Kliininen Radiografiatiede - sorf.fi

Kliininen Radiografiatiede

2/2017 / Journal of Clinical Radiography and Radiotherapy Vol 15

2 Kliininen Radiografiatiede 2017 Kliininen Radiografiatiede 2017

Kliininen Radiografiatiede-lehti on Radiografian Tutkimusseura ry:n ja Suomen Röntgenhoitajaliitto ry:n julkaisu, jonka tarkoituksena on välittää kliinisestä radiografiatieteestä uusinta tietoa ja välittää sen tutkimustuloksia sekä toimia tieteellisenä keskustelufooruminan. Lehti julkaisee kliinisen radiografiatieteen käytännöstä, koulutuksesta ja tutkimuksesta alkuperäisartikkeleita sekä tutkittuun tietoon perustuvia katsauksia, tapausselostuksia alaan liittyvistä kehittämistöistä sekä akateemisten opinnäytetöiden (pro gradu-tutkielmat, lisensiaattityöt, väitöskirjat) lyhyitä esittelyitä.

Toimituskunta • Editorial board

Aronen Hannu, ProfessoriHenner Anja, TtTJussila Aino-Liisa, TtTNiemi Antti, TtTTenhunen Mikko, DosenttiTenkanen-Rautakoski, Petra, DIWalta Leena, TtT

Toimituksen osoiteEditorial Address

Kliininen RadiografiatiedeSuomen Röntgenhoitajaliitto ryPL 14000060 Tehy

Toimitusihteeri Editorial Assistant

Katariina KortelainenPuh. 0400 231 791Email: katariina.kortelainen(at)sorf.fi

Julkaisija • Publisher

Suomen Röntgenhoitajaliitto ryPL 14000060 TehyPuh. 0400 231 791Tel. +358 400 231 791Email: katariina.kortelainen(at) sorf.fiSociety of Radiographers in Finland

Päätoimittaja • Editor-in-Chief Eija Metsälä, FT Radiografian ja sädehoidon tutkinto-ohjelma Metropolia Ammattikorkeakoulu PL 4033 00079 Metropolia Tel. +358 50 377 8177 Email: eija.metsala(at)metropolia.fi Helsinki Metropolia University of Applied Sciences FI-00300 Helsinki Finland

Tilaukset ja osoitteenmuutokset Kliininen Radiografiatiede-lehtiSuomen Röntgenhoitajaliitto ry PL 14000060 TehyEmail: katariina.kortelainen(at)sorf.fi

Tilaushinnat 10 E/vuosi Suomessa ja Skandinavian maissa Taitto Sanakuva ISSN 1797-142X

Kliininen Radiografiatiede Journal of Clinical Radiography and Radiotherapy

3Kliininen Radiografiatiede 2017 Kliininen Radiografiatiede 2017

Suomalainen ja eurooppalainen radiografian tieteenalan kehitys

Tänä vuonna tuli kuluneeksi 20 vuotta Radiografian tutkimusseuran perusta-misesta ja 10 vuotta Kliininen radiogra-fiatiede -lehden perustamisesta. Nämä molemmat ovat olleet merkittäviä virs-tanpylväitä suomalaisen radiografiatie-teen kehityksessä. Näihin verrattava merkkitapahtuma liittyen tieteenalan kehitykseen lienee ainoastaan tieteen-alakoulutuksen alkaminen Oulun yli-opistossa ensin sivuaineopintoina 1996 ja pääaineopintoina 1999. Oulun yliopis-ton radiografiatieteenalaohjelma oli merkittävä paitsi kouluttaessaan tiedey-liopistosta valmistuvia kandidaatteja, maistereita ja tohtoreita, myös tieteen-alan perustutkimuksen tukipylväänä ja tuottajana. Siksi onkin harmi että vii-meiset sisäänotot Oulun radiografian tieteenalaohjelmaan olivat 2009 josta lähtien tieteenalan kehitys on ollut klii-nistä radiografiatyötä tekevien terveys-alan yksiköiden, Radiografian tutkimusseuran, ammattikorkeakoulu-jen sekä yksittäisten tutkijoiden har-teilla. Tällä hetkellä meillä ei ole tiedeyliopiston suomaa tukea tutkimuk-seen ja alan kehitykseen. Ammattikor-keakoulujen opettajat ja opiskelijat (erit YAMK), kliinistä/hallinnollista röntgen-hoitajan työtä tekevät jatko-opiskelleet tai opiskelevat röntgenhoitajat ovat kes-keisessä roolissa tutkimuksen tuotta-jina. Röntgenhoitajataustaisilla väitöskirjaa aikovilla tai tekevillä henki-löillä ei ole tällä hetkellä mahdollisuutta tehdä väitöskirjaansa ja alansa tutki-musta oman tieteenalansa asiantuntijan ohjauksessa tiedeyliopistossa mutta toi-vomme tilanteeseen pikaista muutosta.

Tieteenalan tilanne ja asema Euro-passa on selkiintymätön. Sen koommin tieteenalan nimestä kuin paradigmas-taan ei ole yksimielisyyttä eikä siitä edes tällä hetkellä käydä kovinkaan paljon keskustelua. European Federation of

Radiography Societies käyttää tieteen-alastamme tällä hetkellä nimitystä radiography kun taas meillä Suomessa tämän lehden ensimmäisen päätoimit-tajan ja tutkijan Sanna Sorppasen (nyk. Ahonen) väitöskirjan (2006) mukaisesti tieteenalastamme käyte-tään nimitystä kliininen radiografia-tiede. Tieteenalamme suurimpia haasteita lähitulevaisuudessa tulevat-kin olemaan paradigmamme selkeyt-täminen sekä kansallisella että kansainvälisellä, erityisesti eurooppalai-sella tasolle, röntgenhoitajien maisteri- ja tohtorinkoulutus mahdollisuuksien turvaaminen omalla tieteenalalla sekä alan realistinen pää- ja sivutoimisen tut-kimustoiminnan mahdollistaminen.

Tarvitsemme sekä kotimaista että kansainvälistä verkostoitumista ja tut-kimushankkeita. Olemme pieni maa jossa röntgenhoitajien määrään suh-teutettuna on kiittävä määrä maiste-rin ja tohtorintutkinnon suorittaneita röntgenhoitajia ja alan tutkimus on suhteellisen vireää. Vaikka kotimai-sella kielellä julkaiseminen on tärkeää, kannustan meitä alan tutkijoita julkai-semaan myös englannin kielellä jotta tuloksemme leviäisivät kansainväli-sesti.

Onnittelemme hyvin voivaa 20-vuo-tiasta radiografiatiedettä ja 10-vuoti-asta Kliinistä Radiografiatiedelehteä!

Eija Metsälä Päätoimittaja

Developments in Finnish and European radiography science

This year is significant year for the Finnish radiography science because it is the 20th anniversary of the Finnish Radiography Research association and 10th anniversary of Journal of Clinical Radiography and Radiotherapy. These both are significant mark points in the development of Finnish radiography science like it was the beginning of scientific education in radiography science in Oulu University firstly as subsidiary studies and in 1999 as major studies.

The situation and position regarding radiography science is unclear. We do not have agreement about the name or paradigm of the radiography science and at the moment there even isn’t much discussion about the topic. European Federation of Radiography Societies nominates our science radiography but in Finland we use the concept clinical radiography according to the doctoral dissertation of Sanna Sorppanen (currently Ahonen). The biggest challenges in near future in our scientific field are clarifying the paradigm of the science both at the national and international, especially at the European level, ensuring scientific education for radiographers at the masters and PhD level and making realistically possible to practice research in the field.

Eija MetsäläEditor in Chief


ABSTRACT

Purpose and aim: Although its professio-nal scope and national curricula vary across different countries, a general aspect of radiography is its combination of operationally complex technology with patient care. For example, com-puted tomography (CT) examinations continually change due to technological improvements, demand for procedures is high placing increased pressure upon radiography staff. The purpose of this article is to develop a deeper understan-ding of how time scheduling affects aspects of care and technology in CT exa-minations. The aim of the study was to determine the significance of time for the care aspect of radiography.

Methods: The case study is based on twenty-six observations of X-ray com-puted tomography (CT scans) in which seven radiographers took part. Inter-views were also conducted with two of the radiographers.

Results: The study showed that the radiographers establish contact with the patient before the scanning, perform the scans and communicate with the patient after the scans. The study indicated that the radiographers attempted to save time in stress cases by reducing the aspect of care while maintaining focus

on the technical and safety aspects of the procedure. The radiographers minimize the conversation, are less aware of the patient’s needs and do not support the patient. In such cases, the radiographers’ contact with the patient is minimal and the care aspect is partly absent.

Conclusion: Scheduling based on the types of examination in the CT depart-ment, rather than on patients’ condi-tions, entails a risk of radiographers according lower priority to care aspects and mainly focusing on the technical aspects of the examination.

Keywords: computer tomography, medi-cal imaging, quality of care, qualitative research

INTRODUCTION

The work of the radiographer consists of both technical procedures and contact with patients (Lundvall et al. 2014). Radiographers must reconcile care and technology in a complex technical set-ting where efficiency is important. The work is based on standardised procedu-res and protocols, with a specific time allocated for each examination. The pur-pose of standardising the time taken for each examination is to make each day more predictable and manageable and

thereby increase efficiency (Timmer-mans and Berg 2003).

Though radiographers work in a technical context, the practice is also social due to the close contact with patients (Niemi and Paasivaara 2007). In Denmark, radiographers responsibi-lities include technical apparatus, nur-sing care and image production. Ethical guidelines for radiographers in Den-mark state that the radiographer must protect the patient’s integrity and take responsibility for the patient’s needs (Thomassen et al. 2012). In Scandinavia, the radiographer is responsible for per-forming the entire radiological examina-tion. The job is considered demanding because it involves two different roles: technical expert and care practitioner (Niemi and Paasivaara 2007).

Radiographers’ caregiving duties include placing the patient in the correct position, ensuring the patient is comfor-table during the examination and mini-mising the radiation dose. Caring is a rich concept that primarily reflects con-cern and respect for as well as attentive-ness to another being (Halldorsdottir and Hamrin 1997). Halldorsdottir and Hamrin (1997) explored how professio-nal caring empowers patients and how the lack of professional caring results in reduced patient health and well-being.

The radiographers who work with CT

The impact of time scheduling in computed tomography on patient care

Authors: (Corresponding author)Marianne PilegaardSenior Lecturer, Master of Science Bachelor’s Degree Program in Radiog-raphy Department of Technology Faculty of Health and Technology Metropolitan University College Mail: [email protected]

Author 2:Professor Helen EgestadDepartment of Health and Care Sciences Faculty of Health Sciences UiT, The Arctic University of Norway Hansine Hansens Mail: [email protected]


must learn new activities because of the changing procedures and new modali-ties for image production, such as angiography examination, cardiac (heart) examinations and biopsy. The radiographers who meet the patients must critically judge the intended actions in relation to observed clinical data to ensure patient safety.

