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Radiography 19 (2013) 104e112

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Radiography

journal homepage: www.elsevier .com/locate/radi

Can skeletal image reporting be taught online: Perspectives of experiencedreporting radiographers?

Lesley Leishman*

School of Health Sciences, Faculty of Health & Social Care, Robert Gordon University, Aberdeen, AB10 7QG, UK

a r t i c l e i n f o

Article history:Received 8 August 2012Received in revised form5 December 2012Accepted 9 December 2012Available online 29 December 2012

Keywords:E-learningCourse deliveryInteractiveHealth professions

* Tel.: þ44 (0) 1224 263262; fax:þ044 (0)1224 263E-mail address: l.leishman@rgu.ac.uk.

1078-8174/$ e see front matter � 2012 The College ohttp://dx.doi.org/10.1016/j.radi.2012.12.003

a b s t r a c t

Background: Image interpretation relies upon expert clinical skill and comprehensive knowledge andunderstanding of the theories and concepts that underpin clinical practices. Traditionally, radiographerreporting education has been delivered using a blend of classroom based learning combined withworkplace clinical practice. The direct and indirect costs of staff development and maintenance of theservice has seen the incorporation of e-learning into courses in other health professions. Yet, despite itsproven success, in the UK radiography has been resistant to progression into e-learning for reporting.This study aims to explore the perceptions of reporting radiographers to interactive online delivery ofskeletal image reporting education.Method: Invitations to participate in the study were sent to 80 radiology departments in the UK.Reporting radiographers were asked to complete an online questionnaire to detail their reportingeducation experiences and to consider whether online delivery was a viable option.Results: A total of 86 radiographers participated in the study. They could see potential benefits of onlinedelivery but agreed it would only be suitable for delivery of theoretical subjects, and that development ofpractical/clinical skills required interaction with experts in the field to enhance learning.Conclusion: Image reporting education is not suitable for entirely online delivery, and a blended learningsolution, where online classroom based learning is combined with work based learning is moreappropriate as it allows for interaction with experts in the field of reporting to facilitate the developmentof reporting skills enhance the overall learning experience.

� 2012 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.

Introduction

The analysis, interpretation and diagnostic reporting of skeletalradiographic images is a complex, multifactorial process that reliesupon both expert clinical skill and comprehensive knowledge andunderstanding of the theories and concepts that underpin clinicalpractices. Traditionally, interpretation and reporting has beentaught using a blend of classroom based learning combined withworkplace clinical practice. The direct and indirect costs of staffdevelopment are widely reported,1 with implications for servicesustainability a particular feature of geographically distant loca-tions.2 A nationally recognised shortage of radiologists3 to super-vise workplace experience and support classroom based academiclearning has challenged health professionals to investigate alter-native mechanisms to deliver image reporting programmes.4

In response, in 2005 a joint venture by the Department of Healthand the Royal College of Radiologists introduced the e-Learning for

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f Radiographers. Published by Else

Health: Radiology e Integrated Training Initiative (R-ITI), a blendedlearning solution, combining traditional teaching models with e-learning techniques, which delivers the entire radiology corecurriculum through an interactive electronic learning platform.5

According to its curriculum guide, the purpose of the R-ITI is tosupplement the learning of ST1-3 specialist registrars on the 5-yearradiology training scheme and increase training capacity withoutputting any additional strain on current resources.

A critical review of literature showed that distance and e-learningformats are also being used more widely in other healthcareprofessions, both at undergraduate and postgraduate level, includingnursing6e8 and dentistry.9,10 Whilst the literature did highlight theissues of lack of interactivity with tutors and peers to enhancethe learning experience6,8,9 and the difficulties faced in teachingclinical/practical skills,7 the literature also highlighted the manypotential benefits, namely the flexibility for the students to fit studyaround personal and professional commitments1,2,6,8,9 and thepotential for the Higher Education Institutions (HEI) to attract largerstudent numbers from a wider geographical area.6,11 The authorsalso discussed possible solutions to the negative issues by embracing

vier Ltd. All rights reserved.

