%)

Disadvantages

Long length of time commitment. 49 (67%)

May forget information between sessions 16 (22%)

Session attendance may be challenging for a

shift workers 8 (11%)

Respondents reported a variety of perceived advantages and disadvantages of an

intensive two-day format for receiving image interpretation education (Table 5.2). A

total of three perceived advantages were identified. The most frequently reported

advantage was that a two-day intensive education program was easy to attend in its


entirety without potential risk of missing one or more education sessions (n=49, 67%).

Four categories of disadvantages were also identified from the coded responses. The

two most frequent perceived disadvantages included that there may be too much

information to learn rapidly (n=43, 59%) and that it may be difficult to concentrate for

long (6 hours per day) durations (n=19, 26%).

Table 5.2 Perceived advantages and disadvantages of an intensive format of

delivery (two-day education session, 12 hours total)

Categories N (%) Advantages

Easy to attend two-day education in entirety 49 (67%)

Intensive repetition of new skills and knowledge

over two days may assist learning 19 (26%)

Accelerated course completion - for immediate

use 5 (7%)

Disadvantages

May be too much information to learn rapidly 43 (59%)

Challenging to concentrate for long duration of

sessions 19 (26%)

Less opportunity to consolidate and revise

between sessions 7 (10%)

Ruins an entire weekend or two days of work 4 (5%)

5.2.5 Discussion This survey has been the first to report Australian radiographers’ perceptions of their

readiness to practice in a radiographer commenting system. The findings indicated

that radiographers felt confident to participate in abnormality detection (Figure 5.1).

However, some radiographers had higher levels of confidence and self-perceived

accuracy in detecting abnormalities than describing abnormalities (Figure 5.2 and 5.3);;

consistent with other work in this field.7, 8 A study conducted by Smith et al,12 reported

a decrease in accuracy when radiographers were required to provide a written


comment. They suggested this finding was associated with radiographers having

difficulty converting their observations into words. Factors contributing to greater

confidence and perceived accuracy in detecting rather than describing abnormalities

may include familiarity with detection only systems, and a perception that commenting

requires a technical skill set acquired through targeted image interpretation education.

Radiographers may also have higher perceived accuracy ratings in detecting and

describing abnormalities of the appendicular skeleton than the axial skeleton (Figure

5.3). The authors speculate that the lower levels of confidence and perceived accuracy

in describing radiographs of the axial skeleton may be attributable to more complex

anatomy and potentially more complex pathology. This finding is also congruent with

previous research from Australia that examined accuracy of radiographer

interpretation by body region.8

Image interpretation education can improve radiographers’ ability and confidence to

interpret and comment on radiographs in the emergency setting.5, 12, 14-16

Radiographers in this investigation frequently reported high desirability ratings for both

the intensive and non-intensive education delivery formats (Figure 5.4). There was no

statistically significant difference between ratings for the intensive and non-intensive

formats among this sample of radiographers. Despite some prior research from other

fields indicating that intensive teaching formats may lead to comparable or slightly

more favourable learning outcomes than non-intensive teaching,17, 18, 22 mixed

opinions regarding the effectiveness of either intensive or non-intensive education

programs remain.23, 24 Radiographers from this investigation reported favourable

desirability ratings for intensive and non-intensive potential formats of image

interpretation education.

Radiographers in this investigation reported a range of perceived advantages and

disadvantages of intensive and non-intensive image interpretation education

programs that were consistent with findings from educational research from other

disciplines.17, 18, 25 In summary, the perceived advantages of the intensive education

format predominantly matched the disadvantages of the non-intensive format.

Similarly, the perceived disadvantages of the intensive education format

predominantly matched the advantages of the non-intensive format. It is likely that

differences between individual radiographer’s learning preferences may explain why


radiographers did not consistently prefer one format over the other. Further research

to evaluate which of these education delivery formats is more effective for delivering

image interpretation education would be valuable for informing the future delivery of

image interpretation education to radiographers.

There are important implications from this study regarding successful implementation

of frontline radiographer commenting systems in emergency settings outside of the

UK. This study has highlighted that some radiographers may lack confidence and

perceived accuracy when describing abnormalities of the musculoskeletal system.

Successful implementation of radiographer commenting systems will be dependent on

radiographers’ confidence and accuracy in interpreting radiographs. Access to

targeted education for radiographers is likely to be helpful in this regard.12, 13, 26, 27

However, in the absence of randomised trials reporting the effectiveness of image

interpretation education programs for radiographers, it is difficult to draw firm

conclusions regarding the intensity with which these education programs should be

delivered.

Strengths, limitations and future research

There are several strengths and limitations of this research influencing the extent to

which these findings can be extrapolated. The sampling approach ensured the sample

represented radiographers who have had exposure to radiographer abnormality

detection systems in order to address the aim of this investigation. However,

radiographers with dissimilar experience and educational backgrounds may not have

responded in the same way as participants in this sample. It is noteworthy that this

investigation only examined radiographers’ perceptions. It did not examine their actual

ability to interpret radiographs nor their actual experience of different formats of

education. Caution is also required before extrapolating that no statistical difference

exists between radiographers’ preference of the two different education delivery

formats. It is plausible that a failure to reject the null hypothesis in this study may be

attributed to either a lack of sensitivity in the measurement instrument or the size of

this sample. Ideally, future research should evaluate the effectiveness of intensive

versus non-intensive delivery of image interpretation education for radiographers, as

well as their experiences in receiving this education. A randomised controlled trial

design and objective outcome measure of ability to detect and describe traumatic


abnormalities would be useful for evaluating image interpretation education formats.

5.2.6 Conclusion This investigation addressed its intended aim, revealing some Australian

radiographers perceive they are not ready to practise in frontline radiographer

commenting systems. Some radiographers lack confidence and perceived ability to

accurately describe traumatic radiographic abnormalities of the musculoskeletal

system. Overall, radiographers in this sample reported mixed preferences for image

interpretation education delivered via intensive and non-intensive formats. It is difficult

to draw firm conclusions regarding the intensity with which image interpretation

education programs should be delivered in the absence of objective data from a

randomised trial;; reporting the effectiveness of intensive and non-intensive image

interpretation education for radiographers. An education effectiveness trial of this

nature remains a priority for future research.

5.2.7 References for Chapter 5 1 Australian Treasury. Intergenerationl Report. Canberra, Australian Capital

Territory, 2010.

2 Health Workforce Australia. National Health Workforce Innovation and Reform

Strategic Framework for Action 2011-2015. 2011.

3 The Society and College of Radiographers. Preliminary Clinical Evaluation and

Clinical Reporting by Radiographers: Policy and Practice Guidance. London: The

Society and College of Radiographers, 2013.

4 Berman L, de Lacey G, Twomey E, Twomey B, Welch T, Eban R. Reducing

errors in the accident department: a simple method using radiographers. British

Medical Journal (Clinical Research ed). 1985;; 290: 421.




6 Brealey S, Scally A, Hahn S, Thomas N, Godfrey C, Crane S. Accuracy of

radiographers red dot or triage of accident and emergency radiographs in clinical

practice: a systematic review. Clin Radiol. 2006;; 61: 604-615.

7 Hardy M, Culpan G. Accident and emergency radiography: a comparison of

radiographer commenting and ‘red dotting’. Radiography. 2007;; 13: 65-71.


8 Smith T, Younger C. Accident and emergency radiological interpretation using

the radiographer opinion form (ROF). The Radiographer. 2002;; 49: 27.

9 McLauchlan C, Jones K, Guly H. Interpretation of trauma radiographs by junior

doctors in accident and emergency departments: a cause for concern? Journal of

Accident and Emergency Medicine. 1997;; 14: 295-298.

10 Vincent C, Driscoll P, Audley R, Grant D. Accuracy of detection of radiographic

abnormalities by junior doctors. Archives of Emergency Medicine. 1988;; 5: 101-109.

11 Willis BH, Sur SD. How good are emergency department senior House officers

at interpreting x-rays following radiographers' triage? European Journal of Emergency

Medicine. 2007;; 14: 6-13.



2009;; 9: 1145.

13 McConnell J, Devaney C, Gordon M, Goodwin M, Strahan R, Baird M. The



184-190.








17 Seamon M. Short-and long-term differences in instructional effectiveness

between intensive and semester-length courses. Teachers College Record. 2004;;

106: 635-650.

18 Davies WM. Intensive teaching formats: a review. Issues in Educational

Research. 2006;; 16: 1-20.

19 Collins D. Pretesting survey instruments: an overview of cognitive methods.

Quality of Life Research. 2003;; 12: 229-238.

20 Kline P. The handbook of psychological testing. Psychology Press, New York,

2000.


21 Wolfe DA, Hollander M. Nonparametric statistical methods. John Wiley & Sons,

New York, 1973.

22 Scott PA. Attributes of high-‐quality intensive courses. New Directions for Adult

and Continuing Education. 2003;; 2003: 29-38.

23 Austin TL, Fennell RR, Yeager CR. Class scheduling and academic

achievement in a non-traditional graduate program. Innovative Higher Education.

1988;; 12: 79-90.

24 Schmidt SL, Richter A. Course formats for teaching management consulting.

The Journal of Education for Business. 2006;; 82: 56-62.

25 Marques J. The Dynamics of Accelerated Learning. Business Education &

Administration. 2012;; 4: 101-112.

26 Lancaster A, Hardy M. An investigation into the opportunities and barriers to

participation in a radiographer comment scheme, in a multi-centre NHS trust.

Radiography. 2012;; 18: 105-108.

27 Howard ML. An exploratory study of radiographer's perceptions of radiographer

commenting on musculo-skeletal trauma images in rural community based hospitals.

Radiography. 2013;; 19: 137-141.

5.3 Thesis Commentary This chapter identified that radiographers reported higher confidence and perceived

accuracy in detecting traumatic abnormalities than to describe abnormalities.

Radiographers frequently reported high desirability ratings for both the intensive and

non-intensive education delivery;; no difference in desirability ratings for these two

formats was evident. This investigation only examined radiographers’ perceptions, it

did not examine their actual ability to interpret radiographs nor their actual experience

of different formats of education. This work helped to establish the foundation for future

research to evaluate the effectiveness of intensive versus non-intensive delivery of

image interpretation education for radiographers, as well as their experiences in

receiving this education. For this to have occurred, it was noted that a randomised

controlled trial design and objective outcome measure of ability to detect and describe

traumatic abnormalities would be useful for evaluating image interpretation education

formats. Chapter 6 described the development and validation of a quantitative


outcome measure suitable for evaluating radiographers’ ability to interpret and

comment on trauma radiographs.

Chapter(6:(Development(and(validation(of(an(image(interpretation(test( 89#

Chapter( 6:( Development( of( a( valid( and(

reliable( test( to( assess( trauma( radiograph(

interpretation(performance(!

!

!

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(

(

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!

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This!chapter!contains!the!content!of!Manuscript!3:!

Neep(MJ,(Steffens(T,(Riley(V,(Eastgate(P,(McPhail(SM.(Development(of(a(valid(and(

reliable( test( to(assess( trauma( radiograph( interpretation(performance.(Radiography.(

2017(May(1I23(2):153N8.

!

This!chapter!is!presented!as!it!was!published,!with!the!exception!of!changes!to!support!

consistent!chapter!formatting!throughout!the!thesis.!!

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(Statement(of(Contribution(of(Co:Authors(for(

Thesis(by(Published(Paper(!

The!authors!listed!below!have!certified!that:!

1.! they!meet!the!criteria!for!authorship!in!that!they!have!participated!in!the!

conception,!execution,!or!interpretation,!of!at!least!that!part!of!the!publication!in!

their!field!of!expertise?!!2.! they!take!public!responsibility!for!their!part!of!the!publication,!except!for!the!

responsible!author!who!accepts!overall!responsibility!for!the!publication?!

3.! there!are!no!other!authors!of!the!publication!according!to!these!criteria?!!4.! potential!conflicts!of! interest!have!been!disclosed!to!(a)!granting!bodies,!(b)! the!

editor! or! publisher! of! journals! or! other! publications,! and! (c)! the! head! of! the!

responsible!academic!unit,!and!!5.! they!agree!to!the!use!of!the!publication!in!the!student’s!thesis!and!its!publication!

on!the!QUT’s!ePrints!site!consistent!with!any!limitations!set!by!publisher!

requirements.!

!

In!the!case!of!this!chapter:!

!

Chapter!6!–!Manuscript!3.!Neep!MJ,!Steffens!T,!Riley!V,!Eastgate!P,!McPhail!SM.!

Development!of!a!valid!and!reliable!test!to!assess!trauma!radiograph!interpretation!

performance.!Radiography.!2017!May!1?23(2):153Y8.!


Study!conception!and!experimental!design,!data!collection!and!

management,!analyses!of!data,!principal!manuscript!writing!and!

preparation,!manuscript!appraisal!and!editing.!!

25/06/2018! !

Tom!Steffens!

!

Aided!experimental!design,!manuscript!appraisal!and!editing!

.!

Victoria!Riley!

!

Aided!manuscript!appraisal!and!editing!

.!

Patrick!Eastgate!

!

Aided!manuscript!appraisal!and!editing.!

!

Assoc,!Prof.!Steven!

McPhail!

Aided!study!conception!and!experimental!design,!primary!support!for!data!

analyses!and!manuscript!appraisal!and!editing.! (Principal(Supervisor(Confirmation(

I!have!sighted!email!or!other!correspondence!from!all!CoYauthors!confirming!their!certifying!

authorship.!(If!the!Co!Yauthors!are!not!able!to!sign!the!form!please!forward!their!email!or!other!correspondence!

confirming!the!certifying!authorship!to!the!RSC).!

Assoc.!Prof.!Steven!McPhail!Name! Signature! Date!

( (



6.1! Preamble(

Chapter! 5! identified! that! radiographers! reported! higher! confidence! and! perceived!

accuracy! to! detect! traumatic! abnormalities! than! to! describe! abnormalities.!

Additionally,! it! described! that! radiographers! frequently! reported! high! desirability!

ratings!for!both!the!intensive!and!nonYintensive!education!delivery.!As!this!study!only!

examined! radiographers’! perceptions,! it! emphasised! that! future! research! should!

evaluate! the! effectiveness! of! intensive! versus! nonYintensive! delivery! of! image!

interpretation!education! for! radiographers,!as!well!as! their!experiences! in! receiving!

this!education.!Unfortunately,!prior!to!this!doctoral!program!of!research!there!was!no!

widely!available!standardised!assessment!instrument!for!evaluating!the!competence!

of! radiographers! in! interpreting! trauma! radiographs.!This!chapter!addressed!Aim!4!

and! described! the! development! and! validation! of! a! quantitative! outcome!measure!

suitable! for! evaluating! radiographers’! ability! to! detect! and! comment! on! traumatic!

radiographic!abnormalities!(see!Figure!6.1).!This! is!an!important!prerequisite!to!the!

successful! evaluation! of! radiographer! commenting! education! and! evaluating!

radiographers’! readiness! to! practice! in! a! PIE! service.! The! outcome! of! this! study!

(developing!a!validated!outcome!measure)!was!used!in!Study!3!to!evaluate!change!in!

radiographers’! image! interpretation! ability.! This! was! the! first! validated! instrument!

based!on!a!typical!adult!emergency!department!caseYmix!of!its!kind!in!this!field.!

!


!

Figure!6.1! Thesis!Structure!–!Chapter!6!

! !


6.2( Development( of( a( valid( and( reliable( test( to( assess( trauma( radiograph(

interpretation(performance(

(

6.2.1(Abstract(

Objectives:(

The!purpose!of!this!investigation!was!to!develop!and!examine!the!preliminary!validity!

and! reliability! among! radiographers! of! a! test! to! assess! trauma! radiograph!

interpretation!performance!suitable!for!use!among!health!professionals.!

(

Methods:((

Stage!1!examined!14159!consecutive!appendicular! and!axial! examinations! from!a!

hospital! emergency! department! over! a! 12! month! period! to! quantify! a! typical!

anatomical!region!caseYmix!of!trauma!radiographs.!A!sample!of!radiographic!cases!

representative! of! affected! anatomical! regions! was! then! developed! into! the! Image!

Interpretation! Test! (IIT).! Stage! 2! involved! prospective! investigations! of! the! IIT’s!

reliability!(interYrater,!intraYrater,!internal!consistency)!and!validity!(concurrent)!among!

41!radiographers.!!

(

Results:((

The! IIT! included! 60! cases.! The!median! (interquartile! range)! clinical! experience! of!

participants!was!5!(2Y10)!years.!Case!scores!were!internally!consistent!(Cronbach’s!

alpha=0.90).!Favourable!interYrater!reliability!(kappa>0.70!for!58/60!cases,!IntraYclass!

Correlation! Coefficient! (ICC)>0.99! for! total! score)! and! intraYrater! reliability!

(kappa>0.90!for!60/60!cases,!ICC>0.99!for!total!score)!was!observed.!There!was!a!

positive!association!between!radiographers’!confidence!in!image!interpretation!and!IIT!

score!(coefficient=1.52,!rYsquared=0.60,!p<0.001).!!

(

Conclusions:((

The!IIT!developed!during!this!investigation!included!a!selection!of!radiographic!cases!

consistent! with! anatomical! regions! represented! in! an! adult! trauma! caseYmix.! This!

study!has!also!provided!foundational!preliminary!evidence!to!support!the!reliability!and!

validity! of! the! IIT! among! radiographers.! The! findings! suggest! that! it! is! possible! to!

assess!image!interpretation!performance!of!adult!trauma!radiographs!with!this!test.!!

!


(

Keywords(

image!interpretation?!trauma?!performance?!validity?!reliability!

!

6.2.2(Introduction(

Accurate!and!timely!interpretation!of!radiographic!images!is!of!paramount!importance!

to!the!delivery!of!a!high!quality!service!in!hospital!emergency!care!settings.!In!these!

settings,!health!professionals!from!a!range!of!clinical!backgrounds!are!be!required!to!

interpret! radiographic! images! as! part! of! their! clinical! practice1.! ! This! may! include!

medical!professionals,2!nurses,

3!physiotherapists

4!and!preliminary!clinical!evaluations!

from!radiographers5!prior!to!the!availability!of!a!radiologist!report.!Education!programs!

to!enhance!image!interpretation!ability!among!health!professionals!exist!in!both!shortY

course!format!and!formal!university!coursework.6Y8!

!

A!valid!and!reliable!image!interpretation!test!that!clinicians!could!complete!prior!to!and!

following! image! interpretation! training! would! assist! in! the! evaluation! of! the!

effectiveness! of! image! interpretation! education! programs! for! enhancing! image!

interpretation!performance.9!In!the!context!of!this!study,!validity!refers!to!the!ability!of!

the! interpretation! test! to! appropriately! quantify! image! interpretation! performance.!

Reliability!refers!to!the!ability!for!test!scores!to!be!consistently!reproduced!under!the!

same!conditions!either!by!the!same!test!score!rater!(intraYrater!reliability)!or!by!another!

test!score!rater!(interYrater!reliability),!and!internal!consistency!refers!to!whether!the!

scores!of!individual!cases!within!an!interpretation!test!are!correlated.!!Several!image!

interpretation! tests! have! been! reported! in! the! literature.2,! 10Y16

! However,! there! is! a!

paucity!of!data!describing!the!validity!and!reliability!of!these!image!tests!which!have,!

to! the!authors’!knowledge,!been!developed! for!use! in! two!studies.3,!17

!Further,! it! is!

unclear!whether!the!content!of!prior!image!tests!represent!the!image!caseYmix!that!a!

clinician!may!expect!to!see!in!the!context!of!their!clinical!practice.!!

!

There! remains!contention! in! the! literature!as! to!whether!manufactured! image! tests!

(i.e.,! hand! picked! cases)! are! an! accurate! indicator! of! interpretive! performance! in!

comparison!to!image!test!banks!that!represent!clinical!practice.!A!typical!manufactured!

test!bank!has!an!abnormality!prevalence!of!70%17,!18

!in!comparison!to!a!lower!reported!

abnormality!prevalence!of!20Y30%!in!image!banks!that!represent!clinical!practice.19,!20

!


A!salient!study!by!Hardy!et!al21!examined!the!influence!of!abnormality!prevalence!bias!

on! the! accuracy! of! interpretation! of! radiographs! by! investigating! radiographers’!

performance! on! manufactured! high! abnormality! prevalence! image! banks! versus!

clinical! practice! image! banks.! The! results! indicated! that! the! manufactured! high!

abnormality!prevalence!test!banks!may!overestimate!abnormality!detection!ability.!!

!

The!overarching!aim!of!this! investigation!was!to!develop!a!valid!and!reliable!image!

interpretation! test! that! could! be! used! as! an! outcome! measure! to! quantify!

radiographers’! performance! in! interpreting! adult! trauma! radiographs.! This! included!

three! specific! objectives.!The! first! objective!was! to! describe! the!anatomical! region!

caseYmix!of!axial!and!appendicular! radiographic!examinations! in!a!hospital! trauma!

setting!over!a!12!month!period.!The!second!objective!was!to!generate!an!image!test!

consisting!of!a!sample!of!images!from!anatomical!regions!representative!of!the!typical!

caseYmix.! The! third! objective!was! to! develop! an! Image! Interpretation! Test! (IIT)! to!

quantify!the!performance!of!radiographers!attempting!to!identify!and!describe!potential!

abnormalities!present! in! the! selection!of! cases,! and!prospectively! examine! validity!

(concurrent)!and!reliability!(intraYrater,!interYrater!and!internal!consistency)!of!the!IIT!

scoring!among!radiographers.!

!

6.2.3(Methods(

This! investigation! was! approved! by! the! Metro! South! Health! and! Queensland!

University!of!Technology!Human!Research!Ethics!Committees.!Participants!provided!

written!informed!consent.!!

