It is vital to gain a patient’s trust in the first few interactions; therefore the member of staff should be correctly attired and maintain a social distance whilst establishing eye contact (Fig. 3.8). Remember also, when calling patients from a waiting area, that speaking too close to a person may appear intrusive; too far away can seem very cold, impersonal and unfeeling. The patient should be called by title and family name, for example Mrs. Smith. If there is more than one person with the same name then it may be necessary to use a first name to clarify the patient’s identification. It is important not to shout from the doorway of the X-ray room or down a corridor as this can breach the patient’s confidentiality. It may also be necessary to assist the patient to stand or walk, or she may be in a wheelchair and unable to move independently.

Figure 3.8 Greeting the patient in the waiting room.

Although there may be time constraints for each examination, never assume that a patient requires assistance to move. A verbal confirmation from the patient establishing her personal needs is vital. If the patient declines assistance, be wary of demonstrating any inappropriate non-verbal communication that indicates impatience.

Confidential questioning

Any confidential questions required for identification of the patient (name, age, address) must be asked with due consideration to the patient’s right to privacy, e.g. in a changing cubicle (Fig. 3.9). There are usually signs in the waiting areas to remind female patients that if there is a possibility of pregnancy they should report it to a radiographer. However, to exclude pregnancy, female patients may also need to be asked about their menstrual cycle. The practitioner will now be working within the patient’s ‘personal space’ and should be aware of some people’s anxiety related to this.

Figure 3.9 Checking personal information in a confidential area.

Preparing the patient prior to the examination

Asking someone to undress can be embarrassing to members of the opposite sex or different age groups and therefore this must be carried out with sensitivity (Fig. 3.10). The instructions must be precise so that the patient does not get confused and anxious, but should not be delivered in a ‘military style’. Conversely, communicating in a reticent manner can give the impression of unreliability and lack of confidence, which may introduce a barrier to the interaction. The patient must also be given instructions on what to do when ready. It is essential that the patient is not asked to wait in public areas in a state of undress where she may feel uncomfortable.

Figure 3.10 Asking the patient to put a hospital gown on.

Preparing the room prior to the examination

Always prepare the X-ray room and equipment prior to carrying out the examination (Fig. 3.11). Consider the nature of the environment in which you work. Although as you become more experienced you may not perceive the technology as being anything other than ‘a means to an end’, for many of your patients their visit may be their only experience of diagnostic imaging. For some, the equipment and procedures can lead to considerable anxiety. Fear of possible pain and of the unknown, as well as apprehension of what the results may reveal, can add to a patient’s stress. Using good observational skills to monitor your patient’s non-verbal behaviours can help determine her needs during the procedure. Pre-procedure information about the investigation is helpful, but supportive interaction between staff and patient during the procedures can facilitate a significant decrease in anxiety levels.

Figure 3.11 Preparing the room prior to the examination.

INTERACTING WITH THE PATIENT DURING THE EXAMINATION

A patient entering the X-ray room may find the equipment quite daunting so the practitioner must realise that the patient may not be actively listening to instructions (Fig. 3.12). Therefore, it is essential to use gestures as well as words toindicate what is required. It is also necessary to use plain language and not technical jargon.

Figure 3.12 In the X-ray room.

The practitioner will now be working within the ‘intimate zone’ so it is important to fully inform the patient, before commencing the procedure, about exactly what you will need to do in terms of touching her body and what actions are needed from her in order to obtain an optimal image. By inviting the patient to position herself wherever possible, any embarrassment associated with your touch can be reduced (Fig. 3.13).

Figure 3.13 Positioning the patient.

Positioning the patient it is an ideal opportunity to make her feel at ease with general conversation. During early days of learning clinical skills it is possible that the technical aspects of positioning equipment and patient may overshadow the use of effective communication. Giving clear explanations of what is required is unlikely to take any longer than trying to manipulate an uninformed, rigid, anxious or embarrassed patient into the optimal position for the image capture. The patient may also need instructions on breathing techniques (e.g. halted inspiration/expiration). A practice of the required technique before the exposure often saves errors and possible repeat images being required due to movement unsharpness.

INSTRUCTING THE PATIENT AFTER THE EXAMINATION

After the examination the patient will be required to wait (possibly remaining in the gown) until the image has been processed and checked for quality and technical suitability. When the checking of the image is complete the patient should be instructed on the process by which they can obtain the results of the examination (Fig. 3.14).

Figure 3.14 Giving instructions to the patient on completion of the examination.

It is not within the remit of a student, assistant practitioner or practitioner to inform the patient of the diagnosis resulting from the image taken. However, the patient will inevitably ask and the response to this type of request can be difficult to deal with, especially if you are aware that there was an abnormality on the image. It is advisable to say that you cannot give details because the image will be looked at by a radiologist/reporting radiographer later. Do not feign ignorance of what the image shows because, as the patient will assume you have some knowledge of the human body, she might infer that you are lying. In this instance, your facial expression needs to match what you are saying.

