Camilla Andersson, BSc,MD, PhD, is a physiciDepartment of RadiologUniversity, Uppsala, Swsenior lecturer, and SiSection of Oncology,Radiation Sciences, UpAhlstr€om, MD, PhD,Department of RadiologUniversity, Uppsala, Swlecturer, Education inUppsala University, Upp

Funding statement: Thisfunding agency in the pu

Conflict of Interest Stateby the authors.

Corresponding author:Medicine and PET, DUniversity Hospital, 75Andersson@radiol.uu.se

1546-0843/$36.00

Copyright� 2015 by the

http://dx.doi.org/10.1016

100

Patient Experience ofan 18F-FDG-PET/CT

Examination: Need forImprovements in Patient

Care

j Camilla Andersson, BSc, RN; Birgitta Johansson, PhD, RN; Cecilia Wassberg, MD, PhD;

Silvia Johansson, MD, PhD; H�akan Ahlstr€om, MD, PhD; and Bj€orn Wikehult, PhD, RN

ABSTRACT: The aims of this study were to investigate the patients’ knowledge about and experience ofan 18F-fluoro-deoxy-glucose (FDG)-positron emission tomography (PET)/computed tomography (CT)examination and to investigate the self-reported feelings of stress, level of physical activity, andhealth-related quality of life (HRQoL) and to find out if this was related to how they experienced the ex-amination. A cross-sectional survey was used to collect information on 198 patients with knownor suspected malignancy. As many as 32% to 63% were satisfied with the nursing staff, the communication,and the professional skills. Most patients did not know beforehand what an FDG-PET/CT examination was.The HRQoL, level of perceived stress, and physical activity were relatively low. A better HRQoL, lower levelof perceived stress, and a higher level of physical activity were correlated to a more positive experience andhigher education to more knowledge about the examination (p! .01e.05). The information before the ex-amination needs to be improved. The results may be used to improve patient care and optimize imagingprocedures. (J Radiol Nurs 2015;34:100-108.)

KEYWORDS: PET/CT; Patient; Experience; Nursing; Imaging.

RN, is a radiographer, and Cecilia Wassberg,an, Section of Nuclear Medicine and PET,y, Oncology and Radiation Sciences, Uppsalaeden; Birgitta Johansson, PhD, RN, is a

lvia Johansson, MD, PhD, is a physician,Department of Radiology, Oncology andpsala University, Uppsala, Sweden; H�akanis a Professor, Section of Radiology,

y, Oncology and Radiation Sciences, Uppsalaeden; Bj€orn Wikehult, PhD, RN, is a seniorNursing, Department of Surgical Sciences,sala, Sweden.

research received no specific grant from anyblic, commercial, or non-for-profit sectors.

ment: No conflict of interest has been declared

Camilla Andersson, Section of Nuclearepartment of Nuclear Medicine, Uppsala1 85 Uppsala, Sweden. E-mail: Camilla.

Association for Radiologic & Imaging Nursing.

/j.jradnu.2014.11.008

www.radiologyn

INTRODUCTION

Molecular imaging in oncology has developed signifi-cantly in recent years. New hybrid imaging techniquesare increasingly used whereby anatomical and func-tional imaging is combined in the same session. Posi-tron emission tomography (PET) combined withcomputed tomography (CT), with the radioactivelylabeled glucose analog 18F-fluoro-deoxy-glucose(FDG), constitutes a standardized examination toolin clinical routine, especially used in cancer imagingfor tumor staging, diagnosis of recurrent disease,monitoring of treatment response, and radiation ther-apy planning (Saif, Tzannou, Makrilia, & Syrigos,2010).

The PET/CT examinations require planning andpreparation on the part of both patients and nursingstaff. Thus, it is important that patients are wellinformed and that the nursing staff is well trained.There are many studies on the imaging field of FDG-PET/CT for many types of cancer, but little is known

JUNE 2015ursing.org

Patient experience of an FDG-PET/CT examination Andersson et alJOURNAL OF RADIOLOGY NURSING

about the patients’ experiences in connection with aPET/CT examination. The patients’ level of satisfac-tion may be an indicator of quality of care (Aikenet al., 2012; Charalambous, 2013). To our knowledge,so far, no studies have been published on this topic.

Patient satisfaction is a widely accepted dimensionof quality care for several reasons: it may improvecompliance to treatment regimens, it is an importantoutcome measure, and it has been described as a factorassociated to improved health status (Aharony &Strasser, 1993; Fitzpatrick, Davey, Buxton, & Jones,1998; Hall & Dornan, 1988). A meta-analysis of theconcept of patient satisfaction showed several aspects,such as availability, overall quality, humaneness, pro-fessional skills, sufficient information, good facilities,and the staff’s interest in psychosocial problems (Hall& Dornan, 1990).

The patient professional interaction is a necessityfor patient satisfaction. It consists of several elementsof which the patient’s goals are important. Goodcommunication should enable the care provider tomeet the patient’s expectations and culminate in acare relationship (Feldman-Stewart, Brundage, &Tishelman, 2005).

