the radiographer-patient relationship: enhancing understanding using a transactional analysis...

Radiography (2008) 14, 323e331

ava i lab le at www.sc ienced i rec t . com

journa l homepage : www.e lsev ie r . com/ loca te / rad i

The radiographer-patient relationship:Enhancing understanding using atransactional analysis approach

Lisa Booth*

School of Medical Imaging Sciences, St. Martin’s College, Bowerham Road, Lancaster LA1 3JD, UK

Received 16 January 2007; revised 23 May 2007; accepted 1 July 2007Available online 24 September 2007

KEYWORDSDiagnostic radiography;Radiographer-patientcommunication;Transactional analysis

* Tel.: þ44 1524 384 580; fax: þ44 1E-mail address: l.booth@ucsm.ac.u

1078-8174/$ - see front matter ª 200doi:10.1016/j.radi.2007.07.002

Abstract Purpose: Government initiatives such as the NHS Plan, the NHS Key Skills Frame-work and the NHS Career framework place communication at the centre of effective patientcare, and role/career development. All advocate a patient-centred approach to dealing withpatients, through open communication styles that encourage patients to become active partic-ipants in their care. Previous research, that has investigated communication in diagnosticradiography, demonstrated a preference for practitioner-centred, rather than patient-centredapproaches to communication, however, there is little evidence to suggest why this should bethe case or how a more patient-centred approach might be encouraged. The present studytherefore sought to explore factors that influence communication in diagnostic radiography,with the view to understanding the barriers to patient-centred care.Method: Semi-structured group interviews took place with 12 radiographers, across two NHStrusts, with the aim of understanding their communication with patients and the factors thatinfluence it. An open coding approach was used to analyse the data.Results: Four attitude categories were identified as influencing the communication used bydiagnostic radiographers. 1. Characteristics of the radiographer. 2. Characteristics of thepatient. 3. The need to produce a diagnostic image. 4. The need to keep the department running.Conclusion: Radiographer-patient communication is evidently influenced by these four attitudecategories. If patient-centred styles of communication are to be encouraged, these factors needto be recognised and taken account of in the selection, education/training and workforce plan-ning of diagnostic radiographers.ª 2007 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.

524 844 590.k

7 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.

324 L. Booth

Introduction

This analysis of radiographer communication intentions,forms part of a wider empirical study.1 These data repre-sent only a small portion of the total data collected, andare based on interviews with diagnostic radiographers.The focus of those interviews was derived from the findingsof a previous observation study2 which demonstrated thatcategories of radiographer behaviours were identifiablethrough Transactional Analysis.

Background

Non-participant observations, that used the TransactionalAnalysis (TA) subscales of the Adjective Check List,3 re-vealed that communication behaviours in diagnostic radiog-raphy could be categorised as Controlling Parent, NurturingParent, Adult, Free Child and Adapted Child.2 The descrip-tions of these behaviours are outlined below.

Controlling Parent

Controlling Parent behaviours are dominant in nature. Herethe radiographer focuses entirely on the technical aspectsof the examination, to the point of excluding the patient’scontribution; there is no use of the patient’s name;information giving takes the form of verbal commands;there are no explanations about the procedure; anda patient’s compliance with positioning is achieved throughthe physical manipulation of the patient. The radiographercontrols the amount of conversation that takes place withthe patient by reducing the amount of eye contact, andasking closed questions which effectively closes the com-munication channel.2

Nurturing Parent

Conversely Nurturing Parent behaviours are sympathetic innature. Radiographers typically introduce themselves topatients, more time is taken to explain the procedure, andadherence with positioning is achieved through the use of‘coaxing’ and ‘praising’ behaviours e.g. ‘‘well done’’, ‘‘yesthat’s great’’, which are used to reinforce appropriatebehaviour/movements. There is commonly social conver-sation about the non-medical aspects of the patient’s care;and as well as task-orientated touch, there is evidence of‘expressive touch’ and ‘terms of endearment’ such as‘‘love’’ or ‘‘dear’’.2

Adult

The Adult uses methodical and organised styles of commu-nicating. The focus is on information giving. For example,radiographers explain the procedure and, importantly,check the patient has understood that explanation; theyinstruct the patient in what is required of them to completethe examination successfully using gestures and examples.Generally there is information exchange with the patientwhich includes the reasons for diagnostic tests and how

they might inform the patient’s care. Voice-tone is evenand precise and the radiographer’s manner is calm andreassuring.2

Free Child

Free Child uses sociable communication behaviours, dem-onstrated by the ‘playful joking’ that occurs between theradiographer and the patient. The behaviours are relaxedand friendly e.g. laughing, joking, and the use of ‘expres-sive touch’. The interactions typically involve play, withamusing or fictional statements sometimes made about theroom, the equipment, the examination, the radiographer,or even the patient.2

Adapted Child

The Adapted Child is the part of the personality that allowsus to ‘adapt’ to new/novel situations and is the source of‘‘creative change’’ (p. 29).4 Radiographers exhibiting Adap-ted Child behaviours seem to lack confidence and appearhurried. There is a reluctance to engage patients in conver-sation and there is a focus on the technical aspects of theexamination, but unlike the confidence seen with Control-ling Parent behaviours, Adapted Child behaviours includemumbling and appearing slower and inhibited.2