L. Leishman / Radiography 19 (2013) 104e112 105

new technologies such as discussion forums6,8 to promote inter-activity, and the use of simulation software9,10 for the developmentof practical skills.

In the radiography profession, the value of blended learning,incorporating e-learning techniques, has been studied12,13 and,despite highlighting the same potential drawbacks as the otherhealthcare professions previously discussed,6e10 it has been shownto be beneficial. Yet, despite this proven success and a growingdemand for online and distance learning provision, in the UnitedKingdom (UK) radiography has been resistant to progression into e-learning for diagnostic reporting. Radiographer reporting continuesto be necessary for the provision of timely reports and effectivepatient care,14 and easier access to flexible training which wouldminimise the effects on personal and professional commitmentswould be beneficial to the radiographers, their employers and ulti-mately the service users. Analysis of all radiographic reportingprogrammes across the UK in 200911 failed to identify any thatdelivered in an interactive electronic format. Similar to the R-ITIelectronic learning platform for radiology, e-Learning for Healthcare(e-LfH): Image Interpretation is a joint venture by the Department ofHealth and the College of Radiographers, an interactive e-learningresource supporting the development of image interpretation skills.Launched in 2010, its focus is on enabling development of basicimage interpretation skills required across the range of NationalHealth Service (NHS) healthcare professions who perform imageinterpretation as part of their clinical role, including radiographers.The level of image interpretation skills to be gained from partici-pation will enable individuals to give an informed opinion onimages, but it does not extend to those of the interpretation anddiagnostic reporting processes undertaken by skilled reportingradiographers, nor is the resource available to HEIs.

Given the progress reported by the R-ITI15 and the slow pace ofchange for radiographic image reporting courses, this study aims toexplore the perceptions of experienced reporting radiographers ofinteractive online delivery of skeletal image reporting education.

Method

Whilst the study was designed to obtain predominantly quali-tative data, some investigation of the demographics of the partic-ipants and frequency of the responses was considered beneficial,given that much of the previous literature had highlighted similarpotential benefits/drawbacks of online course delivery, and itwould be interesting to establish if the participants of this studyhad similar opinions.

A combination of question types was incorporated into the ques-tionnaire; closed-response questions16 were devised from the issuesthat had arisen in the reviewof previous literature. Somedidhoweverallow theparticipant to add their own comments to the list of answersoffered; this was felt to be more appropriate as closed-responsequestions have the potential to introduce bias16 and the purpose ofthe research was to elicit the personal opinions of the radiographerstaking part. Open-ended questions were also incorporated to allowmore detailed responses to be given. Given the high costs and poorresponserateofpostalquestionnaires17 anonline formatwasadopted.

The whole of the UK was targeted to ensure a sizeable sample ofparticipants. It was also felt that the issue of geographical locationwould always be raised by reporting radiographers in Scotland, andtargeting the whole of the UK would enrich the data gathered.

There is currently no national database of reporting radiogra-phers. Previous research requiring similar participants identifiedthem by targeting hospitals throughout the UK that had both anAccident and Emergency (A&E) department onsite and a radiographyservice.18 Some sites (Trusts) had more than one hospital fitting theinclusion criteria, although it was impossible to establish from these

sources howmany, if any, reporting radiographers were employed ateach. The decision was made to work on the assumption that therewould be one reporting radiographer at each of the hospitals,although the researcher was aware that somewould havemore thanone and some would have none at all, giving a potential recruitmentfigure of 240 participants. There is no agreed standard for theacceptable minimum response rate, but it seems to be generallyagreed that below 60% (n ¼ 144) is sub-optimal.19