!

Study!Design!

A!twoYstage!study!design!was!implemented.!Stage!1!involved!the!development!of!the!

IIT!content,!a!reference!standard!for!each!case!and!scoring!criteria.!Stage!2!involved!

prospective!examination!of!preliminary!validity!(concurrent)!and!reliability!(intraYrater,!

interYrater,!and!internal!consistency)!of!the!IIT!scoring.!!

!

Stage(1N(IIT(Development(

Selection!of!image!test!content!for!the!IIT!was!consistent!with!guidelines!suggested!

by!Streiner!and!Norman.22!Appendicular!and!axial!skeleton!radiographic!images!for!

suspected!trauma!were!captured!from!digital!radiographic!examinations!undertaken!


in!a!large!metropolitan!adult!hospital!emergency!department.!!An!audit!of!consecutive!

adult! examinations!over! a! 12!month! period!was!undertaken! to! quantify! the! typical!

anatomical!region!caseYmix!referred!for! investigation! in! this!setting.!Quantifying!the!

proportion!of! trauma!cases! from!each!anatomical! region! facilitated! the!selection!of!

examinations! representative! of! the! anatomical! region! caseYmix! in! typical! clinical!

practice.!!

!

The!total!number!of!cases!to!be!included!in!the!test!instrument!was!60.!The!decision!

to! include! 60! radiographic! examinations! was! considered! carefully! during! study!

planning.! The! investigators! were! primarily! influenced! by! consideration! of! the! total!

duration!of!the!assessment,!as!they!wanted!the!utility!of!the!IIT!to!be!as!adaptable!to!

the! clinical! environment! and! feasible.! This! process! began! with! the! investigators!

examining!a!variety!of!university!based!assessments!and!observing!that!a!90!minute!

assessment!duration!was!common!and!thus!would!likely!be!a!reasonable!duration!for!

the!IIT.!The!authors!then!considered!what!would!constitute!a!reasonable!amount!of!

time! to! interpret! each! examination.! To! the! authors’! knowledge,! the! only! published!

guideline! available! that! recommends! an! average! time! to! interpret! a! radiographic!

examination! is! from! the! Royal! College! of! Radiologists,! United! Kingdom.! They!

recommend! approximately! 90! seconds! per! examination.23! Considering! these! two!

factors!(total!assessment!time!divided!by!total!time!per!examination),!the!total!number!

of!examinations!to!include!in!the!IIT!was!elected!to!be!60.!

!

The!selection!of!the!60!cases!followed!a!threeYstep!process.!First,!the!proportion!of!

cases!required!for!each!body!region!was!calculated!(last!row,!Figure!6.2).!Second,!a!

date! was! randomly! selected! as! a! starting! point! for! identifying! eligible! consecutive!

cases.! Third,! consecutive! cases! from! that! date! were! examined! against! eligibility!

criteria! (traumaYrelated! referral,! appendicular! or! axial! skeleton,! radiographic!

examination!was!complete)!until!the!quota!for!each!body!region!was!filled.


!

!Figure!6.2! Image!Interpretation!Test!development!flow!diagram!!


A" reference" standard" for" each" case" and" scoring" criteria" were" then" established." A"

reference"standard"is"the"correct"interpretation"for"each"case"in"the"IIT"and"indicates"

whether" a" traumatic" abnormality" was" present," and" if" present," the" key" elements"

(anatomical" location" and" pathology)" that" should" be" described" in" an" accurate"

interpretation." It" was" created" by" a" panel" of" experienced" experts" (2" consultant"

radiologists"and"1"consultant"reporting"radiographer)"and"involved"two"members"of"the"

panel," independent" of" one" another," reporting" each" case" in" the" IIT." The" third"

independent" expert"was" available" to"mediate" any" disagreements" between" the" two"

primary"experts."This"consensus"became"the"reference"standard."When"completing"

the" IIT," participants" were" required" to" view" each" case" and" first" decide" whether" an"

abnormality"was"present,"and"provide"a"brief"description"of"the"perceived"abnormality"

(if" present)." Scoring" an" interpretation" of" a" radiograph" is" not" necessarily" a" binary"

decision"between"normal"and"abnormal."The"authors"of"this"study"acknowledge"that"it"

is"possible"to"have"an"incomplete"or"a"partly"correct"or"incorrect"interpretation."After"

reviewing"literature"in"the"field,"the"authors"of"this"study"could"not"find"an"appropriate"

scoring"criteria"that"incorporated"the"scoring"of"an"interpretation"that"was"potentially"

incomplete"or"only"partly"correct/" incorrect."Therefore"the"investigators"developed"a"

new"and"novel"scoring"criteria"to"be"trialled"for"cases"with"and"without"an"abnormality"

present"(described"in"Table"6.1)."

"

Table"6.1" Scoring"criteria"for"each"case"in"the"Image"Interpretation"Test"

"

CRITERIA' SCORE'For'radiographic'cases'with'a'traumatic'abnormality' "

Abnormality(not(detected(( 0"

Abnormality(detected,(but(not(described(correctly( 1"

Abnormality(detected,(description(incomplete((but(not(incorrect)(( 2"

Abnormality(detected(and(correctly(described(in(entirety(( 3"

( "

For'radiographic'cases'with'no'traumatic'abnormality' "

False(abnormality(reported(or(described(( 0"

Correct(report(of(absence(of(any(traumatic(abnormality(( 3"

"


Stage(2(–(Prospective(validity(and(reliability(testing((

To"examine"the"validity"and"reliability"of"the"IIT"and"scoring"system,"a"volunteer"sample"

of" radiographers"who"worked" in" the"emergency"medical" imaging"departments" from"

three"metropolitan"hospitals"in"Brisbane,"Australia"were"invited"to"participate"(n="50)."

Radiographers"were"considered"eligible"for" inclusion"if" they"had"at" least"12"months"

clinical" experience" and" currently" worked" in" an" emergency" setting." FortyNone"

radiographers"met"the"inclusion"criteria"and"provided"informed"consent."

"

Radiographers"were" first"provided"with"guidelines" for"categorisation"of" radiographic"

examinations" based" on" prior" research" by" Robinson" and" colleagues.24" These"

guidelines" indicated" that" a"normal" finding" should" include"anatomical" variants," nonN

traumatic" pathology," old" fractures" and" evidence" of" previous" surgery," unless"

specifically"related"to"the"presentation.""In"contrast,"an"abnormal"finding"would"include"

joint" effusions," fractures," dislocations," subluxations" and" soft" tissue" swelling."

Participants"were"informed"they"had"90"minutes"to"complete"the"60"case"IIT"and"were"

responsible"for"managing"their"time."Within"the"90"minute"timeNframe"they"were"able"

to"revisit"cases"they"were"initially"unsure"about.""

"

The"anonymised"DICOM"(Digital"Imaging"and"Communications"in"Medicine)"images"

were"embedded"into"an"image"review"software"(Codonics"Clarity"Viewer"version"6.1,"

Middleburg"Heights,"Ohio,"USA)."Participants"could"adjust" image"contrast/"density,"

zoom,"pan"and"invert"an"image"as"would"be"possible"in"clinical"practice."The"images"

were"reviewed"using"a"standard"personal"computer"monitor"(2Nmegapixels)"that"was"

consistent"to"reviewing"images"in"the"clinical"practice"setting."In"an"attempt"to"simulate"

the"clinical"setting,"the"completion"of"the"IIT"took"place"in"a"semiNdarkened"room"and"

each"participant"was"able" to"view"all" available"projections" for"each"examination."A"

member"of"the"research"team"supervised"the"assessments"and"participants"were"not"

able"to"contact"another"colleague"for"assistance.""Neither"a"clinical"history"nor"access"

to"previous"imaging"for"each"case"was"provided"to"the"participants"completing"the"IIT."

Not"including"clinical"history"with"each"case"permitted"the"investigators"to"assess"how"

well" participants" scanned" and" interpreted" the" radiographic" images," rather" than"

assessing"how"well" they"interpreted"case"histories"in"combination"with"radiographic"

images."Participants"recorded"their"interpretation"on"a"separate"paper"response"form"

for" each" case." " Two" radiographers" with" postgraduate" qualifications" in" image"


interpretation"served"as"a"panel"of" independent" raters" to" compare" responses" from"

participants" to" the" reference" standard" for" each" case." In" addition" to" providing" a"

description" of" the" pathology" (perceived" to" be)" present," the" participants" were" also"

asked" to" provide" a" ‘confidence" rating’" to" indicate" how" confident" they"were" in" their"

interpretation" on" a" 5Npoint" Likert" scale" (normal," probably" normal," possibly" normal,"

probably"abnormal"and"abnormal)."For"inclusion"in"analyses,"confidence"ratings"were"

scored" for"each"case" from"5" to"1" for"normal"cases"and"1" to"5" for"abnormal"cases"

across"the"respective"Likert"response"options.""

"

Data"Analysis"

To" address" the" first" and" second" objectives," the" number" (and" percentage)" of"

radiographic"examinations"from"each"anatomical"region"was"calculated"from"the"audit"

of"consecutive"cases"over"the"12"month"period."To"address"the"third"objective,"a"series"

of"analyses"were"conducted"to"investigate"the"reliability"and"validity"of"the"IIT"scoring."

To"examine" interNrater"reliability"of" test"scoring," the"percentage"of"cases"with"exact"

agreement"and"near"agreement" (disagreement"of"only"one"point"on" the" IIT"scoring"

system,"Table"1)"was"calculated"between"the"two"raters"for"each"case"in"the"IIT."To"

consider"interNrater"reliability"of"the"scoring"after"taking"into"account"agreement"due"to"

chance"(expected"agreement),"Cohen’s"kappa"coefficients"(quadratic"weighting)"were"

calculated" for" each" case." Expected" agreement" due" to" chance" determined" when"

calculating" kappa" coefficients" is" a" product" of" the" frequencies" in" each" response"

category"present"relative"to"the"total"number"of"responses."Therefore,"when"a"large"

proportion"of" responses" fall" into" the"same"category,"expected"agreement" is"higher"

than"when"there"is"an"equal"distribution"of"responses"across"each"possible"response"

category." This" series" of" analyses" (percent" exact" agreement," near" agreement" and"weighted"Cohen’s"kappa)"were"then"repeated"to"examine"intraNrater"reliability,"where"

IIT"scoring"was"completed"by"the"same"rater"for"all"cases"under"identical"conditions(

on"two"different"occasions.""

"

The"scores"from"each"case"were"also"summed"to"provide"an"IIT"total"score."IntraNclass"

correlation" coefficients" were" then" used" to" examine" both" intraNrater" and" interNrater"

reliability"for"the"IIT"total"scores."Cronbach’s"alpha"was"used"to"examine"whether"the"

scores"of" individual"cases"within"an" interpretation"test"were"correlated."To"examine"

concurrent" validity," Spearman’s" rho"was" used" to" examine" the" correlation" between"


image" interpretation" score" and" radiographer’s" confidence" score" for" each" case." To"

examine"whether" the"sum"of"confidence"ratings"was"correlated"with" the"sum"of" IIT"

case"scores,"an"ordinary"least"squares"regression"was"undertaken."A"scatterplot"with"

the"line"of"best"fit"from"the"regression"was"also"prepared"to"visualise"this"relationship."

Statistical"analysis"was"undertaken"using"Stata"13"(Version"13`"StataCorp,"College"

Station,"TX,"USA)."

'6.2.4'Results'Stage"1N"IIT"development"

The" number" (and" percentage)" of" radiographic" examinations" from" each" anatomical"

region"from"the"audit"of"consecutive"cases"over"the"12Nmonth"period"is"presented"in"

Figure" 6.1." In" summary," the" audit" included" 14159" axial" and" appendicular" skeletal"

radiographic" examinations" distributed" across" anatomical" regions" of" shoulder" and"

humerus" (8%),"hand"and"wrist" (17%),"elbow"and" forearm" (5%)," facial"bones" (9%),"

pelvis"and"femur"(20%),"knee"and"tibia"(10%),"foot"and"ankle"(15%)"and"spine"(16%)."

The" final" IIT" consisted" of" 60" cases" consistent" with" the" proportion" of" normal" and"

abnormal" cases" and" distribution" of" anatomical" regions" representing" typical" clinical"

practice" as" indicated" by" frequencies" presented" in" Figure" 6.1." This" included" both"

normal" cases"and" cases"with" abnormalities" (bony"abnormality," signs"of" soft" tissue"

trauma,"and"traumatic"joint"disruptions).""The"reference"standard"was"created"for"each"

case," with" only" one" disagreement" initially" occurring" between" two"members" of" the"

expert"panel."This"was"resolved"during"arbitration"with"the"third"expert"panel"member"

until"consensus"was" reached."The" reference"standard"descriptions" included"simple"

descriptions" of" an" obvious" abnormality," descriptions" of" subtle" abnormalities" and"

complex"cases"with"multiple"point"descriptions"of"single"or"multiple"abnormalities."

'Stage"2N"Reliability"and"validity"testing"

A" total" of" 41" (82%" response" rate)" radiographers" responded" to" the" invitation" and"

participated"in"this"study."The"median"(interquartile"range)"years"of"clinical"experience"

was"5"(2N10)"years."The"total"range"of"experience"was"12"months"to"36"years"of"clinical"

experience."The"median"(interquartile"range)"of"cases"completed"by"participants"within"

the"90"minutes"was"42"(29N55)."

"


There"was"good"agreement"between"raters"across"the"IIT"cases"indicating"favourable"

interNrater"reliability."The"median"(interquartile)"range"kappa"was"0.91"(0.85N0.97)"and"

>0.70"for"58"of"the"60"cases."Similarly,"the"level"of"agreement"for"repeated"measures"

for"a"single"rater"(as"an"indicator"of"intraNrater"reliability)"was"excellent"with"Cohen’s"

kappa"coefficients"above"0.90"for"all"items."The"intraNclass"correlation"coefficients"(and"

95%"confidence"intervals)"that"examined"concordance"between"the"sum"of"all"case"

scores"between"the"two"raters"and"between"the"same"rater"on"two"occasions"were"

both">0.99"(0.99–1.00)."Internal"consistency"of"scoring"across"the"60"cases"was"also"

favourable"with"a"Cronbach’s"alpha"of"0.90.""

"

Analyses"of"associations"between"the"case"scores"and"participants’"confidence"ratings"

supported" the" concurrent" validity" of" IIT" items." The" median" (interquartile" range)"

Spearman’s"rho"for"the"60"cases"was"0.82"(0.70N0.88)."It"was"not"possible"to"calculate"

a"correlation"coefficient"for"4"of"the"60"items"due"to"all"participants"reporting"the"same"

confidence" rating" for" those" cases" (i.e.," no" variance" in" confidence" ratings)." It" was"

interesting"to"note"that"one"item"had"a"negative"coefficient"whereby"an"item"was"more"

difficult" to" interpret" than" participants" realised." There" was" a" positive" association"

between" confidence" and" IIT" score" (coefficient=1.52," rNsquared=0.60" p<0.001)`" this"

association"has"been"visualised"in"Figure"6.3.""

" "


'Figure"6.3" Scatter"plot"with"line"of"best"fit"representing"the"association"between"the"

sum" of" Image" Interpretation" Test" performance" scores" and" the" sum" of" confidence"

ratings"

'6.2.5'Discussion'This" twoNstage" research" investigation" was" successful" in" developing" an" outcome"

measure" for" assessing" image" interpretation" performance." Reliability" and" validity"

testing" of" the" IIT" and" the" novel" scoring" system" that" has" been" introduced" in" this"

investigation"has"provided"an"empirical"foundation"to"support"the"reliability"and"validity"

of"the"IIT"as"an"outcome"measure"that"may"have"potential"application"in"education,"

clinical"and"research"settings.""

"

The"approach"to"case"selection"used"in"the"development"stage"of"this"study"may"be"

considered" advantageous" in" comparison" to" previous" research" that" only" contain"

abnormal"cases.25"The"ability" to" interpret"abnormal" traumatic"pathology" is"certainly"

important`" however," it" is" at" least" equally" important" to"be"able" to"exclude" traumatic"

abnormalities"from"normal"anatomy."The"approach"utilised"in"this"study"enabled"the"

selection"of"images"with"abnormality"rates"consistent"with"clinical"practice"rather"than"

select" an" arbitrary" ratio" of" abnormal" to" normal" radiographs" (for" example," 50%" of"

each).15,"16,"26"Prior"studies"have"also"investigated"image"interpretation"performance"


using"cases"that"did"not"contain"a"broad"range"of"anatomical"regions,3,"16,"17,"27""which"

may"plausibly"bias"performance.28"In"contrast,"the"present"investigation"ensured"that"

the" final" test" contained" anatomical" regions" that" represented" an" anatomical" region"

caseNmix"typical"of"that"seen"in"an"adult"hospital"emergency"department.""

"

Another"key"consideration"in"the"development"of"any"radiographic"interpretation"test"

is"the"reference"standard"which"may"affect"the"validity"of"study"findings.29"It"has"been"

reported" that"utilising"a"panel"of" independent"experts"promotes"objective"unbiased"

scoring"and"reduces"the"risk"of"inaccurate"interpretation"in"the"reference"standard.30"

Several"studies"have"developed"a" reference"standard"using"only"one"expert.3,"16,"31"

Notably" the"present"study"employed"a"3Nperson"panel"of" independent"experienced"

experts."

"

The" successful" implementation" of" an" image" interpretation" test" also" hinges" on" the"

quantification"of"performance"in"terms"of"ability"to"detect"and"describe"the"presence"

or"absence"of"abnormalities."The"scoring"criteria"for"the"IIT"were"designed"to"reward"

both" the" correct" detection" and" description" of" abnormalities" as" well" as" the" correct"

identification"of"the"absence"of"an"abnormality."The"scoring"criteria"tested"in"this"study"

were"designed"to"provide"a"pragmatic"indication"of"participants’"image"interpretation"

performance." It" was" not" necessarily" meant" as" a" comprehensive" proxy" of" risk"

attributable"to"each"interpretation"error."It"is"plausible"that"scenarios"might"exist"where"

each"1Npoint"difference" in" the"scoring"system"may"not"necessarily"have"equivalent"

clinical"risk"implications.""

"

One"challenge"in"the"validation"of"the"item"scoring"was"the"absence"of"a"gold"standard"

criterion" for" image" interpretation" ability." The" confidence" ratings" provided" by"

participants" for" each" case"were" based" on" an" ordinal" (Likert)" scale" and" it" was" not"

necessarily"true"that"the"differences"between"each"adjacent"response"option"on"this"

Likert" scale" were" equivalent." The" measurement" properties" of" these" scales" in" the"

context"of" this" IIT"could"be"explored"(for"example,"using"Item"Response"Theory)" in"

further"detail" in"a" future"study"when" the" IIT"has"been" implemented"among"a" larger"

sample" of" participants." " However" in" the" context" of" this" study," the" investigators"

considered"that"radiographers’"confidence"would"act"as"a"suitable"reference"criterion"

for"the"purpose"of"item"scoring"validation"for"most"cases.""A"notable"exception"would"


be"a"case"where"an"item"was"deceptive"in"its"complexity"or"simplicity."For"example,"a"

case"with"two"abnormalities"present"where"only"one"abnormality"was"easy"to"detect"

or"a"case"that"represented"an"unusual"variant"of"normal."In"either"case,"the"confidence"

rating"maybe"expected"to"be"disproportionate"(or"even"inverse)"to"the"item’s"score."

The"investigators"identified"three"such"occurrences"within"the"IIT"and"were"satisfied"

that"the"results"supported"the"concurrent"validity"of"the"IIT"scoring.""

"

There" are" several" other" notable" strengths" and" limitations" of" this" study." It" may" be"

considered"a"strength" that" the"90"minute" testing"procedure" for" the" IIT" (average"90"

seconds" per" case)" was" consistent" with" the" Royal" College" of" Radiologists" clinical"

practice"guidelines"for"a"suitable"time"to"review"a"radiographic"examination.23"Another"

potential"strength"was"that"the"participants"who"contributed"to"the"reliability"and"validity"

testing"were"drawn"from"multiple"hospitals"and"included"radiographers"with"a"range"of"

clinical" experience" levels." A" further" conceivable" strength" of" this" study" was" the"

response"rate."The"82%"response"rate"may"be"considered"high"when"compared"with"

previous"radiographer" image" interpretation"studies.5,"21,"25"The"authors"propose" that"

the"higher"participation"rate"in"this"study"may"be"due"to"the"current"interest"in"image"

interpretation"amongst"practising"radiographers"in"the"region"or"the"desire"to"accrue"

professional"development"points"as"required"by"their"registration"body."The"IIT"only"

contains"adult"trauma"radiographs"and"consequently"performance"on"the"IIT"may"not"

reflect" participants’" abilities" to" interpret" other" forms" of" imaging," paediatric" or" nonN

trauma"pathologies.""

"

A" limitation"regarding"these"participants"was"that" they"were"all" radiographers."Prior"

research"has"acknowledged"that"establishing"validity"and"reliability"of"a"measurement"

tool" is" required" across" a" range" of" subjects" (in" this" case" perhaps" professions)" and"

clinical" settings.30" Notably" though," it" is" this" radiographer" population" that" has" been"

involved"in"a"range"of"studies"on"radiographic"image"interpretation"and"they"provide"a"

logical"starting"point"for"validating"this"IIT.5,"8,"9,"32,"33"Nonetheless,"testing"among"other"

professions"and"health"professional"students"remains"a"worthwhile"future"direction"for"

research." It" is"also"noteworthy"that" the"trauma"caseNmix"may"differ" from"facilities" in"

dissimilar"regions"where"caseNmix"may"be"influenced"by"attributes"of"local"climate"and"

environment"or"other"population"factors.29"The"decision"not"to"provide"a"clinical"history"

for"each"case`34,"35""and"the"implementation"of"a"timeNlimit"for"completing"the"IIT"are"


notable"points"of"caution"against"extrapolating"image"interpretation"performance"in"the"

present"study"to"dissimilar"circumstances."""