Though radiography is useful for ima-ging, it is also potentially harmful because of radiation risks (Lundvall et al. 2014). Thus, radiographers must gua-rantee that measures for ensuring patient safety are enacted. Radiog-raphers’ practical work is comprised of planning, implementation and evalua-tion stages, where safety aspects and interaction with the patient are critical (Ahonen 2009). Anderson et al. (2008) focused on radiographers’ areas of pro-fessional competence related to good nursing care. They shared their findings in two main areas: direct and indirect patient-related areas of competences (Andersson et al. 2008). The direct patient-related area is defined by four categories: guiding the patient through the examination, performing the exami-nation, supporting the patient and being vigilant. The indirect patient-related area refers to providing good nursing care without direct contact with the patient; organizing the work; ensuring high quality in terms of safety; handling the images; and collaborating with col-leagues (Andersson et al. 2008).

Though integral to the work of radiog-raphers, patient care is sometimes igno-red in favour of technical tasks (Murphy 2001; Murphy 2006). Munn et al. (2014) found that radiographers want to pro-vide care for patients, but given their workload, it is not always possible to spend as much time on care as they would wish. Hellmann & Lindgren (2014) interviewed eight radiographers regarding what they consider the care needs of CT-scan patients. They found that it was important to meet patients needs for information, communication and physical and psychological care (Hellmann and Lindgren 2014). Patients require different amounts of time, but

the radiographers perceived that there was no room to conform to the patients’ needs.

Despite several studies in the area, no research has examined a radiographer’s own professional experience regarding the combination of operationally comp-lex technology with patient care (Lund-vall et al. 2014).

This study examines how the time allocated for CT examinations affects the care aspects of radiographers’ work. The report discusses topical questions related to the challenges faced by radiographers of concurrently provi-ding care for the patient and performing technical routines within a given timef-rame. The research question is as fol-lows: How does the time allocated to a CT scan affect the radiographer’s ability to provide patient care?

METHOD

Design. Case study research is useful for examining a phenomenon in its natural context (Yin 2003). In this study, we emphasized lived experience as a means of developing knowledge (Creswell 2007). The epistemological basis for the study is rooted in the phenomenological/hermeneutical tra-dition. To answer the research question, observations formed the basis for desc-ribing what happens in practice, while conversations and semi-structured interviews were used to elicit opinions from radiographers.

Participants. This study was perfor-med in Denmark. The radiographers observed worked in two CT-scanning units at a university hospital. Choosing which radiographers to observe was a random process as selection depended on who happened to be working at the CT laboratory at the particular time. The observations were made over five days, between 07:00 and 15:00. Seven radiog-raphers (three women and four men) were observed. A total of twenty-six observations were performed. The radiographers’ degrees of work experi-ence with CT technology varied from one year to ten years. The two inter-

views were carried out in connection with the observations. Statements were also taken from five other observed radiographers as they prepared for their next respective patient. Unstructured questions were asked based on the researcher’s observations. Immediately after the interview, the statements were written down.

Observations. During the observa-tions, the researcher followed the radiog-rapher into the examination room and observed both radiographers in the ope-ration room during the scan. The resear-cher stood clear of the radiographer and the patient inside the CT room. The intention was to cause as little disruption as possible both of the conversation bet-ween the radiographer and the patient and of the actual examination itself. Before observations started, a guide was drafted to describe the focus of the observations. The objective was to obtain greater insight into the relationship bet-ween radiographer and patient: What is emphasised in the communication? How long do radiographers spend talking with patients? Notes were written down immediately after the examinations and detailed descriptions were made at the end of the day.

Semi-structured interviews and conversations. The interviews were conducted by one researcher in associa-tion with the observations. The inter-views consisted of open questions that focused on daily work. The interview guide was designed to determine what radiographers think about and what they focus on while performing their duties. The interviews were conducted during working hours in a quiet room away from the ward, where the radiographers could speak freely. Each interview lasted about 1.5 hours. A digital voice recorder was used. Verbatim transcriptions were pro-duced the day after the interviews were conducted. In addition, the researcher had conversations with five other radiog-raphers before and after the examina-tions.

Analysis. The data acquisition and data processing were carried out in the spring and summer of 2009. The analysis was


Research ethics. The Danish Data Protection Agency deemed the study exempt from its registration require-ment, as no personal information (e.g., the radiographers’ identities or health status) was recorded. The radiographers took part in the study voluntarily and were informed that they could withdraw at any time without being obliged to pro-vide a reason. The radiographers were given verbal and written information about the study and each participant signed a consent form. Patients were given the opportunity to opt out of the study if they wished or to request that researchers were not present during their examinations. The radiographers were anonymised, as were the hospitals where the study was conducted. The selected practice descriptions consisted of examinations that all radiographers would recognise, irrespective of workp-lace. The audio recordings were stored in a locked cabinet that could only be acces-sed by the researchers. All sound recor-dings and observation notes were deleted approximately four weeks after the study was completed.

FINDINGS

Seven radiographers participated in the study, performing 26 X-ray computed tomography (CT scans) in total. All the observed examinations were of cancer patients: 25 were CT scans of the abdo-

conducted using the entire process desc-ribed by Kvale and Brinkmann (2009), where empirical evidence was analysed based on the radiographers’ context. The researchers initially searched for themes that emerged from the data, allowing issues that appeared significant for the radiographers to come to light. This method includes thematic structural analysis, which reflects a way of seeking to identify and formulate themes. In the analysis of the observations and inter-views, the researchers sought similarities and differences. This was primarily an inductive approach, but theoretical deductions guided the process. Text from interviews and observations were read carefully so that the researchers could develop an overall impression of the text. The overall impression could be divided into two main entities: contact with the patient and no contact with the patient. The main theme was to treat the patient as a unique person while performing the examination. The sub-themes concerned the patient s needs during the examina-tion (Table 1). All themes were summari-zed and reflected on in relation to the research question. Meaningful informa-tion from all the interviews was compa-red and examined to identify patterns, similarities and variations in the data. The themes emerged through a process of asking questions about the text and cons-tantly moving between meaningful units and the entire text.

men and one was a CT scan of the cerebrum. Two radiographers worked together on each of the examinations. One was responsible for the technical part of the CT scan and was present in the operation room. The other handled the technical equipment in the examina-tion room and took care of the patient. This entailed conversing with the patient and conducting procedures such as inserting peripheral vein catheters (PVCs) and a small flexible rectal cathe-ter, injecting the contrast agent and pla-cing the patient in the correct position. With each new patient, the radiog-raphers alternated between patient con-tact and technical duties. Three main themes emerged during data analysis: the relationship with the patient, the examination time and saving time.

The relationship with the patient All the observed radiographers expressed that they have busy days. One radiogra-pher said: “It is booked closely. Although we work structured, there is no time bet-ween the patients”. All the observed radiographers stated that the time alloca-ted the examinations controls their work. Another radiographer said: “Time provi-des a framework to work within. It con-sists of virtual boxes that break up our day and guide our time with the patients”. A third radiographer stated: “How much time we have for patients is affected by the program of the day.”

Table 1: Themes from observations and interviews

Overall impression Main theme Sub-themes Themes

Contact and no contact with the patient

To treat the patient as a unique person while performing the examination

Patient s needs The relationship with the patient

Patient s situation

The examination time

Patient s conditions

To save time


The radiographers indicated that they want to do a good job. They explain that a good examination requires a strong working relationship with the patients. One radiographer stated: “A good CT examination is one where I produce useful images, and I can only do that if I have a good working relationship with the patient. If you have a good working relationship, it is usually a positive experience for the patient. The relation-ship is more important than the time frame.”

The observations show that, during a CT scan, the radiographer’s time is divi-ded between conversation, procedures and the actual scan. There were many cases where the radiographer establis-hed contact with the patient during the examination and a few cases where the radiographer had minimal contact with the patient while administrating the

treatment (Table 2). The following observation describes one of many exa-minations that proceeded in a more or less similar manner: A woman in her sixties attends a CT scan for suspected colon cancer. When the patient arrives at the examination room, the radiogra-pher greets her with a smile. While she changes, the radiographer asks the patient about her weight and whether she is allergic to contrast agents. The patient says she is afraid of getting contrast because of a TV programme in which people had died after being injected with contrast. The radiogra-pher listens to the patient’s concerns and reassures her that this department does not use that type of contrast. The patient lies on the examination table. The radiographer informs the patient about the examination, asks the patient about her personal identifica-

tion number (CPR number) and inserts the PVC. Throughout this part of the process, the radiographer and patient keep talking to each other. After the examination, the patient says with a smile that she thinks the examination was easy. The examination lasted around 20 minutes and was booked at 20 minutes.

The examination time Several radiographers expressed that the examination time determined in the booking system does not comply with the elapsed time. The examination is expected to proceed without complica-tions, but unexpected incidents happen quite often. Many examinations booked for 10 minutes actually lasted for 20 to 25 minutes because the booking was ina-dequate, the patient suffered from impai-red mobility and/or the patient needed

Table 2: Observations – relationship with the patient

Example of observations: many examinations were performed this way

Contact with the patient

– The radiographer greets the patient with a smile.

– The radiographer listens and signals that there is enough time: makes eye contact with the patient, has an open body language and speaks quietly. – The radiographer listens to the patient. – The radiographer asks the patient questions and follows up on the patient s answers during the examination.

– There is contact and conversation between the radiographer and the patient during the entire examination.

Example of observations: some examinations were performed this way

No contact with the patient

– The radiographer greets the patient without a smile.

– The communication is one-way and only consists of information about the examina-tion.

– The radiographer briefly informs the patient about the examination.

– There is minimal contact during the examination and the radiographer is not engaged in the patient s needs. – The radiographer does not engage in the patient s situation or in conversation with the patient.


much help (Table 3). The radiographers indicated that they strive to meet indivi-dual patient needs. One radiographer noted: “When the patients are nervous, I spend more time talking to them.” Anot-her says: “It’s a challenge to prepare patients psychologically so that it is pos-sible to complete the examination in the time available”.

Example two reflects an examination where the patient’s condition required more time than was allotted for a stan-dard examination: The patient is an

80-year-old woman. She has questions about metastases. The radiographer asks if the patient has any diseases, and the patient says she has diabetes but cannot remember which medicine she takes. About ten minutes later, the radiogra-pher has a response from the laboratory about serum creatinine and has identi-fied the diabetes medicine. The radiogra-pher has problems with inserting the PVC for the patient and gives up after two attempts. The ward doctor is con-tacted, arrives in a matter of minutes,

but cannot insert the PVC either. The anaesthesiology nurse is contacted, and she arrives after about eight minutes and successfully inserts the PVC. The radiographer talks to the patient about the patient’s work while waiting for the anaesthesiology nurse. The examination takes about 40 minutes but was booked at 20 minutes.

Usually, the radiographer had no impact on how the program was estab-lished, but one of the radiographers who was the manager of the laboratory


Patient s needs – Patient is nervous before the examination; the radiographer spends more time to inform the patient

– Patient has other diseases that can affect the examination time.

Patient s situation – Patient s physical situation requires more time than the scheduled time

– Patient with dementia

– Patient with pain

– Patient with disabilities

Patient s condi-tions

– Patient who has been exposed to accidents– Emergency care situations

Table 3: Observations – examination time


The radiographer s behavior during the examination

– The radiographer does not ask about the patient s reactions.

– The radiographer is limiting the time in the examination room with the patient.

– The radiographer uses closed questions.

– The radiographer has a limited conversation with the patient and answers questions with few words.

– The radiographer signals that there is not much time, talks fast and has limited eye contact with the patient.

– There is minimal contact between the radiographer and the patient during the examination.