Although radiographer behaviour fits broadly into thesefive categories, a small majority of radiographer-patientinteractions can be categorised as Parental in nature(52.6%),1,2 which reflects the nature of communicationseen in other areas of health care, such as nursing, wherea preference for Parental communication has also beenfound.5 The analyses of Booth1,2 and Emrich5 demonstratesthat one style of communication dominates throughouta single interaction. Given the complexity of human inter-actions and the many factors that impact on them, it is un-likely that this is actually the case. Nonethless the Parentalstyles identified by both Booth1,2 and Emrich5 are generallyconsidered undesirable in health care as they: encouragepatients to be dependent on the practitioner5; do not en-courage patients to be active participants in their care6;and encourage patients to adopt the ‘sick role’ i.e. theyare illness maintaining,5,7 Adult communication, found tomake up 26% of radiographer-patient interactions,2 discour-ages this.7 Adult behaviours treat patients as equals duringinteractions,5 by encouraging them to ask questions and tobecome more active in their care7; a philosophy supportedby the NHS Key Skills Framework (KSF).8 The KSF identifiescommunication as one of six key dimensions that are cen-tral to effective working in health care. Good communica-tion is described as the ability to ‘‘develop and maintaincommunication with people on complex matters, issuesand ideas.in complex situations’’,8 and it is argued thatgood communication also underpins the other five dimen-sions of the KSF. Achieving good communication requiresa practitioner to place the needs of the patient at the cen-tre of interactions, a notion known as patient-centredcare.9 Patient-centred care advocates open-communica-tion styles, treating patients as equals, and offering expla-nations and instructions that are within a patient’s capacityof understanding.10 Behaviours that are arguably part of

The radiographer-patient relationship 325

Adult, Nurturing Parent and Free Child communication.2

Conversely the practitioner-centred approach views pa-tients in terms of the disease from which they are suffering.Here practitioners do not actively involve patients in con-versations as it is the practitioner who sets the agendafor what will be discussed, as well as what advice and infor-mation will be given.11 An approach that can be likened tothe behaviours seen in both the Adapted Child and Control-ling Parent communication styles.2

Therefore, previous research has identified ‘how’ radiog-raphers communicate with patients,2 but more evidence isneeded to explain ‘why’ they might communicate in a partic-ular way. Without understanding this, it becomes difficultto ascertain how radiographers might be encouraged toadopt patient-centred communication over the preferredpractitioner-centred approaches. Semi-structured group in-terviews were therefore conducted with a total of 12 radiog-raphers from two NHS trusts, with the aim of understandingthe nature of communication in diagnostic radiography andthe factors that might influence it.

Method

Approval for the research was gained from the two Trustsfrom which the research participants were recruited, andthe research was consistent with ‘St. Martin’s CollegeEthical Principles and Guidelines for Research InvolvingPeople’.

Two semi-structured, group interviews took place. Thesemi-structured approach allowed a number of open-endedquestions to be asked in a loosely structured format, whichensured the researcher covered all issues, whilst beingafforded the freedom to diverge or pursue responses inmore detail.12,13 The group interview technique ‘‘capital-ised on the communication between the participants inorder to generate more data.participants were encour-aged to talk to one another, ask questions, exchange anec-dotes and comment on each others’ experiences and pointsof view’’ (p. 20)12 while the interviewer ‘listened in’ andrecorded these conversations.

Sample

The semi-structured interviews were conducted by theresearcher with qualified general radiographers whoworked in two NHS trusts. Volunteers were recruited byplacing a notice that explained the purpose of the study onstaff notice-boards. Exclusion criteria were: staff gradesuperintendent III and above, non-general radiographersand radiographers who had been involved in an earlierstage of the research. Twelve volunteers were recruited,six from each hospital trust. Eight were female and fourwere male. Eight were radiographer grade, two were ofsenior II grade and two were senior I grade. Although sucha small conveniently selected sample generates findingsthat cannot be generalised to the population as a whole;the aim of the research was to discover meaning abouta previously un-researched phenomenon, so generalisabilitywas not the main concern at this stage of theinvestigation.14

Procedure

The interviews were audio-taped, as it was considered thatwriting responses down would have been distracting to theparticipants.13 Audio-taping also gave credibility to thefindings, as the tape could be replayed for accurate tran-scription. The transcriptions were analysed by the inter-viewer and another experienced researcher to ensureconsistency, reliability and validity of the findings.

Two interviews took place, one in each trust, at timesthat were mutually convenient for the radiographers andthe interviewer. A week prior to the interviews thevolunteers were given consent forms, along with a descrip-tion of five communication styles that had been identifiedfrom earlier observations1,2 (these descriptions are outlinedearlier in this paper); the name of each communicationstyle was omitted from these descriptions, as it wasthought that these might influence the participants’responses.

At the beginning of each interview the purpose of theinterview was explained and permission to use the taperecorder confirmed. It was explained again that any re-sponses would be kept strictly confidential and it was alsoexplained that although the interviewer had a number ofissues to cover, the purpose of conducting the interviewswas to allow the radiographers to raise any issues they feltwere relevant. Consent forms were handed back to theresearcher at this point. One interview lasted 60 min, andthe other lasted almost 90 min.