"

Some" additional" important" considerations" for" future" research" will" be" to" examine"

discriminate"validity,"testNretest"reliability"and"performance"of"the"IIT"over"longitudinal"

assessments" to" investigate" its" responsiveness." A" consideration" for" the" future"

application"of" this" IIT" is" the"potential" for"case"recall" if"an" identical" test"was"used"at"

follow"up"assessments."To" limit" case" recall" bias,"a" second" IIT"with"different" cases"

could" be" developed," although" it" is" possible" that" presenting" cases" in" a" different"

(random)"order"may"also"prevent"recall"of"particular"sequences"of"cases.""

"

6.2.6'Conclusion'The"IIT"developed"during"this"investigation"included"a"selection"of"radiographic"cases"

consistent"with"attributes"of"an"adult"trauma"caseNmix."Results"of"this"study"provide"

foundational"evidence"to"support"the"concurrent"validity"of"the"instrument"as"well"as"

internal"consistency," interNrater"and" intraNrater"reliability"of" the"novel"scoring"criteria"

among" radiographers." Further" testing" is" warranted," including" testing" among" other"

clinical" disciplines," examination" of" other" elements" of" validity" and" reliability" and" to"

examine"performance"over"longitudinal"assessments."

"

'6.2.7'References'for'Chapter'6'1" Eastgate"P,"Davidson"R,"McPhail"SM."Radiographic"imaging"for"traumatic"ankle"

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doctors" in" accident" and" emergency" departments:" a" cause" for" concern?" Journal( of(

Accident(and(Emergency(Medicine."1997`"14:"295N298."

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7" Hardy"M,"Culpan"G."Accident"and"emergency" radiography:"a"comparison"of"

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69N77."

10" Pusic"MV,"Andrews"JS,"Kessler"DO,(et(al."Prevalence"of"abnormal"cases"in"an"

image"bank"affects"the"learning"of"radiograph"interpretation."Medical(Education."2012`"

46:"289N298."

11" Boutis"K,"Pecaric"M,"Seeto"B,"Pusic"M."Using"signal"detection"theory"to"model"

changes" in" serial" learning" of" radiological" image" interpretation."Advances( in(Health(

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12" Tudor"G,"Finlay"D."Is"there"an"improvement"in"performance"when"radiographs"

are"reNreported"at"24"hours?"British(Journal(of(Radiology."1999`"72:"465N468."

13" Minnes"BG,"Sutcliffe"T,"Klassen"TP."Agreement"in"the"interpretation"of"extremity"

radiographs" of" injured" children" and" adolescents." Academic( Emergency( Medicine."

1995`"2:"826N830."

14" McConnell"J,"Webster"A."Improving"radiographer"highlighting"of"trauma"films"in"

the"accident"and"emergency"department"with"a"short"course"of"study"N"an"evaluation."

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15" Piper" K," Paterson" A," Godfrey" R." Accuracy" of" radiographers'" reports" in" the"

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18" Coleman"L,"Piper"K."Radiographic"interpretation"of"the"appendicular"skeleton:"

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emergency" radiographic" examinations" by" radiographers:" a" review"of" 11000" cases."


20" Hardy"M,"Snaith"B,"Scally"A."The"impact"of"immediate"reporting"on"interpretive"

discrepancies" and" patient" referral" pathways" within" the" emergency" department:" a"

randomised" controlled" trial." British( Journal( of( Radiology." 2013`" 86:" 20120112N

20120112."

21" Hardy" M," Flintham" K," Snaith" B," Lewis" EF." The" impact" of" image" test" bank"

construction" on" radiographic" interpretation" outcomes:" a" comparison" study."

Radiography."2016`"22:"166N170."

22" Streiner"DL,"Norman"GR,"Cairney"J."Health(measurement(scales:(a(practical(

guide(to(their(development(and(use."Oxford"university"press,"2014."

23" The"Royal"College"of"Radiologists."Clinical" radiology"workload:"guidance"on"

radiologists’"reporting"figures."The"Royal"College"of"Radiologists,"London,"2012."

24" Robinson" P," Wilson" D," Coral" A," Murphy" A," Verow" P." Variation" between"

experienced"observers"in"the"interpretation"of"accident"and"emergency"radiographs."


25" Smith"T,"Traise"P,"Cook"A."The"influence"of"a"continuing"education"program"on"

the"image"interpretation"accuracy"of"rural"radiographers."Rural(and(Remote(Health."

2009`"9:"1145."

26" Kelly"B,"Rainford"L,"Gray" J,"McEntee"M."Collaboration"between" radiological"

technologists"(radiographers)"and"junior"doctors"during"image"interpretation"improves"

the"accuracy"of"diagnostic"decisions."Radiography."2012`"18:"90N95."


27" McConnell" J,"Devaney"C,"Gordon"M,"Goodwin"M,"Strahan"R,"Baird"M."The"

impact" of" a" pilot" education" programme" on" Queensland" radiographer" abnormality"

description" of" adult" appendicular"musculoNskeletal" trauma."Radiography." 2012`" 18:"

184N190."

28" Brealey"S,"Scally"A,"Thomas"N."Methodological"standards"in"radiographer"plain"

film"reading"performance"studies."British(Journal(of(Radiology."2002`"75:"107N113."

29" Brealey"S,"Scally"A."Methodological"approaches"to"evaluating"the"practice"of"

radiographers’"interpretation"of"images:"a"review."Radiography."2008`"14:"46N54."

30" Brealey" S," Scally" A." Bias" in" plain" film" reading" performance" studies."British(

Journal(of(Radiology."2001`"74:"307N316."

31" Hazell"L,"Motto"J,"Chipeya"L."The"influence"of"image"interpretation"training"on"

the" accuracy" of" abnormality" detection" and" written" comments" on" musculoskeletal"

radiographs"by"South"African"radiographers."Journal(of(Medical(Imaging(and(Radiation(

Sciences."2015`"46:"302N308."

32" Brealey"S,"Scally"A,"Hahn"S,"Thomas"N,"Godfrey"C,"Coomarasamy"A."Accuracy"

of"radiographer"plain"radiograph"reporting"in"clinical"practice:"a"metaNanalysis."Clinical(

Radiology."2005`"60:"232N241."

33" Brealey"S,"Scally"A,"Hahn"S," Thomas"N,"Godfrey"C,"Crane"S."Accuracy" of"

radiographers" red" dot" or" triage" of" accident" and" emergency" radiographs" in" clinical"

practice:"a"systematic"review."Clin(Radiol."2006`"61:"604N615."

34" Tudor"G,"Finlay"D,"Taub"N."An"assessment"of" interNobserver"agreement"and"

accuracy"when"reporting"plain"radiographs."Clinical(Radiology."1997`"52:"235N238."

35" Song" KS," Song" HH," Park" SH,( et( al." Impact" of" clinical" history" on" film"

interpretation."Yonsei(Medical(Journal."1992`"33:"168N172."

"

6.3" Thesis"Commentary"This" chapter" described" the" development" and" validation" of" a" quantitative" outcome"

measure"suitable"for"evaluating"radiographers’"ability"to"detect"and"describe"traumatic"

radiographic"abnormalities."This"study"provided"foundational"preliminary"evidence"to"

support"the"reliability"and"validity"of"the"IIT"among"radiographers."The"findings"suggest"

that" it" is" possible" to" assess" image" interpretation" performance" of" adult" trauma"

radiographs"with"this"test."Chapter"7"presents"the"findings"of"a"randomised"controlled"

trial" that" examined" the"effectiveness"of" an" image" interpretation" education" program"

delivered"over"an"intensive"twoNday"period"(intensive)"versus"a"series"of"regular"(90"


minutes" x" 9)" workshops" (nonNintensive)" designed" to" improve" the" ability" of"

radiographers" to" detect" and" comment" on," abnormalities" visualised" on" trauma"

radiographs."

"

Chapter(7:(Randomised(controlled(trial(of(intensive(v(non6intensive(education( 111"

Chapter(7:(Evaluating( the(effectiveness(of(

intensive( versus( non6intensive( image(

interpretation(education(for(radiographers:(

a(randomised(controlled(trial(!

!

(

(

(

(

(

!

!

!

!

!

This!chapter!is!presented!as!two!individual!manuscripts,!each!manuscript!is!presented!

as!published,!apart!from!changes!to!support!consistent!chapter!formatting!throughout!

the!thesis.!The!two!manuscripts!are!listed!below.!

(

Manuscript!4!

Neep( MJ,( Steffens( T,( Eastgate( P,( McPhail( SM.( Evaluating( the( effectiveness( of(

intensive(versus(non# intensive( image( interpretation(education( for( radiographers:(a(

randomised(control(trial(study(protocol.(Journal(of(Medical(Radiation(Sciences.(2018(

March(1G65(1):63670.(

!

Manuscript!5!

Neep( MJ,( Steffens( T,( Eastgate( P,( McPhail( SM.( Evaluating( the( effectiveness( of(

intensive( versus( non6intensive( image( interpretation( education( for( radiographers:( a(

randomised(controlled(trial.(Journal(of(Medical(Radiation(Sciences.(In(press.(


Statement(of(Contribution(of(Co6Authors(for(Thesis(by(Published(Paper(

!

The!authors!listed!below!have!certified!that:!



their!field!of!expertise@!!2.! they!take!public!responsibility!for!their!part!of!the!publication,!except!for!the!

responsible!author!who!accepts!overall!responsibility!for!the!publication@!

!

3.! there!are!no!other!authors!of!the!publication!according!to!these!criteria@!!4.! potential!conflicts!of! interest!have!been!disclosed!to!(a)!granting!bodies,!(b)!the!


responsible!academic!unit,!and!!!5.! they!agree!to!the!use!of!the!publication!in!the!student’s!thesis!and!its!publication!

on!the!QUT’s!ePrints!site!consistent!with!any!limitations!set!by!publisher!

requirements.!

!!


!

Chapter!7!–!Manuscript!4.!Neep!MJ,!Steffens!T,!Eastgate!P,!McPhail!SM.!Evaluating!the!

effectiveness!of!intensive!versus!non!intensive!image!interpretation!education!for!radiographers:!a!randomised!control!trial!study!protocol.!Journal!of!Medical!Radiation!

Sciences.!2018(March(1G65(1):63670.!"

Contributor( Statement(of(contribution*(Michael!Neep!

!



preparation,!manuscript!appraisal!and!editing.!

29.05.18 !

Tom!Steffens! Aided!experimental!design!and!manuscript!appraisal!and!editing.!

Patrick!Eastgate! Aided!manuscript!appraisal!and!editing.!

Assoc,!Prof.!Steven!

McPhail!



I!have!sighted!email!or!other!correspondence!from!all!CoVauthors!confirming!their!certifying!

authorship.!(If!the!Co!–authors!are!not!able!to!sign!the!form!please!forward!their!email!or!other!correspondence!





7.1! Preamble(

The!previous!four!chapters!have!explored!the!gaps!in!the!current!evidence!including!

the!benefits,!barriers!and!enablers!to!introducing!a!PIE!system.!They!also!identified!

radiographers’!perceptions!of!their!confidence!in!their!image!interpretation!ability!as!

well!as!their!perceived!accuracy.!Specifically,!Chapter!6!described!the!development!

and! validation! of! a! quantitative! outcome! measure! suitable! for! evaluating!

radiographers’!ability!to!detect!and!comment!on!traumatic!radiographic!abnormalities.!

Furthermore,! the! findings! of! these! previous! chapters! played! an! integral! role! in!

informing!the!methodology!employed!in!this!final!study!(Study!3).!Chapter!7!reports!

the!findings!of!the!penultimate!study!in!this!thesis.!This!chapter!addressed!Aim!5!(i.e.!

to!evaluate!the!comparative!effectiveness!of!intensive!(2Vday!workshop)!versus!nonV

intensive! (90!minutes!x!9)! formats!of!delivering!an!education!program!designed! to!

improve!radiographers’!abilities!to!detect!and!comment!on!radiographic!abnormalities!

in! trauma! settings)! and! Aim! 6! (i.e.! to! investigate! radiographers’! experiences! in!

completing! the! intensive! or! nonVintensive! education! programs! and! their! perceived!

readiness! for!participation! in!a!PIE!system)!(see!Figure!7.1).!The!primary!outcome!

measure! employed! in! this! study! was! the! IIT! developed! in! the! previous! chapter.!!

Chapter!7!is!divided!into!two!parts.!Part(a)!will!describe!the!study!protocol!that!was!

proposed!and!subsequently!followed!(written!in!future!tense)!and!Part(b)(will!present!

the!findings!from!the!completed!trial.!

!


!

Figure!7.1! Thesis!Structure!–!Chapter!7!

! !


7.2( Part( a)( Evaluating( the( effectiveness( of( intensive( versus( non6intensive(

image( interpretation( education( for( radiographers:( a( randomised( control( trial(

study(protocol!

(

7.2.1(Abstract(

Background:(

Radiographer!commenting!systems!have!not!been!successfully!implemented!in!many!

Australian!hospitals,!despite!evidence!of!their!benefit!and!adoption!elsewhere,!such!

as!the!United!Kingdom.!An!important!contributor!to!the!lack!of!widespread!adoption!of!

radiographer!commenting!in!Australia!(and!likely!elsewhere)!is!the!limited!availability!

of!accessible!education!options! for! radiographers.!The!purpose!of! this! randomised!

controlled! trial! is! to! compare! the! effectiveness! of! the! same! image! interpretation!

education! program! delivered! over! an! intensive! twoVday! period! (intensive! format)!

versus!a!series!of!shorter!regular!workshops!(nonVintensive!format).!!

(

Methods:(

The!study!design!is!a!multiVcentre,!stratified!(by!years!of!experience)!two!group!parallel!

arm!single!blind! (assessor!blinded)! randomised!controlled! trial.!Participants!will! be!

allocated!to!one!of!two!groups:!1)! intensive!format!of!education!or!2)!nonVintensive!

format! of! education! in! a! 1:1! ratio.! Participants! will! undergo! assessments! before!

education,! at! one! week! postVintervention! completion! and! at! 12! weeks! postV

intervention!completion.((

(

Discussion:(

Findings! from! this! trial! will! be! of! relevance! to! radiographers! seeking! image!

interpretation! training! as! well! as! organisations! providing! image! interpretation!

education! to! prepare! clinical! staff! for! participation! in! a! radiographer! commenting!

system.!A!limitation!of!the!trial! is!that!the!sample!will!be!inclusive!of!radiographers,!

and!findings!may!not!be!able!to!be!directly!extrapolated!to!other!clinical!disciplines!

(e.g.,!junior!doctors,!physiotherapists,!or!nurse!practitioners).!!

(

Trial( Registration:( Australian! New! Zealand! Clinical! Trials! Registry! –!

ACTRN12612000210875(

! !


7.2.2(Introduction(

Access! to!appropriate!and! timely!medical! imaging! is! important! for! the!provision!of!

effective!emergency!healthcare!in!hospital!settings.1,!2!Findings!from!medical!imaging!

investigations! underpin! many! diagnostic! and! treatment! decisions,! particularly! for!

people!who!have!presented!to!hospital!following!a!trauma!event.!Even!with!the!rise!in!

use!of!computed!tomography!since! its!development! in!1972,3,!4! radiographic! image!

series! remains! the!primary! imaging!modality! requested! for!patients!who!may!have!

sustained!trauma.5!

!

In!emergency!settings,! the!definitive! radiology!report!may!not!be!available!within!a!

clinically!relevant!timeframe.2!This!means!that!treatment!decisions!are!likely!to!have!

been! implemented! by! the! referring! clinical! team! before! the! radiologist’s! report! is!

available! in!many!cases.!Unfortunately,!delay!between! radiographic! image!capture!

and!the!availability!of!the!radiologist’s!report!can!contribute!to!missed,!incomplete!or!

incorrect!diagnoses.2,!6,!7

!!One!approach!to!mitigate!risk!and!better!support!junior!or!

inexperienced! members! of! the! referring! clinical! team! is! the! recording! of! a! brief!

comment! by! the! radiographer! at! the! time! of! image! capture! to! highlight! any!

abnormalities!they!may!have!detected.8,!9!10,!11

!

!

It!has!been!suggested! that! radiographer!commenting! that!highlights!and!describes!

acute!abnormalities!at!the!point!of!care!may!enhance!patient!management!in!hospital!

emergency! departments.!10,! 12V14

! However,! this! enhancement! is! dependent! on!

radiographers’! ability! to! detect! and! describe! abnormalities! when! viewing! and!

interpreting!trauma!radiographs.!Importantly,!radiographer!performance!in!this!regard!

can!be!improved!as!a!result!of!targeted!education!in!image!interpretation.15V18

!

A!radiographer!commenting!system!has!not!been!successfully!implemented!in!many!

Australian!hospitals,!despite!evidence!of!its!benefit!and!adoption!elsewhere,!such!as!

the!United!Kingdom.10,!13,!19

!An!important!contributor!to!the!lack!of!widespread!adoption!

of! radiographer! commenting! in!Australia! (and! likely! elsewhere)!may!by! the! limited!

availability!of!accessible!and!effective! training!options!for!radiographers.11!Two!key!

factors!limiting!access!to!appropriate!education!are!likely!to!include!the!availability!of!

suitably!qualified!experts!to!deliver! image!interpretation!education!and!the!ability!of!

radiographers!from!geographically!diverse!locations!to!access!it.!!

!


A!potential!solution!to!facilitate!the!accessibility!of!training!is!to!offer!different!formats!

of!education!delivery!that!can!be!potentially!flexible!with!radiographers’!schedules.!In!

preparation! for! the! present! trial! two! specific! formats! for! delivery! of! a! shortVcourse!

image!interpretation!education!program!for!radiographers!were!considered.!The!two!

formats!include!the!same!educational!content!delivered!at!different!intensities!by!the!

same!facilitators.!One!approach!includes!an!intensive!delivery!2Vday!training!suitable!

for!radiographers!who!may!require!the!training!to!be!completed!in!a!short!amount!of!

time!(e.g.,!a!rural!radiographer!travelling!to!a!metropolitan!centre!or!radiographers!who!

can!only!complete!training!on!days!away!from!clinical!work).!The!other!approach!is!a!

nonVintensive! delivery! of! short! regular! workshops! that! may! have! potential! to! be!

incorporated! into! regular! hospital! inVservice! education! programs.! Although! prior!

studies!involving!imaging!interpretation!among!radiographers!have!been!promising,!8,!

9,!12,!16!to!date!there!is!no!study!that!has!compared!the!accuracy!of!radiographer!image!

interpretation! for! skeletal! xVrays! from! radiographers! who! have! received! different!

formats!of!an!educational!intervention.!

!

The!purpose!of!this!randomised!controlled!trial!is!to!compare!the!effectiveness!of!the!

same! image! interpretation! education! program! delivered! over! an! intensive! twoVday!

period!(intensive!format)!versus!a!series!of!shorter!regular!workshops!(nonVintensive!

format).!The! intended!effect!of! this!education!program!is! to! improve!radiographers’!

ability!to!detect!and!describe!abnormalities!visualised!on!trauma!radiographs.!

(

7.2.3(Methods(

Study!design!

The! Standard! Protocol! Items:! Recommendations! for! Interventional! Trials! (SPIRIT)!

2013!guidelines!were!used!when!preparing!this!study!protocol.20!The!study!design!is!

a!multiVcentre,!stratified!(by!years!of!experience)!two!group!parallel!arm!single!blind!

(assessor! blinded)! randomised! controlled! trial! (Figure! 7.2).! Participants! will! be!

allocated!to!one!of!two!groups:!1)! intensive!format!of!education!or!2)!nonVintensive!

format! of! education! in! a! 1:1! ratio! to! examine! whether! either! education! delivery!

approach! is!superior! to! the!other.!Participants!will!undergo!an!assessment!of! their!

ability! to! interpret! adult! skeletal! xVrays,! before! education,! at! one! week! postV

intervention! completion! (primary! timeVpoint)! and! at! 12! weeks! postVintervention!

completion.!


!

Figure!7.2( Study!design!–!randomised!control!trial(

!

Ethics!statement!

The!Human!Research!Ethics!Committees!of!both!the!Metro!South!Hospital!and!Health!

Service! (HREC/11/QPAH/172)! and! the! Queensland! University! of! Technology!

(1200000061)!approved!this!research.!!

!

!


Setting!and!participant!recruitment!

Radiographers! will! be! recruited! from! three! metropolitan! hospital! medical! imaging!

departments!in!south!east!Queensland.!These!hospitals!were!chosen!as!they!each!

have!a!dedicated!emergencyVimaging!department.!Radiographers!eligible!for!inclusion!

in! the! study!must! be! currently! working! in! an! emergencyVimaging! department! and!

willing! to! undertake! either! intensive! or! nonVintensive! image! interpretation! training.!

Radiographers!in!the!participating!sites!will!be!invited!to!participate!in!the!study!via!

email!invitation.!This!will!be!achieved!by!sending!the!radiographer!clinical!educator!at!

each!of!the!sites!an!email!asking!them!to!forward!the!invitation!to!participate!to!all!their!

radiographers! who! rotate! through! their! emergencyVmedical! imaging! department.!