A number of studies have investigated patients’ ex-pectations and satisfaction in relation to other typesof diagnostic examinations than PET/CT(Nightingale, Murphy, & Blakeley, 2012; T€ornqvist,M�ansson, Larsson, & Hallstr€om, 2006). T€ornqvistet al. (2006) concluded that patients needed to haveconfidence in the staff to feel secure during a magneticresonance imaging (MRI) examination. Nightingaleet al. (2012) found that written information beforethe examination was helpful, and on-going repeated ex-planations and reassurance were important to reducepatients’ anxiety and distress during the examinationprocedure. Still, each individual patient has specificneeds, and the nursing staff should be aware of theirinteraction with the patient and how it affects his/herability to deal with the examination.

Furthermore, receiving information has been shownto reduce patients’ anxiety and promote a positive atti-tude before undergoing an examination at a nuclearmedicine department. Thus, the patient care providedby the nursing staff is fundamental to promoting pa-tient satisfaction (Lledo et al., 1995). Cancer patients’needs, expectations, and experiences may also vary dur-ing the different stages of cancer treatment and man-agement, and may depend on other factors such asage, gender, and educational status (Mistry, Wilson,Priestman, Damery, & Haque, 2010). According toOllivier et al. (2009), most patients were (91e98%) ina radiology imaging department were generallysatisfied with the care provided during ultrasound,

VOLUME 34 ISSUE 2 www.radiologyn

mammography, CT, or MRI. However, 71% of the pa-tients in this study would have appreciated additionalinformation about the examination and some patientsfelt worried before the examination, and the reasonfor this was in most cases anxiety about the results.

The 18F-FDG-PET/CT requires that the patient hasfollowed the given instructions beforehand and alsostaff members’ instructions after arriving to the depart-ment (Boellaard et al., 2010). FDG is a glucose analogthat reflects the increased metabolism in neoplasticviable and inflammatory cells (glycolytic pathway).Because the examination provides both anatomical(CT) and functional information (PET), there arerigorous pre-examination requirements. Patients musthave fasted for at least 6 hours but with the intake ofnoncarbohydrate fluids to ensure adequate hydration.The blood glucose level should be 8.0 mmol/L or lower,corresponding to 150 to 200 mg/dL; and in patientswith diabetes, the disease needs to be well controlled.It is important that documentation regarding relevantdetails in the patient history (recent surgery, inflamma-tory conditions, and treatments such as chemo or radi-ation therapy) is available. The FDG is injectedintravenously, and during the subsequent 60-min up-take phase, the patient should be kept warm and remainsilent and relaxed. The patient is also asked to drink wa-ter during this period and empty the urinary bladderimmediately before the PET/CT examination. The pa-tient is shown into the examination room and is posi-tioned supine on the couch of the PET/CT scannerwith the arms elevated over his/her head. It is importantthat the patient remains in the same position during theentire examination procedure to avoid image artifacts.The total time from the patient’s arrival at the nuclearmedicine department to his/her departure is approxi-mately 2-3 hours, including a 30-min PET/CT examina-tion time (Boellaard et al., 2010).

According to Romero, Vivas-Consuelo, and Alvis-Guzman (2013), health-related quality of life (HRQoL)is a concept that has a wide variety of definitions. Still,there is an evidence-based perception that has its focuson the individual’s well-being. The HRQoL is also auseful indicator to measure health and disease. TheHRQoL relates to how disease affects patients’ well-being or patients’ perceived quality of life (QoL;Ashing-Giwa, 2005). Cancer diagnosis is a traumaticexperience that may affect different aspects of the pa-tients’ life, such as physiological well-being and theability to physical activity. Karabulu, Erci, Ozer, andOzdemir (2010) studied the prevalence and severity ofsymptoms in patients with cancer and found that themost common symptoms were fatigue, difficulty toremember, sadness, loss of appetite, lack of enjoymentof life, pain, distress, difficulty to walk, and dry mouth.

101ursing.org

Andersson et al Patient experience of an FDG-PET/CT examinationJOURNAL OF RADIOLOGY NURSING

Rustad, David, and Currier (2012) found that cancerpatients and survivors have an increased risk to developposttraumatic stress disorder in comparison with thegeneral population, which could negatively affect theoutcome of the treatment. Physical activity has provento have health benefits across many diseases, includingcancer (Broderick, Ryan, O’Donnell, & Hussey, 2014).Mishra et al. (2012) found that physical activity or ex-ercise interventions improves cancer patients’ HRQoLwhen it is given at the same time as the patients un-dergo cancer treatment and also reduces anxiety withbreast cancer patients.

Because the 18F-FDG-PET/CT examination is depen-dent on the patient’s cooperation and the procedure maybe experienced as cumbersome, it would be interesting toevaluate the patient experience of the PET/CT examina-tion and also the characteristics of the populationremitted to the examination, such as physical activity,level of perceived stress, and experienced HRQoL. Thedesirable consequences of this study should be high pa-tient satisfaction and patient care in nuclear medicine de-partments. The aims of the study were to investigate thepatients’ knowledge about and experience of the 18F-FDG-PET/CT examination. An additional aim was toinvestigate the self-reported feelings of perceived stress,the level of physical activity, and the experiencedHRQoL and to find out if this was related to how thepatients experienced the examination.