Table 4: Observations - how radiographers save time


noted: “I have influence on booking of emergency examinations, and by experi-ence, I know that I have to add 10 minu-tes more than the standard time because patients often are very sick and a doctor is involved in the examination.”

Saving timeSometimes, examinations are affected because the ward is behind schedule for the day. One radiographer said: “Time is important. We have a lot of stress and the stress leaves less energy to make a proper examination. It feels like assembly line work, and it s not nice for neither us nor the patients.” Most radiographers deal with these situations by minimising contact with the patient to “save” time (Table 4). Underlining this point, one radiographer said: “There is really only one place to save time, and that’s from the patients. The scan itself takes just two minutes, of course. It’s everything else that takes time”. Anot-her radiographer said: “Time sets the frameworks for communication with patients.” All the radiographers were concerned about adhering to the time-table and daily schedule.

Example three describes an examina-tion on a day when the ward was behind schedule: A 60-year-old woman has been diagnosed with rectal cancer and comes to the CT scan with questions about metastases in the lungs and liver. The ward is behind schedule, and the radiog-rapher calls the patient in approximately 10 minutes later than the appointed time. The radiographer greets the woman. The radiographer asks the woman about her weight and CPR number. The patient is then shown to the examination table. She is informed about the examination, about the warm sensation she may experience on her face, and that she may feel as if she is urinating. The patient is asked if she has any allergies. The radiographer says nothing while she inserts the PVC. With her attention focused exclusively on per-forming the procedure, the radiographer does not look at the patient. The radiog-rapher leaves the room and the scan starts. After approximately three minu-

tes, the scan is complete and the radiog-rapher returns to the examination room. The patient is shaking all over. The radiographer asks whether the sha-king is of relief or from feeling cold. The woman looks at the radiographer with a serious expression but does not res-pond. Without saying a word to the patient, the radiographer removes the PVC. The radiographer tells the woman to stay on the examination table for a while and leaves the room. About five minutes later, the radiographer returns and tells the patient that she can put on her clothes and go home. The examina-tion lasts about 15 minutes but was booked at 20 minutes.

DISCUSSION

The results show that time provides the framework for how radiographers inte-ract with the patient. The radiographers perform care duties when establishing contact with the patients before scan-ning, placing the patient in the correct position, ensuring the patient is com-fortable during the examination and ending the relationship after the exami-nation. The radiographers are respon-sible for the patient’s well-being while in the CT department (The International Society of Radiographers and Radiologi-cal Technologists 2003). The radiog-raphers’ statements demonstrate that they perceived their job as a combina-tion of operational technology, human communication and patient care in accordance with Lundvall et al. (2014) and Andersson et al. (2008).

In example one, the radiographer had time to provide care: e.g., by reassuring the patient. This is consistent with Lundvall et al.’s study (2014), which claims that during the examination, the radiographers must consider the patient’s mental state. The example shows that the patient’s anxiety is redu-ced when the radiographer takes the time to respond to what the patient says. This is consistent with Carlsson and Carlsson’s study (2013), which shows that MRI patients report that a positive dialogue with the radiographer

is crucial for dealing with their anxiety and discomfort. In example two, the radiographer had to wait for test results and for an anaesthesiology nurse. The radiographer used the waiting time to chat with the patient. The radiographer could not adhere to the scheduled time frame and thus chose to communicate with the patient in the waiting time.

By contrast, in example three, the radiographer did not talk with the patient and “saved” five minutes by minimizing the care aspect during the examination. This indicates that time can be a decisive factor in the level of care given to the patient. Time can also reduce contact with the patient to the minimum level, where only the information necessary to complete the examination is conveyed. The radiographer did not verbally address the patient when the patient was shaking all over but continued to perform the medical and technical actions. When the radiographer is behind schedule, there is a risk of the technology becoming the most prominent aspect of the encounter with the patient. Technical actions are actions that have a specific objective in mind, and practical actions are actions in the social sphere that are modelled on commonly or universally valid norms or values (Skjervheim 1996).

In example three, the patient was likely quite anxious about what the scan would show, as the patient was being examined for possible metastases. The radiographer covered safety aspects for the patient related to the use of techno-logy and medicine distribution but did not meet the patient’s need for psycho-logical/mental care (Hellmann and Lindgren 2014). The radiographer was not vigilant to the patient needs in accordance with Anderson’s et al. (2008) description of good nursing care. The patient was shaking, but the radiogra-pher performed medical and technical actions without addressing the patient as a subject. This can be seen understood by Thompson’s (2005) description of how patients are objectified when exa-mined using technology. Thompson (2005) describes how women are treated as objects during gynaecological exami-


nations and claims that objectification of the patient is legitimate as long as it is only temporary. In other word, it is legitimate for a health care provider to temporarily treat the patient as an object after having established contact (Thompson 2005). Dealing with the patient as an object during scanning is acceptable, but after the scanning the radiographer must continue contact with the patient.

The interviews show that radiog-raphers wish to take care of the patient, but they feel they must comply with the time allocated; thus, the provider-patient relationship aspect of treatment is disregarded. This indicates that radiographers attempt to comply with standardized times even though their professional judgement is underestima-ted. Timmermans and Berg (2003) point out that standardisation can make the convert clinical practice into “cookbook medicine”, where adhering to protocol and rules is more important than provi-ding individual care to patients. The health care provider must follow those rules even if those regulations are not in accordance with the health care provider’s own or professional ethical guidelines (Timmermanns and Berg 2003). Timmermans and Berg (2003) state that standardisation can have a detrimental effect on practice when standards are based not on the indivi-dual patient, but on the average patient. The technical actions and safety issues of healthcare are then seen as primary, thus relegating the patient’s needs. In other words, strong emphasis on rules and regulations can result in radiog-raphers not treating patients as unique people with individual needs.

Patients need different amounts of time for their examination, but the radiographers in this study perceived that there was no room to conform to the patients needs. This is in accor-dance with Hellmann and Lindgren (2014), in which the radiographer tried to make time by limiting patient com-munication to the minimum required, thereby reducing the examination time. The results show that the radiog-

raphers sometimes only ask the patient questions related to the procedure’s safety aspects. All radiographers safe-guard patient security concerning pos-sible reactions to the contrast medium and enquire about allergies. The safety aspects are related to the use of techno-logy and medicine distribution, specifi-cally the use of radiation and contrast media, and have a caring aspect (Andersson et al. 2008).

The radiographers expressed that they find it stressful when the allotted time is not adapted to suit the patient’s needs. This is consistent with Sehlen et al.’s study (2009), which shows that time pressure is a source of stress for radiog-raphers. When the radiographer is behind the day`s schedule, the radiogra-pher feels stress and has less energy to conduct a proper examination. Occupa-tional stress in the radiography field is a very common health problem (Vinu 2006).

IMPLICATIONS FOR PRACTICE

Radiographers must be aware of the dis-tinction between dealing with objects and dealing with persons in order to pro-perly treat patients as subjects before and after scanning. Time required for a CT examination must be adjusted in accordance with radiographers experi-ences and the patient s condition. Use of standard time for all patients can lead to less care for patients.

STUDY LIMITATIONS

Despite its fruitful findings, this study has some limitations. For example, pre-testing was not performed in this study. Pre-testing would increase validity of the study. Though this is a study with limited scope, it shows a correlation between the observations and the radiographers sta-tements, which can represent other radiographers in the same situation. When findings are compared with the theory, this limited qualitative study will have transfer value, as described by Kvales and Brinkmanns’s (2009) notion of analytic generalising. In this study,

the data selection was carried out in 2009. The analysis was conducted partly in 2009 and partly in 2014 and 2015. This may have affected the analysis, but xxxx, who was in charge of the transc-ription, met regularly with xxxx to ensure the validity of the findings and interpret the data.

SUGGESTIONS FOR FUTURE STUDIES

This study was based on observations and interviews with radiographers. More observational studies of clinical encounters and interviews with patients can expand both clinicians and resear-chers knowledge of how radiographers can do their jobs. It could be useful to find out what patients think and feel about the care they receive during CT examinations. More research of this topic would be useful for enhancing pro-fessionalization and improving patient care.

CONCLUSION

This study indicates that scheduling affects the way in which radiographers perform their work. Scheduling allot-ments provide radiographers with a fra-mework, as each patient has a predetermined time available for their CT examination. Patients need different amounts of time, and the use of standard times for all patients leads to time pressure for the radiographer. Radiog-raphers attempt to maintain the timef-rame by minimizing interaction with the patient. Then, the radiographers mainly concentrate on the technical and security aspects of the examinations. The caring aspect, which includes communication and being vigilant to patients’ needs, can be absent. Although the radiographers think that the patient relationship is more important than the time frame, they partially elect not to conduct caring acts in order to adhere to the time pro-gram. Standardising the time allocated for examinations is not a neutral process but one that helps to define the radiographer’s practice. The radiographer


feels a cross pressure; in one way, they want to do good work, but in another, they must follow the daily program.

ACKNOWLEDMENTS

The authors extend their gratitude to the study participants.

CONFLICTS OF INTEREST

The authors have no funding or conflicts of interest to disclose.

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ABSTRACT

Radiology departments use intravascular contrast media to enhance visibil-ity during radiographic procedures. Con-trast agents are administered by radiographers’ and can in rare cases cause acute hypersensitivity reactions that can lead to fatal unless rapid and appropriate therapy. Long time may pass between a radiographers’ higher education training session and an acute hypersensitivity reaction, which can affect the prepared-ness in an emergency situation and cause uncertainty.

The aim of the study was to describe factors in radiographer’s professional performance which can be crucial in pre-paredness for acute hypersensitivity reactions to intravascular contrast media.

The method was a qualitative design inspired by the approach “the Critical Incident Technique”.

The result showed that radiographers’ considered experiences of acute hyper-sensitivity reactions as very important for a high level of preparedness. Other conditions highlighted as important were theoretical knowledge, local know-ledge and patient safety. Radiographers’ are responsible to keep themselves well-informed and updated on laws, ordinan-ces, regulations, local procedures and guidelines, medicines etc. The result described occasions when difficulties have arisen and situations where the radiographers’ have experienced a lack of support. A proposal was that radiology

departments should organize simula-tion-based training sessions, where all professionals continually may practice scenarios that can arise during an acute hypersensitivity reaction. Another pro-posal was the need for a forum for joint reflection and knowledge sharing. The conclusion is that experience, by simula-tor training or real clinical situations, is important for a high level of prepared-ness. Simulation of acute hypersensiti-vity reactions is recommended.

Keywords: radiographer, acute hyper-sensitivity reactions, preparedness, intravascular contrast media, critical incident technique.

BACKGROUND

The majority of radiological activities use daily intravascular contrast media; agents that are often crucial for providing correct diagnoses in radiological diagnos-tics, as they create contrast differences in the image and are used to distinguish specific organs (Thomsen et al., 2014).

The use of radiographic mapping meth-odologies has increased in recent decades, which has led to a significant increase in the usage of contrast media. Those cur-rently available are generally considered safe, but their use is not completely risk free (Beckett et al., 2015). Adverse effects occur and the range is from mild allergic-like reactions to rare but serious and life-threatening hypersensitivity reactions.