Radiographers!will! be! excluded! from! the! study! if! they:! have! previously! completed!

formal!education!in!image!interpretation!or!commenting!(e.g.,!a!master’s!degree!that!

included!image!interpretation!coursework)@!are!not!available!to!attend!training!at!the!

potential! scheduled! times@!or! don’t! hold! full! registration!as!a! radiographer!with! the!

national! board.! Accompanying! the! original! email! invitation! will! be! a! participant!

information! sheet! and! a! consent! form.! The! participant! information! sheet! provides!

potential! participants! with! the! necessary! understanding! for! the! motivation! and!

procedures!that!underpin!this!study!as!well!as!further!information!to!allow!them!to!give!

informed!consent.!There!will!also!be!opportunity!for!potential!participants!to!contact!a!

member!of!the!research!team!for!further!information!or!to!ask!further!questions.!The!

participant! information! sheet! also! includes! details! explaining! that! the! education!

sessions! will! be! held! out! of! normal! business! hours.! For! example,! the! intensive!

education!will!be!held!on!weekends!and!the!nonVintensive!education!will!be!held!in!the!

evenings.!Participants!are!encouraged!to!ensure!they!are!available!to!attend!all!the!

education!sessions.!Participants!will!provide!written!informed!consent!and!are!free!to!

withdraw!this!consent!at!any!time.!Written!consent!forms!will!be!collected!by!a!member!

of!the!research!team!prior!to!participation.!

!

Randomisation!!

Computerised!random!number!generation!will!be!used!to!generate!the!randomisation!

sequence!by!a!researcher!not!otherwise!involved!in!the!recruitment!or!assessment!of!

participants.! Participants! will! be! stratified! into! four! bands! by! years! of! clinical!

experience!(1V2@!3V5@!6V12@!13!years+)!to!minimise!the!risk!of!differences!in!experience!

levels!between!groups.!Concealment!of!allocation!will!occur!through!use!of!numbered!


opaque!envelopes!containing!the!group!allocation!for!each!participant!and!stored!in!a!

locked!filing!cabinet!until!the!time!of!allocation.!After!a!participant!has!completed!their!

baseline! assessment,! an! intervention! coVordinator! will! be! permitted! to! access! the!

envelope!with!the!corresponding!participant!number!and!open!the!envelope!to!reveal!

allocation! (to! either! the! intensive! format! or! nonVintensive! format).! The! baseline!

assessment!will!involve!participants!completing!the!primary!and!secondary!outcome!

measures.!This!assessment!will!be!conducted!at!the!participant’s!place!of!work!and!

scheduled! in! consultation! with! the! participant! and! their! manager! to! ensure! their!

attendance.!

!

Intervention!

The!standardised!education!intervention!will!be!delivered!in!two!formats:!One!group!

will! receive! intensive!education!(twoVday! intensive!format!of!delivery)!and!the!other!

group!will!receive!nonVintensive!or!more!traditional!education!(sequential!90Vminute!

tutorials!delivered!(at!least)!one!week!apart).!!!

!

Both!formats!contain!identical!content! in!the!same!overall! ‘education!time’!covering!

appendicular! and! axial! skeletal! trauma.! The! educational! program! was! originally!

developed! to! enhance! junior! emergency! doctors’! skills! in! interpreting! trauma!

radiographs.! This! program! has! been! refined! to! suit! radiographers! by! the! original!

developer.!To!cater!for!multiple! learning!styles!the!program!incorporates!a!blended!

learning! environment! combining! two! distinct! modes,! passive! traditional! classroom!

teaching! and! an! interactive! visual! practical! component.21!Within! the! two!modes! of!

learning,!a!number!of!learning!aids!are!included!to!cater!for!different!learning!styles!

incorporating!multiVsense,!psychomotor!and!affective!strategies.22,!23

!The!education!

program! also! integrates! several! original! acronyms! and! mnemonics! to! assist! the!

learner!with!memory! retention!and!support! them!practising! the!skills! learnt! to!build!

capability.!!

!

The!program!is!divided!into!nine!90Vminute!workshops!(see!Table!7.1)!including!using!

a! search! strategy@! how! to! structure! findings,! common! traumatic! pathology,! normal!

variants!and!frequently!missed!abnormalities.!Paediatric!trauma!is!not!covered!in!this!

education!program,!as!the!education!program!has!been!developed!at!a!site!that!is!not!

a!paediatric!(<14!year!of!age)!centre.!To!standardise!intervention!delivery,!the!same!


facilitators,!both!of!whom!are!members!of!the!research!team,!experienced!in!image!

interpretation! and! facilitation! of! training,! will! deliver! the! courses! (together).! The!

facilitators!are!not!aware!of!the!contents!of!the!assessments!nor!involved!with!marking!

the!assessments.!Class!size!will!be!comparable!for!both!formats.!To!facilitate!learning!

opportunities!and!interactions!within!the!education!sessions,!the!size!of!each!class!will!

be!kept!to!approximately!12!students.24,!25

!!

!

Table!7.1! Education!intervention!content!outline!

Workshop( Subject(1! ! General!principles!and!strategy!for!interpretation!of!skeletal!trauma!

!

2! ! Hand,!wrist!and!forearm!

!

3! ! Face!including!mandible!

!

4! ! Foot,!ankle!and!tibia/fibula!

!

5! ! Knee!and!distal!femur!

!

6! ! Pelvis!and!hips!

!

7! ! Shoulder!and!humerus!

!

8! ! Spine!

!

9! ! Review!of!all!content!

!

To! promote! ongoing! participation! in! the! nonVintensive! educational! intervention,!

radiographers! in! this!group!will! receive! reminders!prior! to!each!weekly!session!via!

email.!Furthermore,!to!promote!completion!of!the!education!program!for!participants!

in!both!groups,!this!education!program!is!eligible!for!accrual!of!continuing!professional!

development! points! (equal! to! 13.5! hours)! recognised! by! the! national! registration!

board.!A!certificate!of!completion!as!evidence!of!accrual!of!the!continuing!professional!

development!points!will!be!provided!to!participants!who!complete!the!training.!!

!

!

!

Outcome!measures!


Primary(outcome(measure(

The!primary!outcome!measure!will!be!the!Image!Interpretation!Test!(IIT)!assessment!

score,! which! has! favourable! evidence! supporting! its! validity! and! reliability! among!

radiographers.26(The!development!of!this!test!has!been!described!in!detail!in!an!earlier!

publication.26! This! assessment! involves! participants! examining! a! test! bank! of!

radiographic!examinations!(presented!in!random!order)!to!try!to!identify!abnormalities!

(and! provide! a! descriptive! comment! when! an! abnormality! is! observed).! The! IIT!

assessment! contains! 60! examinations.! It! includes! various! appendicular! and! axial!

skeletal! radiographs! with! a! distribution! of! anatomical! regions! and! proportion! of!

abnormal!cases! that!has!been!reported!as!consistent!with!a! typical!adult!case!mix!

from!a!hospital!emergency!department.26!This!case!mix!was!determined!by!conducting!

an!audit!of!consecutive!adult!examinations!over!a!12Vmonth!period.!A!description!of!

this! audit! has! been! described! previously.26! Participants! in! the! trial! will! have! their!

responses! for! each! IIT! examination! (e.g.,! detection! of! normal! or! abnormal! and!

description! of! abnormalities! identified)! scored! by! a! blinded! examiner.! ! Two!

radiographers!with!postgraduate!qualifications!in!image!interpretation!will!serve!as!a!

panel!of!independent!examiners!to!score!and!compare!participant!responses!to!the!

reference!standard!for!each!examination.!The!examiners!will!not!be!involved!with!the!

study!design,!conduct!or!education!intervention!(and!blinded!to!group!allocation!and!

participant’s!identity).!A!reference!standard!has!been!created!for!each!examination!by!

a! panel! of! experienced! experts! (two! consultant! radiologists! and! one! consultant!

reporting!radiographer).26!A!novel!rating!scale!has!also!been!developed!and!validated!

in!an!earlier!publication!(Table!7.2).26!The!examiners!will!be!trained!on!how!to!use!the!

rating! scale! by! the! site! investigator! (MN).! They!will! be! provided!with! a! guide! and!

worksheet!to!enable!a!consistent!framework!for!marking.!!By!using!the!rating!scale,!

each!examination!in!the!IIT!will!be!given!a!numerical!value!with!a!maximum!total!score!

of! 3! and! a!minimum! of! 0.!When!marking! assessments,! discordant! ratings! will! be!

discussed!between!the!examiners!until!consensus!reached.!

!

! !


Table!7.2! Scoring!criteria!for!each!examination!in!the!Image!Interpretation!Test!

!

CRITERIA( SCORE(

For(radiographic(cases(with(a(traumatic(abnormality( !

Abnormality(not(detected(( 0!

Abnormality(detected,(but(not(described(correctly( 1!

Abnormality(detected,(description(incomplete((but(not(incorrect)(( 2!

Abnormality(detected(and(correctly(described(in(entirety(( 3!

( !

For(radiographic(cases(with(no(traumatic(abnormality( !

False(abnormality(reported(or(described(( 0!

Correct(report(of(absence(of(any(traumatic(abnormality(( 3!

!

To! determine! which! format! of! delivery! resulted! in! greater! improvement! and!

maintenance! of! image! interpretation! capability,! the! IIT! will! be! completed! prior! to!

education!commencement,!one!week!after!education!completion!and!at!12!weeks!post!

education! completion! for! both! formats.! A! 12Vweek! reassessment! will! provide! an!

indication!of!whether!there!is!difference!in!the!maintenance!of!improvements!observed!

at!the!first!postVintervention!assessment.!The!12Vweek!duration!was!also!chosen!so!

that! a! comparison! could! be! made! between! the! 12Vweek! post! intensive! format!

assessment,!with!the!oneVweek!post!nonVintensive!format!assessment!as!these!would!

be!approximately!the!same!number!of!weeks!post!intervention!commencement!(i.e.!

approximately! 13! weeks).! To! help! limit! case! recall! bias! at! individual! assessment!

points,!each!test!bank!of!images!will!be!presented!in!random!order.!The!order!of!the!

cases! will! be! determined! by! a! computerVgenerated! randomisation! sequence.! To!

minimise!the!impact!of!postVtest!discussion,!participants!will!be!asked!not!to!discuss!

the!cases!within!the!test.!This!however!could!not!be!directly!monitored!or!controlled!

by!the!investigators.!

(

Primary(outcome(measure(procedure(

Before!each!assessment,!radiographers!will!be!provided!with!a!guideline!(see!Table!

7.3)!for!classification!of!radiographic!examinations!based!upon!a!prior!investigation.27!

The!anonymised!DICOM!(Digital!Imaging!and!Communications!in!Medicine)!images!


will!be!embedded! into!an! image!review!software!program!(Codonics!Clarity!Viewer!

version!6.1,!Middleburg!Heights,!Ohio,!USA).!Prior!to!interpreting!and!commenting!on!

radiographs! in! the! IIT,! each! participant! will! receive! instruction! on! how! to! use! this!

software!to!view!each!image.!This!software!program!has!the!capability!to!adjust!image!

contrast/! density,! zoom,! pan! and! invert! an! image! as!would! be! possible! in! clinical!

practice!settings.!

!

Table!7.3! Examination!classifications!for!primary!outcome!measure!

!

Findings!

Abnormal( ( ( ( ( (

! ! ! 1.!Fractures!! ! ! ! !

! ! ! 2.!Joint!disruptions!! ! ! !

! ! ! 3.!Joint!effusions!! ! ! !

! ! ! 4.!Soft!tissue!swelling! ! !

Normal!

1.!Anatomical!variants!

! ! ! 2.!NonVtraumatic!pathology!

! ! ! 3.!Old!fractures!

! ! ! 4.!Evidence!of!previous!surgery!

!

To!simulate!the!clinical!setting!and!typical!workflow,!the!assessment!will!take!place!in!

a! semiVdarkened! room! with! a! time! restriction! (a! total! of! 90! minutes! assigned! to!

complete!the!assessment).!The!images!will!be!reviewed!using!a!standard!personal!

computer!monitor!(2Vmegapixels)!that!is!consistent!to!reviewing!images!in!the!clinical!

setting.!Neither!a!clinical!history!nor!access!to!previous!imaging!for!each!examination!

in! the! IIT! will! be! permitted.! Not! including! clinical! history! is! designed! to! ensure!

participant’s!responses!to!the!IIT!are!entirely!dependent!on!how!well!they!scan!and!

interpret!the!radiographic!images,!rather!than!an!assessment!of!how!well!they!interpret!

case!histories!in!combination!with!radiographic!images.!

(

(

(


Secondary(outcome(measure(

In!addition! to!providing!a!description!of! the!pathology!(perceived! to!be)!present! for!

each!examination,! the!participants!will!be!asked! to!provide!a! ‘confidence! rating’! to!

indicate!how!confident!they!are!in!their!interpretation!on!a!5Vpoint!Likert!scale!(normal,!

probably!normal,!possibly!normal,!probably!abnormal!and!abnormal).!These!ratings!

will!be!reported!at!baseline!and!at!followVup!assessments.!

!

Two!questionnaires!will!also!be!administered!(the!first!to!be!completed!at!the!baseline!

assessment! prior! to! randomisation,! the! second! is! completed! at! the! 12Vweek! postV

intervention! assessment).! The! content! and! format! of! the! two! questionnaires! is!

comparable,!with!the!exception!of!an!additional!question!in!the!second!questionnaire!

to! investigate! the! participant’s! perception! of! the! education! format! they! received!

(Appendix!C!and!D).!These!questionnaires!will!be!completed!via!a!secure!webVbased!

platform.! The! development! process! for! these! secondary! questionnaires! followed!

recommendations! for! the! design! and! conduct! of! selfVadministered! surveys! for!

clinicians.28!The!process!involved!forming!a!panel!of!local!content!and!survey!design!

experts!who! assisted! in! item! generation,! reduction! and! pretesting.! Both! electronic!

questionnaires!were!piloted!with!a!small!convenience!sample!of!radiographers!(n=6).!

Questionnaire! flow,! format,! interpretability,! redundant! items! and! overall! length! of!

questionnaires! were! assessed.! Each! questionnaire! will! be! distributed! to! all!

participants! via! an! email! containing! a! hyperlink! to! the! secure! webVbased! survey!

platform.!

(

Sample(size(calculation(

Owing!to!a!lack!of!similar!studies!to!inform!effect!size!assumptions,!the!research!team!

took! a! pragmatic! approach! to! determining! an! appropriate! effect! size! to! use! in! the!

sample! size! calculation.29! The! team! consulted! three! medical! imaging! clinical!

educators! to! consider! what! they! would! classify! as! a! meaningful! difference! in! the!

primary! outcome!measure! that!would! lead! them! to! choose!one!education! delivery!

format!over!the!other.!Their!responses!indicated!that!a!difference!of!more!than!one!

correctly!described! image,!which!equated! to!4!points!or!more!on! the! IIT,!would!be!

considered!a!significant!difference.!Therefore,!the!target!sample!size!will!be!48!(24!

participants!per!group).!A!sample!size!of!24!participants!per!group!provides!greater!

than! 80%! power29! to! detect! a! 4Vpoint! difference! between! groups! in! the! primary!


outcome!(IIT!score)!at!a!significance!level!of!0.05%,!assuming!a!standard!deviation!of!

4.5!and!a!dropout!rate!<15%.!

!

Statistical!methods!

Data!analyses!will!be!performed!using!Stata!(StataCorp,!College!Station,!TX,!USA).!

Conventional! descriptive! statistics! will! be! used! to! describe! the! sample! (years!

experience! as! a! radiographer,! age,! gender,! current! or! previous! involvement! in! a!

radiographer! abnormality! detection! system,! as!well! as! the! primary! and! secondary!

outcomes).! Data! will! be! analysed! according! to! the! intentionVtoVtreat! principles.!

Outcome! measures! will! be! compared! within! and! between! intervention! groups! at!

baseline,!and! follow!up!assessments!using!generalised! linear!models! to!determine!

whether!there!were!differences!between!groups!and!changes!in!primary!or!secondary!

outcomes!over!time!(group!by!time!interaction).!The!primary!timeVpoint!of!interest!is!

the!oneVweek!postVintervention!assessment.!From!these!analyses,!it!will!be!possible!

to! determine!which!method! of! education! delivery! (if! any)! had! a! greater! impact! on!

improving!the!radiographers’!ability! to!detect!and!describe!abnormalities!on!trauma!

radiographs,!with!the!opportunity!to!adjust!for!baseline!confounders!if!indicated.!!

!

7.2.4(Discussion(

Errors! in! the! interpretation! of! radiographs! in! the! emergency! department! have!

important! consequences! for! patients! and! clinicians.5! Failure! to! correctly! identify!

abnormalities!on!radiographs!in!a!timely!manner!may!result!in!delayed!or!inappropriate!

treatment! leading! to! suboptimal! outcomes! for! patients! and! potential! medicoVlegal!

claims! against! clinicians.6! Radiographer! commenting! has! been! proposed! as! a!

mechanism! to! reduce! diagnostic! errors! by! providing! an! immediate! opinion! on! a!

radiograph!at!the!time!of!image!capture!by!the!performing!radiographer.10,!12,!14

!The!

potential! benefits! of! radiographer! commenting! are! likely! to! be! dependent! on! the!

radiographer’s! ability! to! detect! and! describe! abnormalities! when! viewing! and!

interpreting! trauma! radiographs.! Consequently,! access! to! effective! training! that!

radiographers! receive! in! preparation! for! a! radiographer! commenting! role! is!

paramount.! This! will! be! the! first! randomised! controlled! trial! to! evaluate! the!

effectiveness!of!intensive!and!nonVintensive!formats!of!delivery!of!image!interpretation!

education.! ! This! study! will! generate! valuable! evidence! regarding! how! image!


interpretation! education! can! be! effectively! delivered! to! radiographers! in! hospital!

settings!nationally!and!internationally.!!

!

There!are!several!limitations!of!this!study!that!should!be!considered.!The!possibility!of!

recall!bias!is!always!a!potential!limitation!with!studies!that!involve!the!completion!of!

the!same!assessment!during!a!relatively!short!time!frame.!To!minimise!participants!

memorising!cases!between!assessments,!this!study!will!undertake!two!preventative!

actions.!Firstly,!a!minimum!time!period!between!any!two!assessments!of!five!weeks!

will!be!employed.!!Secondly,!a!computerVgenerated!randomisation!sequence!will!be!

used! to! present! each! 60! case! assessment! in! random! order,! further! limiting! the!

potential! for! case! recall.! An! additional! limitation! that! is! a! risk! when! employing! a!

voluntary!sampling!method! for!participation! in!a! research!study! is! the!possibility!of!

selfVselection!bias.!Radiographers!who!respond!to!the!participation!invite!may!have!a!

greater! interest! in! image! interpretation! education! than! nonVresponders.! Another!

potential! limitation!is!that!there!was!no!pilot!data!to!inform!sample!size!calculations!

prior!to!the!study!commencement.!If!significant!findings!are!not!observed!in!the!final!

analyses,!a!postVhoc!power!calculation!based!on!trial!data!will!be!conducted!to!inform!

planning! for! future! studies.! Furthermore,! the! knowledge! and! capabilities! of! rural!

radiographers!in!comparison!to!radiographers!from!metropolitan!areas!has!not!been!

contemplated! in! this! study! and! may! be! considered! a! limitation! of! this! trial! which!

required! participants! to! be! available! to! receive! either! intervention! format.! Future!

research!investigating!their!difference!would!be!worthwhile.!!

!

Findings!from!this!trial!are!likely!to!be!of!relevance!to!radiographers!seeking!image!

interpretation! training! as! well! as! organisations! providing! image! interpretation!

education! to! prepare! clinical! staff! for! participation! in! a! radiographer! commenting!

system.! A! further! limitation! of! the! trial! is! that! the! sample! will! be! inclusive! of!

radiographers,!and!findings!may!not!be!able!to!be!directly!extrapolated!to!other!clinical!

disciplines!(e.g.,!junior!doctors,!physiotherapists,!or!nurse!practitioners).!Nonetheless,!

this!trial!will!provide!insight!into!how!image!interpretation!education!can!be!effectively!

delivered! and! pave! the! way! for! future! research! among! other! relevant! health!

professions! including!physiotherapists,!nurse!practitioners!and!doctors!who!work! in!

emergency!department!settings.!!

!


Trial(status(

The!trial!was!recruiting!at!the!time!of!submission.!

!

( (


(((((

Statement(of(Contribution(of(Co6Authors(forThesis(by(Published(Paper(

The!authors!listed!below!have!certified!that:!!



their!field!of!expertise@!!2.! they!take!public!responsibility!for!their!part!of!the!publication,!except!for!the!

responsible!author!who!accepts!overall!responsibility!for!the!publication@!

!

3.! there!are!no!other!authors!of!the!publication!according!to!these!criteria@!!4.! potential!conflicts!of!interest!have!been!disclosed!to!(a)!granting!bodies,!(b)!the!


responsible!academic!unit,!and!!!5.! they!agree!to!the!use!of!the!publication!in!the!student’s!thesis!and!its!

publication!on!the!QUT’s!ePrints!site!consistent!with!any!limitations!set!by!

publisher!requirements.!

!!


!

Chapter!7!–!Manuscript!5.!Neep!MJ,!Steffens!T,!Eastgate!P,!McPhail!SM.!Evaluating!the!

effectiveness!of!intensive!versus!nonVintensive!image!interpretation!education!for!

radiographers:!a!randomised!controlled!trial.!2018.!Submitted!to!Journal!of!Medical!

Radiation!Sciences.!In!press.!

!




preparation,!manuscript!appraisal!and!editing.!!

25/06/2018! !

Tom!Steffens!

!

Aided!experimental!design!and!manuscript!appraisal!and!editing.!

!

Patrick!Eastgate!

!

Aided!manuscript!appraisal!and!editing.!

!

Assoc.!Prof.!Steven!

McPhail!



I!have!sighted!email!or!other!correspondence!from!all!CoVauthors!confirming!their!certifying!

authorship.!(If!the!Co!–authors!are!not!able!to!sign!the!form!please!forward!their!email!or!other!correspondence!





