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British Journal of Radiology (2004) 77, 657-661
© 2004 British Institute of Radiology
doi: 10.1259/bjr/53007610
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Full Paper

Interpretation of trauma radiographs by radiographers and nurses in the UK: a comparative study

M Hardy, MSc, BSc (Hons), DCR(R) and C Barrett, PhD, BSc (Hons), RGN

Division of Radiography, School of Health Studies, 25 Trinity Road, Bradford, West Yorkshire BD5 0BB, UK


   Abstract
Top
 Abstract
Introduction
 Method
 Results
 Discussion
 Conclusion
 References
 
The purpose of this study was to identify the number of hospitals employing nurses and radiographers formally to undertake radiographic interpretation of trauma images and to compare the education undertaken by these professionals and any limitations imposed. A cross-sectional questionnaire survey of nurse and radiographer managers responsible for Accident and Emergency services within National Health Service hospitals in the UK was undertaken in January 2002. A total of 526 questionnaires were distributed. Response rates of 75.3% (n=198/263) and 69.2% (n=182/263) were received from radiographer and nurse managers, respectively. 96 nurse managers (52.7%, n=96/182) indicated that nurses within their departments were formally interpreting radiographs as part of their extended role whereas only 68 radiography managers (34.3%, n=68/198) indicated that radiographers were undertaking this role. Education to support radiographic interpretation varied markedly with 92.6% (n=63/68) of radiographers having undertaken a postgraduate qualification in image interpretation. In contrast, nurse education at all levels was more generic to the nursing role. The range of examinations which nurses and radiographers were permitted to interpret also varied markedly. Radiographic interpretation is undertaken by both nurses and radiographers. However, there is interprofessional and intraprofessional inconsistency in the range of examinations they are permitted to interpret and the level of education provided to support this role. Consequently, it can be surmised that national variation in service delivery and quality exists and a review of current service delivery strategies is recommended.


   Introduction
Top
 Abstract
 Introduction
Method
 Results
 Discussion
 Conclusion
 References
 
The reporting of Accident and Emergency (A&E) radiographs constitutes a major portion of the reporting workload of many clinical radiology departments [1]. Between 30% and 72% of patients attending A&E departments in the UK are referred for radiographic examination [2] and the role of plain film radiography in this situation is to assist in the accurate diagnosis of acute trauma or illness in order to direct appropriate patient treatment and management.

Many A&E physicians view the radiograph as an extension of the clinical examination, as the provisional diagnosis, based upon clinical signs and symptoms, can be confirmed or refuted upon inspection of the films [3]. However, the value of radiography in this context is not determined by the actual presence of trauma or pathology on the radiograph, but is instead dependent upon the clinician's ability to identify accurately and recognise any trauma or pathology present.

Traditionally, the responsibility for interpreting radiographic images within the A&E environment has been with the medical clinicians. However, the expansion of the role of the radiographer and nurse has resulted in the radiographic interpretation of trauma radiographs being undertaken by these non-medical health professionals.

Development of radiographer interpretation
The development of the role of the radiographer to include the interpretation of trauma radiographs has slowly progressed since the late 1980s. This development has been heavily directed within both the clinical and academic environments by radiologists acting as clinical teachers, mentors and advisors to academic course design and assessment [4]. The consequence of such radiological involvement has been that radiographers wishing to interpret trauma radiographs are expected to be equally as able as a radiologist to undertake the role. As a result, radiography education centres have adopted a number of intensive education strategies to develop the interpretive ability of radiographers [5, 6].

Although a limited number of studies have been published examining the accuracy of radiographer highlighting within the context of a "red dot" system [7–9], only one substantial study considering the accuracy of radiographer interpretation and reporting has been identified [10]. The results of this study, which reviewed the accuracy of radiographer interpretations of 11 322 trauma images, suggested that the sensitivity and specificity rates of the reporting radiographers were over 99%. The study concluded that non-medical staff may interpret skeletal radiographs from the A&E department with a high level of accuracy indistinguishable from that of a radiologist. However, the authors acknowledged that the radiographers within this study were appropriately educated, experienced and motivated with respect to radiographic interpretation and therefore may not represent the profession as a whole.