The interviews began with a ‘grand tour’ question15 ‘Haveyou read the descriptions of the communication styles? Whatdo you think?’ The decision to keep the first question open-ended and non-directive was a deliberate attempt to avoidinterview bias, which is where an interviewer inadvertentlyencourages particular responses from their participants,through subtle verbal/non-verbal behaviours.14 The open-ended nature of the question therefore encouraged partici-pants to begin speaking, but the conversation that thentook place between the participants meant that there wasvery little need for further input from the interviewer. Fur-thermore, the non-directive nature of the question meantthat the content of these conversations was not affectedby the interviewer’s agenda.15 However, the researcherwas interested in the participant’s attitude towards all fivecommunication styles, therefore, if the grand tour questiondid not elicit a conversation about these, the interviewerwould encourage conversation by asking a more directopen-ended question e.g. ‘What about communication style5?’ (in this case communication style 5 refers to Free Child).Although more directive, the open-ended phrasing of thequestion meant responses were still valid, as participantswere articulating their own experiences, rather than con-forming to a pre-determined set of categories that hadbeen decided on previously by the researcher.15

All participants appeared to contribute equally, perhapsdue to the informal nature of the interviews, or becausethe participants knew each other and the interviewer.There was some concern that the relationship, betweenthe interviewer and the participants, might have createda ‘response bias’, where participants respond to questionsin a way that gives a favourable impression, a response

326 L. Booth

style known as social desirability.14 This response style isparticularly relevant when anonymity from the researcheris not preserved. However, Becker (1970), cited by Saksand Allsop15 stated that ‘‘.the information disclosed byparticipants (during interviews) is so detailed that it guardsagainst bias by making it difficult for participants to pro-duce data that uniformly supports a mistaken conclusion’’(p. 82). With this method being used to triangulate findingsfrom an observational study, it was possible to infer thatthe responses were reliable and valid, as they supportedwhat had been observed in practice. Over-all it was per-ceived that the relationship between the interviewer andthe participants actually added to the level of honesty,rather than detracting from it, but it was noted that partic-ipants tended to comment that it was other radiographers,and not themselves, who exhibited negative behaviour to-wards patients. This might be attributable to a lack ofself-awareness, rather than a deliberate attempt to givea favourable impression to the researcher, as many of thecomments were extremely honest, to the point that the re-searcher was surprised at the level of detail offered.

Analysis

The interview record was first transcribed verbatim from thetape recordings that had been made, the analysis of whichmade use of the inductive open-coding technique.12 Thisanalysis involved identifying a question and then attemptingto answer, ‘‘verify, confirm and qualify’’ that question bysearching through the data (p. 78).12 Once categories and co-des had been determined by the interviewer they werepassed to a second researcher, along with the transcripts,to establish the reliability of the categories and codes.

Results

Four categories of findings emerged from this analysis:

1. Characteristics of the radiographer e subdivided into1a. Personality1b. Confidence

2. Characteristics of the patient e subdivided into2a. Age of the patient2b. Behaviour of the patient2c. Patient illness or injury

3. The need to produce a diagnostic image4. The need to keep the department running

Data Interpretation

Although the research participants were provided withnumeric identifiers for the communication styles, ratherthan using the conventional labels for the reason explainedearlier, the conventional labels are used in this interpreta-tion to aid readers’ understanding.

The characteristics of the radiographerAccording to the radiographers interviewed, how theycommunicate depends largely upon their personality.They went on to discuss that individuals tend to

communicate using the same communication style, what-ever the circumstance. These responses are represented inthe comments below.

e ‘some people are single mindedly one way’e ‘communication is a personality trait of their lives’.

However, there are other influences on communicationand the radiographers recognised their use of interactionsthat can be characterised as ‘Adapted Child’ when faced withnew examinations, examinations that they did not undertakeregularly, or when dealing with new equipment e.g.

e ‘communication is down to confidence’e ‘it’s the individual’s perception of themselves.if you

pick up a card and think ‘‘I hate doing these, because9 out of 10 times I have to repeat it’’.you wouldn’ttalk to the patient’.

They also commented on the use of Adapted Childbehaviours by students, perhaps because students arefaced with novel examinations/equipment more oftenthan qualified staff;

e ‘You see it with students.they’re less sure’.

Characteristics of the patientDespite their own personal characteristics and how theseinfluence communication, there was a general feelingamongst the radiographers that they still tried to,

‘negotiate their approach every time a patient camethrough the door’.

They commented that they would use ‘Nurturing Parent’behaviours with elderly patients and children. However, ifpatients are a similar age to the radiographer, it seems thatAdult behaviours are preferred,

e ‘I wouldn’t use it [Nurturing Parent] on somebody myage.it could be patronising.with those patients Iwould be more likely to be [Adult]’

e ‘I would use it [Nurturing Parent] with certainpatients.old patients’

e ‘I’d be [Nurturing Parent] with old people, geriatricsand kids’.