MATERIALS AND METHODS

Participants

A consecutive sample of 198 patients (106 men and 92women) who were scheduled for a standard 18F-FDG-PET/CT examination were asked to participate in thestudy during October 2011 and April 2012. Criteriafor inclusion were 18 years or older, fluent in Swedish,reason for referral known or suspected malignancy,and scheduled for 18F-FDG-PET/CT examination forthe first time. Criteria for exclusion were inability tounderstand Swedish; younger than 18 years of age; orif another protocol than standard was used, such asprotocols especially designed for radiotherapy plan-ning; or when the patient also had intravenous iodinecontrast during the examination. The patients wereasked to participate in the study after completion ofthe examination. They received oral and written infor-mation regarding the study procedure by the nursingstaff who carried out the examination. Patients whoagreed to participate received a questionnaire.

Data Collection

The questionnaire consisted of questions concerningpersonal demographics, such as age, gender, civil

102 www.radiologyn

status, level of education, occupation, monthly income,and profession. There were also three questions aboutthe patient’s level of perceived stress; responses weremade on a five-point scale (0[ “almost never” to 4[ “almost always”). Three questions concerned thepatient’s physical activity; responses were made on asix- or seven-point scale. One question was about theparticipant’s daily activity (0[ “sitting still” to 5[ “heavy labor”). Another question was about theparticipant’s frequency of walking or cycling (0[ “almost never” to 5[ “2 hr per day”). One questionasked about the participant’s frequency of other exer-cise (0[ almost never to 6[ “O5 hr per week”).Two questions concerned the participant’s knowledgeof the 18F-FDG-PET/CT examination; responses weremade on a four-point scale (0[ “not at all” to 3[ “quite a lot”), and the Cronbach alpha value forthese two questions was 0.89, which indicates good reli-ability. Three questions were concerned about the pa-tient’s discomfort during the 18F-FDG-PET/CTexamination; responses were made on a four- or five-point scale, and the Cronbach alpha value for thesethree questions was 0.55. One question asked how ex-hausting the examination was to the patient. The re-sponses were scored 0[ “not at all exhausting” to 3[ “very much exhausting.” A second question was towhat extent the examination corresponded to the pa-tient’s expectations. The responses were scored 0[ “much easier” to 4[ “much worse.” The last ques-tion was did you feel trapped during the examination?The responses were scored 0[ “not at all trapped” to3[ “very much trapped.” All the above questionswere constructed by the authors.

Eight of the questions were from the Patient Experi-ences Questionnaire (PEQ; Pettersen, Veenstra,Guldvog, & Kolstad, 2004), an instrument measuringpatient experience that has shown good validity andreliability (Garratt, Helgeland, & Gulbrandsen, 2011).Responses were made on a five-point scale (0[ “notat all” to 5[ “to a very high degree”) and the Cron-bach alpha value for these eight questions was 0.90.

The European Organization for Research and Treat-ment of Cancer (EORTC) has developed a cancer-specific QoL Questionnaire (QLQ-C30). It consists of30 items addressing different aspects of patients’HRQoL and has shown good validity and reliability(Aaronson et al., 1993; King, 1996; Niezgoda &Pater, 1993). The questions are transformed into scalessuch as global health and QoL scale, functional scales(physical, role, cognitive, emotional, and social), andsymptom scales (fatigue, pain, nausea, and vomiting).The questionnaire also consists of six single-item ques-tions (dyspnea, insomnia, loss of appetite, constipation,diarrhea, and financial difficulties). All scale and

JUNE 2015ursing.org

Table 1. The demographic characteristics of the studypopulation (NZ 169)

Characteristics Mean (Range)/n (%)

Age 64 (19e92)

Gender

Male 90 (53)

Female 79 (47)

Civil status

Married/cohabitant 104 (62)

Single 47 (28)

Widow/widower 17 (10)

Education

Compulsory school 65 (39)

Upper secondary school 63 (38)

University 0e4 years 27 (16)

University O4 years 13 (8)

Occupation

Working 63 (38)

Sick leave 17 (10)

Studies 2 (1)

Homework 11 (7)

Unemployed 6 (4)

Other 65 (40)

Monthly income

0e4,999 5 (3)

5,000e9,999 16 (10)

10,000e14,999 49 (30)

15,000e19,999 23 (14)

20,000e24,999 32 (20)

25,000e29,999 13 (8)

30,000e34,999 8 (5)

O35,000 16 (10)

Profession

Blue collar worker 76 (49)

White collar worker 64 (41)

Entrepreneur 11 (7)

Other 4 (3)

Stress* 4 (0e10)

Physical activity* 4 (0e14)

*A higher score represent a higher level of stress or physical

activity, respectively.

Patient experience of an FDG-PET/CT examination Andersson et alJOURNAL OF RADIOLOGY NURSING

single-item scores were linearly transformed into a 0 to100 scale, with higher scores reflecting either moresymptoms or higher levels of functioning (Fayerset al., 2001).