Development of nurse interpretation
The majority of patients attending A&E departments in the UK have, in the past, been clinically examined and treated by a junior grade of doctor (Senior House Officer (SHO)/Casualty Officer), often undertaking their first post registration position and having little effective clinical experience [11]. This approach to A&E service provision received criticism for being driven by staffing constraints and convenience rather than by "efforts to provide a consistent high standard of patient care" [12]. In addition, the practice of medically reviewing all A&E attendances was argued to result in excessive patient waiting times and inappropriate allocation of resources. This prompted the current UK government to initiate the dissolution of professional boundaries [13] and promote role development within the nursing profession [14] in order that patient waiting times and throughput targets might be met [15]. Despite reservations from other health professions [16], one of the areas identified in many A&E departments as suitable for nursing role development was the requesting and interpretation of trauma radiographs.

The first identified published study to report that nurses were formally interpreting radiographic images was undertaken in 1993 by Freij et al, although it was not published until 1996 [17]. This single centre retrospective study compared the ability of experienced nurse practitioners and junior casualty doctors to request appropriately and to interpret radiographs with respect to 150 adult extremity examinations. The results demonstrated that the ability of nurses and SHOs was comparable with both professional groups having approximately 93% overall sensitivity with regard to radiographic interpretation. Since then, a number of further studies have been undertaken [18–20], all of which agree with the conclusions of the study by Freij et al [17] that the ability of nurses to interpret radiographs is comparable with that of SHOs although their data with respect to the accuracy of radiographic interpretations does not concur. Importantly, no identified nursing study has considered the suitability of the junior casualty doctor/SHO as the benchmark standard comparator despite a number of published studies highlighting the inconsistent and often unacceptable ability of SHOs to interpret radiographic images [11, 21–25]. Despite this, Cooper et al [26] have argued that many departments are restricting the role of the nurse unnecessarily by not allowing nurses to interpret radiographs. Other nursing authors have however urged caution, arguing that the development of the nursing role should provide benefit to both patient and service and have emphasised the importance of robust and reliable evidence to support and direct role development [27].

From the literature above it is evident that both nurses and radiographers are developing their roles with respect to the interpretation of trauma radiographs. However, despite this development being documented within both professions, no study has yet identified the prevalence of such developments or compared the roles of the nurse and radiographer with respect to the interpretation of trauma radiographs. This study therefore considers the extended roles of nurses and radiographers in the UK with respect to the interpretation of trauma radiographs and examines the education and training undertaken by these two professions to support this role.


   Method
Top
 Abstract
 Introduction
 Method
Results
 Discussion
 Conclusion
 References
 
Following a critical review of the literature reported elsewhere [28] and attainment of local ethical approval, a cross-sectional descriptive survey was undertaken using a postal questionnaire as the data collection tool. This approach permitted the collection of data at a specific point in time [29], facilitated the optimization of the study breadth [30] and allowed adequate description and quantification of the research variables [31].

The questionnaire was designed to elicit factual information regarding the actual practice of nurses and radiographers with respect to the interpretation of trauma radiographs as well as information regarding education and training to support this role.

Two pilot studies were undertaken to ensure the accuracy and relevance of the final questionnaire. Initially, two members of academic staff from the Divisions of Nursing and Radiography, University of Bradford, were asked to complete the questionnaire and comment upon its design, content and ease of completion. The responses from this first pilot study informed changes to the questionnaire design, including the insertion of additional relevant questions and alterations to profession-specific terminology. The second pilot study involved four nurses and radiographers working within the local clinical A&E environment who were not included in the later survey. The returned pilot questionnaires indicated that the revised questionnaire was easily understood and completed and a full survey was undertaken with questionnaires being distributed during the week beginning 14th January 2002 with return requested by 15th February 2002.