There are several known risk factors such as previous anaphylaxis, asthma and multi-allergy (Beckett et al., 2014; Svensk förening för bild- och funktionsmedicin 2015; Clement & Webb, 2014; Thomsen, 2014). Iodine, gadolinium and ultrasonic contrast media can each cause acute hypersensitivity reactions, whether they have been administered per os, per rectum or by injection (Svensk förening för bild- och funktionsmedicin 2015; Thomsen, 2014).

When an acute hypersensitivity reac-tion occurs, this is a critical situation in which recognition of symptoms and rapid treatment can be life-determining. Acute hypersensitivity reactions occur per definition within 60 minutes after contrast media have been administered (Svensk förening för bild- och funk-tionsmedicin 2015; Clement & Webb, 2014; Thomsen, 2014).

Anaphylaxis is defined as serious, most often fast-acting, acute systemic hypersensitivity reaction from multiple organ systems, and potentially life threatening (Beckett et al., 2014; Gülen & Wickman, 2016; Gülen & Gottberg, 2007; Thomsen, 2014). Anaphylaxis always brings about respiratory, cardio-vascular and/or severe generalized effects. Commonly observed are coinci-dental symptoms from the skin, mucous membranes or gastrointestinal tract (Beckett et al., 2014). Anaphylaxis demands rapid treatment in order to avoid respiratory obstruction and/or

In the eye of the storm- radiographers’ experiences of acute hypersensitivity reactions to intravascular contrast media

Karin Grénlecture, MSc, Karolinska Institutet; [email protected]

Georgios Panagiotidis ass prof, PhD, Karolinska Institutet, [email protected]

Kent Fridellprogramdirector, PhD, Karolinska Institutet, [email protected]

Contact person: [email protected]


cardiovascular collapse (Beckett et al., 2014; Gülen & Wickman, 2016; Gülen & Gottberg, 2007).

The Swedish Society of Radiology (SFBFM) is an association of professional practitioners, with a special interest in imaging and functional medicine that publishes national recommendations, reports and guidelines. The Swedish lan-guage publication, “Nationella rekommen-dationer om överkänslighetsreaktioner av kontrastmedel” (National Recommenda-tions concerning Hypersensitivity Reac-tions to Contrast Media) deals with hypersensitivity reactions triggered by radiological contrast media and contains recommendations for risk assessment, prophylaxis, treatment and allergologic investigation. The document was devel-oped by the Contrast Agent Group at SFBFM, a subdivision of the Swedish Uro-radiological Association (SURF), with specific responsibility for guidelines in the use of contrast media within imaging and functional medicine (Svensk förening för bild- och funktionsmedicin 2015). Amongst the recommendations prepared by SFFA for reception and treatment of anaphylaxis in emergency medical care, it is stated, inter alia, that adrenaline given intramuscularly in thigh and at an early stage is the most important initial treat-ment of anaphylaxis. After repeated intramuscular injections with no effect, adrenaline may be administered intrave-nously under ECG monitoring by an anes-thetist or a physician well-acquainted with the practice (Thomsen, 2014; Sven-ska föreningen för allergologi, 2015).

PURPOSE

The purpose of the study is to describe the factors in the professional practice of the radiographer that may have decisive importance in their emergency prepared-ness for dealing with acute hypersensi-tivity reactions caused by intravascular contrast media.

METHOD

DesignFor this study, a qualitative design was

chosen inspired by the “Critical Incident Technique” (CIT) method, with the pur-pose of analyzing and describing the experiences of radiographer in respect of acute hypersensitivity reactions. From such a starting point, the purpose of the study then became to locate events in a serious and acute situation, experienced by radiographers and linked to the goal – a functioning and effective emergency preparedness. From the “critical incident” described by the interviewees data was collected by open-ended interviews with respon-dents where they are telling about their experiences from this kind om situa-tions.

Critical Incident methodology was chosen because it is a flexible and is able to be used to solve practical problems (Flanagan, 1954; Kemppainen, 2000; Andersson et al., 2008). CIT is consid-ered to be useable to advantage in seri-ous situations, and according to Flanagan, it has been developed to clar-ify relevant details and facts and to reduce personal opinions, perceptions and generalizations (Flanagan, 1954)

CIT is appropriate for the study of positive and negative events in a par-ticular context and may be likened to a procedure used to collect important information regarding behavior or activity in a particular situation. A “crit-ical event” is a key concept in CIT and for an event to be judged critical, it must have been either positive or negative. “Critical events” can be accumulated in a variety of ways, for example through interviews, self-reports and observa-tions, and informants are usually asked to tell a story about an experience they themselves have had. According to Fla-nagan, the general rule of thumb is to accumulate events until saturation takes place (Flanagan, 1954; Kemp-painen, 2000).

The CIT methodology comprises the following five steps: clarify the purpose of the study; plan; collect data; analyze and interpret the data; and finally, report the results (Carlsson, 2008; Fla-nagan, 1954). In this study, the “critical events” were the behaviors and activi-

ties that can be derived from the radiog-rapher’s emergency preparedness for an acute hypersensitivity reaction caused by intravascular contrast media. The goal: a functioning and effective emergency pre-paredness.

SelectionThe selection of participants was made based on the informants’ areas of knowl-edge and theoretical backgrounds and with the aim that the interview material would have the greatest potential of cast-ing light on the current problem (Green, 2014). One criterion for participation in the study was that the radiographer would have been privy to at least one acute hypersensitivity reaction caused by intravascular contrast media. The inter-views were conducted on eight radiogra-phers in five radiological departments. Those participating in the study had between one and 29 years’ professional experience, with a median value of 12.5 years, and both sexes were represented.

AnalysisThe content analysis in this study was conducted in several stages and begun with the analysis units being divided into sentences. The sentences were condensed into briefer sentences, then abstracted and given codes. The codes were then sorted into different categories that were eventually combined into themes. The themes and categories that emerged during the analysis process are presented as headings in the result (Graneheim & Lundman, 2004).

ReliabilityCredibility for the result of this study will be found in the method used for the study. In the sample or selection the study used radiographers that been in the situations that was the aim of the study ‘’describe experiences of acute hypersensitivity reactions ‘’. By using open ended questions around the described ‘’critical incidence’’ the radiog-raphers was able to tell, in their own words, the experience. These are seen in the questions in the results.

There are transferability reached in this


study results when, in the discussion, e.g are applicate to other acute situations like cardiopulmonary resuscitation (CPR).

Confirmability for the study, was reached during the analysis phase by presenting findings and getting feed-back from the respondents.

Dependability for this study could be found when the results or parts of the results was presented for groups of other radiographers with different experience of the radiography field.

Ethical AspectsQualitative data may contain material of a sensitive nature, which places strict demands on written information about the purpose of the study and informed consent. The informants in this study were therefore notified in advance about the purpose of the study and the approach to be taken during the inter-views. Prior to commencement of the interview, informants gave their consent to participation in the study and were verbally appraised of their possibility of interrupting the interview at any time and without penalty, if desired. It was emphasized that the informant could be confident that a need for anonymity would be satisfactorily met, and there was no risk of identification (Polit & Beck 2010). Furthermore, it was empha-sized that the study’s interview material would be treated confidentially, in order to preserve the anonymity of the infor-mants and that it would only be used for research purposes.

RESULTS

The analysis findings resulted in three themes and eight categories. In order to make the results easier to understand, they are presented based on the themes that emerged from the analysis: “The calm before the storm”, “Winds that blow up and die down” and “After the storm” (fig 1). All quotes in the result section have been italicized. The themes and the names of these are describing the events that ends up in acute hyper-sensitive reactions and the categories are the content of each step in this event.

THE CALM BEFORE THE STORM

Presented below is the headings describ-ing the situation for the radiographers when they are taking part in situation where contrast media is given. They have a preparedness for acute situations by theoretical knowledge, experienced based knowledge, local knowledge and patient safe method knowledge.

Experience-based Knowledge

The informants in this study had each participated in several acute hypersensi-tivity reactions caused by intravascular contrast media. These experiences have brought a clear awareness that an acute hypersensitivity reaction may occur at any time and without warning.

“I’m on the alert all the time. I attempt to have contact with and monitor the patient. When I do an examination using a contrast agent, I focus. I try not to have conversa-tions with my colleagues. It can even get to the point where I tell them to be quiet because we’re conducting an examination. ... It’s about patient safety ... I try to be ... I’m focused on the patients the whole time!”

An acute hypersensitivity reaction caused by contrast media was described by the informants as a phenomenon that

may differ from one time to another. The majority considered it important to have a high level of emergency preparedness, to have been present at and had experi-ence of acute hypersensitivity reactions, and thereby been given the opportunity of building on their experience over time.

“How you deal with the situation, I believe, simply comes from experience, which you pick up ... I think you just act out of the knowledge you’ve built up over the years and the number of allergic reactions you’ve dealt with.”

The informants appeared concerned that many radiographers lacked experi-ence of acute hypersensitivity reactions and expressed views that radiological activities had not introduced such on a regular basis. Several informants expressed their misgivings and gave examples of how a lack of training could affect the situation where an acute hypersensitivity reaction was involved.

“We do CPR exercises on a regular basis ... We practice a lot with such situations, but we don’t practice contrast media reactions to the extent that I think we should. And that’s in fact the basis of everything. You don’t get experience ... you can’t get experi-ence from something you don’t get a chance to practice on.”

The informants in this study claimed that there has only been one single

The Calm before the Storm

• Experience-basedKnowledge

• Theoretical Knowledge• Local Knowledge• Patient-safe Working

Methods

Winds that blow up and die down?

• Symptoms• Prescriptions • Emergency

Medicines

After the storm

• Proposals for routines and guidelines

Figure 1. The figure describing the process on acute hypersensitivity reactions to intravas-cular contrast media


instance of simulation-based exercises among the radiological activities dis-cussed in the study. The exercise oppor-tunity carried out on the computerized tomography directly related to a CPR exercise also led to discussions on how the activities ought to go about imple-menting this type of exercise.

“It was very useful ... It was good ... It so rarely happens. Then you have to prac-tice.”

Theoretical Knowledge

In terms of useful theoretical knowledge of an acute hypersensitivity reaction, the informants referred to local routines and guidelines, memoranda, method books, emergency binders, treatment reviews, etc.

“It’s my duty to know ... Every X-ray clinic has guidelines for how to handle contrast media responses, so just read and learn.”

It emerged that there are occasions when even the most experienced and well-read radiographer can get blocked and be in need of quick access to written procedures and guidelines to do with measures to be taken in emergency con-trast agency reaction situations. Acces-sibility is important and it was considered a matter of urgency that documentation relating to acute hypersensitivity reac-tions is established and/or located in strategically selected places.

“It’s always good to have a list to work from and that there’s somewhere you can look, because you never know. You can’t say how experienced you are. One day you’ll have a bad day.”

It also emerged that routines and guidelines in radiological activities need to be reviewed with some regularity and that the activities should be sure that all printed matter is replaced when docu-mentation has been updated so that there are no old versions lying around in the activity.

“There was one routine, but it wasn’t totally up-to-date, and most importantly it hadn’t been discussed to ensure it was clear. Routines are something that need to be brought out and looked at often, I reckon.”

Local KnowledgeWhen a situation of acute hypersensiti-vity reaction occurs in the radiological activity, according to the informants, it is of great importance that radiographer have confidence in their working envi-ronment – that they know where things are and are used to their radiology lab.