Authorization to use questions from PEQ andEORTC-QLQ-C30 was granted. The questionnairealso provided opportunities for the patient to supplyfree-text comments. Each patient could choose to eithercomplete the questionnaire while still at the departmentor take it home and return it by post within 1 month ina stamped self-addressed envelope. A reminder and acopy of the questionnaire were sent by post to partici-pants who after 3 weeks had failed to reply. The studywas approved by the regional ethical review board inUppsala, Sweden (No.2011/277).

Data Analysis

The collected data were analyzed using Statistical Pack-age for Social Sciences, SPSS version 20.0. Descriptivestatistics were used for the demographic data and thepatients’ responses to questions about their knowledgeand experience of the 18F-FDG-PET/CT examination.Spearman’s correlation coefficient was used to investi-gate if patient knowledge and experience of the 18F-FDG-PET/CT examination was correlated to perceivedstress, physical activity, and HRQoL. Correlations toHRQoL were restricted to scales/items in theEORTC-QLQ-C30 that may be most likely to influencethe experience of the examination, that is, the func-tional scales, dyspnea, fatigue, and pain. The threequestions about the perceived stress were summarizedinto one variable. The new variable range was 0 to10, where a higher score indicates more stress. Thethree questions about the patient’s physical activitywere also summarized into one variable and the newvariable range was 0 to 14, where a higher score indi-cates more physical activity. The summarized variablesfor stress and physical activity were used in the correla-tion analyses. The level for statistical significance wasset at p value lower than .05 (two tailed). Participants’free-text comments were analyzed using categorizationof responses.

RESULTS

Participants

About 9 of 198 patients declined to participate and 189patients accepted to participate in the study. Of these,20 participants completed the questionnaire at the nu-clear medicine department, whereas169 chose to take ithome and return it by post. A reminder and a copy ofthe questionnaire were sent to 44 of the participantswho had not replied by post within 3 weeks. Around20 patients did not return the questionnaire. Theresponse rate was 89% or 169 participants, 90 men

VOLUME 34 ISSUE 2 www.radiologyn

and 79 women. The participants mean age was 64years (range, 19e92; Table 1). The participants hadmixed diagnoses and the most common diagnosiswere known or suspected lung cancer. Seven partici-pants were inpatients.

Patient Knowledge, Information, and Satisfaction

More than one-half (52%) of the participants did notknow at all what an FDG-PET/CT examination wasbefore the examination, and 46% did not know howthe FDG-PET/CT examination was conducted(Table 2). This indicates a low degree of patient knowl-edge about the FDG-PET/CT examination. The resultsshow that as many as 32% to 63% of the participantswere satisfied with the nursing staff, the communica-tion, and the professional skills to a high degree or a

103ursing.org

Table 2. Patients knowledge and discomfort regardingan FDG-PET/CT examination (nZ 169)

Parameters n (%)

Did you know before the examination what a PET-FDG

examination was?

Not at all 87 (52)

Some 56 (33)

Quite a lot 22 (13)

I knew very much 3 (2)

Did you know before the procedure how the PET-FDG

examination was conducted?

Not at all 78 (46)

Some 63 (38)

Quite a lot 21 (13)

I knew very much 6 (4)

Did you feel trapped during the examination?

Not at all 122 (72)

Some 40 (24)

Much 7 (4)

Very much 0

How exhausting was the examination?

Not at all 106 (63)

Some 44 (26)

Much 10 (6)

Very much 8 (5)

Was the examination as you had expected it to be?

Much easier 51 (30)

A bit easier 50 (30)

Just as I expected 56 (33)

A bit worse 12 (7)

Much worse 0

FDG Z Fluoro-deoxy-glucose; PET Z positron emission

tomography; CT Z computed tomography.

Andersson et al Patient experience of an FDG-PET/CT examinationJOURNAL OF RADIOLOGY NURSING

very high degree (Table 3). However, 20% of the partic-ipants had some degree and 8% to a low degree satis-faction with the information they received before theexamination, and 34% of the participants to some de-

Table 3. Results of patient satisfaction and information regpopulation survey with questions from PEQ and questions d

Parameters

Not at

all, n (%

Are you satisfied with the information you received before the

examination?

5 (3)

Are you satisfied with the information you received when you

came to the examination?

1 (1)

Are you satisfied with the interaction with the nursing staff

during the examination?

1 (1)

Did the nursing staff communicate in an understandable way? 5 (3)

Did the nursing staff convey a caring attitude? 0

Did you feel confident in the professional skills of the nursing

staff?

0

Did the nursing staff have adequate time for you when you

needed them?

1 (1)

Did you get the impression that the work of the hospital was

well organized?

9 (6)

FDG Z Fluoro-deoxy-glucose; PET Z positron emission tomograp

questionnaire.

104 www.radiologyn

gree and 8% to a low degree thought that the nursingstaff communicated in an understandable way. The re-sults also showed that participants were satisfied to avery high degree with the interaction with the nursingstaff during the examination and 62% felt confidentto a high degree in the professional skills of the nursingstaff (Table 3).