The questionnaire was distributed to every hospital in the UK (excluding Northern Ireland) that had both an A&E department and a department of clinical radiology. 263 hospitals fulfilled these criteria and as a large sample size was preferred to maximize the number of responses, no further limitation to the sample size was implemented. A purposive sampling strategy was adopted to enable the representativeness of the research sample to be maximized [32]. As nurse and radiographer managers have both a knowledge of role extension within their respective departments and a managerial responsibility to encourage and direct professional development [13, 33], they were selected as the most appropriate people to represent the views of their own department and profession. All data collected were anonymous and analysed using the SPSS statistical package (SPSS Inc., Chicago, IL) to accurately describe and display response data.


   Results
Top
 Abstract
 Introduction
 Method
 Results
Discussion
 Conclusion
 References
 
A total number of 526 questionnaires were dispatched during the week beginning 14th January 2002. 198 questionnaires (75.3%, n=198/263) were returned from radiographer managers and 182 questionnaires (69.2%, n=182/263) were returned from nurse managers.

The managers were asked if radiographers and nurses in their respective departments formally undertook the interpretation of radiographic images as part of their agreed extended roles (Figure 1Go). 96 (52.7%, n=96/182) nursing managers indicated that nurses were undertaking the interpretation of radiographic images as part of the locally agreed extended role within their departments. Of these, 86 (89.6%, n=86/96) were A&E departments, 8 (8.3%, n=8/96) were Minor Injuries Units (MIU) and 2 (2.1%, n=2/96) were unspecified departments. In contrast, only 68 radiographer managers (34.3%, n=68/198) indicated that radiographers were formally undertaking the interpretation of radiographic images. However, of these hospitals (88.2%, n=60/68) considered the radiographer's interpretation and report to be definitive and only 8 hospitals (11.8%, n=8/68) required the radiographer's interpretations to be double considered by a radiologist. Importantly, 62 hospitals within this study (31.3%, n=62/198) were identified by radiographer managers as having no system of formal radiological review of trauma radiographs and only 24 hospitals (12.1%, n=24/198) were identified as providing a "hot" reporting service.



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  		Figure 1. Formal interpretation of radiographic images.

 
The range of radiographic examinations that nurses and radiographers could interpret varied within each profession. The limitations placed upon radiographers undertaking radiographic interpretation (Figure 2Go) were defined by skeletal regions (e.g. appendicular skeleton) whereas nursing limitations (Figure 3Go) were generally more anatomically specific (e.g. hand).



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  		Figure 2. Radiographic interpretation limitations – radiographers (n=67).

 


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  		Figure 3. Radiographic interpretation limitations – nurses (n=96).

 
All hospital sites formally employing radiographers to interpret trauma radiographs (data missing from 1 site) permitted radiographers to interpret radiographs of the appendicular skeleton (humerus to finger tips, femur to toes). 34 hospitals (50.7%, n=34/67) also permitted radiographers to interpret radiographs of the axial skeleton (pelvis, spine, skull and face). However, only 3 hospitals allowed radiographers to interpret chest radiographs and 2 hospitals permitted interpretation of abdominal radiographs by radiographers. No patient age limitations were specified by any of the respondents. In contrast, nurse limitations were much more varied and although 96 nurse managers indicated that nurses undertook radiographic interpretation within their departments, 20 failed to identify what restrictions, if any, were in place (Figure 3Go).

It can be seen from Figure 3Go that radiographic interpretation by nurses is generally limited to the upper and lower limbs. In addition, age restrictions ranging between 1 and 16 years were applied in 32 hospitals (33.3%, n=32/96). Radiographic interpretation of axial skeleton examinations, chest and abdomen, is undertaken by nurses in less than 8.3% of departments.

Education and training to support radiographic interpretation by nurses and radiographers also varied (Figure 4Go).