Approval to carry out the study was granted by the School ofHealth Sciences Research Review Group (SRRG) at the Robert Gor-don University. An application was subsequently made for approvalof the project proposal by the NHS Research Ethical Committee(REC) and the NHS Research and Development (R&D) offices.Approval was granted for Scotland but correspondence receivedfrom the National Institute for Health Research Coordinated Systemfor gaining NHS Permission (NIHR CSP) Unit in England stated thatthe study was not eligible for inclusion in the NIHR Clinical ResearchNetwork (NIHR CRN) Portfolio, because it was a student project withno external funding. The letter did state, however, that this decisiondid not mean that the researcher was prevented from gaining NHSpermission outside the CSP. Communication with the local NHSResearch Scotland Coordinating Centre (NRSCC) confirmed that thisrefusal would mean the researcher contacting the REC of eachindividual site (Trust) where permission to carry out the researchwas being sought. Further information on the process was soughtfrom the NHS R&D Forum Website (http://www.rdforum.nhs.uk/001.asp) and this provided the researcher with contact informa-tion for the individual R&D offices throughout the United Kingdom.Four months later a cut-off date was set for receiving approvals andletters and participation packs were sent to the sites who had bythen approved the project (n ¼ 80).

Initial contact was made with the radiology managers, askingthem to act as gatekeepers for the project, only passing on partic-ipation information to the relevant staff member(s) if they felt itappropriate. Informed consent was gained from participantsthrough a check box at the start of the online questionnaire. Thetime frame set for data collection was 4 weeks.

Where previous studies have sought to explore participants’perceptions by questionnaire, where open questions are incorpo-rated to elicit unique individual responses, data analysis has been inthe form of coding/categorisation of responses and identification ofthemes.13,20 Given the purpose of the research, this was felt themost appropriate method for this study. Frequency of responses tothe questions was analysed using the Statistical Package for SocialSciences (SPSS v.19.0) statistical package.

Results

By the end of the specified data collection period, 86 participantshad completed the online questionnaire. As this was above the setminimum 60% response rate, the data collection period was termi-nated.Of the 86participantswho completed the onlinequestionnaire,72.1% (n ¼ 62) were female, which was to be expected in a femaledominated profession; 81.3% of all qualified diagnostic radiographystaff in the UK in 2007 were female.21 The majority of participantswere either in the 36e45years age range (34.9%;n¼ 30)or the 46e55years age range (37.2%; n ¼ 32). The results of this question were asexpected and, given that radiographer reporting is an advanced skillpracticed by experienced clinicians, it was not surprising to see only2.3% of participants (n ¼ 2) in the 20e25 years age group (Fig. 1).

Geographical location of current place of employment

Participants were asked for the geographical location of theircurrent place of employment to establish whether or not the

Figure 1. Graph representing age range of participants.

L. Leishman / Radiography 19 (2013) 104e112106

questionnaire had been distributed widely throughout the UK. Ithad already been decided that the entire UK ought to be targeted,rather than just Scotland (the researcher’s own home country/placeof work) in order to reduce the bias that might have been intro-duced due to remote geographical location. Targeting the UK asa whole would also allow for a larger sample size.

Figure 2. Graph representing geographical lo

Given the issues surrounding the R&D approvals process outwith Scotland, and given that the arrival of the deadline date sawapproval from only 68 of the 146 sites approached, the spread ofparticipants is encouraging (Fig. 2). What is interesting is that of the12 participants in the “All Other Responses” category, 2 stated thattheir place of work was in Wales (1 North; 1 South West), despite

cation of current place of employment.

L. Leishman / Radiography 19 (2013) 104e112 107

the researcher having had no contact with the central coordinatingoffice there. It was suggested that these participants had possiblyworked in England at the time the study details were issued, andthen moved to a new post in Wales before completing the onlinequestionnaire, but this seemed very unlikely. The only other alter-native solution was that the central office had passed on theinformation to individual sites as part of the R&D approval processand that the study had been accessed by staff at the two sites beforethe approval process had been completed.