“It’s very important to know where the emergency kit is, otherwise you end up in a fix, and you need to give emergency medi-cine, and you don’t know where the emer-gency kit is. It’s absolutely crucial!”

Patient-safe Working Methods

Informants in this study reported that they performed self-checks in addition to those that their employer required radiographer to do as regards routines and those included in their regular, daily work. The informants talked about safety routines and controls that they themselves had designed to prepare themselves mentally and to ensure that all material that might be needed, for example, in an acute hypersensitivity reaction situation was available during their own shift work.

“It’s about everything being available should I need it in my work ... It’s the same with the emergency kit of course ... Then over the years I’ve discovered my own ways of doing things, because it’s easier for me, but above all, it’s about patient safety.”

During the interviews, the infor-mants stressed the importance of radiographers establishing a good rela-tionship with their patients at the beginning of examinations using intra-vascular contrast media. Several infor-mants noted that radiographer should work target-oriented and try to gather as much relevant information as possi-ble during the relatively short meeting with the patient.

“By reading their notes and asking ques-tions myself, I get a picture of the patient ... To inform ... There’s a lot of information that needs to be dealt with before.”

In the meeting with the patient, it was noted that the radiographer has an excellent opportunity of checking the patient over and gathering additional

information by looking at the skin, lis-tening to the tone of voice, detecting whether the patient has a cough and any-thing else that could later change if the patient experiences symptoms of an acute hypersensitivity reaction.

“Before the examination, when I’m in the lab with the patient, I always note how the patient’s face looks and so on to be prepared if there is a reaction in fleck contrasts, urticaria or anything else.”

The informants stressed the impor-tance of the radiographer’s maintaining their observation of the patient through-out the examination in conjunction with contrast agency-enhanced examina-tions, in order to detect early signs that the patient is unwell and possibly devel-oping an acute hypersensitivity reaction.

“You take your eye off the console and look instead at the patient. It’s obvious if the patient isn’t feeling well ... he’ll take hold of his throat and twist and turn”

The informants also identified differ-ent personal qualities that are considered beneficial when an acute hypersensitiv-ity reaction occurs.

“It’s about being calm ... Try to concentrate ... Don’t panic ... Don’t run around the yard, like a chicken with no head.”

WINDS THAT BLOW UP AND DIE DOWN?

This is the heading under which, the results are presented, based on what has happened during acute hypersensitivity reactions and as reported by the radiog-raphers in this study. This section inclu-des the events surrounding the symptoms, prescribing and emergency medicinal treatments in respect of emer-gency preparedness where cases of acute hypersensitivity reaction take place.

SymptomsWhen the informants described the introduction of a suspected acute hyper-sensitivity reaction, the scenarios they reported were very similar: as soon as the radiographer discovers that the patient is appearing to be feeling unwell, they walk or hurry in to where the patient is. They explained how, in such a situation, the


radiographer talks to the patient, obser-ves the patient, analyzes and monitors the situation to determine whether or not the condition is worsening. The informants said that this is a critical stage and that it is important that the radiographer recognizes and records any and all emerging symptoms to ensure that the patient is able to receive rapid and adequate care.

“It might be no more than a minor rash that perhaps disappears by itself ...”

The informants in this study reported a range of differing symptoms that they had noted in acute hypersensitivity reac-tions, including urticaria, redness of the skin, itching, coughing, hoarseness, vomiting, swelling, breathing difficul-ties, unconsciousness, reductions in heart rate and blood pressure. It turned out that none of the informants had been offered any direct form of training in assessing the various symptoms that may arise in an acute hypersensitivity reaction. Such tended to take place indi-rectly, when local guidelines and rou-tines were updated and emailed or when new guidelines were presented. Instead, the informants referred to symptomatic symptoms they had experienced from previous acute hypersensitivity reac-tions.

“Practiced assessing the symptoms? No, not at all! We’ve maybe just discussed it. And then we’ve talked about what our guidelines were, but no more than that.”

“We’ve maybe not talked rashes and phlegm in the throat and itching. No, we haven’t done that. It’s probably just been experiential stuff.”

The informants explained how they continue to monitor the patient and follow the symptoms and progress of the condition, as well as being prepared for further measures; like standing by or calling for assistance. The informants presented these situations as sometimes a bit chaotic and associated with certain difficulties. The problems raised by them in this context were about not finding things in the premises, not finding equipment or emergency medication, having difficulties with alarm buttons or signals, having difficulty contacting doc-

tors, there being non-existent or out-of-dated guidelines, lack of communication facilities, doubling up on tasks, block-ages/hindrances, confusion and general stress.

“Otherwise, I’m usually a pretty calm person, but just then ... everything just went blank.”

Prescriptions

The informants continued to recount the course of events in an acute hypersensi-tivity reaction and described that the radiologist arrives, supports and is expected to take over command. In anti-cipation of prescriptions, the informants described how they continue to find and prepare drugs that the radiologist would be likely to prescribe.

“Then I start preparing my emergency bag and selecting drugs ahead of time so as to be ready in case they’re going to be prescribed.”

However, it was found that there were times in connection with the prescribing of drugs, when informants perceived that the expectation of support from the radiologists had been ill-founded. They described events where the radiologists had elected to wait and so no immediate prescription had been given, despite the fact that the radiographer, in his/her experience, had determined that the patient’s acute symptoms demanded medical treatment.

“What I feel many times is lacking, is that the radiologist isn’t up on the situation.”

“It was really difficult because the radi-ologist didn’t at all take charge of the situation as you’d want them to.”

One strategy that came up to assist the radiologist in making out an appropriate prescription was for the radiographer to begin making drug suggestions for treat-ment of the symptoms being exhibited by the patient,.

“If the radiologist has some experience, then it works very well, but when they’re a tad less experienced ... then you may need take a bit more responsibility yourself.”

“I usually say something like: ‘When they’ve got symptoms such as facial swelling and swollen airways, we usually give Epi-phene. Shall I do that?’”

When the situation described above has occurred, according to the infor-mants, it is of great benefit to be in a radiological department where it is pos-sible to call on urgent assistance from other doctors: the emergency team, heart-start, narcotics or the like. Infor-mants said that this possibility is usually used anyway, regardless of whether the radiologist is an experienced doctor and used to such situations, as the reinforce-ment is perceived as extra safety precau-tion.

“I saw how affected the patient had become – breathing, reddishness and so ... The radiologist would have preferred to have just left, and said: ‘We’ll wait a bit. It’ll probably improve.’ But at the same time, the fact was ... we realized the situation was serious and we didn’t have an emergency team to call on. We had to call an ambulance ...”

Emergency MedicinesWhere an acute hypersensitivity reac-tion occurs resulting from the use of contrast media, it is crucial to be able to give the patient the correct treatment to alleviate the condition. The informants gave examples of various emergency medicines that may be relevant in this context: adrenaline, cortisone, antihis-tamines and oxygen. The informants described how they acquired their kno-wledge and skills about these drugs, including basic pharmalogical training; lectures and meetings; local routines and guidelines; discussions with collea-gues, radiologists and other doctors; practical exercises with drugs; and pre-vious acute hypersensitivity reactions.

“I’ve read quite a bit. Watched what col-leagues do. Asked doctors. Yes, during your basic training education, you learn quite a lot.”

In the case of adrenaline, which was said to be the most important drug in an acute hypersensitivity reaction, the informants said that the radiological departments in this study use pre-filled adrenaline pens. These have been described as a very simple alternative compared to a radiographer’s having to load a syringe with adrenaline from a


vial and then dispense it.“There should be readily available

drugs that just need to be administered without having to calculate over much. This seems important to me, because we don’t deal with these drugs on a daily basis.”

However, it turned out that infor-mants have experienced certain difficul-ties with the adrenaline pen, despite the benefits of a simplified mode of adminis-tration. Not being prepared and able to handle the exact operation was described as a major concern. It was found that, for safety reasons, adrenaline pens were fitted with a safety device, so that the injection should not be triggered by mis-take. One of the informants described an occasion when this safety device was for-gotten, which meant that the adrenaline pen failed to work.

“When they gave the go-ahead and arrived with a prescription, all I had to do was push the adrenaline pen in, but nothing happened ... I just panicked. I felt totally incompetent.”

As for other emergency drugs referred to by the informants, the cortisone prep-aration Solu-Cortef was mentioned as potentially difficult to administer. The informants said that preparation of the drug could be tricky when the powder needed to be mixed with liquid to give the injection fluid. Another difficulty that was raised with respect to Solu-Cor-tef, was its administration rate, namely how quickly or slowly the drug should be given. Antihistamines were mentioned only in passing, as was oxygen. Accord-ing to the informants, there were no dif-ficulties associated with these.

“One time, I ended up in a situation where I was unable to prepare a Solu-Cortef solu-tion and I felt myself unequal to the job. It felt like my level of knowledge was quite inadequate.”

Some informants reported that they had received training in the use of adren-aline pens and Solu-Cortef, while others expressed that they had received no practical training whatsoever. In this context, the informants noted that anx-iety, stress and shortage of time can evoke fears that mistakes can be made,

but that uncertainty about drug admin-istration can to a certain extent be coun-teracted if there is a supportive colleague in the vicinity and ideally another expe-rienced radiographer.

“I do not know how it would have gone if my radiographers hadn’t been in the room. If I’d been alone, well ...”

“We were actually two radiographers, so we could complement one another.”

AFTER THE STORM

Proposals for routines and guidelinesUnder this heading, results are pre-sented about areas concerning what fol-lows an acute hyper-sensitivity reaction. The section contains suggestions from radiographer that can provide the basis for recommendations relating to routi-nes and guidelines for good emergency preparedness.

The informants in this study gave sug-gestions as to how radiological depart-ments can educate their healthcare professionals about acute hypersensi-tivity reactions. The proposals that were raised dealt with further training which included reviewing local practices and guidelines, various symptoms and emergency medicine in the radiogra-pher’s everyday environment; and at the lab, where a range of techniques wherein intravascular contrast agents are used as well as practical exercises on dum-mies, and so on.

“Yes, an exercise that you can participate in. Where you don’t just read about what you have to do.”

“Training together with the radiologist who still has the main responsibility. Some form of team building, collaborative exer-cises, so it feels safe and you know that everybody knows what they should do act. It’s a big wish.”

In the case of the individual radiogra-pher, the informants suggested a rou-tine that regularly went through emergency kits, emergency bags, etc. This would facilitate the radiographer being able to stay up-to-date on emer-gency medicines used by the radiologi-cal activity and to detect possible

shortcomings that may be remedied by the radiographer taking responsibility for his/her own education.

“I’d be sure to check through the drugs myself when I had the time. I think that’s something you have to start with. “

When an acute hypersensitivity reac-tion has occurred, the informants felt it was important to have a brief status meeting with the healthcare staff who had been involved. Here, the intention is to reflect over what has taken place – what went well and what could be improved. The informants felt that these critique sessions were necessary, but that there were no provisions for such and if they take place, these meetings are some-thing that are currently an outcome an independent initiative and only take place if time permits.

“It was only because we had a respite between two patients that we could sit down and talk about it. It hadn’t been decided that we’d sit and talk about it. It was more that it just happened.”

DISCUSSION

The purpose of the study was to describe factors in the radiographer’s professional practice that can have a decisive impact on the preparedness for acute hypersen-sitivity reactions caused by intravascular contrast media.

