The radiographer-patient relationship: Enhancing understanding using a transactional analysis approach

Abstract

Purpose

Government initiatives such as the NHS Plan, the NHS Key Skills Framework and the NHS Career framework place communication at the centre of effective patient care, and role/career development. All advocate a patient-centred approach to dealing with patients, through open communication styles that encourage patients to become active participants in their care. Previous research, that has investigated communication in diagnostic radiography, demonstrated a preference for practitioner-centred, rather than patient-centred approaches to communication, however, there is little evidence to suggest why this should be the case or how a more patient-centred approach might be encouraged. The present study therefore 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 NHS trusts, with the aim of understanding their communication with patients and the factors that influence it. An open coding approach was used to analyse the data.

Results

Four attitude categories were identified as influencing the communication used by diagnostic radiographers. 1. Characteristics of the radiographer. 2. Characteristics of the patient. 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 attitude categories. If patient-centred styles of communication are to be encouraged, these factors need to be recognised and taken account of in the selection, education/training and workforce planning of diagnostic radiographers.

Introduction

This analysis of radiographer communication intentions, forms part of a wider empirical study.¹ These data represent only a small portion of the total data collected, and are based on interviews with diagnostic radiographers. The focus of those interviews was derived from the findings of a previous observation study² which demonstrated that categories of radiographer behaviours were identifiable through Transactional Analysis.

Non-participant observations, that used the Transactional Analysis (TA) subscales of the Adjective Check List,³ revealed that communication behaviours in diagnostic radiography could be categorised as Controlling Parent, Nurturing Parent, Adult, Free Child and Adapted Child.² The descriptions of these behaviours are outlined below.

Controlling Parent behaviours are dominant in nature. Here the radiographer focuses entirely on the technical aspects of the examination, to the point of excluding the patient's contribution; there is no use of the patient's name; information giving takes the form of verbal commands; there are no explanations about the procedure; and a patient's compliance with positioning is achieved through the physical manipulation of the patient. The radiographer controls the amount of conversation that takes place with the patient by reducing the amount of eye contact, and asking closed questions which effectively closes the communication channel.²

Conversely Nurturing Parent behaviours are sympathetic in nature. Radiographers typically introduce themselves to patients, more time is taken to explain the procedure, and adherence with positioning is achieved through the use of ‘coaxing’ and ‘praising’ behaviours e.g. “well done”, “yes that's great”, which are used to reinforce appropriate behaviour/movements. There is commonly social conversation 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

The Adult uses methodical and organised styles of communicating. The focus is on information giving. For example, radiographers explain the procedure and, importantly, check the patient has understood that explanation; they instruct the patient in what is required of them to complete the examination successfully using gestures and examples. Generally there is information exchange with the patient which includes the reasons for diagnostic tests and how they might inform the patient's care. Voice-tone is even and precise and the radiographer's manner is calm and reassuring.²

Free Child uses sociable communication behaviours, demonstrated by the ‘playful joking’ that occurs between the radiographer and the patient. The behaviours are relaxed and friendly e.g. laughing, joking, and the use of ‘expressive touch’. The interactions typically involve play, with amusing or fictional statements sometimes made about the room, the equipment, the examination, the radiographer, or even the patient.²

The Adapted Child is the part of the personality that allows us to ‘adapt’ to new/novel situations and is the source of “creative change” (p. 29).⁴ Radiographers exhibiting Adapted Child behaviours seem to lack confidence and appear hurried. There is a reluctance to engage patients in conversation and there is a focus on the technical aspects of the examination, but unlike the confidence seen with Controlling Parent behaviours, Adapted Child behaviours include mumbling and appearing slower and inhibited.²

Although radiographer behaviour fits broadly into these five categories, a small majority of radiographer-patient interactions can be categorised as Parental in nature (52.6%),1, 2 which reflects the nature of communication seen in other areas of health care, such as nursing, where a preference for Parental communication has also been found.⁵ The analyses of Booth1, 2 and Emrich⁵ demonstrates that one style of communication dominates throughout a single interaction. Given the complexity of human interactions and the many factors that impact on them, it is unlikely that this is actually the case. Nonethless the Parental styles identified by both Booth1, 2 and Emrich⁵ are generally considered undesirable in health care as they: encourage patients to be dependent on the practitioner⁵; do not encourage patients to be active participants in their care⁶; and encourage patients to adopt the ‘sick role’ i.e. they are illness maintaining,5, 7 Adult communication, found to make up 26% of radiographer-patient interactions,² discourages this.⁷ Adult behaviours treat patients as equals during interactions,⁵ by encouraging them to ask questions and to become more active in their care⁷; a philosophy supported by the NHS Key Skills Framework (KSF).⁸ The KSF identifies communication as one of six key dimensions that are central to effective working in health care. Good communication is described as the ability to “develop and maintain communication with people on complex matters, issues and ideas…in complex situations”,⁸ and it is argued that good communication also underpins the other five dimensions of the KSF. Achieving good communication requires a practitioner to place the needs of the patient at the centre of interactions, a notion known as patient-centred care.⁹ Patient-centred care advocates open-communication styles, treating patients as equals, and offering explanations and instructions that are within a patient's capacity of understanding.¹⁰ Behaviours that are arguably part of Adult, Nurturing Parent and Free Child communication.² Conversely the practitioner-centred approach views patients in terms of the disease from which they are suffering. Here practitioners do not actively involve patients in conversations as it is the practitioner who sets the agenda for what will be discussed, as well as what advice and information will be given.¹¹ An approach that can be likened to the behaviours seen in both the Adapted Child and Controlling Parent communication styles.²

Therefore, previous research has identified ‘how’ radiographers communicate with patients,² but more evidence is needed to explain ‘why’ they might communicate in a particular way. Without understanding this, it becomes difficult to ascertain how radiographers might be encouraged to adopt patient-centred communication over the preferred practitioner-centred approaches. Semi-structured group interviews were therefore conducted with a total of 12 radiographers from two NHS trusts, with the aim of understanding the nature of communication in diagnostic radiography and the factors that might influence it.