7.3( Part( b)( Evaluating( the( effectiveness( of( intensive( versus( non6intensive(

image(interpretation(education(for(radiographers:(a(randomised(controlled(trial.(

(

7.3.1(Abstract(

Introduction:((

The!purpose!of!this!randomised!controlled!trial!was!to!compare!the!effectiveness!of!

intensive!and!nonVintensive!formats!of!delivery!of!image!interpretation!education!for!

radiographers.!!

(

Methods:((

A!multiVcentre,!stratified!(by!years!of!experience),!two!group!parallel!arm,!single!blind,!

randomised!controlled!trial!was!conducted.!Participants!(n=48)!were!allocated!to!one!

of! two! groups! to! receive! image! interpretation! education:! 1)! intensive! format! of!

education!(13.5!hours!over!2!consecutive!days)!2)!nonVintensive!format!(sequential!

90Vminute! tutorials! delivered! one! week! apart).! Participants! underwent! an! xVray!

interpretation!test!before!education,!at!oneVweek!postVintervention!completion!and!at!

12Vweeks!post!intervention!completion.!

(

Results:!!

Image! interpretation!performance!was!not! significantly! different! between!groups!at!

baseline.! A! generalized! linear! model! indicated! that! participants! who! received! the!

intensive! education! format! improved! their! image! interpretation! performance! by! a!

greater!margin!than!the!group!that!received!nonVintensive!education!at!the!oneVweek!

(p=0.002)!and!12Vweek!(p<0.001)!followVup!assessments.!!

(


(

Conclusions:((

Although!both! formats! of! education!delivery!may!be!beneficial,! the! findings!of! this!

study! have! indicated! that! the! intensive! format! of! delivery! was! more! effective! at!

improving! radiographers’! ability! to! interpret! trauma! radiographs! in! the!weeks! after!

completion!of!the!image!interpretation!program.!!

!

Keywords(

Image!interpretation,!education,!radiographers,!randomised!control!trial!

(

7.3.2(Introduction(

Failure! to! identify! fractures! is! the! most! common! diagnostic! error! occurring! in!

emergency! departments.5,! 30V32

! Radiographer! commenting! or! Preliminary! Image!

Evaluation!(PIE)33!has!been!suggested!as!a!potential!mechanism!for!reducing!these!

errors.!A!PIE!is!a!brief!written!description!provided!by!a!radiographer,!which!describes!

findings!of!a!radiographic!examination!at!the!time!of!image!acquisition.8V12,!34,!35

!The!

benefits!arising!from!PIE!are!likely!to!be!proportional!to!radiographer’s!ability!to!detect!

and! describe! abnormalities! when! interpreting! trauma! radiographs.! Consequently,!

training! that! improves!radiographers’! interpretive!skills! is! imperative.!No!prior!study!

has! compared! delivery! of! different! formats! of! image! interpretation! education! for!

radiographers.!(

!

The!purpose!of!this!randomised!controlled!trial!was!to!compare!the!effectiveness!of!

the! same! image! interpretation! education! program!delivered! over! a! twoVday! period!

(intensive!format)!versus!a!series!of!shorter!regular!workshops!(nonVintensive!format).!

The!primary!intended!effect!of!this!education!program!was!to!enhance!radiographers’!


ability!to!detect!and!describe!potential!abnormalities!visualised!on!trauma!radiographs.!

Secondary! aims! included! examining! participants’! ratings! of! their! confidence,!

perceived! image! interpretation! accuracy! and! opinions! of! the! quality! of! image!

interpretation!education!received.!

(

7.3.3!Methods(

Study!design!

Details!of!the!trial!protocol!have!been!previously!described.36!In!summary,!the!study!

design!was!a!multiVcentre,!stratified!(by!years!of!experience)!two!group!parallel!arm,!

single!blind!(assessor!blinded),!randomised!controlled!trial!(Figure!7.3).!Participants!

were! allocated! to! one! of! two! groups:! 1)! intensive! format! of! education! or! 2)! nonV

intensive! format! of! education! in! a! 1:1! ratio.! Participants! completed! assessments!

before!education,!at!one!week!postVintervention!completion!and!at!12Vweeks!postV

intervention! completion.! The! study! period! opened! in! September! 2012,! final!

recruitment! closed! in! July! 2017! and! the! last! followVup! assessments! finalized! in!

January!2018.!!

!


!

Figure!7.3( Study!design!–!randomised!trial(

!

Ethical!considerations!

Participants!provided!written!informed!consent!with!freedom!to!withdraw!at!any!time.!

The! study! was! approved! by! the! Metro! South! Hospital! and! Health! Service!

(HREC/11/QPAH/172)!and!the!Queensland!University!of!Technology!(1200000061)!

human! research! ethics! committees! and! prospectively! registered!

(ACTRN12612000210875).!!

!


Setting!and!participant!recruitment!

Radiographers! were! recruited! from! three! hospitals! with! dedicated! emergency!

departments!in!Queensland,!Australia.!Radiographers!were!eligible!for!inclusion!if!they!

currently! worked! in! an! emergencyVimaging! department! and! were! agreeable! to!

undertake! either! intensive! or! nonVintensive! image! interpretation! training.! Eligible!

radiographers!were!invited!to!participate!via!email.!Radiographers!were!excluded!from!

participation!if!they!had!previously!completed!formal!training!in!image!interpretation!

(for!example,!a!masters!degree!that!included!image!interpretation!coursework),!were!

not!available!to!attend!the!proposed!education!at!the!scheduled!training!times!or!were!

currently!completing!their!supervised!practice!year!(intern!year).!

!

Sample(size(

The!a!priori!sample!size!calculation!estimated!that!a!target!of!48!participants!should!

be!recruited.36!!A!sample!size!of!24!participants!per!group!provided!greater!than!80%!

power!to!detect!a!4Vpoint!difference!between!groups!in!the!primary!outcome!(IIT!score)!

at!a!significance!level!of!0.05%,!assuming!a!standard!deviation!of!4.5!and!a!dropout!

rate!<15%.36!

!

Randomisation!!

Participants!were!stratified!by!years!of!clinical!experience!(1V2@!3V5@!6V12@!13!years+)!

to!minimise!the!risk!of!experience!imbalance!between!groups.!A!computerVgenerated,!

permuted!block!random!number!schedule!was!developed!by!a!researcher!(SMM)!not!

involved!in!the!recruitment!or!assessment!of!participants.!Concealment!of!allocation!

occurred!using!opaque,!consecutively!numbered!envelopes!stored!in!a!locked!filing!

cabinet.!One!envelope!was!opened!for!each!participant!(by!site!investigators!TS!and!


MN)!in!order!of!recruitment!on!completion!of!each!participant’s!baseline!assessment!

to!reveal!their!group!allocation.!Each!participant!was!allocated!to!either!the!intensive!

format!or!nonVintensive!format!of!education.!!

!

Intervention!

The!education!program!was!delivered!in!two!formats:!One!group!received!intensive!

education! (twoVday! intensive! format!of!delivery)!and! the!other!group! received!nonV

intensive!or!more!traditional!education!(sequential!90!minute!tutorials!delivered!once!

per!week).!!!

!

Both! formats! contained! identical! educational! content,! for! the! same! duration! (13.5!

hours).! The! education! program! covered! interpretation! of! appendicular! and! axial!

skeletal!trauma!and!was!based!on!a!successful!program!described!previously.36!The!

program!was!divided!into!nine!90!minute!workshops!(Table!7.4).!Key!areas!covered!

included! the!use!of!an!original! search!strategy,!how! to!structure! the!description!of!

findings,! common! injuries,! normal! variants! and! frequently! missed! abnormalities.!

Paediatric!trauma!was!not!covered,!as!the!education!program!was!developed!at!a!site!

that!was!not!a!paediatric!(<14!year!of!age)!centre.!To!standardise!intervention!delivery,!

the! same! two! instructors,! both! of! whom! had! considerable! experience! in! image!

interpretation!and!facilitation!of!training,!delivered!both!formats.!The!facilitators!were!

not! aware! of! the! contents! of! the! assessments! nor! involved! with! marking! the!

assessments.!Furthermore,!because!the!total!educational!content!delivery!time!was!

standardised,!this!promoted!equivalent!inVclass!learning!experience!for!both!groups!

regarding!the!facilitator!time!attributed!to!each!component!of!the!education.!!

!


!

Table!7.4! Education!intervention!content!outline!

!

Workshop( Subject(1! ! General!principles!and!strategy!for!interpretation!of!skeletal!trauma!!

!

2! ! Hand,!wrist!and!forearm!

!

3! ! Face!including!mandible!

!

4! ! Foot,!ankle!and!tibia/fibula!

!

5! ! Knee!and!distal!femur!

!

6! ! Pelvis!and!hips!

!

7! ! Shoulder!and!humerus!

!

8! ! Spine!

!

9! ! Review!of!all!content!

!

Outcome!measures!

Primary(outcome(measure(

The!Image!Interpretation!Test!(IIT)!assessment!score!was!used!to!determine!which!

format! of! delivery! resulted! in! greater! improvement! and! maintenance! of! image!

interpretation! ability.! The! development! of! this! instrument,! as! well! as! evidence!

supporting!its!validity!and!reliability!for!examining!radiographers’!image!interpretation!

ability!has!been!described!previously.26(The!IIT!required!participants!examining!a!test!

bank! of! radiographic! examinations! (presented! in! random! order)! to! identify!

abnormalities! (and! provide! a! descriptive! comment! when! an! abnormality! was!

observed).! The! IIT! assessment! contained! 60! cases! presented! in! DICOM! format!

(Digital!Imaging!and!Communications!in!Medicine).!It!included!various!appendicular!

and!axial!adult!skeletal!radiographs!with!a!distribution!of!anatomical!regions!designed!

to!be!representative!of!a!typical!adult!case!mix!from!a!hospital!emergency!department.!


The! proportion! of! normal! and! abnormal! cases! in! the! IIT!was! also! designed! to! be!

consistent!with!typical!clinical!practice!in!hospital!emergency!departments.26!!

!

The!IIT!was!completed!prior!to!education!commencement,!oneVweek!post!education!

completion! and! at! 12!weeks! post! education! completion.!Before! each! assessment,!

radiographers!were!provided!with!a!guideline!for!classification!of!each!radiographic!

examination!consistent!with!prior!research!in!the!field.27!This!guideline!indicated!that!

a! normal! finding! should! include! anatomical! variants,! nonVtraumatic! pathology,! old!

fractures! and! evidence! of! previous! surgery,! unless! specifically! related! to! the!

presentation.!!In!contrast,!an!abnormal!finding!would!include!joint!effusions,!fractures,!

dislocations,! subluxations! and! soft! tissue! swelling.! Prior! to! interpreting! and!

commenting!on!radiographs!in!the!IIT,!each!participant!received!instruction!on!how!to!

use! the! image! review! software! (Codonics! Clarity! Viewer! version! 6.1,! Middleburg!

Heights,! Ohio,! USA).! This! software! provided! the! participant! with! functionality!

consistent!with! that! of! the! clinical! setting!where! they! could! adjust! image! contrast/!

density,!zoom,!pan!and!invert!an!image.!To!simulate!the!clinical!setting!and!typical!

workflow,!the!assessment!took!place!in!a!semiVdarkened!room!with!a!time!restriction.!

Ninety!minutes!was!assigned!to!complete!the!assessment,!consistent!with!the!prior!

validation!of! the! IIT.26!Participants!were!permitted! to!complete! the! IIT!cases! in!any!

order!which!included!whether!or!not!to!interpret!or!skip!past!a!particular!case.!!

!

Two!radiographers!with!postgraduate!qualifications!in!image!interpretation!served!as!

a!panel!of!independent!raters!to!score!each!case!completed!by!participants!against!

the!reference!standard.!The!scoring!criteria!(Table!7.5)!and!reference!standard!were!

consistent!with!the!prior!validation!of!the!IIT.26!The!raters!were!trained!on!how!to!use!


the!scoring!criteria!by! the!site! investigator! (MN)!and!were!provided!with!a!marking!

guide!and!worksheet! to!ensure!a! consistent! framework! for!marking.! !By!using! the!

scoring!criteria!each!case!in!the!IIT!was!given!a!numerical!value!with!a!maximum!total!

score!of!3!and!a!minimum!of!0!(the!theoretical!maximum!score!for!the!60!IIT!items!

was! 180).! A! third! independent! rater! was! available! to! mediate! any! disagreements!

between!the!two!primary!raters.!In!addition,!because!the!IIT!is!a!timed!test,!the!number!

of!items!not!attempted!was!recorded!at!each!assessment.!!

!

Table!7.5! Scoring!criteria!for!each!examination!in!the!Image!Interpretation!Test!

!

!

CRITERIA' SCORE'For(radiographic(cases(with(a(traumatic(abnormality( "

Abnormality(not(detected(( 0"Abnormality(detected,(but(not(described(correctly( 1"

Abnormality(detected,(description(incomplete((but(not(incorrect)(( 2"Abnormality(detected(and(correctly(described(in(entirety(( 3"

( "For(radiographic(cases(with(no(traumatic(abnormality( "

False(abnormality(reported(or(described(( 0"Correct(report(of(absence(of(any(traumatic(abnormality(( 3"

!

Secondary(outcome(measures(

In!addition!to!providing!a!description!of!the!pathology!(perceived!to!be)!present,!the!

participants!were!also!asked!to!provide!a!‘confidence!rating’!to!indicate!how!confident!

they!were! in! their! interpretation!on!a!5Vpoint!Likert!scale! (normal,!probably!normal,!

possibly!normal,!probably!abnormal!and!abnormal).!Confidence!ratings!were!scored!

for!each!case!from!5!to!1!for!normal!cases!and!1!to!5!for!abnormal!cases!across!the!

respective!Likert!response!options.!This!scoring!approach!ensured!that!confident!but!

incorrect! ratings!were!awarded! the! lowest!score! (1),!while!definitive!correct! ratings!


were!awarded!the!highest!score!(5)!for!confidence!ratings!on!each!IIT!case.!These!

ratings!were!recorded!at!baseline!and!at!both!followVup!assessments.!

(

Participants!also!completed!a!questionnaire!on!two!occasions!(see!Appendix!C!and!

D).!The!first!was!completed!following!the!baseline!IIT!(but!before!randomisation)!and!

the! second! was! complete! after! the! 12Vweek! assessment.! The! first! questionnaire!

included!a!series!of!ratings!using!11Vpoint!Likert!scales.!Specifically,!participants!were!

asked! to! rate! (selfVperception)! their! confidence! in! detecting! and! describing!

abnormalities,!confidence!to!participate!in!radiographer!commenting,!and!accuracy!in!

detecting!and!describing!abnormalities!of!the!appendicular!and!axial!skeleton.!In!each!

case! 0! represented! “not! at! all! (confident! or! accurate)”! and! 10! represented! “very!

(confident!or!accurate)”.!The!same!ratings!were!completed!after! the!12Vweek!postV

education! assessment.! In! addition,! at! the! 12Vweek! postVeducation! assessment,!

participants!were!asked!to!rate!statements!about!the!volume,!complexity!and!intensity!

of!the!education!they!received!(0!represented!strongly!disagree!and!10!represented!

strongly!agree).!!

!

Statistical!Analysis!

Outcome! measures! were! compared! between! groups! at! baseline! using! unpaired!

betweenVgroup!comparisons.!Mixed!effects!generalised!linear!models!(Poisson!family!

for!total!counts!of!item!scores,!Gaussian!family!for!numeric!questionnaire!ratings)!were!

used!to!examine!changes!occurring!at!the!oneVweek!and!12Vweek!post!intervention!

assessment!in!comparison!to!baseline,!as!well!as!whether!there!was!difference!in!the!

amount!of!change!over!time!between!those!who!received!the!intensive!versus!nonV

intensive!education!format!(group!by!time! interaction).!From!these!analyses,! it!was!


possible!to!determine!which!method!of!education!delivery!(if!any)!had!a!greater!impact!

on!improving!radiographers’!a)!ability!to!detect!and!describe!abnormalities!on!trauma!

radiographs! on! the! IIT! b)! selfVrated! (perceived)! interpretation! accuracy! and! c)!

confidence! in! image! interpretation,! with! the! opportunity! to! adjust! for! baseline!

confounders! in!each!of! these! three!models,! if! indicated.!There!was!no!evidence!of!

differences!between!groups!at!baseline!and!findings!were!entirely!consistent!whether!

or! not! potential! confounders! were! included! in! the! generalised! linear! models.!

Therefore,!results!from!the!unadjusted!models!have!been!presented.!In!addition,!box!

plots!were!prepared!to!visualise!the!performance!of!participants!in!each!group!at!each!

of!the!three!assessments.!

!

The!aforementioned!analyses!were!conducted!following!intentionVtoVtreat!principles.!

Of! the! 144! assessment! points! (48! participants! x! 3! assessments),! 13! (9%)!

assessments! contained!missing! data.!All!missing! data!were! from!participants!who!

dropped!out!prior!to!completing!all!followVup!assessment!points.!Wilcoxon!rankVsum!

tests!confirmed!there!were!no!significant!differences!at!baseline!across!the!primary!

and! secondary! outcomes! between! participants! who! did! and! did! not! drop! out.! All!

available! data! from! the! 131! (91%)! completed! assessments! were! used! in! the!

aforementioned! generalised! linear! mixed! models! for! the! primary! analyses.! To!

examine!the!potential!impact!of!any!missing!data,!sensitivity!analyses!were!conducted!

using!both!last!value!carried!forward!and!multiple!imputation!using!chained!equations!

(M=20)!to!account!for!missing!data.37!!However,!these!findings!were!consistent!with!

the!primary!analyses,!regardless!of!how!the!missing!data!were!treated,!therefore!the!

primary!analyses!with!all!completed!assessments!have!been!presented.!

!


7.3.4!Results(

Participant!characteristics!

FortyVeight! participants!were! recruited! (24! participants!were! allocated! to! each! trial!

arm)!and!42!(88%)!completed!the!training!(Figure!7.2).!Six!participants!dropped!out!of!

the!nonVintensive!training!program!prior!to!completion.!No!participants!dropped!out!of!

the! intensive! training! program,! although!one! participant! from! the! intensive! training!

group!was!not!available!to!complete!all!the!followVup!assessments.!At!baseline,!there!

were!no!between!group!differences!in!age,!gender!and!years!of!clinical!experience.!!

The!median!(IQR)!years!of!clinical!experience!was!4!(2!to!7)!and!3!(2!to!6)!for!the!

intensive!and!nonVintensive!arms!respectively.!The!median!(IQR)!age!was!27!(24!to!

31)! for! the! intensive!group!and!27! (25! to!34)! for! the!nonVintensive.!There!were!16!

(67%)!females!in!the!intensive!group!and!14!(58%)!in!the!nonVintensive!group.!

!

Primary!outcome!–!Image!Interpretation!Test!

There!was!no!significant!difference!in!total!IIT!score!at!baseline!between!the!intensive!

(median! (IQR)! =75! (52! to! 88))! and! nonVintensive! (median! (IQR)! =75! (59! to! 93))!

education!formats.!Both!groups!had!higher!oneVweek!median!(IQR)!postVeducation!IIT!

scores! (intensive:!87! (54! to!128)@!nonVintensive:!78! (63! to!106))!and!12Vweek!post!

education! IIT! scores! (intensive:! 124! (89! to! 138)@! nonVintensive:! 97! (71! to! 123))!

compared!to!baseline!assessments.!The!IIT!generalized!linear!mixed!model!indicated!

that!this!represented!significant!improvement!across!the!entire!sample!(both!groups)!

at!the!one!week!(coefficient!(95%CI)!=0.20!(0.15!to!0.25),!p<0.001)!and!12Vweek!post!

education!assessment!(coefficient!(95%CI)!=0.41!(0.36!to!0.45),!p<0.001).!The!group!

by!time!interaction!indicated!that!the!intensive!group!improved!by!a!greater!margin!at!

the! oneVweek! (coefficient! (95%CI)! =0.11! (0.01! to! 0.22),! p=0.03)! and! 12Vweek!


(coefficient!(95%CI)!=0.15!(0.05!to!0.24),!p<0.01)!post!intervention!assessments!than!

the! nonVintensive! group.! This! can! also! be! seen! in! Figure! 7.4!where! the! box! plots!

indicated! there! was! a! greater! propensity! for! improvement! in! IIT! score! among! the!

intensive!group.!!

!

Figure!7.4! Box!plots!of!image!interpretation!scores!(by!group!and!assessment)!

!

The!median!(IQR)!number!of!unattempted!IIT!cases!at!the!baseline!assessment!was!

comparable!for!both!trial!arms!(intensive:!13!(0!to!24)@!nonVintensive:!14!(3!to!20)).!A!

significant!effect!of!timeVpoint!from!the!linear!mixed!models!(inclusive!of!both!groups)!

indicated!that!the!number!of!unattempted!cases!was!higher!than!baseline!at!the!oneV

week! postVintervention! assessments! (coefficient! (95%CI)! =0.39! (0.28! to! 0.50),!

p<0.001),! but! lower! than! baseline! at! the! 12Vweek! post! assessments! (coefficient!

(95%CI)!=V0.14!(V0.26!to!V0.02),!p<0.01).!However,!the!median!(IQR)!of!unattempted!


IIT!cases!for!the!intensive!group!was!lower!than!the!nonVintensive!group!at!both!the!

oneVweek!(intensive:!17!(0!to!34)@!nonVintensive:!23!(12!to!28))!and!12Vweek!followVup!

assessments!(intensive:!6!(0!to!14)@!nonVintensive:!14!(4!to!21)).!The!group!by!time!

interaction!also!indicated!the!intensive!group!had!fewer!unattempted!IIT!cases!at!both!

the!oneVweek!(coefficient!(95%CI)!=V0.20!(V0.40!to!0.02,!p=0.07),!and!12Vweek!follow!

up!assessments!(coefficient!(95%CI)!=V0.46,!(V0.71!to!V0.21),!p<0.001).!!