Patient characteristics are therefore important inradiographer-patient relationships and will influence howradiographers communicate. For example, if a patient isintoxicated, or is too familiar, then radiographers are morelikely to exhibit Controlling Parent behaviours, probablybecause it enables them to exhibit a more dominantposition in the interaction,

e ‘sometimes when the patient winds you up you’re [Con-trolling Parent]’

e ‘I find I’m [Controlling Parent] with people who aredrunk, I shout over them.be firm’

e ‘I become defensive and [Controlling Parent] whensomebody is really forward’.

The radiographer-patient relationship 327

Conversely if the radiographer knows the patient, thenthey feel comfortable taking on a less dominant role in theinteraction e.g.

e ‘I’m not often [Free Child].but with patients who arerepeat visits, because they know what’s going to happen,I might be then, because I can relax with them more’.

A patient’s illness or injury also influences how radiog-raphers communicate. For example, Adult behaviours mightbe used in situations where radiographers are faced withconflicting stimuli e.g. poly trauma patients. These patientsare often in a lot of pain, they will require some degree oftechnique modification, there is usually bleeding and oftenthere are other health-care personnel in the x-ray room. Todeal with these stimuli efficiently, the radiographer needsto work in a methodical and organised manner.

e ‘With accidents you’ve got to be [Adult]; in-out; effi-cient; and on the ball’

The radiographers went on to explain that the praisingused in the Nurturing Parent style was a helpful techniquewhen examining patients who are in a lot of pain. They usethis technique to encourage patients to overcome their fearof experiencing pain, and in doing so persuade the patientto move into the desired position.

e ‘You use [Nurturing Parent] if they’re in a lot of pain;they need coaxing into doing it’

But it is the technical styles of communicating i.e.Adapted Child and Controlling Parent that would be usedin emotionally stressful situations;

e ‘Sometimes I avoid [Nurturing Parent], because youdon’t feel happy being sympathetic someone who mightstart crying on you’

e ‘You’d be [Adapted Child] with patients who are reallyill and you don’t know how to deal with that’.

This focus on the technical task ‘protects’ radiographersfrom engaging in a potentially emotional conversations withpatients and prevents,

‘giving patients an opening that you as a radiographerwon’t be able to deal with’.

The need to produce a diagnostic imageRadiographers use a range of communication behaviours tohelp them achieve their goal of producing a technical image.

e ‘you can use communication to get the best (image) outof the patient’.

For example, the radiographers interviewed stated thatNurturing Parent behaviours are used to reinforce appro-priate behaviours in the patient that consequently assist inthe process of producing a diagnostic image.

e ‘coaxing the patient, makes taking the x-ray easier foryou’.

Whereas they comment that they use Adult behavioursto demonstrate to a patient exactly what is required ofthem, to ensure that a diagnostic image is produced.

e ‘You have to say WHY it is important they don’t move’e ‘sometimes, instead of modifying your technique you

can interact with the patient in such a way as to getthem to do something.like straightening their elbow’

e ‘I find if you show them what they need to do..’.

Keeping the department runningPerhaps the greatest predictor of Controlling Parent be-haviour is the need to keep the department running.

e ‘You’d be more likely to be [Controlling Parent] ifyou’ve got a big queue of patients, you’re going to con-centrate on your technical role’

e ‘If you’re not focussed on the technical outcome youare going to be there all day and other patients willsuffer’

e ‘You don’t use [Adult] when its busy.I don’t think youcan give the patient as much information as you wouldif you had more time’

e ‘If you’re busy you will tend to move more quickly to re-straining a child than if it is quiet’.

Discussion

Given the relatively small sample size used in the currentstudy and how the experience of being a radiographer isprobably influenced by individual hospital environmentsand clinical specialities, this study must be viewed as anexploratory investigation of factors that can influencecommunication events in diagnostic radiography. Thesefactors have been found to include: personality andconfidence of the radiographer; the age of the patient;the behaviour of the patient; the patient’s illness or injury;the need to produce a diagnostic image; and the need tokeep the department running. It is unlikely that this list isexhaustive and it is possible that further investigation, thatuses a sample more appropriate to the population asa whole, would reveal other factors relevant to communi-cation in diagnostic radiography. Nonetheless, the initialdata that are presented here seem to support evidence andcomments within the existing radiographic literature and gosome way towards understanding and identifying some ofthe barriers to the effective communication that is es-poused in the NHS Key Skills Framework.8

It has been argued that the personal characteristics ofradiographers are important for presenting a professionalimage and when providing good patient-care. Because ofthis it has been suggested that personality characteristics,particularly those that are associated with the personalityconstruct ‘extroversion’, should form the basis of personnelselection into radiography.16 Extrovert individuals are gen-erally ‘socially outgoing, uninhibited and good at makingand maintaining interpersonal contacts’.17 Nonetheless,selection for radiography personnel remains largely subjec-tive, perhaps because it is believed that ‘students who per-form well clinically do not always perform well academically

328 L. Booth

and vice versa’.18 However, research in both dentistry19 andnursing20 contradict this belief, and advocate personnel se-lection on the basis of extroversion, finding it to be associatedwith improved clinical performance19 and successful aca-demic performance.20 Similarly, Arnold18 found extroversionand good clinical performance to be related in radiography,and did not find any evidence to suggest that extroversionand poor academic performance were correlated.