The findings of this study show that radiographer with previous experience of acute hypersensitivity reactions are well aware that such reactions may occur at any time and without warning. It has been found that experience of having been present in several acute hypersensitivity reactions is important for a good level of preparedness. Acute hypersensitivity reactions, however, occur very rarely, and this knowledge and experience may there-fore be limited. Experience-based knowl-edge is something that develops through practical situations with events that lead to discussions and reflections with col-leagues. This is supported by Coles who believes that how a situation is assessed is based on previous experiences (Coles, 2002). According to another study by Kolz, et al, knowledge and experience are


important for the outcomes of the work performed (Kolz et al., 1998)

The findings of this study also show that there is concern that radiological activities seldom offer training opportu-nities for dealing with acute hypersensi-tivity reactions due to the fact that many radiographers lack experience in such situations. Amongst other things, the study showed that there had been only one instance of simulation-based educa-tion, but that it was very instructive. A study by Worth, et al highlights the need for regular training for healthcare profes-sionals working in environments where acute hypersensitivity reactions can occur (Worth & Sheikh, 2013). Studies dealing with skills training within CPR also show that regular education and repetition assist healthcare professionals in main-taining their skills levels and their pre-paredness for emergency situations (Oh & Han, 2008; Berden et al., 1993).

The findings showed that the radiogra-phers taking part in this study were quick to recognize the symptoms of an acute hypersensitivity reaction and that they have good experience of following the course of the condition. However, it cannot be clarified that they use any spe-cific strategy when assessing the patient’s symptoms. The findings of the study would tend to indicate that in radiological activities there are no training opportuni-ties in assessing symptoms and that radiographer are made to refer to and rely upon previous experience of similar situ-ations. Training radiographer in recogniz-ing the symptoms of acute hypersensitivity reactions has great value, since it is the radiographer who is closest to the patient and the one who can most quickly detect an acute hypersensi-tivity reaction. This highlights the impor-tance of preventive training in assessing symptoms, and in other forms than those having their foundations in theory, and that radiographer can exercise this by fol-lowing national recommendations per-taining to hypersensitivity reactions, which prescribe an initial ABCDE assess-ment of a patient suspected of undergoing an acute hypersensitivity reaction (Svensk förening för Bild- och funktionsmedicin

2015). The study also found that certain difficulties may arise when patients show signs of acute hypersensitivity reaction. These difficulties may in some respects be attributed to deficiencies related to areas that are considered in this study as pre-requisites for good preparedness.

During the study, the radiographers indicated that the support they receive from radiologists can sometimes be inad-equate and that delays have occurred in connection with the radiologist’s making out prescriptions. That the radiologists would prefer to wait for support from more experienced emergency teams or specialists with more experience and more knowledge of emergency drugs, is confirmed by a study made by Lightfoot, et al, who believe that radiologists dis-playing this behavior are basically uncer-tain and lacking knowledge of how to handle acute hypersensitivity reactions (Lightfoot et al., 2009). The fact that radi-ologists may have limited knowledge of acute hypersensitivity reactions are also confirmed by a study made by Confino-Cohen, et al, which underlines the impor-tance of training programs to improve knowledge in this regard (Confino-Cohen & Goldberg, 2004). Training that treats symptoms and adequate treatment of acute hypersensitivity reactions increases the radiologist’s knowledge within the various areas and makes them feel more secure in their diagnosis and treatment (Echenique et al., 1997). The findings showed there was a desire for improved cooperation between radiogra-pher and radiologists. In order to estab-lish this, especially where dealing with acute hypersensitivity reactions was con-cerned, both radiographers and radiolo-gists should participate in joint training programs with exercises aimed at jointly creating conditions for better coopera-tion (Beckett et al., 2015).

The study’s findings also indicated that radiographers finding themselves in an acute hypersensitivity reaction may be concerned about mistakes being made because they are inexperienced, under stress and pressed for time. In this con-text, the importance of support from another radiographer was emphasized,

highlighting the importance of having another professional to turn to for help and advice when needed. In stressful work situations, the risk of healthcare-related injuries increases, which may lead to a deterioration of the quality of the healthcare. This was described in a study undertaken by Robert, et al. It found that stress in work situations is an obstacle that can affect the safety of both patients and healthcare professionals (Roberts & Grubb, 2014).

Another result of this study was that radiological departments rarely – if ever – provide training in dealing with acute hypersensitivity reactions. One proposal presented was about the need for simula-tion-based training opportunities where different occupational categories like radiographer and radiologists are repre-sented. In recent years, simulation exer-cises have become an increasingly common element in healthcare, with the aim of facilitating training in decision-making and communication under emergency con-ditions. Such training would be carried out under safe conditions and without any risk to patient life. In a study by Aura, et al simulation is judged to be particularly suit-able for radiographer (Aura et al., 2016). This is also supported by another study undertaken by Echenique, et al. (1997). Another scientific publication shows that team training and communication can be developed to a great extent through simu-lation and that feedback is an important part (Issenberg & Scalese, 2008).

The results also highlighted the impor-tance of radiographers having discus-sions and critique sessions following instances of acute hypersensitivity reac-tion caused by intravascular contrast media. The radiographers participating in the study felt it was most rewarding to have such discussion times with col-leagues and that professional help was not needed. The importance of “unbur-dening” discussions is supported by Oriot & Alinier, who also emphasizes the importance of the group where recovery is concerned after difficult experiences (Oriot & Alinier, 2017). Follow-up dis-cussions are considered important in order to mull over the situation, talk


about what has been good and discuss any corrective measures.

CONCLUSION

The study’s findings showed that the radiographer who had been involved in acute hypersensitivity reactions consi-dered that experience of such is of signi-ficant importance for good preparedness in the future. Other conditions identi-fied as important for the emergency pre-paredness in dealing with acute hypersensitivity reaction caused by int-ravascular contrast media were theoreti-cal knowledge, local knowledge and a patient-safe working method. It was found that much of the responsibility for being read-up and updated about laws, regulations, constitutions, local practi-ces and guidelines, drugs, etc., lies with the individual radiographer. In the fin-dings of the study, a suggestion was put forward that radiological departments should organize simulation-based trai-ning opportunities, in which all occupa-tional categories can continuously exercise their dealing with the scenarios that may potentially arise in an acute sensitivity reaction. Another suggestion that was discussed concerned the need for forums for common reflection and knowledge dissemination.

The recommendation arrived at is that radiological departments should intro-duce simulation-based training oppor-tunities as a matter of urgency in order to develop a higher level of emergency preparedness.

In order for radiographer to be able to stand firm in the face of the winds of acute hypersensitivity, let us act accord-ing to the words of wisdom of Tacticus: “Exercitatio artem parat” – “Practice makes perfect”

ACKNOWLEDGEMENTS

We wish to express our great apprecia-tion to Jessica Ekberg, Karolinska Insti-tutet, who contributed to the study in it s finale version

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Opinnäytetyön tarkoituksena oli kuvata millaiset tekijät ovat yhteydessä Lean-menetelmän juurtumisen onnistumi-seen tai epäonnistumiseen sekä aiempien tutkimusten pohjalta, että tar-kastelun alla olevassa kuvantamisyksi-kössä röntgenhoitajien näkökulmasta. Tavoitteena oli tuottaa kehittämisehdo-tuksia siihen, miten parantaa Lean-menetelmän käyttöä tutkittavassa yksikössä.

Tutkimuskysymykset olivat seuraa-vat: Mitkä tekijät ovat yhteydessä Lean-menetelmän onnistuneeseen juurtumiseen? Mitkä tekijät ovat yhte-ydessä Lean-menetelmän epäonnistu-neeseen juurtumiseen? ja Mitä Lean-menetelmän työkaluja yksikössä on käytössä ja millaisia kokemuksia niistä on? Kahteen ensimmäiseen tut-kimuskysymykseen haettiin vastausta sekä systemoidun kirjallisuushaun, että fokusryhmähaastattelun ja tee-makirjoitusten avulla. Kolmanteen, työkaluja koskevaan kysymykseen haettiin vastausta fokusryhmähaas-tattelulla ja teemakirjoitusten avulla. Systemoidussa kirjallisuushaussa tar-kastelun kohteena oli koko terveyden-huolto. Tutkimuksen empiirisessä osassa kohderyhmänä olivat Lean-menetelmästä tietoiset ja/tai sitä hyö-dyntävät röntgenhoitajat. Systemoitu kirjallisuushaku tuotti 18 hyväksyttyä lähdettä, joiden pohjalta laadittiin tutkimuksen teoreettinen viitekehys. Fokusr yhmähaastattelussa ja

teemakirjoituksissa vastaajia oli yhteensä yhdeksän kappaletta. Fokusr yhmä haastatte lun ja teemakirjoitusten aineisto analysoi-analysoi-tiin teorialähtöisen sisällönanalyysin avulla. Sisällönanalyysia ohjasi syste-moidun kirjallisuushaun pohjalta luotu teoreettinen viitekehys.

Kehittämistyön tuloksena saatiin kuva Lean-menetelmän juurtumiseen yhteydessä olevista tekijöistä niin terve-ydenhuollossa yleensä kuin tutkimuk-sen kohteena olevassa yksikössäkin. Huolimatta siitä, että terveydenhuol-lossa työskennellään erilaisissa ympä-ristöissä, systemoidun kirjallisuushaun tulosten mukaan juurtumisprosessiin vaikuttavat tekijät ovat hyvin samankal-taisia kaikkialla. Lean-menetelmän juurtuminen vaatii muutosvalmiutta organisaatiotasolla, jatkuvan kehittämi-sen kulttuurin vahvistamista, toimivaa viestintää, koulutusta ja henkilöstön sitouttamista kaikilla tasoilla. Tärkeää on kuitenkin tunnistaa aina kohteen eri-tyispiirteet ja mukauttaa Lean-menetel-män jalkauttaminen niiden mukaisesti. Lean-menetelmän yksittäisten työkalu-jen käyttö ei useinkaan muuta toiminta-kulttuuria laajemmin ja positiiviset vaikutukset voivat olla lyhytaikaisia. Tutkimuksen kohteena olevassa yksi-kössä henkilöstön asenteet Lean-mene-telmään ja sen tuomiin hyötyihin olivat ristiriitaiset. Vastauksissa näkyi niin halua kehittää toimintaa, kuin selkeää muutosvastarintaakin. Jotta menetel-

mää voitaisiin hyödyntää paremmin, tulee kiinnittää erityistä huomiota hen-kilöstön koulutukseen, tiedottamiseen, toimintakulttuuriin aktiiviseen muut-tamiseen ja toiminnan seurantaan käy-tettyjen mittareiden parempaan hyödyntämiseen.

Tämän työn tulosten avulla voidaan paremmin ymmärtää mitkä erityispiir-teet ja haasteet vaativat enemmän huo-miota juuri tutkittavassa yksikössä. Koska ruohonjuuritason henkilöstö on avainasemassa juurtumisprosessissa, tutkimuksen tulokset antavat kuvan siitä, miten henkilöstö kokee toiminnan muutokset. Lean-menetelmän juurtu-misprosessin ja siihen yhteydessä ole-vien tekijöiden tunnistaminen auttaa esimiehiä viemään muutosta eteenpäin.