!

Secondary!outcome!–!Item!classification!confidence!!

The!median!(IQR)!sum!of!confidence!ratings!for!IIT!cases!at!baseline!was!comparable!

for!both!trial!arms!(intensive:!184!(141!to!215)@!nonVintensive:!186!(163!to!216)).!The!

significant!effect!of!timeVpoint!from!the!linear!mixed!models!(inclusive!of!both!groups)!

indicated! confidence! was! lower! than! baseline! at! the! oneVweek! post! intervention!

assessments!(coefficient!(95%CI)!=V0.11,!(V0.17!to!V0.08),!p<0.001),!but!higher!than!

baseline!at! the!12Vweek!post! intervention!assessments! (coefficient! (95%CI)!=0.07,!

(0.03! to! 0.10),! p<0.001).! However,! the! median! (IQR)! confidence! ratings! for! the!

intensive! group! was! higher! than! the! nonVintensive! group! at! both! the! oneVweek!

(intensive:!168!(101!to!230)@!nonVintensive:!150!(128!to!202))!and!12Vweek!followVup!

assessments!(intensive:!220!(178!to!237)@!nonVintensive:!188!(159!to!216)).!The!group!

by!time!interaction!also!confirmed!the!intensive!group!had!higher!confidence!ratings!

from!IIT!cases!than!the!nonVintensive!group!at!both!the!oneVweek!(coefficient!(95%CI)!

=0.11! (0.04! to! 0.17),! p<0.001),! and! 12Vweek! follow! up! assessment! (coefficient!

(95%CI)!=0.13,!(0.06!to!0.19),!p<0.001).!!

!

Median!(IQR)!for!each!of!the!questionnaires’!confidence!and!accuracy!numeric!ratings!

are!presented!for!each!group!in!Table!7.6.!! !

Chapter(7:(Randomised(controlled(trial(of(intensive(v(non6intensive(education( 144#

Table&7.6& Radiographers’&perceived&confidence&and&accuracy&regarding&image&interpretation&ability&### ## Intensive#Group# Non1#Intensive#Group#

Topic# ##

#Baseline#(n=24)#

12#week#Follow1up#(n=23)#

Baseline#(n=24)#

12#week#Follow1up#(n=18)#

## ##Median#(IQR)#

Median#(IQR)#

Median#(IQR)#

Median#(IQR)#

Confidence# Detecting#traumatic#abnormalities# 6#(517)# 8#(619)# 6#(617)# 8#(718)## Describing#traumatic#abnormalities# 5#(316)# 7#(518)# 5#(415)# 6#(518)## To#participate#in#radiographer#commenting# 7#(518)# 8#(719)# 6#(617)# 8#(718)#

Accuracy# Detecting#Appendicular#traumatic#abnormalities# 7#(618)# 8#(719)# 7#(618)# 8#(718)## Describing#Appendicular#traumatic#abnormalities# 6#(516)# 7#(618)# 6#(416)# 7#(518)## Detecting#Axial#traumatic#abnormalities# 6#(417)# 7#(618)# 7#(517)# 7#(617)#

## Describing#Axial#traumatic#abnormalities# 5#(416)# 6#(517)# 5#(416)# 6#(517)#Note:&0&represented&“not&at&all&(confident&or&accurate)”&and&10&represented&“very&*confident&or&accurate)”&#&

& &

Chapter(7:(Randomised(controlled(trial(of(intensive(v(non6intensive(education( 145$

The$linear$mixed$models$indicated$that$both$groups$improved$at$the$128week$follow8

up$ assessment$ when$ compared$ to$ the$ baseline$ across$ all$ self8perception$

questionnaire$ ratings$ (p$ value$ range$<0.001$ to$0.001).$However,$ only$ the$ rating$of$

ability$to$detect$abnormalities$of$the$axial$skeleton$had$a$significant$(p<0.05)$group$by$

time$interaction$that$indicated$a$greater$increase$observed$among$the$intensive$group$

than$ the$ non8intensive$ group$ at$ the$ 128week$ assessment.$ For$ the$ remainder$ of$

questionnaire$ ratings$ neither$ group’s$ self8rated$ confidence$ improved$ by$ a$ greater$

margin$than$the$other$at$the$follow8up$assessment.$Similarly,$there$were$no$significant$

between8group$ differences$ in$ participants’$ median$ (IQR)$ ratings$ of$ the$ volume$

(intensive:$8$(7$to$10)O$non8intensive:$8$(8$to$10)$or$complexity$(intensive:$9$(7$to$10)O$

non8intensive:$9$(8$to$10))$of$educational$content.$For$ratings$of$whether$the$education$

received$was$too$intensive,$both$groups$provided$ratings$at$the$low$end$of$the$scale$

indicating$ participants$ did$ not$ find$ the$ education$ delivery$ they$ received$ to$ be$ too$

intense.$However,$the$intensive$group’s$median$(IQR)$rating$trended$toward$being$a$

little$higher$than$the$non8intensive$group$(intensive:$3,$(2$to$5)O$non8intensive:$1,$(1$to$

3),$coefficient$(95%CI)$=1.36,$(80.16$to$2.87),$p=0.08).$

$

There$were$no$adverse$events$attributable$to$the$education$intervention$or$to$taking$

part$in$the$study.$

!

7.3.5$Discussion!

This$was$the$first$randomised$control$trial$comparing$the$effectiveness$of$intensive$and$

non8intensive$formats$of$delivery$of$image$interpretation$education$for$radiographers.$$

Although$both$ formats$ of$ education$delivery$may$be$beneficial,$ the$ findings$of$ this$

study$ have$ indicated$ that$ the$ intensive$ format$ of$ delivery$ was$ more$ effective$ at$


improving$ radiographers’$ ability$ to$ interpret$ trauma$ radiographs$ in$ the$weeks$ after$

completion$of$the$image$interpretation$education$program.$Participants$who$completed$

the$intensive$format$also$reported$better$confidence$in$their$image$interpretations$than$

the$ non8intensive$ group.$ One$ of$ the$ key$ findings$ was$ that$ the$ non8intensive$

intervention$arm$experienced$a$greater$ number$of$ dropouts,$which$may$ reflect$ the$

challenges$encountered$by$participants$committing$to$a$series$of$9$short$workshops$

compared$to$a$two8day$intensive$program.$This$higher$drop8out$rate$(12%)$for$the$non8

intensive$education$delivery$in$comparison$to$the$intensive$(0%),$suggests$potential$

pragmatic$advantages$in$addition$to$educational$outcome$advantages.$

$

Several$prior$studies$have$explored$ the$effect$of$ image$ interpretation$education$on$

radiographers’$ability$to$interpret$radiographs.10,$15818,$38840$The$results$of$prior$studies$

were$encouraging$with$each$reporting$beneficial$effects.$However,$unlike$the$current$

study,$these$studies$did$not$use$a$randomised$control$trial$research$design$and$there$

has$been$no$previous$comparison$of$different$ formats$of$education$delivery.$ In$ the$

current$study,$ the$radiographers$ in$both$ trial$arms$yielded$higher$ test$scores$at$ the$

one8week$ and$ 128week$ follow8up$ assessments$ when$ compared$ to$ the$ baseline$

scores.$ Two$ previous$ studies15,$ 17$ employed$ an$ immediate$ assessment$ following$

education$and$a$follow$up$assessment$similar$to$the$current$study.$Utilising$a$42$case$

test$bank$of$radiographs,$the$accuracy$of$radiographer$interpretation$decreased$from$

71.4%$ to$65.47%$ following$ two$days$of$education.15$However,$at$6810$weeks$after$

education,$the$accuracy$had$improved$to$be$greater$than$pre8education$level$(80.95%$

v$71.4%).$A$similar$finding$was$demonstrated$in$study$performed$by$McConnell$et$al,17$

which$utilised$a$test$bank$of$102$appendicular$radiographs.$This$study$demonstrated$

a$pre8education$radiographer$accuracy$of$82%,$which$decreased$to$81.4%$following$


the$ education$ and$ exhibited$ an$ improved$ accuracy$ of$ 86.8%$ 8810$ weeks$ post$

education.$$Although$these$studies$found$improvements$in$image$interpretation$ability$

at$the$final$assessment,$they$reported$a$reduction$in$performance$immediately$after$

the$ education.$ They$ postulated$ that$ the$ subsequent$ increase$ in$ performance$ was$

possibly$due$to$the$direct$effect$of$completing$the$course$and$the$period$of$time$(6810$

weeks)$in$which$to$reflect$on$the$content$included$in$the$education.$Two$other$studies16,$

39$incorporated$longer$follow8up$assessments$following$education.$Smith$et$al16$used$

a$ 25$ case$ image$ bank$ to$ assess$ 16$ radiographers’$ ability$ to$ interpret$ axial$ and$

appendicular$radiographs.$They$were$assessed$before$an$education$program$and$6$

months$after.$The$pre$and$post$education$accuracy$was$not$ statistically$ significant$

(57.3%$v$61.0%).$Mackay39$assessed$133$radiographers’$ability$ to$detect$ traumatic$

pathology$ following$ a$ two8day$ education$ program.$ Using$ a$ 30$ case$ image$ bank,$

assessments$were$completed$before$education,$immediately$following$education$and$

at$ 6$ months.$ The$ results$ demonstrated$ that$ radiographers’$ sensitivity$ to$ detect$

pathology$ significantly$ improved$ between$ the$ pre$ (78.9%)$ and$ immediate$ (88.2%)$

assessments.$However,$at$the$6$month$assessment$it$fell$below$the$baseline$sensitivity$

(76.5%).$Interestingly,$both$studies$found$that$the$benefit$of$education$had$dissipated$

by$six$months$after$training.$This$suggests$that$radiographers$need$ongoing$training$

to$ maintain$ their$ skills.$ This$ would$ be$ particularly$ pertinent$ in$ medical$ imaging$

departments$where$a$PIE$system$has$not$been$embedded.$The$authors$of$the$current$

study$propose$that$the$increase$in$performance$that$was$found$at$both$the$one8week$

assessment$and$the$128week$follow8up$assessment$in$their$study$was$potentially$due$

to$ the$effectiveness$of$ the$education$program$and$ that$ participants$practising$ their$

acquired$skills$while$working$in$the$clinical$setting$between$the$end$of$the$education$

program$and$ the$ final$ assessment.$ It$would$ be$worthwhile$ to$ explore$whether$ this$


enhanced$performance$is$maintained$over$a$longer$period$(e.g.$beyond$6$months).$It$

is$interesting$to$note$that$the$number$of$unattempted$cases$on$the$timed$IIT$increased$

at$the$one8week$assessment$for$both$groups,$which$may$reflect$that$participants$were$

not$ yet$ time8efficient$ in$ applying$ their$ recently$ acquired$ image$ interpretation$ skills.$

However,$the$non8intensive$group$attempted$fewer$cases$than$the$intensive$group$at$

both$the$one8week$and$128week$follow8up$assessments.$Furthermore,$the$intensive$

group$ completed$ more$ cases$ at$ the$ 128week$ assessment$ than$ at$ the$ baseline$

assessment$ (and$ achieved$ a$ higher$ IIT$ score$ indicating$ greater$ accuracy).$ These$

findings$support$the$conclusion$that$the$intensive$format$of$delivery$was$more$effective$

than$the$non8intensive$format.$

$

There$is$a$paucity$of$literature$that$reports$radiographers’$confidence$in$their$ability$to$

interpret$ radiographs.$ Coleman$ and$ Piper14$ was$ one$ study$ that$ assessed$

radiographers’$accuracy$and$ their$confidence$ to$ interpret$a$20$case$ image$bank$of$

appendicular$ radiographs.$ Their$ findings$ revealed$ a$ moderate$ positive$ correlation$

(r=0.51)$between$radiographers’$mean$confidence$in$their$image$interpretation$ability$

and$their$actual$test$score$accuracy$(p=0.02).$$To$the$authors’$knowledge$the$current$

study$was$the$first$study$that$assessed$radiographers’$image$interpretation$confidence$

before$and$after$education.$In$the$current$study,$the$questionnaire$findings$indicated$

that$ radiographers’$ image$ interpretation$confidence$ improved$at$ the$128week$ rating$

when$ compared$ with$ baselineO$ however,$ self8reported$ confidence$ changes$ were$

similar$ across$ groups.$ Interestingly,$ this$ finding$ was$ in$ contrast$ to$ the$ confidence$

ratings$ of$ specific$ cases$ in$ the$ IIT,$ where$ scoring$ rewarded$ confidence$ in$ correct$

interpretation$of$each$case$and$penalised$confidence$in$incorrect$interpretation.$This$

finding$differs$from$the$Coleman$and$Piper14$study.$The$current$study$highlights$the$


importance$of$including$a$quantitative$measure$of$image$interpretation$performance,$

such$as$the$IIT,$when$evaluating$image$interpretation$education.$$

$

A$study$published$ in$20149$ identified$that$radiographers$considered$targeted$ image$

interpretation$education$to$be$desirable,$regardless$of$intensity.$Prior$research$in$other$

fields$has$examined$the$merits$of$intensive$and$non8intensive$education$formats.41843$

The$ results$ of$ the$ current$ study$were$ consistent$with$ these$ prior$ studies’$ findings,$

which$have$indicated$that$intensive$formats$may$lead$to$comparable$or$slightly$more$

favourable$learning$outcomes$than$non8intensive.41843$

$

Methodologically,$this$study$exhibits$several$strengths.$Within$the$field$of$radiographer$

PIE$ education,$ this$ study$ represents$ the$ largest$ sample$ size$ and$ a$ robust$ RCT$

research$design.$A$further$strength$is$the$inclusion$of$participants$from$three$centres,$

adding$support$to$the$likelihood$that$findings$can$be$generalized.$$In$this$study,$the$

use$ of$ a$ longer8term$ follow$ up$ (12$ weeks$ post$ education)$ can$ be$ considered$ a$

strength,$ but$ further$ research$ investigating$ whether$ performance$ continues$ to$

improve,$ is$maintained$ or$ diminishes$ beyond$ 12$ weeks$ is$ likely$ to$ be$ worthwhile.$

Another$ strong$ aspect$ of$ the$ study$ was$ that$ the$ primary$ outcome$ measure$ had$

undergone$testing$which$supported$its$validity$and$reliability$among$radiographers.26$

$

There$are$several$limitations$in$this$study$that$should$be$considered.$There$remains$

disparity$ in$the$literature$as$to$whether$manufactured$image$tests$(i.e.,$hand8picked$

cases)$are$an$accurate$indicator$of$interpretive$performance$in$comparison$to$image$

test$banks$that$have$been$developed$to$represent$clinical$practice.$A$study$by$Hardy$

et$al44$investigated$radiographers’$image$interpretation$performance$on$manufactured$


image$ banks$ versus$ clinical$ practice$ image$ banks.$ The$ results$ indicated$ that$ the$

manufactured$ high$ abnormality$ prevalence$ test$ banks$ that$ contain$ a$ higher$

abnormality$ prevalence$may$ overestimate$ abnormality$ detection$ ability.$ Therefore,$

caution$is$required$when$extrapolating$the$results$of$the$current$study$that$employed$

an$image$bank$that$represented$typical$clinical$practice$versus$a$manufactured$image$

bank.$The$possibility$of$recall$bias$is$a$potential$limitation,$as$participants$completed$

the$ same$ assessment$ during$ a$ relatively$ short$ time$ frame.$ To$ minimise$ this,$ two$

preventative$measures$were$employed.$Firstly,$a$minimum$time$of$five$weeks$elapsed$

between$ any$ two$ assessments.$ $ Secondly,$ a$ computer8generated$ randomisation$

sequence$was$used$to$present$the$60$IIT$cases$random$order,$further$limiting$potential$

for$case$recall$associated$with$sequential$cases.$A$further$limitation$of$this$study$is$that$

the$IIT$only$contained$adult$trauma$radiographs$and$consequently$performance$on$the$

IIT$may$not$reflect$radiographers’$abilities$to$interpret$other$types$of$radiographs,$for$

example,$ paediatric$ or$ non8trauma.$ Although$ validated,$ the$ unique$ scoring$ criteria$

utilised$in$this$study$can$be$considered$a$limitation.$Last,$it$was$interesting$to$note$that$

the$assumptions$for$the$a$priori$sample$size$estimate$did$not$match$the$distribution$of$

primary$ outcome$ data$ from$ the$ trial.$ Nonetheless,$ because$ a$ significant$ between$

group$difference$on$this$measure$was$observed,$Type$II$error$did$not$occur.$

$

7.3.6$Conclusion$$

In$summary,$findings$suggest$that$the$intensive$format$of$delivery$was$more$effective$

at$ improving$ radiographers’$ ability$ to$ interpret$ trauma$ radiographs,$ although$

participants$ demonstrated$ improvement$ in$ image$ interpretation$ ability$ in$ both$ trial$

arms.$These$findings$may$be$of$great$relevance$to$health$care$providers,$emergency$

department$ and$ medical$ imaging$ department$ directors$ seeking$ to$ improve$


radiographers’$or$any$other$health$professionals’$ image$interpretation$ability.$Future$

research$could$explore$whether$image$interpretation$ability$is$maintained,$improves$or$

diminishes$beyond$the$12$weeks$assessed$in$this$study.$

$

7.4$ References!for!Chapter!7!

1$ Walsh8Kelly$ CM,$ Melzer8Lange$ MD,$ Hennes$ HM,( et( al.$ Clinical$ impact$ of$

radiograph$misinterpretation$in$a$pediatric$ED$and$the$effect$of$physician$training$level.$

The(American(Journal(of(Emergency(Medicine.$1995O$13:$2628264.$

2$ Eastgate$P,$Davidson$R,$McPhail$SM.$Radiographic$imaging$for$traumatic$ankle$

injuries:$a$demand$profile$and$investigation$of$radiological$reporting$timeframes$from$

an$Australian$tertiary$facility.$Journal(of(Foot(and(Ankle(Research.$2014O$7:$25.$

3$ Hussein$W,$Mullins$PM,$Alghamdi$K,$Sarani$B,$Pines$JM.$Trends$in$advanced$

computed$ tomography$ use$ for$ injured$ patients$ in$ United$ States$ emergency$

departments:$2007–2010.$Academic(Emergency(Medicine.$2015O$22:$6638669.$

4$ Larson$ DB,$ Johnson$ LW,$ Schnell$ BM,$ Salisbury$ SR,$ Forman$ HP.$ National$

trends$ in$CT$use$ in$ the$emergency$department:$1995–2007.$Radiology.$2011O$258:$

1648173.$

5$ Pinto$A,$Reginelli$A,$Pinto$F,(et(al.$Errors$in$imaging$patients$in$the$emergency$

setting.$British(Journal(of(Radiology.$2016O$89:$20150914.$

6$ Kachalia$A,$Gandhi$TK,$Puopolo$AL,(et(al.$Missed$and$delayed$diagnoses$in$

the$ emergency$ department:$ a$ study$ of$ closed$ malpractice$ claims$ from$ 4$ liability$

insurers.$Annals(of(Emergency(Medicine.$2007O$49:$1968205.$

7$ Kim$YW,$Mansfield$ LT.$ Fool$me$ twice:$ delayed$ diagnoses$ in$ radiology$with$

emphasis$on$perpetuated$errors.$American(Journal(of(Roentgenology.$2014O$202:$4658

470.$

8$ McConnell$ J,$ Devaney$ C,$ Gordon$ M.$ Queensland$ radiographer$ clinical$

descriptions$ of$ adult$ appendicular$musculo8skeletal$ trauma$ following$ a$ condensed$

education$programme.$Radiography.$2012O$19:$48855.$

9$ Neep$ MJ,$ Steffens$ T,$ Owen$ R,$ McPhail$ SM.$ A$ survey$ of$ radiographers'$

confidence$ and$ self*perceived$ accuracy$ in$ frontline$ image$ interpretation$ and$ their$


continuing$educational$preferences.$Journal(of(Medical(Radiation(Sciences.$2014O$61:$

69877.$

10$ Hardy$M,$Culpan$G.$Accident$and$emergency$ radiography:$a$comparison$of$

radiographer$commenting$and$‘red$dotting’.$Radiography.$2007O$13:$65871.$

11$ Neep$ MJ,$ Steffens$ T,$ Owen$ R,$ McPhail$ SM.$ Radiographer$ commenting$ of$

trauma$radiographs:$A$survey$of$the$benefits,$barriers$and$enablers$to$participation$in$

an$Australian$healthcare$setting.$Journal(of(Medical(Imaging(and(Radiation(Oncology.$

2014O$58:$4318438.$

12$ Smith$T,$Younger$C.$Accident$and$emergency$radiological$interpretation$using$

the$radiographer$opinion$form$(ROF).$The(Radiographer.$2002O$49:$27.$

13$ Snaith$B,$Hardy$M.$Radiographer$abnormality$detection$schemes$in$the$trauma$

environment—An$assessment$of$current$practice.$Radiography.$2008O$14:$2778281.$

14$ Coleman$L,$Piper$K.$Radiographic$interpretation$of$the$appendicular$skeleton:$

a$ comparison$ between$ casualty$ officers,$ nurse$ practitioners$ and$ radiographers.$

Radiography.$2009O$15:$1968202.$

15$ McConnell$J,$Webster$A.$Improving$radiographer$highlighting$of$trauma$films$in$

the$accident$and$emergency$department$with$a$short$course$of$study$8$an$evaluation.$