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  		Figure 4. Education and training to support radiographic interpretation.

 
It can be inferred from Figure 4Go that the predominant training/education strategy to support radiographers undertaking radiographic image interpretation is postgraduate education with 92.6% (n=63/68) of radiographer managers reporting that postgraduate education, either with or without associated in house training, had occurred. In contrast, only 32.3% (n=31/96) of nursing managers indicated that nurses had undertaken postgraduate education to support this role. Instead, the predominant education tool for nurses was either locally arranged in house training (36.5%, n=35/96) or in house training associated with an accredited or continuous professional development (CPD) short course (31.3%, n=30/96).

The adoption of audit procedures to evaluate radiographic interpretation practice by nurses and radiographers was asked of both professions (Figure 5Go).



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  		Figure 5. Audit of radiographic image interpretation practice.

 
56 radiography managers (82.6%, n=56/68) indicated that image interpretation by radiographers was audited whereas only 55 nurse managers (57.3%, n=55/96) indicated this was the case. In contrast, the auditing of nurse requests for radiographic examinations was undertaken in 70.5% (n=105/149) of hospitals where the extended nursing role included the requesting of radiographs.

The external validity of these results was assessed using "wave" analysis and the first and last 10 questionnaires returned from each profession were analysed for similarities with respect to the number of departments employing nurses and radiographers to interpret trauma images. As a result of direct similarity, it was possible to assume that the results were not biased and that the non-respondents would not have provided information markedly different from that already received. Consequently, the external validity of the results can be assured and any conclusions generalized to the population as a whole.


   Discussion
Top
 Abstract
 Introduction
 Method
 Results
 Discussion
Conclusion
 References
 
The need to improve the standard of patient care and reduce waiting times within A&E departments holds a position of paramount importance within the government improvement strategies for the National Health Service. In addition, as a result of recruitment and retention difficulties within all health professions, there is a need to optimize the working practices of health professionals by expanding upon their traditional roles to include additional duties normally undertaken by the medical practitioners. An example of this is radiographic interpretation.

Despite the almost simultaneous role development with respect to the interpretation of trauma radiographs within radiography and nursing, the education and training undertaken by these professions in order to support this role has varied markedly. A likely reason for this variation is that development of the radiographer and nurse extended role has often been under the direction of the radiologist and A&E physician, respectively. Consequently, a level of satisfactory education may have been determined to be one that reflects local standards of practice within their respective departments rather than one that has been determined and agreed against best practice standards.

However, it is important that any role development and associated professional responsibility are undertaken to support service quality. Consequently, the re-development of any health professional roles should be associated with a re-evaluation of service provision and standard. The limited amount of literature identified has indicated that, following a period of appropriate training and education, radiographers have an ability to interpret trauma radiographs similar to that of a consultant radiologist [6, 24]. In contrast, nurses have tended to compare their ability to interpret radiographic images with those of SHOs [17–20]. As a result, it may be inferred that radiographers who have undergone specific education and training in order to interpret radiographic images are able to interpret radiographs with greater accuracy than their nursing colleagues.

However, current practice protocols fail to implement effectively the interpretation of trauma radiographs by radiographers at a time that would maximize patient benefit. Instead, the majority of hospitals (89.7%, n=61/68) employing radiographers to interpret trauma radiographs offer a retrospective radiographic interpretation service rather than a "hot" radiographer reporting service at the time of patient attendance to the A&E department. As a result, the development of the radiographer's role with respect to the interpretation of trauma radiographs has not been linked to an evaluation of A&E service needs but instead has tended to emulate local radiological reporting practices. Consequently, as neither a radiographer nor radiologist interpretation is automatically available in the majority of hospitals to inform the diagnosis and treatment of trauma at the time of patient attendance, the misinterpretation of trauma radiographs remains one of the major causes of litigious action against Radiology and A&E departments [2, 34–37].