Patient Discomfort

Most (63%) participants did not think that the FDG-PET/CT examination was exhausting at all, whereas5% thought that it was very much exhausting(Table 2). A total of 38 participants wrote commentsregarding which aspects of the examination were ex-hausting. A total of 24 participants commented onphysical factors such as arm position and back painduring the PET/CT acquisition. About 11 participantscommented on emotional factors such as a sense ofinsecurity or loneliness. Three participants com-mented on the water intake during the subsequentphase between FDG injection and PET/CT acquisi-tion. Of those participants who wrote comments, 28felt that the examination was somewhat exhausting,5 that it was quite exhausting, and 5 that it was veryexhausting. Another question was if the examinationwas as the participant expected it to be. Most thoughtthat the examination was a bit easier (30%) or mucheasier (30%) than they expected (Table 2). About72% did not feel trapped at all and none of the partic-ipants felt much trapped during the examination(Table 2). Some patients who knew they sufferedfrom claustrophobia received anxiolytic medicationjust before examination. In the present study, onlytwo patients were given this treatment, and thus

arding an FDG-PET/CT examination of the studyesigned for this study (NZ 169)

)

To a low

degree, n (%)

To some

degree, n (%)

To a high

degree, n (%)

To a very high

degree, n (%)

14 (8) 34 (20) 81 (48) 34 (20)

4 (2) 17 (10) 71 (42) 76 (45)

1 (1) 7 (4) 54 (32) 106 (63)

13 (8) 57 (34) 69 (41) 24 (14)

4 (2) 8 (5) 59 (35) 98 (58)

0 7 (4) 57 (34) 105 (62)

2 (1) 11 (7) 59 (35) 96 (57)

2 (1) 7 (5) 74 (48) 62 (40)

hy; CT Z computed tomography; PEQ Z patient experiences

JUNE 2015ursing.org

Table 4. Health-related quality of life of studypopulation measured by the EORTC-QLQ-C30

Parameters N Mean SD

Global health status (QoL) 167 57 24

Functional scales

Physical functioning (PF) 168 73 25

Role functioning (RF) 167 66 36

Emotional functioning (EF) 168 68 25

Cognitive functioning (CF) 169 80 24

Social functioning (SF) 166 74 28

Symptom scales/items

Fatigue (FA) 166 40 28

Nausea and vomiting (NV) 167 9 17

Pain (PA) 168 27 31

Dyspnea (DY) 168 39 34

Insomnia (SL) 168 33 35

Appetite loss (AP) 168 22 29

Constipation (CO) 168 16 29

Diarrhea (DI) 168 9 20

Financial difficulties (FI) 169 18 30

EORTC-QLQ-C30 Z European Organization for Research and

Treatment of Cancer Quality of Life Questionnaire; SD Z standard

deviation.

Patient experience of an FDG-PET/CT examination Andersson et alJOURNAL OF RADIOLOGY NURSING

medication does not explain the few reports of feelingtrapped.

Health-Related Quality of Life

The results from EORTC-QLQ-C30, means, and stan-dard deviations are shown in Table 4. Mean score forglobal health status (QoL) was relatively low (mean:57). Functional scale scores were higher than 50.Cognitive functioning had the highest score (mean:80) and role functioning had the lowest score (mean:66). Symptom scale scores and single-item scores werelower than 50. The highest symptom scale score was fa-tigue (mean: 40) and the highest single-item score wasdyspnea (mean: 39).

Stress and Physical Activity

The levels of perceived stress were relatively lowbecause most of the participants had a score of 4 orless on the summary scale, which had a maximum scoreof 10 (Table 1). The levels of physical activity were alsorelatively low because one-half of the participants had ascore of 4 or less on the summary scale, which had amaximum score of 14 (Table 1).

Correlations to Health-Related Quality of Life andBackground Data

A number of correlations between the participants’experience of the PET-FDG examination and differentitems of EORTC-QLQ-C30, level of education,perceived stress, and physical activity were found(Table 5). High patient satisfaction correlates to a high-er QoL and EORTC-QLQ-C30 functional scales

VOLUME 34 ISSUE 2 www.radiologyn

(p! .05e.01), whereas low patient satisfaction corre-lates to worse dyspnea and fatigue (p! .05e.01).High patient discomfort correlates to worse fatigue,pain, and dyspnea (p! .05e.01), whereas low patientdiscomfort, especially how exhausting they experiencedthe examination correlates to higher functional scores(p! .05e.01). High patient satisfaction did also corre-late to lower levels of perceived stress (p! .05e.01)and the patient’s feelings of being trapped during theexamination correlated to higher levels of perceivedstress (p! .01). Also patients with higher education re-ported more knowledge about the examination(p! .01) and patients with a higher level of physicalactivity were more satisfied (p! .05).