Lähteet

Andersen, Hege – Ingebrigtsen, Tor – Rovik, Kjell Arne 2014. Lean thinking in hospi-tals: is there a cure fot the absence of evidence? A systematic review of reviews. BMJ Open. 2014. (s.1-8.)

Aronsson, Håkan – Brommels, Mats – Maz-zocato, Pamela – Savage, Carl – Thor, Johan 2010. Lean thinking in health-care: a realist review of the literature. Quality and Safety in Health Care. Vol. 19. (s.376-382.)

Brandao de Souza, Luciano – Pidd, Michael 2011. Exploring the barriers to lean health care implementation. Public Money and Management. January/2011. (s. 59-66.)

D Anreamatteo, Antonio – Ianni, Luca –

Nina Holm2017MetropoliaSosiaali- ja terveysalan johtaminen YAMK

Systemoitu kirjallisuushaku terveydenhuollosta ja tapaustutkimus kuvantamisessa

Lean-menetelmän juurtumisen onnistumisen esteet ja edellytykset:


Lega, Federico – Sargiacomo, Massimo 2015. Lean in healthcare: A comprehen-sive review. Health Policy. 119/2015.(s.1197-1209.)

Poksinska, Bozena 2010. The Current State of Lean Implementation in Health Care:Literature Review. Quality Management Health Care. Vol.19. No. 4. (s. 319-329.)


Tausta ja tarkoitusHallituksen kärkihanke on digitalisoida julkiset palvelut. Sen tarkoitus on raken-taa palvelut käyttäjälähtöisiksi digitaa-lisia toimintatapoja uudistamalla ja luoda asiakaslähtöiset digitalisoinnin periaatteet (Valtionvarainministeriö 2016). Röntgenhoitaja käyttää työssään päivittäin erilaisia tietojärjestelmiä: röntgentuotannonohjausjärjestelmää (RIS, Radiological Information System), kuva-arkistoa (PACS, Picture Archiving and Communication System) ja erilaisia potilastietojärjestelmiä sekä lukuisia muita. Niiden käytön hyvä hallinta on tärkeä osa-alue röntgenhoitajan työssä. Informaatioteknologian hallitseminen ja sen hyödyntäminen tuo haasteita röntgenhoitajien osaamiseen tulevai-suudessakin. (Luotolinna-Lybeck 2011). Kehittämistyön tarkoituksena oli käyt-täjälähtöisesti kehittää röntgenhoitajien perehdytystä kuvantamisen tietojärjes-telmiin. Tavoitteena oli, että uuden perehdytysoppaan avulla röntgenhoita-jat voivat syventää ja kehittää ammatil-lista osaamistaan kuvantamisen tietojärjestelmien käyttäjinä.

Menetelmät

Kohderyhmänä olivat järjestelmäpalve-luita käyttävät röntgenhoitajat Ppshp:n sairaaloissa ja ympäristökuntien terveys-keskuksissa. Kehittämistyö toteutettiin käyttäjälähtöisesti kehittämistutkimuk-sena ja kolmivaiheisena. Vaiheessa I kar-

toitettiin strukturoidulla Webropol -kyselyllä röntgenhoitajien (N=76) tieto-järjestelmäosaaminen ja kehittämistoi-veet. Aineisto analysoitiin Webropol –raportointityökalulla ja esitettiin suorina jakaumina ja ristiintaulukoinnilla. Vai-heessa II kyselyn tulokset esitettiin osas-tonhoitajille ja asiantuntijaryhmälle (N=3). Asiantuntijakeskusteluissa nousi esille yhteisesti sovittavat kehittämistar-peet ja niiden pohjalta tuotettiin uusi perehdytysmateriaali RIS- ja PACS järjes-telmiin sähköiseen muotoon. Vaiheessa III röntgenhoitajat (N=3) perehtyivät uuteen perehdytysmateriaaliin, jonka jälkeen he arvioivat materiaalia ryhmähaastatte-lussa. Avoimet kysymykset, asiantuntija-keskustelut ja röntgenhoitajien ryhmähaastattelu analysoitiin sisällön analyysillä. Asiantuntijakeskusteluissa käytettiin Open Space – tekniikkaa, joka on avoin keskustelumenetelmä. (Kylmä & Juvakka 2007; Toikko & Rantanen 2009; Tuomi & Sarajärvi 2009.)

Keskeiset tulokset

Ensimmäisessä vaiheessa röntgenhoita-jille tehdyn kyselyn perusteella voidaan todeta, että röntgenhoitajat hallitsevat päivittäin käyttämänsä tietojärjestel-mien toiminnot hyvin, mutta harvem-min käytettäviä toimintoja huonosti. Terveyskeskuksien röntgenhoitajien kehittämisideat olivat pääasiassa kou-luttamiseen, informointiin ja syvälli-sempään perehdyttämiseen liittyviä.

Ppshp:n röntgenhoitajien vastauksista nousi esille useita kehittämisideoita. Koulutus ja infotilaisuudet koettiin tär-keiksi, koska niissä pystyisi samalla esit-tämään kysymyksiä kouluttajille. Kokonaisuudessaan parempaa, syste-maattista perehdyttämistä ja selkeitä kirjallisia ohjeita nousi esille useissa vas-tauksissa. Osastoille haluttiin myös vas-tuuhoitajat, jotka huolehtisivat uusien työntekijöiden perehdyttämisestä ja tiedottaisivat uusista toiminnoista sekä pitäisivät ohjeistuksen ajan tasalla. Tie-tojärjestelmien perehdytykseen toivot-tiin systemaattisuutta ja uutta perehdytysmateriaalia.

Toisessa vaiheessa tehtiin systemaat-tinen perehdytysohjelma kuvantamisen hoitohenkilökunnalle ja sähköisessä muodossa oleva perehdytysopas RIS- ja PACS-järjestelmiin. Tuotetta tehdessä konsultoitiin asiantuntijoita ja tarkis-tettiin tuotteen oikeellisuus.

Kolmannessa vaiheessa haastatelta-ville lähettiin tuotettu perehdytysmate-riaali hyvissä ajoin ennen haastattelua ja pyydettiin kirjaamaan aika, joka meni materiaalin läpikäymiseen. Haastattelu-tilana oli TV-studio, joka on rauhallinen ja häiriötön tila. TV-studiossa pystyi myös videoimaan haastattelun. Tämän jälkeen oli vielä vapaamuotoinen keskus-telutilaisuus järjestelmäasiantuntijoiden kanssa, jossa perehdyttämismateriaali käytiin läpi vielä kerran. Kaikki haastat-teluun osallistujat olivat sitä mieltä, että ei kannata käydä kaikkia asioita kerralla

Vesa OksanenAnja HennerLiisa KiviniemiOulun ammattikorkeakoulu, Yamk Sosiaali- ja terveysalan kehittämisen ja johtamisen tutkinto-ohjelmaOpinnäytetyö

Röntgenhoitajan tietojärjestelmäosaamisen kehittäminenPerehdytysopas ja -ohjelma kuvantamisen hoitohenkilökunnalle. 2016.


läpi. Osastonhoitajakokouksessa päätet-tiin valita kolme vastuuhoitajaa, joiden tehtäviin kuuluu systemaattinen pereh-dytys ja uusista toiminnoista tiedottami-nen.

Tulosten merkitys

Sähköisten potilastietojärjestelmien käyttöönotto helpottaa ja nopeuttaa työtä, lisää työ- ja asiakastyytyväisyyttä ja parantaa hoidon laatua. Ennen järjes-telmien käyttöönottoa on hyvä pitää käyttökoulutuksia ja ensimmäisen kuu-kauden aikana on annettava vierikoulu-tusta käyttäjille, jokaisessa yksikössä pitäisi olla nimetyt vierikouluttajat. Vie-rikoulutuksella on suuri merkitys järjes-telmien oppimisen kannalta. (Valta 2013.) Nimetyt vastuuhoitajat voivat toimia vierikouluttajina uusille työnteki-jöille.

Yksin päivystysaikaan työskentelevän röntgenhoitajan osaamisvaatimukset ovat haasteelliset. Päivystävän röntgen-hoitajan on osattava toimia itsenäisesti. Kuvalähetykset, arkistohaut ja kuvien tallentaminen on päivystysaikana osat-tava. (Luotolinna-Lybeck 2011, 78–79.) Myöskään terveyskeskuksissa röntgen-hoitajilla ei aina ole mahdollisuutta kysyä neuvoa, eikä käyttötuki aina ole välttämättä saatavilla puhelimen väli-tyksellä. Perehdytysoppaan avulla rönt-genhoitaja voi tarkistaa eri toimintoja, jotka ovat saattaneet unohtua niiden vähäisen tarpeen takia. Tästä on hyötyä myös potilaille, koska heidän hoitoonsa ei tule katkoksia, esim. röntgenkuvien lähetyksessä toiseen organisaatioon.

Tuotetun perehdytysmateriaalin avulla röntgenhoitajat pystyvät itsenäi-sesti syventämään ja kehittämään osaa-mistaan kuvantamisen tietojärjestelmien käytössä. Materiaalin avulla nimetyt vastuuhoitajat voivat systemaattisem-min perehdyttää uusia röntgenhoitajia. Röntgenhoitajien hyvä osaaminen kuvantamisen tietojärjestelmien käy-tössä nopeuttaa potilaan hoitoa, vähen-tää turhia tutkimuksia, jolloin potilas säästyy turhalta säteilyaltistukselta sekä säästää yhteiskunnan menoja ter-veydenhuollossa. Tuotetut materiaalit

voidaan muokata radiologeille, lähettä-ville lääkäreille, potilaskuljettajille ja muille kuvantamisen tietojärjestelmiä käyttäville soveltuviksi.

Lähteet

Kylmä, J. & Juvakka, T. 2007. Laadullinen terveystutkimus. Helsinki: Edita Prima Oy.

Luotolinna-Lybeck, H. 2011. Röntgenhoita-jan tulevaisuuden osaaminen. Teoksessa P.

Nygren & R. Nurminen (toim.) Tulevaisuuden osaaminen varsinais-suomen sairaanhoi-topiirissä. Turun ammattikorkeakoulun raportteja 114. Tampere: Tampereen Yli-opistopaino Oy – Juvenes Print, 70–79. Viitattu 16.3.2016, http://julkaisut.tur-kuamk.fi/isbn9789522162052.pdf

Toikko, T. & Rantanen, T. 2009. Tutkimuksel-linen kehittämistoiminta. Näkökulmia kehittämisprosessiin osallistamiseen ja tiedontuotantoon. 3. korjattu painos. Tampere: Tampereen Yliopistopaino Oy – Juvenes Print.