   Conclusion
Top
 Abstract
 Introduction
 Method
 Results
 Discussion
 Conclusion
References
 
It may be argued that the radiological review of trauma radiographs following patient discharge from A&E limits the likelihood of litigation and supports the effective provision of A&E services. However, in this study, 31.3% of hospitals (n=62/198) were identified by radiographer managers as having no system of formal radiological review of trauma radiographs. Additionally, as a result of high radiological workloads, it is uncertain whether the service offered by other radiology departments provides timely feedback to the A&E departments. Consequently, as current radiology service delivery strategies prevent the majority of radiographers qualified to interpret trauma radiographs from informing patient diagnosis and treatment at the time of initial attendance, the role of nurses with respect to the interpretation of trauma radiographs is likely to expand rapidly. However, the diverse nature of A&E service provision means that radiographic interpretation is only one small aspect of the nursing role. Consequently, it is unlikely that nurse education will ever place a similar emphasis on the accuracy of radiographic interpretation as postgraduate radiographer education. As a result, unless re-organization of radiology service delivery strategies can be undertaken to allow qualified radiographers to issue radiographic interpretations of trauma radiographs at the time of patient attendance, it is unlikely that A&E patients will be able to benefit directly from the development of radiographer interpretation.

Received for publication September 10, 2003. Revision received November 19, 2003. Accepted for publication February 3, 2004.


   References
Top
 Abstract
 Introduction
 Method
 Results
 Discussion
 Conclusion
 References
 