The present study also seems to support the view thatpersonality should be a consideration when selectingradiography personnel. For example, the radiographersinterviewed suggested that each radiographer has a pre-ferred style of communicating and that this preferred styleis closely related to the radiographer’s personality. Thisfinding is perhaps unsurprising in that the behavioursidentified during the course of this investigation are basedupon the theory of Transactional Analysis (TA). According toTA an individual’s personality consists of three ego-states;the Parent; the Adult; and the Child. Everybody’s person-ality is structurally alike, in that they have a Parent, anAdult and a Child, but they differ in the working arrange-ment of these three areas the extent to which the Parent,Adult and Child function.21 Nonetheless these functionaldifferences mean that everybody has a personality that isunique to them which, because personality and behaviourare closely linked, results in behaviour that is relatively con-sistent. This perhaps explains why the radiographers inter-viewed discussed communication as a ‘personality trait oftheir lives’. However, an individual’s experiences and be-liefs allows them to adapt the working arrangement of theirego-states (and so behaviour)21 and it is this skill that wouldallow radiographers to ‘negotiate their approach every timea patient comes through the door’. Nonetheless these con-trasting views highlight one of the most fundamental prob-lems when using an interview technique, in that whatpeople say they do and what they actually do might be quitedifferent.14 It would be interesting therefore, to undertakefurther investigations to determine which is more predictiveof communication in radiography; a radiographer’s personal-ity or a radiographer’s experiences and beliefs. The outcomeof such a study would determine whether or not personalityshould, in fact, form the basis of personnel selection into di-agnostic radiography.

It does seem, however, that experience is important.Radiographers can lack confidence and self esteem, whichmanifests itself in submissive behaviour,22 such as AdaptedChild.2 Confidence, in particular, affects technical exper-tise, as well as interpersonal skills and patient care.23 Theradiographers interviewed highlighted how confidence intechnical abilities ‘if you pick up a card and think ‘‘I hate do-ing these, because 9 out of 10 times I have to repeatit’’.you wouldn’t talk to the patient’; as well as confidencein dealing with patients ‘You’d be [Adapted Child] with pa-tients who are really ill and you don’t know how to deal withthat’, ultimately affects communication.

Given the importance of confidence in terms of techni-cal/interpersonal competence, it has been argued thatradiographers who lack confidence should be supportedand mentored during a first-post registration year to ensurethat they meet the requirements necessary to be consid-ered competent to practice.22 Those radiographers whodemonstrate high standards of competence, and possess

skills more usually seen with experience, could be encour-aged and supported in a similar way. The aim of this supportwould be to maximise future career potential and govern-ment initiatives such as the NHS Plan,24 The NHS CareerFramework25 and the NHS Key Skills Framework,8 seem tosupport such a move, although the associated costs andimplications for the training and education of diagnosticradiographers would need to be considered before sucha programme could be rolled out nationally.

Although radiographer characteristics are important,radiographers are, in fact, only one element of a muchmore complicated process. Interactions between radiogra-phers and patients are interpersonal exchanges, where theradiographer and the ‘‘patient are reacting emotionally toone another’’,26 as such the patient also contributes to thestyle of communication used. The radiographers inter-viewed acknowledge this, stating that they tried to ‘nego-tiate their approach’. Negotiating how best to talk topatients is a commonly talked about feature of healthcareinteractions,26 and age of the patient has been found to beone factor that does influence practitioner ‘talk’.27 For ex-ample, facilitative behaviours such as coaxing and praising(associated with Nurturing Parent behaviours), are moreoften seen when health practitioners are dealing with olderadults27 and the current research also demonstrated a pref-erence for Nurturing Parent behaviours when dealing withthis patient group. An explanation for this is offered bythe work of Levinson et al.,26 where it was demonstratedthat practitioners feel more warmth and enthusiasm forolder patients, than they do towards younger patients. Lev-inson et al.26 went on to argue that this finding disputes anyconcerns that ageism is undermining quality of care. How-ever, the sample of 66 doctors (predominantly male) and660 patients (predominantly female), that was used in thestudy, allowed for an inherent bias that favoured the el-derly patient, in that the mean age of the sample was60 years old. Studies that look specifically at inequality inhealth care certainly consider ageism to be a significantproblem.28,29 Nowhere is this more evident than in the re-ferral rates for diagnostic procedures. For example, in2003 only 79% of patients aged 61 and over were offeredbrain imaging after stroke, compared to 97% of patientsaged 60 and under.28 It is therefore more likely that the com-munication seen with older adults is not because they areviewed more positively by practitioners, but is actually be-cause they think older people aremore likely to misunderstandinstructions and explanations, due to age-related cognitivefailure.30 This stereotype actually leads to older adults beingtreated in a Nurturing Parent-Child fashion and is a phenome-non known as ‘‘the rescue game’’, where the helper actuallytakes over the task and consequently takes away the patient’scontrol (p. 146).4 These Nurturing Parent behaviours are ac-cepted inhealth careas they appear to reconcile the caring ap-proach practitioners are expected to adopt alongside thetechnical functions they are actually performing.31