DISCUSSION

To our knowledge, this is the first study on this topic.The main findings were that most patients did notknow beforehand what an FDG-PET/CT examinationwas or how it was conducted. More educated patientsreported a higher knowledge about the examination.Most patients were to a very high degree satisfiedwith the interaction with the nursing staff and theirprofessional skills. However, it may be a goal to in-crease this figure even further. The results also showthat the patients were less satisfied with the informationthey received before the examination and the nursingstaff’s ability to communicate with them in understand-able way. In a study by Lledo et al. (1995), they foundthat information before the examination is an impor-tant tool to help reduce patient anxiety and improvepatient satisfaction when undergoing an examinationin a nuclear medicine department. Similar to our study,they also found that patients were overall satisfied withthe patient care provided by the nursing staff. Highoverall patient satisfaction with nursing staff and pa-tient care are confirmed by Ollivier et al. (2009) whoalso found that waiting time and worry about the re-sults may generate anxiety with patients in an imagingdepartment and it is important to give the patient infor-mation about the reason and purpose for the examina-tion. This shows high general patient satisfaction withnursing staff and patient care during different diag-nostic examinations. However, information before theexamination and individualized communication mayimprove patient satisfaction even further and are sug-gested to be tested in future studies. The present resultsshow that most patients did not know what an FDG-PET/CT examination was or how it was conducted,and some patients were not satisfied with the informa-tion they received before the examination. This infor-mation consisted of a paper together with the timefor the appointment and/or information by the nursingstaff over the telephone. Construction of a website with

105ursing.org

Table 5. Results of Spearman’s correlations analysis connection between the patient’s experience of an FDG-PET/CT examination and patient educationlevel, level of perceived stress, physical activity, and health-related quality of life*

Parameters Education QoL PF RF EF CF SF FA PA DY Stress

Physical

activity

Did you know before the

examination what a PET-

FDG examination was?

.257**

Did you know before the

procedure how the PET-FDG

examination was conducted?

.255**

Are you satisfied with the

information you received

before the examination?

.214**

Are you satisfied with the

information you received

when you came to the

examination?

.163*** .206** �.180***

Are you satisfied with the

interaction with nursing staff

during the examination?

.181*** �.197***

Did the nursing staff

communicate in an

understandable way?

Did the nursing staff convey a

caring attitude?

.158*** .189*** �.195*** �.180*** �.235**

Did you feel confidence in the

professional skills of the

nursing staff?

.184*** �.179*** �.193*** �.176*** .178***

Did the nursing staff have

adequate time for you when

you needed them?

.177*** .173*** .171*** .165*** �.208** �.215** �.206** .159***

Did you get the impression that

the work of the hospital was

well organized?

�.215** �.199***

How exhausting was the

examination?

�.219** �.219** �.185*** �.252** �.239** .336** .204** .277**

Was the examination as you had

expected it to be?

�.167*** .214** .163***

Did you feel trapped during the

examination?

�.165*** �.266** .179*** .242**

FDG Z fluoro-deoxy-glucose; PET Z positron emission tomography; CT Z computed tomography. QoL, Global health and quality of life scale; Functional scales (high valueZ better

function): PF, physical functioning; RF, role functioning; EF, emotional functioning; CF, cognitive functioning; SF, social functioning; Symptom scales/item (high valueZworse symptom):

FA, fatigue; PA, pain; DY, dyspnea; education (high valueZ high level of education; stress (high valueZworse stress); physical activity (high valueZ high level of physical activity; questions

regarding patient knowledge about and experience of an 18F-FDG-PET/CT examination (high valueZmore knowledge about or better experience of the examination). Light gray squares

show positive correlations and dark gray squares show negative correlations. **p! .01, ***p! .05.*European Organization for Research and Treatment of Cancer health-related quality of life questionnaire (EORTC-QLQ-C30).

Andersso

net

al

Patientexperience

ofanFDG-PET/C

Texam

inationJO

URNALOFRADIO

LOGY

NURSIN

G

106

JUNE2015

www.ra

diologynursin

g.org

Patient experience of an FDG-PET/CT examination Andersson et alJOURNAL OF RADIOLOGY NURSING

information about the examination could be one op-tion for increasing patient knowledge and may improvepatient satisfaction about the information before theexamination.

Most of the patients in the present study thought thatthe examination was not exhausting at all, and none ofthe patients felt very much trapped during the examina-tion. Indicating that the examination does not make thepatient feel claustrophobic; however, patients’ with ahigher level of perceived stress felt more trapped duringthe examination and patients who expressed high levelsof perceived stress were also less satisfied. These findingsare similar to findings by T€ornqvist et al. (2006) whofound that patients needed to interact with the nursingwhile undergoing an MRI examination during whichsome patients feel claustrophobic. Patients who feltclose to panic during the examination needed informa-tion, trust, and reassurance from the staff. This meansthat a positive interaction between the patient and thenursing staff may result in good imaging quality. Onepossible explanation to our findings is that patients levelof perceived stress and feelings of claustrophobia arereduced when the patient is satisfied with the interactionwith the nursing staff.

The time the patient spent in the PET/CT cameraand the fixed position of the body especially the armscould be strenuous for the patient. Nightingale et al.(2012) found that the body positioning instructionsgiven by the clinical staff during a nuclear medicine car-diac examination were not sufficient for patients. In-structions need to be complemented by a caringinteraction based on each patient’s expectations. Itmay be a goal for the nursing staff to identify these pa-tients and to find different solutions to decrease patientdiscomfort during the time the patient spend in thePET/CT camera. Different interventions need to betested to improve patient satisfaction. For instance, so-lutions could be found for comfortably supporting thepatient’s arms while they are elevated over the head.