British(Journal(of(Radiology.$2000O$73:$6088612.$

16$ Smith$T,$Traise$P,$Cook$A.$The$influence$of$a$continuing$education$program$on$

the$image$interpretation$accuracy$of$rural$radiographers.$Rural(and(Remote(Health.$

2009O$9:$1145.$

17$ McConnell$ J,$Devaney$C,$Gordon$M,$Goodwin$M,$Strahan$R,$Baird$M.$The$

impact$ of$ a$ pilot$ education$ programme$ on$ Queensland$ radiographer$ abnormality$

description$of$ adult$ appendicular$musculo8skeletal$ trauma.$Radiography.$ 2012O$ 18:$

1848190.$

18$ Hargreaves$J,$Mackay$S.$The$accuracy$of$the$red$dot$system:$can$it$improve$

with$training?$Radiography.$2003O$9:$2838289.$

19$ Howard$ML.$An$exploratory$study$of$radiographer's$perceptions$of$radiographer$

commenting$on$musculo8skeletal$trauma$images$in$rural$community$based$hospitals.$

Radiography.$2013O$19:$1378141.$

20$ Chan$A8W,$Tetzlaff$ JM,$Altman$DG,( et( al.$ SPIRIT$ 2013$ statement:$ defining$

standard$protocol$items$for$clinical$trials.$Annals(of(Internal(Medicine.$2013O$158:$2008

207.$


21$ Cassidy$S.$Learning$styles:$an$overview$of$ theories,$models,$and$measures.$

Educational(Psychology.$2004O$24:$4198444.$

22$ Honey$ P,$ Mumford$ A.$ The( learning( styles( helper's( guide.$ Peter$ Honey$

Maidenhead,$2000.$

23$ Thompson$C,$ Crutchlow$E.$ Learning$ style$ research:$ a$ critical$ review$ of$ the$

literature$ and$ implications$ for$ nursing$ education.$ Journal( of( Professional( Nursing.$

1993O$9:$34840.$

24$ Glass$GV,$Smith$ML.$Meta8analysis$of$research$on$class$size$and$achievement.$

Educational(Evaluation(and(Policy(Analysis.$1979O$1:$2816.$

25$ Slavin$R.$Class$size$and$student$achievement:$is$smaller$better?$Contemporary(

Education.$1990O$62:$6.$

26$ Neep$M,$Steffens$T,$Riley$V,$Eastgate$P,$McPhail$S.$Development$of$a$valid$

and$ reliable$ test$ to$ assess$ trauma$ radiograph$ interpretation$ performance.$

Radiography.$2017O$23:$1538158.$

27$ Robinson$ P,$ Wilson$ D,$ Coral$ A,$ Murphy$ A,$ Verow$ P.$ Variation$ between$

experienced$observers$in$the$interpretation$of$accident$and$emergency$radiographs.$

British(Journal(of(Radiology.$1999O$72:$3238330.$

28$ Burns$KE,$Duffett$M,$Kho$ME,(et(al.$A$guide$for$the$design$and$conduct$of$self8

administered$surveys$of$clinicians.$Canadian(Medical(Association(Journal.$2008O$179:$

2458252.$

29$ Chow$S8C,$Wang$H,$Shao$J.$Sample(size(calculations(in(clinical(research.$CRC$

Press,$2007.$

30$ Berlin$L.$Defending$the$“missed”$radiographic$diagnosis.$American(Journal(of(

Roentgenology.$2001O$176:$3178322.$

31$ Guly$ H.$ Diagnostic$ errors$ in$ an$ accident$ and$ emergency$ department.$

Emergency(Medicine(Journal.$2001O$18:$2638269.$

32$ Williams$SM,$Connelly$DJ,$Wadsworth$S,$Wilson$DJ.$Radiological$ review$of$

accident$and$emergency$ radiographs:$a$18year$audit.$Clinical(Radiology.$2000O$55:$

8618865.$

33$ Murphy$A,$Neep$M.$An$investigation$into$the$use$of$radiographer$abnormality$

detection$ systems$ by$ Queensland$ public$ hospitals.$ Journal( of( medical( radiation(

sciences.$2018O$65:$80885.$


34$ Neep$MJ.$Is$radiographer$commenting$the$answer?$Journal(of(Medical(Imaging(

and(Radiation(Oncology.$2013O$57:$2068206.$

35$ McConnell$ J,$ Baird$ M.$ Could$ musculo8skeletal$ radiograph$ interpretation$ by$

radiographers$ be$ a$ source$ of$ support$ to$ Australian$medical$ interns:$ a$ quantitative$

evaluation.$Radiography.$2017O$23:$3218329.$

36$ Neep$MJ,$Steffens$T,$Eastgate$P,$McPhail$SM.$Evaluating$the$effectiveness$of$

intensive$ versus$ non*intensive$ image$ interpretation$ education$ for$ radiographers:$ a$

randomised$control$trial$study$protocol.$Journal(of(medical(radiation(sciences.$2018.$

37$ Royston$ P,$ White$ IR.$ Multiple$ imputation$ by$ chained$ equations$ (MICE):$

implementation$in$Stata.$Journal(of(Statistical(Software.$2011O$45:$1820.$

38$ Loughran$C.$Reporting$of$fracture$radiographs$by$radiographers:$the$impact$of$

a$training$programme.$British(Journal(of(Radiology.$1994O$67:$9458950.$

39$ Mackay$ S.$ The$ impact$ of$ a$ short$ course$ of$ study$ on$ the$ performance$ of$

radiographers$ when$ highlighting$ fractures$ on$ trauma$ radiographs:“The$ Red$ Dot$

System”.$British(Journal(of(Radiology.$2006O$79:$4688472.$

40$ Piper$ KJ,$ Paterson$ A.$ Initial$ image$ interpretation$ of$ appendicular$ skeletal$

radiographs:$a$comparison$between$nurses$and$radiographers.$Radiography.$2009O$

15:$40848.$

41$ Kucsera$ JV,$ Zimmaro$ DM.$ Comparing$ the$ effectiveness$ of$ intensive$ and$

traditional$courses.$College(Teaching.$2010O$58:$62868.$

42$ Seamon$ M.$ Short8and$ long8term$ differences$ in$ instructional$ effectiveness$

between$ intensive$ and$ semester8length$ courses.$Teachers( College( Record.$ 2004O$

106:$6358650.$

43$ Daniel$ EL.$ A$ review$ of$ time8shortened$ courses$ across$ disciplines.$ College(

Student(Journal.$2000O$34:$2988308.$

44$ Hardy$ M,$ Flintham$ K,$ Snaith$ B,$ Lewis$ EF.$ The$ impact$ of$ image$ test$ bank$

construction$ on$ radiographic$ interpretation$ outcomes:$ a$ comparison$ study.$

Radiography.$2016O$22:$1668170.$

$

!


7.5! Thesis!Commentary$No$ prior$ study$ had$ examined$ the$ effectiveness$ of$ two$ different$ formats$ of$ image$

interpretation$education$for$radiographers.$This$chapter$compared$the$effectiveness$

of$ an$ intensive$ versus$ non8intensive$ image$ interpretation$ education$ program.$ The$

findings$suggest$that$the$intensive$format$of$delivery$was$more$effective$at$improving$

radiographers’$ability$to$interpret$trauma$radiographs,$although$both$formats$reported$

improvements.$This$chapter$provided$valuable$empirical$evidence$to$inform$the$way$

critical$ image$ interpretation$ education$ is$ delivered$ to$ radiographers$ nationally$ and$

internationally.$$

$

Chapter$ 8$ draws$ together$ the$ findings$ of$ this$ doctoral$ program$ of$ research$ and$

describes$the$implications$and$applications$of$those$findings$to$clinical$practice.$The$

limitations$of$the$research$and$recommendations$for$further$research$are$discussed$in$

this$final$chapter.$

!

Chapter(8:(Thesis(Implications(and(Recommendations( 156$

Chapter( 8:( Thesis( Implications( and(Recommendations(!

(8.1! Preamble!This!chapter!provides!a!discussion!for!the!overall!thesis!(see!Figure!8.1).!It!presents!

an! overview! of! the! main! findings! from! Studies! 1! –! 3,! implications! for! practice,!

noteworthy!strengths!and! limitations!of! the! three!studies!and! recommendations! for!

future!research.!This!chapter!integrates!pertinent!information!from!preceding!chapters!

in!relation!to!the!thesis!aims!as!well!as!providing!a!conclusion!to!the!thesis.!

!

!Figure!8.1! Thesis!Structure!–!Chapter!8!

! !


!

8.2! Summary(of(Findings(This!program!of!research!has!added!to!the!existing!knowledge!in!the!field!by!being!

the!first!to:!

1.! Explore!Australian!radiographers’!perceptions!of!potential!benefits,!barriers!and!

enablers!of!introducing!a!PIE!system!(Aim!1).!

2.! Describe! Australian! radiographers’! current! image! interpretation! selfMefficacy!

(Aim!2).!

3.! Investigate! which! (if! any)! format! of! image! interpretation! education!

radiographers!currently!prefer!(Aim!3).!

4.! Develop! and! validate! a! quantitative! outcome! measure! that! evaluates!

radiographer!PIE!skills!(Aim!4).!

5.! Evaluate! the! comparative! effectiveness! of! intensive! (2Mday)! versus! nonM

intensive!(90!minute!x!9)!formats!of!delivering!an!education!program!designed!

to!improve!radiographers’!abilities!to!provide!a!PIE!in!trauma!settings!(Aim!5).!

6.! Investigate!Australian!radiographers’!experiences!in!completing!an!intensive!or!

nonMintensive! image! interpretation! education! program! and! their! perceived!

readiness!for!participation!in!a!PIE!system!(Aim!6).!!

Figure! 8.2! illustrates! the! overall! structure! of! this! thesis! and! summarises! the!main!

research!findings!of!each!chapter!in!relation!to!the!thesis!aims.!

!


Figure'8.2' Thesis'Structure'–'Research'findings'


8.3!! Implications/for/Practice/

Five!key!implications!for!practice!arising!from!this!research!are!presented!below.!

/

8.3.1!A/validated/outcome/measure/to/test/image/interpretation/performance(

This!thesis!developed!and!validated!the!first!quantitative!outcome!measure,!the!Image!

Interpretation!test!(IIT),!which!is!suitable!for!testing!radiographers’!ability!to!detect!and!

describe!pathology!visualised!on!adult! trauma!radiographs.!This!outcome!measure!

has!potential!application!in!education,!clinical!and!research!settings.!One!example!in!

the! education! setting!might! involve! the! assessment! of! undergraduate! radiography!

students’! image! interpretation! ability! prior! to! graduation.! In! Australia,! it! is! now! an!

expectation! that! all! graduating! radiographers!are!able! to! competently!provide! their!

opinion!on!the!radiographs!they!acquire!(i.e.!providing!a!PIE).1!At!present,!there!is!a!

lack!of!evidence! that! indicates!whether! these!graduates!could!provide!an!accurate!

PIE.! Furthermore,! there! is! insufficient! evidence! that! indicates! that! the! current!

assessment!of!undergraduate! image! interpretation!skills!are!adequate! in!preparing!

graduate!radiographers!to!provide!accurate!PIEs!in!the!clinical!setting.!One!reason!for!

this! is! that! most! of! these! assessments! consist! of! a! manufactured! test! bank! of!

radiographic!images,!where!the!images!have!been!selected!based!on!one!person’s!

subjective!decision!of!anatomical! regions!and!case!complexity.!Literature!suggests!

that!this!method!of!test!bank!design!can!over!estimate!image!interpretation!ability.2!!

!

There!are!several!potential!applications!of!the!IIT!in!the!clinical!setting.!One!example!

might!consist!of!an!image!interpretation!test! that!health!professionals!(e.g.!doctors,!

radiographers,!nurses!and!physiotherapists)!could!complete,!prior! to!and! following,!

image!interpretation!training!which!would!assist!in!the!evaluation!of!the!effectiveness!

of!the!completed!education.!This!application!might!prove!particularly!valuable!for!junior!

medical! doctors! who! traditionally! have! limited! image! interpretation! skills! at! the!

beginning!of!their!careers.3,!4!These!professionals!are!then!required!to!enhance!these!

skills!while!working!in!the!clinical!setting.!A!further!clinical!application!of!this!instrument!

might! be! as! a! measure! of! competency! for! health! professionals! who! interpret!

radiographs! as! part! of! their! role.! This! instrument,! or! future! iterations! of! it! with! an!

extended! image! bank,! could! be! completed! on! an! annual! basis! and! used! as! an!

indicator!of!quality!for!clinicians!and!managers.!!

!


There!are!also!potential!applications!of!the!IIT!in!research!contexts.!An!example!of!

utilizing!this!IIT!in!the!research!setting!might!include!assessing!the!image!interpretation!

performance! of! physiotherapists! who! are! involved! in! treatment! and! diagnosis! of!

patients!who!present! to!emergency!departments.!At!present,! there! is!no!published!

evidence!which!documents!the!image!interpretation!performance!of!this!professional!

group.! This! raises! concern! as! accurate! patient! treatment! relies! on! the! correct!

interpretation!of!medical! imaging,!and!definitive! radiological! reports!are!not!always!

available!at!the!point!of!care!when!treatment!decisions!are!being!made.!

!

8.3.2! An/ education/ program/ that/ improves/ image/ interpretation/ ability/ for/

radiographers(

This! thesis!was!the!first! to! investigate! the!effectiveness!of! two! image! interpretation!

education!delivery!formats!for!radiographers!in!Queensland.!The!results!demonstrated!

significant! improvements! in! radiographers’! image! interpretation! performance! for!

participants! in!both!the! intensive!and!nonNintensive!education!format.!However,! the!

intensive!format!of!delivery!was!more!effective!than!the!nonNintensive!format.!Based!

on!this!program!of!research,!it!would!be!appropriate!to!implement!this!training!program!

further!among!practicing!radiographers! in!Australia!(as!well!as! internationally).!This!

will!likely!have!significance!for!trauma!settings!where!effective!education!delivery!will!

assist! in! maximising! performance! of! radiographers! and! ultimately! reduce! risk! of!

diagnostic!errors!and!improve!the!overall!quality!of!health!service!for!patients!in!this!

high!volume,!high!risk!environment.!It!is!noteworthy!to!mention!that!alternative!short!

courses!in!image!interpretation!are!available!in!Australia,!however!there!is!no!empirical!

evidence!reporting!the!effectiveness!of!these!education!programs.!

!

When!planning!the!implementation!of!an!image!interpretation!education!program!it!is!

worthwhile!considering!the!dropNout!rates!observed!in!Study!3.!This!study!indicated!a!

higher!dropNout!rate!(12%)!for!the!nonNintensive!group!in!comparison!to!the!intensive!

group! (0%).! This! suggests! there! are! potential! pragmatic! advantages! beyond! the!

educational! and! confidence! benefits! from! the! intensive! training! format! of! delivery.!

Caution! should! be!used!when! considering!whether! to! deliver! this! education!within!

business!hours!or!outNofNhours.!Given! the!unpredictable!nature!of!clinical!workload!

and!demand,!it!is!possible!that!scheduling!education!outside!of!business!hours!could!

assist! in! attaining! higher! attendance! rates! and! reduce! the! need! for! repeated!


scheduling!of! image! interpretation! training.!However,! the!effect!of!scheduling! times!

and!attendance!were!beyond!the!scope!of!this!thesis.!

!

The!intervention!used!in!this!trial!can!easily!be!translated!from!the!research!setting!to!

the!clinical!setting!and!could!also!be!implemented!and!evaluated!across!a!range!of!

health!professionals!including!junior!emergency!doctors,!physiotherapists!and!nurse!

practitioners.! Improving! the! image! interpretation! capabilities! of! radiographers! and!

other!health!professions!practicing! in! these!settings,!will! likely!minimise! the! risk!of!

missed!or!incorrect!diagnosis!due!to!delay!in!radiologist!reports.!This,!in!turn,!will!most!

likely!have!a!positive!impact!on!the!care!of!many!patients.!!

!

8.3.3/Awareness/of/the/benefits,/barriers/and/enablers/of/implementing/PIE/in/

Australia/

There! is!a!paucity!of!evidence! reporting! that!PIE!systems!have!been! implemented!

widely! throughout! Australia.! The! outcomes! of! this! research! provide! insight! for!

Australian! workforce!managers! in! understanding! radiographers! perceptions! of! the!

benefits,!barriers!and!enablers!of!participating!in!a!PIE!system.!Study!1!was!the!first!

Australian!study!which!identified!the!key!benefits!of!a!PIE!system!including:!‘assisting!

multiNdisciplinary! teams’,! ‘patient! care’,! ‘radiographer! ability’,! ‘professional! benefits’!

and!‘quality!of!imaging’.!As!this!study!was!based!in!Queensland,!caution!is!required!

when!extrapolating! the! findings!across!all! states!and! territories.! ! It! is! interesting! to!

consider! that! radiographers! perceived! that! their! quality! of! imaging! would! improve!

following!participation!in!a!PIE!system.!This!finding!is!consistent!with!prior!research!in!

this!field!from!the!UK.5,!6!One!possible!reason!for!this!perception!might!be!that!when!

radiographers!are!asked!to!provide!their!interpretive!opinion!on!a!radiographic!image,!

they!assess!the!quality!of!imaging!with!a!new!perspective.!Rather!than!assessing!the!

quality!of!an!image!against!a!text!book!example,!they!may!assess!it!based!on!whether!

the!clinical!question!can!be!answered!from!the!imaging!acquired.!In!discussion!with!

radiographers! from! several! UK! medical! imaging! departments! which! have!

implemented!PIE,!they!indicated!that!they!did!observe!an!improvement!in!the!quality!

of!imaging!at!a!department!level.!These!opinions!should!be!considered!with!caution!

as!there!have!not!yet!been!any!quantitative!studies!that!have!assessed!whether!the!

quality!of!imaging!does!improve!following!the!implementation!of!PIE.!

!


Furthermore,!Study!1!reported!the!leading!perceived!barrier!to!the!implementation!of!

PIE! in! emergency! care! settings! was! access! to! effective! image! interpretation!

education.! Successful! implementation! of! a! PIE! system! hinges! on! addressing! this!

barrier.!The!findings!from!this!program!of!research!may!assist!workforce!managers!in!

recognising!that!investment!in!targeted!PIE!training!will!likely!improve!radiographers’!

confidence! and! ability! which! may! have! a! positive! impact! on! radiographers’!

participation!in!a!PIE!system.!!

!

8.3.4/Some/Australian/radiographers/perceive/they/are/not/ready/to/participate/

in/a/PIE/system(

This! research!was! the! first! to! report! that! some!Australian! radiographers!may! lack!

confidence! and! perceived! accuracy! when! describing! abnormalities! of! the!

musculoskeletal!system.!This!finding!may!raise!concern!with!the!Medical!Radiation!

Practice!Board!of!Australia!and!workforce!managers.!The!Medical!Radiation!Practice!

Board! of! Australia’s! statement! on! professional! capabilities! for! medical! radiation!

practice1! recommends! that! radiographers!are! to!communicate! results!of!diagnostic!

tests! to! the!referring!clinical! team!when!they! identify!significant!abnormal! findings.1!

This! research! has! demonstrated! some! radiographers! in! Australian! emergency!

settings!may!not!be!following!this!recommendation.!Perhaps!this!should!be!a!point!of!

concern! among! radiographers,! workforce! managers! and! to! the! Medical! Radiation!

Practice! Board! of! Australia.! Successful! implementation! of! PIE! systems! will! be!

dependent!upon!radiographers’!confidence!and!accuracy!in!interpreting!radiographs.!

Access!to!targeted!education!for!radiographers!is!likely!to!be!helpful!in!this!regard.!

!

8.3.5/ Development/ of/ PIE/ nationally/ and/ internationally/ since/ the/

commencement/of/this/research/

The! results! of! this! research! have! already! impacted! clinical! practice! in! Australian!

hospitals.! In! the! last! two! years,! the! candidate! has! been! involved! in! assisting! the!

implementation!of!PIE! in!4!hospitals.!The!candidate!has!provided!advice!regarding!

image! interpretation! education,! PIE! design,! rollNout! methodology! and! evaluation!

strategies.!Throughout!this!program!of!research,!the!candidate!has!been!developing!

strong! national! and! international! collaborations.! The! network! of! researchers! and!

decisionNmakers! whom! the! candidate! has! been! involved! with! has! strengthened,!

leading!to!more!opportunities!to!be!involved!in!multiNcentre!research!in!this!field.!!One!


example!of! this!networking!has!been! involvement! in! the!design!of!an! international!

research!project!(involving!UK,!Australia,!Canada!and!Singapore)!investigating!image!

interpretation! performance! amongst! radiographers! working! in! these! different!

countries.!The!research!the!candidate!has!described! in! this! thesis!over! the! last!six!

years!(as!a!partNtime!doctoral!candidate),!has!also!resulted!in!an!invitation!from!the!

Australian! Society! of! Medical! Imaging! and! Radiation! Therapy! (the! peak! body!

representing!medical!radiation!practitioners!in!Australia)!to!participate!in!developing!

the!certification!process!for!PIE!within!Australia.!This!is!currently!underway!and!is!likely!

to!be!completed!in!2019.!!

!

Work! related! to! this! topic,! but! beyond! the! scope!outlined! in! this! doctoral! research!

program!has!also!been!performed,!which!involved!implementing!one!of!the!first!PIE!

systems! into! an! Australian! metropolitan! emergency! department.! A! manuscript!

reporting!the!results!of!that!study!is!planned!for!submission!to!a!peerNreviewed!journal!

in! late! 2018.! Outside! of! the! field! of! medical! imaging! but! based! on! the! research!

presented!in!this!thesis,!the!candidate!has!been!involved!in!training!medical!doctors!

and!nurse!practitioners! in! image!interpretation! in!the!emergency!setting.!He!is!also!

currently! collaborating! with! a! group! of! emergency! department! physiotherapists! in!

designing! a! study! to! determine! the! performance! of! physiotherapists’! image!

interpretation! ability.! Following! the! successful! dissemination! of! findings! generated!

from!this!program!of!research!and!the!active!contribution!by!this!candidate!within!the!

medical! imaging! field,! the! candidate! hopes! there! will! be! an! increase! in! the!

implementation!of!PIE!systems!nationally!and!internationally.!!