Tuomi, J. & Sarajärvi, A. 2009. Laadullinen tutkimus ja sisällönanalyysi. 9. uudis-tettu laitos. Vantaa: Hansaprint Oy

Valta, M. 2013. Sähköisen potilastietojärjes-telmän sosiotekninen käyttöönotto. Seitsemän vuoden seurantatutkimus odotuksista omaksumiseen. Väitöskirja. Itä-Suomen yliopisto. Yhteiskuntatietei-den ja kauppatieteiden tiedekunta. Kuopio. Viitattu 16.3.2016, http://epub-lications.uef.fi/pub/urn_isbn_978-952-61-1217-6/urn_isbn_978-952-61-1217-6.pdf

Valtionvarainministeriö. 2016. Digitalisoi-daan julkiset palvelut. Viitattu 19.2.2016, http://vm.fi/digitalisoidaan-julkiset-palvelut


Kliininen radiografiatiede -lehti on Radiog-rafian Tutkimusseura ry:n ja Suomen Rönt-genhoitajaliitto ry:n julkaisu, jossa julkaistaan radiografian alaan (käytäntö, koulutus ja tutkimus sekä radiografiatiede) liittyviä, suomen-, ruotsin- ja englanninkie-lisiä tieteellisiä alkuperäisartikkeleita. Artikkelien tulee olla aikaisemmin julkaise-mattomia. Lehdessä julkaistaan myös tut-kittuun tietoon perustuvia katsauksia, tapausselostuksia alaan liittyvistä kehittä-mistöistä, sekä akateemisten opinnäytetöi-den (pro gradu -tutkielmat, lisensiaattityöt, väitöskirjat) lyhyitä esittelyitä. Julkaisu on erityisesti kiinnostunut kirjoituksista, jotka edistävät kliinistä radiografiaa (diagnos-tiikka, isotoopit ja sädehoito), niihin liitty-vää koulutusta ja tutkimusta sekä radiografiatiedettä.

Kaikki alkuperäisartikkeleiksi tarkoitetut käsikirjoitukset ja katsaukset käyvät läpi ns. vertaisarvioinnin. Kirjoittajien nimiä ei tässä yhteydessä ilmoiteta arvioijille eikä arvioijien nimiä kirjoittajille.

Artikkelissa saa olla kokonaisuudessaan noin 30000 merkkiä välilyönteineen (sisäl-täen tekstin, tiivistelmät, taulukot, kuviot ja lähdeluettelon). Opinnäytetöiden esitte-lyjen enimmäispituus on 3500 merkkiä. Artikkelissa taulukoiden ja kuvioiden merk-kimäärät arvioidaan siten, että puolen sivun taulukon lasketaan vievän 2250 merkkiä. Teksti kirjoitetaan rivivälillä kaksi A4 -kokoiselle paperille käyttäen vasemmalla 3 cm:n marginaalia. Tavutusta ei käytetä. Kappalejakojen tulee olla selkeät. Sivunu-merot merkitään oikeaan yläkulmaan (ei otsikkosivulle).

a) Käsikirjoituksen rakenne (lukuun ottamatta opinnäytetöiden esittelyjä;ks. kohta b)

Käsikirjoituksessa tulee olla1. Otsikkosivu, jolle kirjoitetaan käsi-

kirjoituksen otsikko, kirjoittajien etu- ja sukunimi, oppiarvo suomeksi ja englan-niksi, asema työssä, toimipaikka ja säh-köpostiosoite. Lisäksi ilmoitetaan yhdyshenkilön nimi, osoite, sähköposti-osoite ja puhelinnumero.

2. Tiivistelmä kirjoitetaan samalla kie-lellä kuin itse artikkeli. Tiivistelmän pituus on noin 1250 merkkiä, ja siinä kerrotaan tekstin keskeinen sisältö (tut-kimusraportissa tutkimuksen tarkoitus/tavoite, menetelmät, tulokset ja päätel-mät). Tiivistelmän yhteyteen kirjoite-taan 3–5 asiasanaa indeksointia varten. Tekijöiden nimiä ei mainita.

3. Englanninkielinen tiivistelmä (Abstract), jonka on oltava suora käännös alkuperäiskielen tiivistelmästä (ml. asiasanat). Englannin kielen kielen-tarkastus on kirjoittajien vastuulla. Teki-jöiden nimiä ei mainita.

4. Tekstisivut, joissa tekstin jäsentely noudattelee yleisiä tieteellisen artikkelin rakennetta koskevia ohjeita (kirjoituksen luonteesta riippuen sovel tuvin osin). Tut-kimusraporttiin perustuvassa artikkelissa tulee esittää seuraavat asiat: johdatus aiheeseen, teoreettiset lähtökohdat tai kirjallisuuskatsaus, tutkimuksen tarkoi-tus/tavoite ja tutkimusongelmat, mene-telmät (kohderyhmä, aineiston keruu ja analyysi), keskeiset tulokset ja pohdinta (päätelmät, tutkimuksen luotettavuus ja eettiset näkökohdat sekä tutkimuksen merkitys radiografian alalle). Väliotsikoi-den tulee olla lyhyitä ja selkeitä ja otsi-kointi enintään kolmitasoista. Pääotsikot kirjoitetaan isoilla kirjaimilla, toisen tason otsikot pienillä ja kolmannen tason otsikot pienin kursiivikirjaimin. Katsauk-sissa ja kehittämishankkeita koskevissa tapausselostuksissa sovelletaan edellä kuvattua rakennetta mahdollisuuksien mukaan.

5. Tekstin kirjallisuusviitteet merki-tään ilmoittamalla tekijä ja vuosiluku sulkeisiin (Virtanen 2007). Jos tekijöitä on kaksi, merkitään molempien sukuni-met (Virtanen & Lahtinen 2007), jos use-ampia, vain ensimmäisen sukunimi ja ym. (Virtanen ym. 2007). Yhteisöistä merkitään nimi ja painovuosi (Säteily-turvakeskus 2007). Useita viitteitä peräkkäin esitettäessä viitteet järjeste-tään julkaisuvuoden mukaan vanhim-masta uusimpaan ja samana vuonna julkaistut aakkosjärjestyksessä.

Ohjeet kirjoittajille

6. Taulukot ja kuviot tehdään kukin erilliselle sivulle numeroituna ja otsikoi-tuna (taulukon otsikko yläpuolelle ja kuvion alapuolelle). Otsikkotekstin tulee kertoa, mitä taulukko tai kuvio esittää. Taulukot ja kuviot numeroidaan juoksevin numeroin, joiden mukaisesti taulukkoon/kuvioon viitataan tekstissä.

7. Lähdeluettelo otsikoidaan ”Lähteet”,

ja sen tulee sisältää kaikki ja vain teks-tissä mainitut lähteet. Ne luetellaan läh-deluettelossa aakkosjär jestyksessä seuraavasti

Kirjat Carlton R, Adler A. 1996. Principles of

radiographic imaging. 2nd edition. Delmar Publishers, London. Standertskjöld-Nordenstam C-G, Kormano M, Laasonen EM, Soimakallio S, Suramo I. 1998. Kliininen radiologia. Kustannus Oy Duodecim, Jyväskylä.

Artikkeli kirjassa Korhola O. 2005. Röntgendiagnostiikan

kehitys. Teoksessa: Radiologia Suomessa. Historiikki vuoteen 2005. WSOY, Jyväskylä, 16-21.

Virkkunen P, Salonen O. 1999. Kuvantamismenetelmät. Teoksessa: Joensuu H, Roberts PJ, Teppo L. (toim.) Syöpätaudit. 2. painos. Kustannus Oy Duodecim, Vammala, 98-109.

Lehtiartikkeli Decker S, Iphofen R. 2005. Developing

the profession of radiography: Making use of oral history. Radiography 11(4), 262-271.

Internet-lähde European guidelines on quality criteria

for computed tomography, http://www.drs.dk/guidelines/ct/quality/ (5.1.2007)

Julkaisut ja ohjeet: Säteilyturvakeskus. 2005. Lasten röntgen-

tutkimusoh jeisto. STUK tiedottaa 1/2005. Sosiaali- ja terveysministeriö. 2006. Terve-ydenhuollon valtakunnallisen tietojärjestel-mäarkkitehtuurin periaatteet. Sosiaali- ja terveysministeriön selvityksiä 2006:8. Sosi-aali- ja terveysministeriö, Helsinki.


8. Kiitokset (lähinnä tutkimustyön rahoit-tajille) sijoitetaan artikkelin loppuun ennen lähdeluetteloa.

b) Opinnäytetöiden esittelyjen rakenne:

Pro gradu -tutkielmien, lisensiaattitöi-den ja väitöskirjojen esittelyt (max. 3500 merkkiä) tehdään seuraavan rakenteen mukaan:

– Tekijä(t)– Pro gradu –tutkielman/lisensiaatti-

työn/väitöskirjan nimi– Raportin valmistumis/julkaisuvuosi– Yliopisto ja laitos: – Tutkimuksen tarkoitus ja luonne: (esim.

kuvaileva, selittävä, interventiotutki-mus)

– Menetelmät: (lyhyt kuvaus kohderyh-mästä, tiedonkeruumenetelmästä, aineistosta ja analyysistä)

– Keskeiset tulokset:– Tulosten merkitys radiografian alalle: – Yhteyshenkilön yhteystiedot (nimi,

osoite, puhelinnumero, sähköposti-osoite)

Käsikirjoitusten ulkoasua vastaaviin kysymyksiin vastaa lehden toimitussih-teeri Katariina Kortelainen ([email protected]). Tekijä(t) vastaa(vat) itse tekstin kielentarkastuksesta.

Alkuperäisartikkeliksi tarkoite-tun käsikirjoituksen mukaan tulee liittää saatekirje, josta käy ilmi, onko artikkeli julkaistu samanlaisena jossain muussa julkaisussa, tai onko artikkeli tai sen osa lähetetty arvioitavaksi johonkin toiseen lehteen. Saatekirjeestä tulee käydä ilmi myös tiivistelmän ja koko artikkelin merkkimäärä.

Käsikirjoitus (alkuperäisartikkeleissa saatekirjeineen) tai opinnäytetyön esit-tely lähetetään vain sähköpostitse doc-muodossa päätoimittajalle ([email protected]) ja toimitussihteerille ([email protected]). Päätoi-mittaja vahvistaa kirjoituksen saapumi-sen lehteen vastaussähköpostilla.

Julkaisusopimus: Käsikirjoituksen hyväksymisen jälkeen tekijälle/tekijöille lähetetään allekirjoitettavaksi julkaisus-opimus, jolla julkaisuoikeudet Kliininen radiografiatiede -lehdessä siirtyvät Radiografian Tutkimusseura ry:lle ja Suomen Röntgenhoitajaliitto ry:lle. Hyväksymisen jälkeen kirjoitusta ei saa

julkaista samassa muodossa kysymättä kirjallista lupaa kustantajalta. Käyttöoi-keuden hakeminen tekijänoikeudella suojattuun materiaaliin (ml. taulukot ja kuviot) on kirjoittajan vastuulla.

Erillispainokset: Kirjoittajalle toimitetaan artikkelistaan

kymmenen erillispainosta ilman kustan-nuksia.

26 Kliininen Radiografiatiede 2017

Kliininen Radiografiatiede 2017

SisällysArtikkelit

The impact of time scheduling in computed tomography on patient carePilegaard M, Egested H ………………...................…… 4

In the eye of the strom – radiographersexperiences of acute hypersensitivity reactions to intravascular contrast mediaGrén K, Panagiotidis G, Fridell K ………………………12

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Lean-menetelmän juurtumisen onnistumisen esteet ja edellytykset: Systemoitu kirjallisuus-haku terveydenhuollostaja tapaustutkimus kuvantamisessaHolm N ……………………………………………………… 20 Röntgenhoitajan tietojärjestelmäosaamisen kehittäminenOksanen V, Henner A, Kiviniemi L ........................... 22

Muuta

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Kliininen Radiografiatiede

2/2017 / Journal of Clinical Radiography and Radiotherapy / Volume 15

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