Whereas Nurturing Parent behaviours might be acceptedin diagnostic radiography, the behaviours demonstratedduring emotional interactions are more difficult to recon-cile. It has been said that in order to deal with an oncology/terminally ill patient, radiographers need to ‘‘acknowledgewhat the patient is going through.have empathy, listeningskills and the ability to discuss life and death topics should

The radiographer-patient relationship 329

they arise’’.32 The reality is that radiographers use Control-ling Parent/Adapted Child behaviours to distance them-selves from these patients. Murray and Stanton32 reportedthat this is because diagnostic radiographers find dealingwith oncology patients stressful; partly because they areunable to deal with the strong emotions that are experi-enced; and partly because they fear doing psychologicalharm to the patient. Only 15% of oncology patients, whosecondition merits psychiatric intervention, are ever referredto professionals who might be able to help them.33

In medicine, clinicians also use Controlling Parent behav-iours to avoid engaging with the patient i.e. they divertconversation topics, use closed/leading questions and avoidmaking eye contact.32,34 Some doctors do, however, ac-knowledge that their communication skills are inadequateand have ‘handed-over’ their responsibility to ‘specialist’nurses, but evidence suggests that these nurses are usingthe same distancing techniques.34 The consequence is thatpoor communication exists between practitioners and pa-tients and between practitioners themselves. That is, the as-sumption is often made by each practitioner, that anotherpractitioner ‘‘must have relayed the relevant facts (abouttests and treatments, to a patient) at the appropriatetime’’,34 because of the distancing techniques that are beingemployed; practitioners do not check whether this is in factthe case, as evidenced by Chesson et al.35 who found thatalthough 82% of patients had been told why a radiologicalinvestigation was necessary, 64% did not know which investi-gation they had actually been referred for.

The emotional reactions experienced by practitionersworking in these stressful situations include; feelings offailure; powerlessness; frustration; and grief36; as well asa fear of death and dying (thenatophobia).37 These emo-tional reactions are not exclusive to practitioners whowork in oncology, they have also been seen in practitionerswho deal with prolonged resuscitation/recovery, burn vic-tims, trauma victims, and children in neonatal intensivecare.38 The outcome is generally the same with practi-tioners exhibiting a desire to avoid involvement with thepatient, in an attempt to avoid the strong emotions thatare associated with that person’s care.34 Although thesedistancing techniques are used to ‘protect’ the practitionerfrom experiencing stressful emotions, there is a growingbody of evidence that suggests such techniques actuallylead to occupational ‘burnout’.32,34 The first symptoms ofwhich are; desensitisation to patient’s needs; and distanc-ing oneself from potential stressors at work. Eventuallythese symptoms start to affect personal relationships out-side of the work environment.38 Burnout affects almost25% of health practitioners39 and is associated with highlevels of staff absenteeism and turnover.40 If radiographersare to be encouraged to engage with these emotional situ-ations, it is advocated by Murray and Stanton32 that trainingand support needs to be made available to radiographers.This training should include learning to ask for help and rec-ognising when help is needed, as without this skill distanc-ing techniques will continue and burnout is highly probable.

Distancing techniques and practitioner-centred commu-nication have also been found, in previous studies, to bea consequence of ‘technical priorities’ i.e. the need toproduce a diagnostic image.41 However, the present studyimplies that this might not actually be the case.

Different styles of communication seem to be used, bydiagnostic radiographers, as strategies for achieving a di-agnostic image. This is highlighted by the comment ‘youcan use communication to get the best (image) out of thepatient’. It is worthwhile noting that the behavioursassociated with this diagnostic success are those that aresynonymous with patient-centred care e.g. Free Childbehaviours were identified as being useful when examiningchildren; Nurturing Parent behaviours were preferred whenexamining older adults; and Adult behaviours were found tobe effective in explaining to patients what was required ofthem. These responses raise an interesting notion; radiog-raphers are consciously choosing styles of communicatingthat are based on their desire to achieve a diagnostic image.These types of interactions are known as ulterior trans-actions, where the overt behaviours appear to depict onemessage, but the covert message is actually another.4 Al-though these types of messages are often associated withpsychological ‘game’ playing,42 the fact that radiographersare consciously choosing one style of communicating overanother suggests they are more likely to be ‘manoeuvres’.4

Choosing styles of communication, to control patientbehaviour, was a feature of Hewison’s study.31 Here it wasargued that nurses use ‘Overt Power’ (Controlling Parent)to simply tell patients what to do, and ‘Terms of Endear-ment’ (Nurturing Parent) to persuade patients to undertaketasks. Hewison25 also went on to say that although Adult in-teractions do not appear to be overtly controlling, they doin fact ‘Control the Agenda’, in that the questions askedhave a limited range of responses which ensures the pa-tient’s participation. For example, the question ‘will yoube able to get up on the table?’ gives the impression thatthe patient is being included in a decision, but in factthey are being told that they have to get onto the table.Using communication to achieve patient adherence hasbeen a part of health care research since the late1970s.43 Communication has been found to contribute tothe success of drug/dietary regimes43,44 and attendancefor appointments,45 and the findings of the present studysuggest that communication is also important for achievingdiagnostic success. Successful imaging results in a reductionin repeat/reject rates, which in turn would reduce the ra-diation dose to the patient. Advantages that merit furtherinvestigation.