There can be significant variance in QOL scoresamong studies (King, 1996). However, the HRQoL re-sults are similar to findings in a study made by Larsson,Ljung, and Johansson (2012) who investigated HRQoLin advanced non-small-cell lung cancer patients. Inboth our and their study, global health status was rela-tively low within the study population; and of the func-tional scales, role functioning got the lowest scores; andof the symptom and single-item scales, fatigue and dys-pnea had the highest scores in both studies. Indicatingthat this may be areas of problems for this group of pa-tients and that it may be something nursing staff whocomes in contact with these patients should be awareof. Patients who are satisfied overall with care haverelatively higher global health status (Bredart et al.,

VOLUME 34 ISSUE 2 www.radiologyn

2007). This is similar to our findings where high patientsatisfaction correlates to higher QoL and EORTC-QLQ-C30 functional scales. Patients with more symp-toms were less satisfied and felt more discomfort duringthe examination and it may be a goal for the nursingstaff to identify these patients and to find ways toimprove patient care and satisfaction. The correlationsbetween higher levels of physical activity and the highersatisfaction with the nurses’ care may reflect the associ-ation between HRQoL and physical activity, which hasbeen established in various diagnostic groups includingpatients with lung cancer (Granger, McDonald,Berney, Chao, & Denehy, 2011; Mishra et al., 2012).

Limitations

A questionnaire was used to collect data in the presentstudy. Some of the questions were constructed for thisparticular study and had not been tested with regardto validity and reliability. This limits the possibilitiesto assess the internal validity of the present study. How-ever, the response rate was high and the number of un-answered questions was mostly low, which may indicatethat the questionnaire was deemed relevant and easy tounderstand. An additional strength is that this is thefirst study on this topic, thereby contributing relevantfindings on patients’ experience of an FDG-PET/CT ex-amination. Some questions had responses from lessthan 169 participants. The two questions with thelowest response rate were did you get the impressionthat the work of the hospital was well organized(nZ 154) and about the patient’s monthly income(nZ 162). Explanations for this may be that some pa-tients may find it difficult to assess how well the hospitalis organized on the basis of a single visit to a nuclearmedicine department and that some are reluctant toreveal their income. However, the response rate wasnever below 82% and is not deemed to have a majorimpact on the outcome of this study. To get a well-defined sample, we chose to include only patients whowere having the FDG-PET/CT examination for the firsttime and with the standard PET/CT protocol, whichmost of the patients undergo. Future studies can prefer-ably also include an assessment of the image quality,which would make it possible to investigate the associ-ation between patient satisfaction and image quality.

CONCLUSION

Only a small percentage of the participants knewwhat theFDG-PET/CTexaminationwasorhow itwas conducted.Consequently, the information given to patients beforethe examination needs to be improved.Most of the partic-ipants were satisfiedwith the care provided by the nursingstaff, the interaction, and the staff’s professional skills,although some of the patients did not think that the

107ursing.org

Andersson et al Patient experience of an FDG-PET/CT examinationJOURNAL OF RADIOLOGY NURSING

nursing staff communicated in an understandable way.The nursing staff who carry out the FDG-PET/CT exam-ination should be aware of the fact that different factorssuch as patients’ level of perceived stress, physical activity,and HRQoL may influence their experience of the exam-ination. The registration time and fixed body positioning,especially the arms, during the PET/CT examinationregistrationmay be strenuous for the patient. The presentfindingsmay be used to help optimize imaging proceduresand patient care.

ReferencesAaronson, N.K., Ahmedzai, S., Bergman, B., Bullinger, M., Cull,

A., & Duez, N.J., et al. (1993). The European Organization forResearch and Treatment of Cancer QLQ-C30: a quality-of-lifeinstrument for use in international clinical trials in oncology.Journal of the National Cancer Institute, 85(5), 365-376.

Aharony, L., & Strasser, S. (1993). Patient satisfaction: what weknow about and what we still need to explore. Medical CareResearch and Review, 50(1), 49-79.

Aiken, L.H., Sermeus, W., Van den Heede, K., Sloane, D.M.,Busse, R., & McKee, M., et al. (2012). Patient safety, satisfac-tion, and quality of hospital care: cross sectional surveys ofnurses and patients in 12 countries in Europe and the UnitedStates. British Medical Journal, 344, e1717.

Ashing-Giwa, K.T. (2005). The contextual model of HRQoL: aparadigm for expanding the HRQoL framework. Quality ofLife Research, 14(2), 297-307.

Boellaard, R., O’Doherty, M., Weber, W., Mottaghy, F., Lons-dale, M., & Stroobants, S., et al. (2010). FDG PET andPET/CT: EANM procedure guidelines for tumour PET im-aging: version 1.0. European Journal of Nuclear Medicineand Molecular Imaging, 37(1), 181-200.

Bredart, A., Coens, C., Aaronson, N., Chie, W.C., Efficace, F., &Conroy, T., et al. (2007). Determinants of patient satisfactionin oncology settings from European and Asian countries: pre-liminary results based on the EORTC IN-PATSAT32 ques-tionnaire. European Journal of Cancer, 43(2), 323-330.

Broderick, J.M., Ryan, J., O’Donnell, D.M., & Hussey, J. (2014).A guide to assessing physical activity using accelerometry incancer patients. Supportive Care in Cancer, 22(4), 1121-1130.