Time since qualification

Participants were asked how long it had been since they hadstudied for their reporting qualification in order to establishwhether advances in IT systems in use in HEIs could erase some ofthe issues previously highlighted as barriers to online educa-tion.6,9,12,13 That said, only 29.1% (n ¼ 25) of respondents hadstudied recently, within the previous 2 years (Fig. 3).

Course delivery

A previous study11 had highlighted the fact that, at that time, noHEIs delivered radiographer reporting education in an onlinedistance learning format, and the results from the question regardinghow the courses had been delivered confirmed that this was still thecase, with the 88.4% (n¼ 76)majority following the blended learningapproach, with a combination of block release and work basedlearning, and none offering online course delivery (Fig. 4).

One individual comment on a subsequent question in the surveydid however suggest that online education was being employed,albeit unsuccessfully:

“On line was tried during my course but was abandoned because ofpoor quality image transfer or unavailability of appropriate qualityviewing hardware and access for all of the cohort.”

Figure 3. Graph representing

Further investigation of this participant’s other responses to thequestions revealed that the time since study was 3e10 yearspreviously, and the question of advances in technology ironing outsuch issues must again be considered.

The participants were asked to report on any problems they hadencountered during their studies, the list of responses to thequestion having been derived from the common themes which hadarisen during the review of literature (Fig. 5).

Almost half of the participants (n ¼ 42; 48.8%) reported havingno difficulties, despite the fact that the majority of courses (n ¼ 76;88.4%) had been delivered by block release. That said, the responsesto the next question (Fig. 6) will demonstrate that 68.6% (n ¼ 69) ofparticipants lived within 100 miles, i.e. daily commuting distance,of the HEI so the difficulties around course availability, personalcommitments and professional commitments would not have beenan issue.

Distance from HEI to home/place of employment

The previously highlighted issues concerning geographical loca-tion of the HEI in relation to the student’s home, and the flexibilitythat online education could bring in relation to fitting studies aroundpersonal and professional commitments,1,2,6,8,9,12,13,22 formed thebasis for this question. Given the current geographical location of theparticipants (Fig. 2), it is not surprising that the majority of partici-pants (n ¼ 59; 68.6%) were based within 100 miles of the HEI, thusmaking it easier for these individuals to attend on a day-to-day basisand alleviating some of the problems previously discussed withreference to personal and professional commitments (Fig. 6).

Given the geographical location of the participants at the time ofstudy, it is not surprising that when asked if the course would havebeen more appealing had they not had to attend the HEI, 88.4% saidno. Further to this, when asked what their preferred deliverymethod would be, they were very much in favour of a blendedlearning approach, where work based learning was combined with

time since qualification.

Figure 4. Graph representing course delivery method.

L. Leishman / Radiography 19 (2013) 104e112108

attendance at the HEI, either on a block-release (n ¼ 58; 67.4%) orday-release (n ¼ 16; 18.6%) basis (Fig. 7).

It was encouraging to note that 11.6% (n ¼ 10) of the participantsdid consider blended learning an option, combining work based

Figure 5. Graph representing difficulties en

learning and an online virtual classroom, however none of theparticipants thought that radiographer reporting could be deliveredfully online, echoing potential problems previous studies havehighlighted with regard to teaching practical/clinical skills.7,12,13

countered during enrolment on course.

Figure 6. Graph representing distance from home/place of work to HEI where reporting qualification obtained.

Figure 7. Graph representing preferred method of course delivery.

L. Leishman / Radiography 19 (2013) 104e112 109

L. Leishman / Radiography 19 (2013) 104e112110

When asked specific reasons, the top three responses were thosehighlighted in previous studies, namely lack of face-to-face contactwith peers (n ¼ 78; 90.7%), tutors (n ¼ 70, 81.4%) and lack of expertcontact for lectures (n ¼ 72, 83.7%) (Fig. 8).