!

8.4!! Strengths/and/Limitations/of/this/Research!

There!are!several!key!strengths!and!limitations!of!this!thesis.!The!individual!strengths!

and!limitations!specific!to!Studies!1!–!3(were!considered!within!the!respective!thesis!

chapters!which!detailed!each!of!the!individual!studies.!Several!of!the!overarching!key!

methodological!considerations!merit!noting!regarding!interpretation!of!thesis!findings!

overall.!

!

A!major!strength!of!this!research!program!was!that!it!culminated!in!the!RCT!conducted!

in! Study! 3.! First,! the! RCT! design! is! considered! a! “gold! standard”! for! generating!

scientific!evidence!of!effectiveness.!The!RCT!in!this!research!program!was!a!multiN


centre,! stratified! (by! years! of! experience),! twoNgroup! parallel! arm,! single! blind!

(assessor!blinded),! randomised!controlled! trial.! It!was!prospectively! registered!with!

the!Australian!New!Zealand!Clinical!Trials!Registry.!Secondly,!it!is!noteworthy!that!the!

study! protocol! was! preNspecified! and! written! according! to! SPIRIT! guidelines! for!

interventional! trials.7! Thirdly,! another! strong! aspect! of! the!RCT! is! that! the! primary!

outcome!measure! had! undergone! testing! (in! Study! 2)! which! indicated! favourable!

evidence! supporting! its! validity! and! reliability! amongst! radiographers.! Numerous!

image!interpretation!tests!have!been!used!in!prior!studiesg8N10!however,!there!is!a!lack!

of!data!describing!the!validity!and!reliability!of!these!image!test!banks.!Lastly,!a!further!

strength!in!the!overall!study!design,!was!the!inclusion!of!participants!from!at!least!three!

centres!(Study!1N3)!adding!support!to!the!likelihood!that!findings!can!be!generalised!

beyond!a!single!investigator!site.!!

(

Several!limitations!are!worthwhile!considering.!Firstly,!a!potential!limitation!relating!to(

Studies!1N3!involved!the!use!of!a!voluntary!sampling!method.!Voluntary!sampling!in!

any! study!may! lead! to! the! possibility! of! a! selfNselection! bias.! Radiographers! who!

responded! to! the! invitation! to!participate!may!have!had!a!greater! interest! in! image!

interpretation!education!than!nonNresponders.!Secondly,!all!three!studies!included!a!

sample! of! participants! from! metropolitan! hospitals.! Radiographers! working! in!

dissimilar! settings!or! regional!and! rural! locations,!may!have!had!different! levels!of!

image!interpretation!ability!and!different!perceptions!regarding!the!implementation!of!

a!radiographer!commenting!system!than!those!radiographers!who!participated!in!this!

research.!Thirdly,!a!limitation!regarding!the!participants!involved!in!Study!2!(as!well!as!

the! other! studies),! was! that! they! were! all! radiographers.! Prior! research! has!

acknowledged! that! establishing! validity! and! reliability! of! a! measurement! tool! is!

required!across!a! range!of! subjects! (in! this!case!perhaps!professions)!and!clinical!

settings.11!Notably!though,!it!is!this!radiographer!population!who!has!been!involved!in!

a! range!of! studies! on! radiographic! image! interpretation! and! they! provide! a! logical!

starting! point! for! validating! this! IIT.2,! 12,! 13! Nonetheless,! testing! among! other!

professions!and!health!professional!students,!remains!a!worthwhile!future!direction!for!

research.!A!fourth! limitation!relates!to!the!exclusion!of!paediatric! images! in!the!IIT.!

Published! research! has! acknowledged! the! challenges! of! paediatric! image!

interpretation!in!comparison!to!the!adult!skeleton.14,!15!Therefore,!caution!is!required!

when!extrapolating!the!results!of!this!thesis!that!developed!and!subsequently!used!an!


image!bank!that!did!not!include!radiographic!examinations!of!the!paediatric!skeleton.!

Finally,!the!possibility!of!recall!bias!is!always!a!potential!limitation!with!studies!which!

involve! the! completion! of! an! assessment! that! draws! from! a! limited! item! testNbank!

during! a! relatively! short! timeNframe.! To! minimise! participants! memorising! cases!

between!assessments,!Study!3!undertook!two!preventative!actions.!Firstly,!a!minimum!

time!between!any!two!assessments!of!5!weeks!was!employed.!!Secondly,!a!computerN

generated!randomisation!sequence!was!used!to!present!each!60Ncase!assessment!in!

random!order,!further!limiting!the!potential!for!case!recall!which!may!have!arisen!if!a!

sequential!image!pattern!was!used.!

!

8.5! Recommendations/for/Future/Research//

This! program! of! research! has! identified! seven! key! recommendations! for! future!

research.!!

!

8.5.1/Modify/and/validate/the/IIT/for/other/settings/and/pathology!Study!2!developed!and!validated!the!first!standardised!quantitative!outcome!measure!

suitable! for! evaluating! radiographers’! ability! to! detect! and! comment! on! traumatic!

abnormalities! present! in! radiographic! images! (the! IIT).! The! IIT! only! contains! adult!

trauma! radiographs! and! consequently! performance! on! the! IIT! may! not! reflect!

participants’! abilities! to! interpret! other! categories! of! pathology.! Worthwhile! future!

research!could!explore!developing!and!validating!an!instrument!to!test!paediatric!or!

nonNtrauma!pathologies./Some!additional!important!considerations!for!future!research!

will!be!to!examine!discriminate!validity,!testNretest!reliability!and!performance!of!the!

IIT!over!longitudinal!assessments!to!investigate!its!responsiveness.!A!consideration!

for!the!future!application!of!this!IIT!is!the!potential!for!case!recall,!if!an!identical!test!

were!used!at! followNup!assessments.!To!limit!case!recall!bias,!a!second!IIT,!with!a!

larger!number!of!cases!to!sample,!could!be!developed.!Alternatively,!another!avenue!

worth!exploring!could! include!further!analysis!to!determine!the!minimum!number!of!

images!that!need!to!be!included!in!the!IIT!to!assess!radiographers’!ability!to!detect!

and!comment!on!traumatic!pathology.!A!potential!outcome!might!result!in!the!final!IIT!

only!requiring!the!completion!of!a!random!sample!of!images!(e.g.!20!images)!from!the!

larger! image! pool.! This! would! both! streamline! the! time! required! to! complete! the!

assessment!and!help!mitigate!recall!bias!further!improving!the!overall!utility!of!the!IIT.!

It!is!noteworthy!to!mention!that!the!use!of!a!small!image!test!bank!(e.g.!20!cases)!may!


attract! criticism.! Such! criticisms! may! includeg! insufficient! examples! of! specific!

pathologies,!insufficient!range!of!anatomical!regions!or!lack!of!variation!in!complexity!

to!test!the!participants’!interpretive!ability.!

!

8.5.2!Test/other/professions’/image/interpretation/ability/using/the/IIT(

The!participants! in! this!program!of! research!were!all! radiographers.!An! interesting!

avenue!for!future!research!would!be!to!investigate!the!interpretive!performance!of!the!

array!of!professions!who!are!required!to!interpret!adult!trauma!radiographs!as!part!of!

their!role.!Potential!professions!in!addition!to!radiographers!may!include!emergency!

doctors,!nurse!practitioners!and!physiotherapists.!Such!investigations!may!lead!to!a!

better! understanding! of! the! similarities! and! differences! in! image! interpretation!

performance! between! professions! which! may! underline! incongruences! in! current!

models!of!care!in!the!emergency!setting.!!

!

8.5.3!Educate/and/ test/ radiographers/who/are/working/ in/different/healthcare/

settings/using/the/IIT(

A!future!study!that!incorporates!regional!and!rural!sites!is!warranted!to!assess!whether!

findings!are! likely! to!be!consistent!among! radiographers!working! in! these!different!

locations.!Using!the!faceNtoNface!approach!to!deliver!the!education!program!employed!

in! this!research!might!prove!challenging!when!considering!accessibility! for! regional!

and! rural! sites.! With! the! progression! of! digital! hospital! and! increasing! uptake! of!

telehealth! systems! nationally,! the! use! of! a! teleNeducation! platform! to! reduce!

geographical!barriers!associated!with!accessing!faceNtoNface!education!may!be!timely!

and! worthy! of! investigation.! An! added! advantage! offered! with! a! teleNeducation!

platform! is! the! potential! for! flexible! delivery! and! use! of! blended! learning,! thus!

increasing!the!accessibility!of!education!to!all!health!professionals.16,!17!!

!

8.5.4!Transfer/the/IIT/to/an/online/platform(

The!time!required!to!score!IITs!(approximately!15!minutes!each)!is!another!noteworthy!

consideration.!Exploring!the!potential!for!transferring!the!IIT!to!an!online!platform!may!

improve!the!efficiency!of!administration!and!grading,!whilst!also!potentially!improving!

accessibility.!There!are!several!potential!online!solutions!available.!The!simplest!form!

would! involve! uploading! the! individual! cases! from! the! IIT!with! their! corresponding!

interpretation!to!a!suitable!exam!developer!website!(there!are!many!to!choose!from).!


This!would!then!allow!increased!accessibility,!randomised!cases!(limiting!case!recall),!

automated!scoring!using!key!words,!and!potentially!instantaneous!results!that!could!

be!linked!for!automatic!issuance!of!a!completion!certificate.!A!more!complex!solution!

would!be!to!investigate!employing!computerNadapted!testing.!Computerised!adaptive!

tests!are!a!method!of!test!delivery!based!on!item!response!theory.18,!19!They!operate!

by!adapting!both!the!difficulty!and!quantity,!of!items!viewed!by!each!user.!This!style!

of!testing!provides!a!wide!range!of!benefits!in!addition!to!a!simple!webNbased!solution.!

Some!of! the!additional!benefits!of!computer!adaptive! testing! include:!shorter! tests,!

more!accurate!scores,!greater!test!security!(as!users!are!not!all!completing!the!same!

test)!and!the!software!can!breakdown!results!into!where!strengths!and!weaknesses!

exist.!

!

8.5.5/ Compare/ the/ effectiveness/ of/ university/ based/ image/ interpretation/

education/versus/an/intensive/short/course/format/

A!consideration!for!future!research!could!involve!comparing!the!effectiveness!of!image!

interpretation! education! from! an! undergraduate! radiography! program! against! an!

intensive!short!course!format!(for!example!two!days)!like!the!intervention!utilised!in!

this! research.! Additionally,! a! comparison! of! the! effectiveness! of! a! postgraduate!

radiography!program!(for!example!12N24!months)!against!an!intensive!short!course!

format! could! also! be! conducted.! The! outcome! of! these! potential! studies! could!

significantly!influence!the!radiographer!PIE!field!internationally,!particularly!if!the!short!

course!format!was!proven!to!be!an!appropriate!alternative!to!either!or!both!university!

program!options.!Further!additional!research!could!explore!the!effectiveness!of!face!

to!face!education!(like!the!program!employed!in!this!research)!versus!online!delivery!

of!an!education!program.!

!

8.5.6/ Compare/ the/ psychometric/ properties/ of/ a/ university/ endorsed/

assessment/tool/against/the/IIT//

A! noteworthy! recommendation! for! future! research! could! involve! comparing! the!

psychometric! properties! of! a! university! endorsed! assessment! tool! against! the! IIT/

developed! and! validated! in! this! research.! The! findings! of! this! research! could!

potentially! influence!how!radiographers’!ability!to!provide!a!PIE!is!assessed!both!in!

the!clinical!setting!and!at!university.!

!


8.5.7!Evaluate/the/cost/effectiveness/of/training/and/implementing/PIE(

An! avenue! of! research!which! has! not! been! investigated,! but! is! likely! to! be!worth!

pursing,!involves!the!evaluation!of!the!costNeffectiveness!of!training!and!implementing!

PIE.!Several!factors!need!to!be!considered!in!this!type!of!study!including!the!cost!of!

facilitators!delivering!education!and!cost! to! the!service!of!staff!attending!education.!

Several! challenges!also! exist! in! terms!of! access! to! data! in! this! type!of! study.!For!

example,!obtaining!access!to!the!sensitive!nature!of!data!related!to!rates!and!types!of!

diagnostic! errors.! There! is! also! uncertainty! regarding! the! potential! true! cost! of!

diagnostic!errors!in!terms!of! litigation.!Informal!discussions!with!a!health!economist!

revealed! that! potentially! the! most! costNeffective! approach! is! to! not! implement! a!

solution!but!to!payNout!litigation!claims!when!they!arise.!Robust!economic!modelling!

to!understand!likely!costs!and!effects!of!training!radiographers!and!implementing!PIE!

would! be! likely! to! significantly! affect! the! rollNout! of! risk!mitigation! strategies! in! the!

emergency!department.!

!

8.6! Conclusions!

Collectively,! the! findings! from! the! three! studies! that! constitute! this! thesis! provide!

evidence! to! support! the!conclusion! that! the! intensive! format!of!PIE!education!was!

more! effective! at! improving! radiographers’! actual! and! perceived! ability! to! interpret!

trauma! radiographs! than! the!nonNintensive! format.!However,! radiographers! in!both!

groups!improved.!The!findings!constitute!a!significant!and!original!contribution!to!the!

knowledge! base! regarding! the! development! of! PIE! in! the! Australian! setting.! In!

addition,!use!of! the!newly!developed!and!validated!IIT!outcome!measure!may!also!

afford! valuable! insights!which!are!not! readily!obtainable! from!existing! instruments.!

Whilst!the!program!of!research!presented!in!this!thesis!provides!substantial!support!

for! image! interpretation! by! radiographers,! future! investigations! into! quantitative!

outcome!measures!are!warranted.!Finally,!in!deriving!the!main!findings,!the!present!

program! of! research! provides! valuable! insights! which! will! inform! subsequent!

education! rollNout! strategies! for! PIE! education! among! practising! radiographers! in!

Australia!(as!well!as!internationally).!Improving!the!image!interpretation!capabilities!of!

radiographers!will!likely!minimise!the!risk!of!missed!or!incorrect!diagnosis!due!to!delay!

in!radiologist!reports.!This!will,!in!turn,!be!likely!to!have!a!positive!impact!on!the!care!

of!many!patients.!!

/


8.7/ References/for/Chapter/8/

1! Medical!Radiation!Practitioner!Board!of!Australia.!Professional!capabilities!for!

medical! radiation! practice.! Australian! Health! Practitioner! Regulation! Agency,!

Melbourne,!Victoria,!2013.!

2! Hardy! M,! Flintham! K,! Snaith! B,! Lewis! EF.! The! impact! of! image! test! bank!

construction! on! radiographic! interpretation! outcomes:! a! comparison! study.!

Radiography.!2016g!22:!166N170.!

3! Holt!NF.!Medical!students!need!more!radiology!education.!Academic(Medicine.!

2001g!76:!1.!

4! Nyhsen!CM,!Steinberg! LJ,!O’Connell! JE.!Undergraduate! radiology! teaching!

from!the!student’s!perspective.!Insights(Into(Imaging.!2013g!4:!103N109.!

5! Lancaster!A,!Hardy!M.!An!investigation! into!the!opportunities!and!barriers!to!

participation! in! a! radiographer! comment! scheme,! in! a! multiNcentre! NHS! trust.!


6! Howard!ML.!An!exploratory!study!of!radiographer's!perceptions!of!radiographer!

commenting!on!musculoNskeletal!trauma!images!in!rural!community!based!hospitals.!


7! Chan!ANW,!Tetzlaff! JM,!Altman!DG,( et( al.! SPIRIT! 2013! statement:! defining!

standard!protocol!items!for!clinical!trials.!Annals(of(Internal(Medicine.!2013g!158:!200N

207.!

8! Boutis!K,!Pecaric!M,!Seeto!B,!Pusic!M.!Using!signal!detection!theory!to!model!

changes! in! serial! learning! of! radiological! image! interpretation.!Advances( in(Health(

Sciences(Education.!2010g!15:!647N658.!

9! Pusic!MV,!Andrews!JS,!Kessler!DO,(et(al.!Prevalence!of!abnormal!cases!in!an!

image!bank!affects!the!learning!of!radiograph!interpretation.!Medical(Education.!2012g!

46:!289N298.!

10! Tudor!G,!Finlay!D,!Taub!N.!An!assessment!of! interNobserver!agreement!and!

accuracy!when!reporting!plain!radiographs.!Clinical(Radiology.!1997g!52:!235N238.!

11! Brealey! S,! Scally! A.! Bias! in! plain! film! reading! performance! studies.!British(

Journal(of(Radiology.!2001g!74:!307N316.!

12! Brealey!S,!Scally!A,!Hahn!S,!Thomas!N,!Godfrey!C,!Coomarasamy!A.!Accuracy!

of!radiographer!plain!radiograph!reporting!in!clinical!practice:!a!metaNanalysis.!Clinical(

Radiology.!2005g!60:!232N241.!


13! McConnell! J,! Devaney! C,! Gordon! M.! Queensland! radiographer! clinical!

descriptions! of! adult! appendicular!musculoNskeletal! trauma! following! a! condensed!

education!programme.!Radiography.!2012g!19:!48N55.!

14! Smith!T,!Younger!C.!Accident!and!emergency!radiological!interpretation!using!

the!radiographer!opinion!form!(ROF).!The(Radiographer.!2002g!49:!27.!

15! McConnell! JR.! Can! Radiographer! MusculoNskeletal! Trauma! Radiograph!

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2015.!

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14:!51N55.!

17! Chipps!J,!Brysiewicz!P,!Mars!M.!A!systematic!review!of! the!effectiveness!of!

videoconference!based!tele!education!for!medical!and!nursing!education.!Worldviews(

on(Evidence,Based(Nursing.!2012g!9:!78N87.!

18! Thompson!NA,!Weiss!DJ.!A!framework!for!the!development!of!computerized!

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Appendices 185

Appendices Appendix A Study 1 – Questionnaire 1 1. What is your mother's maiden name (e.g. Smith)?

2. What is your home address street number (e.g. 145)?

3. How many years have you worked in your current profession?

4. What is your age?

5. What is your gender?

6. Do you currently participate in a Radiography Abnormality Detection system

(such as the red dot system)? (Yes or No)

7. For every 100 cases you perform, among how many would you participate in a

Radiography Abnormality Detection System? (e.g. putting a red dot when an

abnormality is evident and no red dot when there is no abnormality evident) (free

text)

8. What do you believe are the benefits of a Radiography Commenting system?

(list up to 6)

9. What are the major barriers that you believe inhibit the use of a Radiography

Commenting system? (list up to 6)

10. What factors do you believe would enable the introduction of a Radiography

Commenting system? (list up to 6)

Appendices 186

11. What level of image interpretation service do you feel is appropriate for

radiographers to provide in a public hospital setting?

(from 1 = strongly disagree, to 5 = strongly agree)

a) Radiographers should never provide an image interpretation opinion

b) Radiographer should provide a verbal opinion when an abnormality is

detected

c) Radiographer should provide a verbal opinion when requested by a referring

MO

d) Radiographers should participate in a “Red Dot” or equivalent system

e) Radiographers should complete a written description for each radiographic

examination via a worksheet

f) Radiographers should provide a full diagnostic report for each radiographic

examination

Appendices 187

Appendix B Study 1 – Questionnaire 2

1. What is your mother's maiden name (e.g. Smith)?





6. Do you feel confident to be involved in an abnormality detection system?

(from 0 = not at all confident, to 10 = very confident)

7. How confident are your imaging interpretation capabilities with respect to

detecting traumatic abnormalities?



describing traumatic abnormalities?


9. What is your perceived level of accuracy in...

(from 0 = not at all accurate, to 10 = very accurate)

a) Detecting abnormalities on trauma radiographs of the appendicular

skeleton?

b) Describing abnormalities on trauma radiographs of the appendicular

skeleton?

c) Detecting abnormalities on trauma radiographs of the axial skeleton?

d) Describing abnormalities on trauma radiographs of the axial skeleton?

Appendices 188

10. If a program to improve radiographers’ ability to detect and describe

abnormalities on trauma radiographs was available to you, please indicate your

preferred mode of delivery of the education.

(from 0 = undesirable, to 10 = very desirable)

a) 8 short 90minute sessions (12 hours)

b) Intensive twoday session (12 hours)

11. What do you perceive are the advantages and disadvantages with the

proposed two modes of education?

Advantages of:

8 short 90minute sessions (free text)

Disadvantages:

8 short 90minute sessions (free text)

Advantages of

Intensive twoday session (free text)

Disadvantages

Intensive twoday session (free text)

Appendices 189

Appendix C Study 3 – Questionnaire 1






6. Do you feel confident to be involved in a Radiography Commenting system?











skeleton?


skeleton?



Appendices 190

Appendix D Study 3 – Questionnaire 2






6. Which education mode did you receive?

a) Regular sessions over 9 weeks

b) Two intensive days

7. Do you feel confident to be involved in a Radiography Commenting system?











skeleton?

Appendices 191


skeleton?



11. Please indicate to what extent you (dis)agree with the following statements

regarding the content of the workshop.

(from 0 = strongly disagree, to 10 = strongly agree)

a) The volume of information presented was suitable for the time allocated.

b) The complexity of information presented was suitable for the style of

education

c) The education program was too intense

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