Charalambous, A. (2013). Variations in patient satisfaction withcare for breast, lung, head and neck and prostate cancers indifferent cancer care settings. European Journal of OncologyNursing, 17(5), 588-595.

Fayers, P.M., Aaronson, N.K., Bjordal, K., Groenvold, M.,Curran, D., & Bottomley, A. (2001). The EORTCQLQ-C30 Scoring Maual (3rd edition). Brussels: EuropeanOrganisation for Research and Treatment of Cancer.

Feldman-Stewart, D., Brundage, M.D., & Tishelman, C. (2005).A conceptual framework for patient-professional communi-cation: an application to the cancer context. Psychooncology,14(10), 801-809. discussion 810-811.

Fitzpatrick, R., Davey, C., Buxton, M.J., & Jones, D.R. (1998).Evaluating patient-based outcome measures for use in clinicaltrials. Health Technology Assessment, 2(14), i-iv. 1-74.

Garratt, A.M., Helgeland, J., & Gulbrandsen, P. (2011). Five-pointscales outperform 10-point scales in a randomized comparisonof item scaling for the Patient Experiences Questionnaire. Jour-nal of Clinical Epidemiology, 64(2), 200-207.

Granger, C.L., McDonald, C.F., Berney, S., Chao, C., & Dene-hy, L. (2011). Exercise intervention to improve exercise

108 www.radiologyn

capacity and health related quality of life for patients withNon-small cell lung cancer: a systematic review. Lung Cancer,72(2), 139-153.

Hall, J.A., & Dornan, M.C. (1988). What patients like abouttheir medical care and how often they are asked: ameta-analysis of the satisfaction literature. Social Scienceand Medicine, 27(9), 935-939.

Hall, J.A., & Dornan, M.C. (1990). Patient sociodemographiccharacteristics as predictors of satisfaction with medicalcare: a meta-analysis. Social Science and Medicine, 30(7),811-818.

Karabulu, N., Erci, B., Ozer, N., & Ozdemir, S. (2010). Symptomclusters and experiences of patients with cancer. Journal ofAdvanced Nursing, 66(5), 1011-1021.

King, M.T. (1996). The interpretation of scores from the EORTCquality of life questionnaire QLQ-C30. Quality of LifeResearch, 5(6), 555-567.

Larsson, M., Ljung, L., & Johansson, B.B. (2012). Health-relatedquality of life in advanced non-small cell lung cancer: corre-lates and comparisons to normative data. European Journalof Cancer Care (England), 21(5), 642-649.

Lledo, R., Herver, P., Garcia, A., Guell, J., Setoain, J., & Asenjo,M.A. (1995). Information as a fundamental attribute amongoutpatients attending the nuclear medicine service of a uni-versity hospital. Nuclear Medicine Communications, 16(2),76-83.

Mishra, S.I., Scherer, R.W., Snyder, C., Geigle, P.M., Berlan-stein, D.R., & Topaloglu, O. (2012). Exercise interventionson health-related quality of life for people with cancer duringactive treatment. Cochrane Database of Systematic Reviews,CD008465.

Mistry, A., Wilson, S., Priestman, T., Damery, S., & Haque, M.(2010). How do the information needs of cancer patientsdiffer at different stages of the cancer journey? Across-sectional survey. Journal of the Royal Society of Medi-cine Short Reports, 1(4), 30.

Niezgoda, H.E., & Pater, J.L. (1993). A validation study of thedomains of the core EORTC quality of life questionnaire.Quality of Life Research, 2(5), 319-325.

Nightingale, J.M., Murphy, F.J., & Blakeley, C. (2012). ‘Ithought it was just an X-ray’: a qualitative investigation ofpatient experiences in cardiac SPECT-CT imaging. NuclearMedicine Communications, 33(3), 246-254.

Ollivier, L., Apiou, F., Leclere, J., Sevellec, M., Asselain, B., &Bredart, A., et al. (2009). Patient experiences and preferences:development of practice guidelines in a cancer imagingdepartment. Cancer Imaging, 9 Spec No A, S92-S97.

Pettersen, K.I., Veenstra, M., Guldvog, B., & Kolstad, A. (2004).The Patient Experiences Questionnaire: development, validityand reliability. International Journal of Quality in HealthCare, 16(6), 453-463.

Romero, M., Vivas-Consuelo, D., & Alvis-Guzman, N. (2013). IsHealth Related Quality of Life (HRQoL) a valid indicator forhealth systems evaluation? Springerplus, 2, 664.

Rustad, J.K., David, D., & Currier, M.B. (2012). Cancer andpost-traumatic stress disorder: diagnosis, pathogenesis andtreatment considerations. Palliative and Supportive Care,10(3), 213-223.

Saif, M.W., Tzannou, I., Makrilia, N., & Syrigos, K. (2010). Roleand cost effectiveness of PET/CT in management of patientswith cancer.Yale Journal of Biology andMedicine, 83(2), 53-65.

T€ornqvist, E., M�ansson, �A., Larsson, E., & Hallstr€om, I. (2006).It’s like being in another world e patients’ lived experience ofmagnetic resonance imaging. Journal of Clinical Nursing,15(8), 954-961.

JUNE 2015ursing.org