Expanded responses to this question echo the findings,including the value of face-to-face contact:

“I don’t think that anything could actually replace sitting ina group, with a radiologist or other expert and viewing/discussingimages. We got to know our group and tutors really well and thevisits to the university were really enjoyable.”

“I think that it is good to be in a group where you meet otherprofessionals who are going through the same study as you are. Itcan be a real help and ideas etc can all be shared.”

The issue of contact with experts in the same field (radiologists;reporting radiographers) was also discussed and it was apparentthat much of the learning of practical reporting skills is work based:

“I felt most of my reporting skills were provided by my mentor- thespecialist knowledge delivered at uni was intense but being able tospeak to my peers and discuss/discovery most were experiencing thesame difficulties was important to me - confidence levels were low!”

This relates back to previous studies where the ability to developclinical skills in an online environment was questioned.7,12,13

One participant also commented favourably on the block-release method of delivery, in relation to the issue of protectedstudy time,6 although a possible solution could be in the form ofa Learning Contract between the employer and student:

“The ability to leave your normal working environment to allowcomplete focus on your study is essential especially in busy radiog-raphy departments where study time could become disruptedaffecting the consistency and quality of any learning activity.”

Figure 8. Graph representing potential problems en

Which topics could/could not be delivered online?

The participants were provided with a list of topics which werelikely to be included in a postgraduate radiographer reportingcourse and asked which they consideredwere/were not suitable foronline delivery, as shown in Table 1.

This process highlighted the fact that many participants thoughtit could be successful in the delivery of theoretical modules,including pattern recognition, where online delivery was consid-ered appropriate by 73.9% (n ¼ 51) participants:

“simple, factual content sits well with e-learning”

On radiological anatomy/osteology; online delivery wasconsidered appropriate by 63.8% (n ¼ 44) participants:

“well established e-learning tools available”

However, online deliverywas not considered appropriate for thedevelopment of reporting (i.e. clinical) skills:

On image viewing principles, evaluation and diagnosis; onlinedelivery was not considered appropriate by 55.1% (n ¼ 38)participants:

“Experience and knowledge of Consultant Radiologists in their fieldof expertise is of paramount importance in learning what is classedas a "hands-on" part of the job. Experience of reporting all qualityof images is important and I don’t feel that this would be performedaccurately online.”

On diagnostic accuracy; online delivery was not consideredappropriate by 58% (n ¼ 40) participants:

“There are lots of factors involved in reaching a final report fora series of images and this varies from one patient to the next evenwith the same or similar set of images. Again, talking and discussing

countered in an online learning environment.

Table 1Topics for delivery.

Theory of pattern recognitionPrinciples of image viewing, evaluation and diagnosisDiagnostic accuracyReport writingClinical auditCurrent research and medico-legal aspects of reportingRadiological anatomy/osteologySkeletal pathologyJoint diseaseNormal variantsOther(s), please specify

L. Leishman / Radiography 19 (2013) 104e112 111

the factors with an expert in the field is important and a valuablelearning experience.”

One topicwhere the responses were very evenly distributedwasin the delivery of pathology. Despite the majority of participantsbeing in favour of online delivery of radiological anatomy/oste-ology, joint disease and normal variants, only 50.7% (n ¼ 35)considered this method appropriate for this particular topic area,compared to 49.3% (n ¼ 34) who did not. Comments from thosewho favoured the online delivery method included:

“Good quality images can be viewed online for teaching purposes.”

“As long as there is a forum for discussion and private questioningof areas that are not understood initially.”

The second comment highlights the fact that online deliverywould be suitable to a certain extent, but that further supportwould also be required, and this a common thread which wasapparent in many of the responses, including those given for thefinal question on other topics that had not been included in the list:

“Probably could be taught online, however it is far more interestingif interaction is possible. Lecturers often bring their own interestingcases to discuss.”