  1. Ihezue CU, Witham F, Sampson M. Reporting A and E films. RAD Magazine 2001;27:21–2.
  2. Beggs I, Davidson JK. Accident and emergency reporting in UK teaching departments. Clin Radiol 1990;41:264–7.[CrossRef][Medline]
  3. Rose JF, Gallivan S. Plain film reporting in the UK. Clin Radiol 1991;44:192–4.[CrossRef][Medline]
  4. Prime NJ, Paterson AM, Henderson PI. The development of a curriculum — a case study of six centres providing courses in radiographic reporting. Radiography 1999;5:63–70.
  5. Loughran CF. Reporting of fracture radiographs by radiographers: the impact of a training programme. Br J Radiol 1994;67:945–50.[Abstract/Free Full Text]
  6. Carter S, Manning D. Performance monitoring during postgraduate radiography training in reporting — a case study. Radiography 1999;5:71–8.
  7. Berman L, de Lacey G, Twomey E, Twomey B, Welch B, Eban R. Reducing errors in the accident department: a simple method using radiographers. Radiography 1986;52:143–4.
  8. Renwick I, Butt WP, Steele B. How well can radiographers triage X-ray films in accident and emergency departments? BMJ 1991;302:568–9.
  9. McConnell J, Webster A. Improving radiographer highlighting of trauma films in the accident and emergency department with a short course of study: an evaluation. Br J Radiol 2000;73:608–12.[Abstract]
  10. Robinson PJA, Culpan G, Wiggins M. Interpretation of selected accident & emergency radiographic examinations by radiographers: a review of 11000 cases. Br J Radiol 1999;72:546–51.[Abstract]
  11. McLauchlan CAJ, Jones K, Guly HR. Interpretation of trauma radiographs by junior doctors in accident and emergency departments: a cause for concern? J Accid Emerg Med 1997;14:295–8.[Abstract/Free Full Text]
  12. O'Leary MK, Smith M, Olmsted WW, Curtis DJ. Physicians' assessment of practice patterns in emergency department radiograph interpretation. Ann Emerg Med 1988;17:1019–23.
  13. Department of Health. A health service of all talents: developing the NHS workforce. London: Department of Health, 2000.
  14. Department of Health. Reforming Emergency Care - Practical Steps 2001 found at http://www.dh.gov.uk/PolicyAndGuidance/OrganisationPolicy/EmergencyCare/Critical Care/fs/en
  15. Department of Health. Delivering the Health Service Plan 2002 found at http://www.publications.doh.gov.uk/deliveringthenhsplan
  16. Meek SJ, Ruffles G, Anderson J, Ohiorenoya D. Nurse practitioners in major accident & emergency departments: a national survey. J Accid Emerg Med 1995;12:177–81.[Abstract/Free Full Text]
  17. Freij RM, Duffy T, Hackett D, Cunningham D, Fothergill J. Radiographic interpretation by nurse practitioners in a minor injuries unit. J Accid Emerg Med 1996;13:41–3.[Abstract/Free Full Text]
  18. Overton-Brown P, Anthony D. Towards partnership in care: nurses' and doctors' interpretation of extremity trauma radiology. J Adv Nurs 1998;27:890–6.[CrossRef][Medline]
  19. Meek S, Kendall J, Porter J, Freij K. Can accident & emergency nurse practitioners interpret radiographs? A multicentre study. J Accid Emerg Nurs 1998;15:105–7.
  20. Benger JR. Can nurses working in remote units accurately request and interpret radiographs? Emerg Med J 2002;19:68–70.[Abstract/Free Full Text]
  21. Vincent CA, Driscoll PA, Audley RJ, Grant DS. Accuracy of detection of radiographic abnormalities by junior doctors. Arch Emerg Med 1988;5:101–9.[Medline]
  22. Thomas HG, Mason AC, Smith RM, Fergusson CM. Value of radiograph audit in an accident service department. Injury 1992;23:47–50.[CrossRef][Medline]
  23. Saab M, Stuart J, Randall P, Southworth S. X-ray reporting in accident and emergency departments — reducing errors. Eur J Emerg Med 1997;4:213–6.[CrossRef][Medline]
  24. Klein EJ, Koenig M, Diekema DS, Winters W. Discordant radiograph interpretation between emergency physicians and radiologists in a pediatric emergency department. Pediatr Emerg Care 1999;15:245–8.[Medline]
  25. Espinosa JA, Nolan TW. Reducing errors made by emergency physicians in interpreting radiographs: longitudinal study. BMJ 2000;320:737–40.[Abstract/Free Full Text]
  26. Cooper MA, Hair S, Ibbotson TR, Lindsay GM, Kinn S. The extent of emergency nurse practitioner services in Scotland. Accid Emerg Nurs 2001;9:123–9.[CrossRef][Medline]
  27. Tye CC, Ross F, Kerry SM. Emergency nurse practitioner services in major accident & emergency departments: a United Kingdom postal survey. J Accid Emerg Med 1998;15:31–4.[Abstract/Free Full Text]
  28. Hardy M, Barrett C. Interpreting trauma radiographs. J Adv Nurs 2003;44:81–7.[CrossRef][Medline]
  29. Creswell JW. Research design: qualitative & quantitative approaches. London: SAGE Publications, 1994:119.
  30. Denscombe M. The good research guide for small-scale social research projects. Buckingham: Open University Press, 1998:6.
  31. Crookes PA, Davies S. Research into practice: essential skills for reading and applying research in nursing and health care. London: Baillière Tindall, 1998:129.
  32. Doordan AM. Research survival guide. New York: Lippincott, 1998:86.
  33. Department of Health. The NHS plan. London: The Stationary Office Limited, 2000.
  34. Robinson PJA, Wilson D, Coral A, Murphy A, Verow P. Variation between observers in the interpretation of accident and emergency radiographs. Br J Radiol 1999;72:323–30.[Abstract]
  35. Goodwin H, Moss J. Identifying areas of clinical risk in the A&E department. Health Care Risk Report 1997:15–17.
  36. Williams SM, Connelly DJ, Wadsworth S, Wilson DJ. Radiological review of accident and emergency radiographs: a 1 year audit. Clin Radiol 2000;55:861–5.[CrossRef][Medline]
  37. Guly HR. Diagnostic errors in an accident & emergency department. Emerg Med J 2001;18:263–9.[Abstract/Free Full Text]



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