Therefore patient-centred behaviours seem to be cor-related with diagnostic accuracy, but radiographers adoptmore practitioner-centred behaviours i.e. Controlling Par-ent, when faced with time pressures and keeping thedepartment running smoothly. It is possible that focussingon the technical task, asking closed/leading questions,using monosyllabic responses and making little eye contact,reduces the amount of conversation that takes place withthe patient. The perception being that these conversationsadd to the time it takes to complete examinations.

As early as 1978 it was proposed that radiographers havetwo roles in caring for patients; a technical role anda psychosocial role.46 Since this time there has beenmuch speculation as to how time-pressures might affectthe importance radiographers attach to these roles, al-though it has always been presumed that the technicalrole would dominate.47 This is perhaps not surprisingwhen the environment in which a radiographer works is

330 L. Booth

considered. This environment, coupled with an educationand research base that is dominated by science and tech-nology, ensures an almost unilateral emphasis on the tech-nical aspects of the radiographer’s role. Although this ‘roleideal’ might be quite different to a radiographer’s personalbeliefs, it has the potential to be the overriding influenceon their behaviour. Nowhere is this more evident than inthe following quote taken during the interviews: ‘If you’renot focussed on the technical outcome you are going to bethere all day and other patients will suffer’.

Evidence suggests that this has not always been thecase. The findings of Reeves and Unett,48 some eight yearsago, suggested that although ‘speed and efficiency’ wereconsidered to be important in radiography, they were notas important as good communication skills. However, theradiographers interviewed in the present study suggestedthat communication becomes less important when depart-ments are busy. When time pressures dominate; speedand efficiency are more important qualities. This changehas possibly emerged due to remote management styles47

and an ever increasing emphasis being placed on ‘as manypatients in as shortest time possible’.49 If communicationis to be central to effective working within the NHS,8

more work is needed to determine the impact of increasedpatient-throughput on communication e.g. delivering the18 week patient pathway, and how these in turn affectpatient understanding, memory, recall, satisfaction andadherence with diagnostic radiography regimes.

Conclusion

This study has yielded several insights into the factors thatinfluence communication in radiography. It demonstratesthat, although radiographers attempt to adapt their com-munication to suit individual patients, internal factors suchas personality and confidence, as well as external factorssuch as producing a diagnostic image and departmentalpressures, play an important part in radiographer-patientinteractions. These factors need to be considered whenattempting to improve communication in diagnostic radi-ography, and when attempting to implement the NHS KeySkills Framework, as this study demonstrates that educa-tion/training will not be enough. For example, support isneeded for radiographers who are working in emotionallystressful situations, if distancing techniques are to beavoided. Post-registration training needs to be consideredfor those radiographers who lack confidence, and consider-ation needs to be given to staff-patient ratios, if radiogra-phers are to consider communication to be as important asspeed and efficiency. It is also possible that personalitycharacteristics should form the basis of personnelselection in radiography, although further research isrecommended.

It would also be interesting to investigate further theinfluence of departmental pressures and practitioner-centred behaviours and how these might ultimately affectpatient satisfaction/adherence. The findings of the presentstudy also suggest a correlation between patient-centredstyles of communication and diagnostic success and this toowarrants further investigation.

Acknowledgements

The author would like to thank Professor D. Manning for hisassistance with managing the data and Professor H. Leath-ard for her help in putting together this paper.

References

1. Booth L. The communication strategies of diagnostic radiogra-phers: a transactional analysis approach. Ph.D thesis. Lancas-ter University; 2002.

2. Booth LA, Manning DJ. Observations of radiographer communi-cation: an exploratory study using Transactional Analysis.Radiography 2006;12(4):276e82.

3. Williams KB, Williams JE. The assessment of transactional anal-ysis ego-states via the adjective checklist. J Pers Assess 1980;44(2):120e9.

4. Steiner C. Scripts people live: transactional analysis of lifescripts. 2nd ed. New York: Grove Press; 1990.

5. Emrich K. Helping or hurting? Interacting in the psychiatric mi-lieu. J Psychosoc Nurs 1989;27:26e31.

6. Rowe J. Self awareness: improving nurse-client interactions.Nurs Stand 1999;14(8):37e40.

7. Parissopoulos S, Kotzabassaki S. Orem’s self-care theory, trans-actional analysis and the management of elderly rehabilita-tion. ICUS Nurs Web J 2004;17:11.

8. The NHS Knowledge Skills Framework and related develop-ment review. London: Department of Health; 2003.

9. Dieppe P. Soundbites and patient-centred care. BMJ 2002;325:605.

10. Stewart M. Towards a global definition of patient-centred care.BMJ 2001;322:444e5.

11. Kendall S. Do health visitors promote client participation? Ananalysis of the health visitor-client interaction. J Clin Nurs1993;2:103e9.