DEALING WITH DIFFICULT OR AGGRESSIVE PATIENTS

In 1999 the Department of Health launched a policy of ‘zero tolerance’ towards intimidation and violence shown to NHS staff members by the general public in the healthcare setting. It should be remembered that all patients have the potential to be aggressive or difficult, not only the inebriated or the overtly psychologically disturbed. The key to diffusing the situation is to become proactive rather than reactive in the reduction of triggers for the unwanted behaviours.

The type of ‘welcome’ received by the patient on arrival in the department can defuse potentially difficult situations.³ There are many reasons for escalating aggressive behaviour including:

• delays resulting from machine breakdown or staff illness. There are, however, times during major accidents when waiting times for non-urgent cases increase – from experience, these rarely result in anger when the situation is explained.

• a practitioner refusing to image a patient due to an incorrect request card (which falls under the IR(ME)R justification protocols).

• the waiting area environment being overcrowded and noisy. It would seem that this becomes even more annoying and irritating with the addition of children.

• patient anxiety about the outcome of the diagnostic tests resulting in misinterpretation of the communication from the practitioner.

The method of reduction appears simple; however, life is not perfect and strategies must be put in place to deal with the aggression demonstrated:

1 If the waiting times for examinations have increased ensure the patients are kept informed of the potential delay. Remember – if you promise a delay of 15 minutes and it is 30 minutes then they will be disheartened; promise the opposite and patients will feel better for the early resolution. A sign indicating the delay is not always suitable because some individuals may appear to queue jump for examinations requiring different equipment.

2 Be observant. When collecting patients from the waiting area ensure that any non-verbal indications of agitation are monitored and acted on before the behaviour escalates into aggression.

3 Use verbal and non-verbal behaviours to alleviate confrontation. Never stand arms folded, raising your voice; a quiet open posture will be far more successful. Also acknowledge the ‘feeling’ not the ‘behaviour’; e.g. ‘I can see you are annoyed, angry, etc. What can I do to alleviate the problem?’ Speak in a quiet manner, shouting will only serve to lose the argument.³

4 Ensure that you do not place yourself in a location so that your exit from an escalating aggressive situation is blocked.

5 If the aggression cannot be de-escalated it is imperative that you remove yourself to a safe location and call for assistance.

INTERPROFESSIONAL WORKING

Your practice will show that there are many other healthcare disciplines with which an imaging practitioner may have a working relationship, and almost every user who seeks medical care interacts with more than one health professional. For some patients, the needs arising from their diagnosis require complex interprofessional collaboration. Problems with interpersonal communication across the different health or social care settings can have a profound impact on the user’s experience of care.

The NHS modernisation agenda emphasises the importance of collaborative and partnership working at all levels of the organisation. The Department of Health promote the inclusion of the service user as an active member of the healthcare team.

Headrick et al ⁴ suggest the following barriers to interprofessional collaboration:

• differences in history and culture

• historical inter- and intraprofessional rivalry

• differences in ideology, jargon and language

• different professional routines

• varying levels of education, preparation, qualifications and status

• fears of diluted professional identity

• differences in accountability, clinical responsibility, salary and rewards.

A multidisciplinary healthcare team is no different to any other group in society. According to Tuckman ⁵ a team passes through various stages (forming, storming and norming) until it reaches a performing stage and a possible phase of adjourning. During the formation there will be the inevitable vying for position and conflict of ideas until the group settles down and performs the required task.

Headrick et al ⁴ highlight that improvements in health outcome are likely to occur if relevant practitioners (and users) are brought together to share knowledge and experiences as a means to agree what improvements are needed. These agreedgoals can be tested in practice and are more likely to result in measurable improvements for patients than concentrating on what appear on the surface to be irreconcilable professional differences.

Quality teamwork and effective interprofessional collaboration share many characteristics:

• Goals or objectives are shared; there is an attainable and evolving, motivating vision with clear direction.

• Member roles and responsibilities are clear and known with responsibility for success shared among members.

• Atmosphere is respectful; mutual support is provided.

• Conflict is acknowledged and examined.

• The team is task orientated; the task is achievable.

• Authority and accountability structures are clear.

• Communication and information sharing is regular and routine.

• An enabling, supportive environment with access to required resources is provided.

Technological advances and the need for cost containment, whilst delivering improved quality and responsiveness of service provision to meet the demands of users, has meant that many NHS staff have had to adapt to changes in skill mix within their discipline. Health reforms have resulted in the adjustment of staff roles and the introduction of new roles or new types of workers, such as Assistant Practitioners.

If we are to provide a quality service for our users, especially at this time of NHS modernisation, it is important that we work hard to minimise the possible impact of interprofessional barriers. One of the major keys to effective collaboration and teamwork is effective interprofessional communication. If high quality care is to be offered by health and social care practitioners, communication must be viewed as a skill, which requires constant attention from each individual.