“This needs interaction with lecturer and peer discussion. Oftenglean other useful information perhaps not relevant to particularpathology being discussed or just helpful hints. Would need muchmore base support if no interactive teaching on course.”

Emerging themes

The key themes which emerged from the coding/categorisationof the responses are shown in Table 2.

Discussion

In considering online delivery of courses, the greatest advantageis its flexibility to enable the students to combine study withpersonal and professional commitments. Yet, when asked if thecourse would have been more appealing had HEI attendance notbeen a requirement, the majority (88.4%) said no. This could havebeen due to a large proportion (68.6%) of participants living within100 miles, i.e. daily commuting distance, of the HEI, thus negating

Table 2Key themes.

Online delivery suitable for theoretical modules onlyNeed face-to-face interaction with peersNeed face-to-face interaction with tutorsReporting skills learned by interacting with experts in the fieldMost learning of reporting skills happens in clinical environment

any such issues. Indeed, the participants favoured the blendedlearning approach of course delivery, combining attendance at theHEI with work-based learning. The previously documented indi-vidual comment in justification for this preferred method alluded toprotected study time, an issue previously highlighted in the litera-ture review6 but it is suggested that a learning contract23 be in placeto define requirements and support mechanisms. What is moreapparent is that the participants preferred the time spent on campus,as it allowed them to interact with their tutors and peers, thusenhancing the overall learning experience and allowing for feedback,questioning and discussion. This was a common theme highlightedin the review of literature6,8,9,12,13,22,24 and one which continuallyfeatured throughout the responses to the questionnaire in this study.

Another common theme to emerge was that of the suitabilityof online delivery of practical/clinical skills, such as imagereporting. This had been previously discussed in the litera-ture7,12,13 and again appeared throughout the questionnaireresponses. Two sub-themes emerged; that of the need for inter-action with experts and colleagues in reporting to learn suchskills; and that most of this learning happens in the clinicalenvironment. The first of these sub-themes relates back to theprevious issue of interaction to promote learning, whilst thesecond supports the blended learning approach to reportingeducation. This is further supported by the participants’ responseswhen asked to consider topics suitable for online delivery; again,any topic considered to be development of clinical/practical skillswas deemed not suitable, and the same reasons were given asjustification. That said, the participants considered some of thetheoretical modules suitable for this delivery method, and a smallminority (11.6%) did select the combination of work basedlearning with an online virtual classroom as their preferred coursedelivery method. Despite all of the potential advantages to onlinelearning, none of the participants thought that radiographerreporting could be delivered fully online.

Conclusion

None of the experienced reporting radiographers who partici-pated in the study considered reporting education suitable forentirely online delivery, although a small minority did considera blended learning solution,where online classeswould be combinedwith work based learning. The participants continually highlightedthe need for interaction with experts in the field of reporting toenhance their learning, particularly in the clinical environment. Themajority of participants did consider online education an option fortheoretical/academic topics but not for learning practical/clinicalskills; again the input fromexperts in thefieldwas seen as essential tothe learning process and development of reporting skills. Interactionwith peers and tutors to enhance the learning experiencewas also anextremely important factor in course delivery method. Whilst themajority considered this in a face-to-face scenario, a small numberdid recognise that there were means of virtual interaction whichcould be employed and be just as beneficial.

Radiographer reporting continues to be necessary in theprovision of effective patient care.14 Easier access to more flexibleeducation which would minimise the effects on personal andprofessional commitments would be beneficial to the radiogra-phers, their employers and ultimately the service users.

Conflict of interest statement

This study was completed as part of a student MSc researchproject. No external funding was received and there are no conflictsof interest.

L. Leishman / Radiography 19 (2013) 104e112112

Acknowledgements

The author would like to thank Dr Mandy Plumb, OxfordBrookes University, for her guidance and support as academicsupervisor, and the staff of the School of Health Sciences, RobertGordon University Aberdeen, for their continued encouragement.

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