12. Pope C, Mays N. Qualitative research in health care. 2nd ed.London: BMJ Books; 2000.

13. Polit DF, Hungler BP. Nursing research, principles andmethods. 4th ed. JB Lippinncott Co; 1991.

14. Lo-Biondo-Wood G, Haber J. Nursing research; methods, criti-cal appraisal, and utilisation. 5th ed. Mosby; 2002.

15. Saks M, Allsop J. Researching health; qualitative, quantitativeand mixed methods. Sage; 2007.

16. DeCann R. What is a good radiographer? Radiogr Today 1985;51(597):127e32.

17. Hill RL, Simon B. Transactional analysis, a better patient ap-proach. Focus Crit Care 1984;11(3):11e6.

18. Arnold M. The importance of personality in the performance ofdiagnostic. Radiography 1997;3(2):83e98.

19. Smithers S, Catano VM, Cunningham DP. What predicts perfor-mance in Canadian Dental Schools. J Dent Educ 2004;68(6):598e613.

20. Fladeland DMY. Nursing programme success, personality andlearning style. University of Minnesoda, 1995 [PH.D].

21. Harris TA. I’m OK e you’re OK. London, England: Arrow Books;1969.

22. Jackson C. Assessment of clinical competence in therapeuticradiography: a study of skills, characteristics and indicatorsof future career development. Radiography 2007;13(2):147e58.

23. McCabe C, Timmins F. Teaching assertiveness to undergraduatenursing students. Nurse Educ Pract 2003;3(1):30e42.

24. Department of Health, The NHS Plan. London: Department ofHealth; 2000.

25. A Career framework for the NHS version 2. London: NHS Mod-ernisation Agency; 2004.

The radiographer-patient relationship 331

26. Levinson W, Frankel RM, Roter D, Drum M. How much do sur-geons like their patients? Patient Educ Couns 2006;61(3):429e34.

27. Zandbelt LC, Smets EMA, Oort FJ, Godfried MH, Haes HCJM.Determinants of physicians’ patient-centred behaviour inthe medical specialist encounter. Soc Sci Med 2006;63:899e910.

28. Fairhead JF, Rothwell PM. Under investigation and under treat-ment of carotid disease in elderly patients with transient is-chaemic attack and stroke: a comparative population study.BMJ 2006;333:525e7.

29. Haight BK, Christ MA, Dias JK. Does nurse education promoteageism? J Adv Nurs 1994;20:382e90.

30. Moss J. The impersonalisation of radiological technology. Can JMed Technol 1988;19(2):55e65.

31. Hewison A. ‘Nurses’ power in interactions with patients’. J AdvNurs 1995;21:75e82.

32. Murray N, Stanton M. Communication and counselling oncologypatients-are diagnostic radiographers adequately supported inthe role. Radiography 1998;4(3):173e82.

33. Ford S, Fallowfield L, Lewis S. Doctor patient interactions inoncology. Soc Sci Med 1996;42(11):1511e9.

34. Fallowfield L, Jenkins V. Effective communication skills are thekey to good cancer care. Eur J Cancer 1999;35(11):1592e7.

35. Chesson RA, McKenzie GA, Mathers SA. What do patientsknow about ultrasound, CT and MRI? Clin Radiol 2002;57(6):477e82.

36. Meier DE, Back AL, Morrison SR. The inner life of physicians andcare of the seriously ill. The patient-physician relationship.JAMA 2001;286(23):3007e8.

37. Chaiken EJ, Thornby JI, Merril J. Cating for terminally ill pa-tients: a comparative analysis of physician assistant’s and

medical student’s attitudes. Pers Phys Ass Edu 2000;11(2):87e94.

38. Badger J. Understanding secondary traumatic stress. Am J Nurs2001;101(7):26e32.

39. Garrosa E, Bernado MJ, Youxin L, Jose LG. The relationship be-tween socio-demographic variables, job stressors and burnoutand hardy personality in nurses. An exploratory study. Int JNurs Stud 2008;45(3):418e27.

40. Duquette A, Kerouac S, Balbir BK, Ducharme F, Saulnier P. Psy-chosocial determinants of burnout in geriatric nursing. Int JNurs Stud 1995;32(5):443e56.

41. Dowd SB. The radiographers role: part scientist part humanist.Radiol Technol 1992;63(4):240e3.

42. Karpman S. Fairy tales and script drama. TAB 1968;7(26):39e43.43. Ley P. Communicating with patients: improving communica-

tion satisfaction and compliance. London: Nelson Thomas;1997.

44. Marks DF, Murray M, Evans B, Willig C, Woodall C, Sykes CM.Health psychology: theory research and practice. 2nd ed. Lon-don: Sage; 2005.

45. Lyon R, Reeves PJ. An investigation into why patients do notattend for out-patient radiology appointments. Radiography2006;12:283e90.

46. Fengler K. The patient-care gap. Radiol Technol 1978;49(5):599e600.

47. Kabler C. Can a radiographer survive on technology alone?Radiol Technol 1986;58(1):19e21.

48. Reeves PJ, Unett EM. Trauma radiography: speed and effi-ciency. J Diagn Radiogr Imaging 1999;2(4):151e8.

49. Delivery of the 18 week patient pathway and beyond: a strat-egy for imaging workforce. London: The National DiagnosticsImaging Board; 2007.