Communication in the delivery of an ultrasound service
Communication, defined as conveying information from one place or person to another serves different purposes depending on the context in which it takes place (van Dulmen, 2002). In healthcare it is essential for patients to communicate the reason for a visit and their level of distress and discomfort as well as their concerns to healthcare professionals. Conversely, patients rely on healthcare professionals to communicate instructions, information and advice (van Dulmen, 2002). Within healthcare in particular, each and every word or gesture appears to have significance (van Dulmen, 2002), emphasising the importance of communication in healthcare.
This work aims to discuss the role and importance of communication in ultrasound service delivery including communication between sonographer and patient and barriers to this communication, communication of examination results to both the patient and referring physician and communication with other healthcare professionals and the wider healthcare team. Communication in ultrasound is especially important since unlike many other areas of radiographic practice, the professional role of the sonographer is unique in its requirement for direct communication with the patient during an investigation (Milne & Spuur, 2009). Sonographers are often also involved in the provision of a differential diagnosis to the patient and communication of the results to the referring physician as an important aspect of their role. Communication among healthcare professionals and the wider healthcare team supports a team approach and reduces the chances of a breakdown in continuity of care, builds relationships and understanding between diverse disciplines and helps professionals to learn from one another (Hegan, 2003).
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A large part of the communication that occurs in the ultrasound department takes place between the sonographer and patient. Since sonographers are in the front line of patient interactions, representing a hospital or healthcare service to each patient encountered and many ultrasound examinations are time-consuming, possibly causing discomfort to the patient, patient relations are a high priority (Makely, 1990).
Communication is important both for building trust between the patient and the sonographer and also to assess the patient's medical condition and knowledge (Persutte, 2001). It is also of high importance to explain the examination procedure to the patient in non-technical terms. This serves to both alleviate anxiety and to gain patient consent to the examination (Hegan, 2003). The way in which this is communicated can put a patient at ease. An adequately informed patient is more likely to co-operate and assist the sonographer in achieving a good diagnostic study on the first attempt, reducing the need for repeat examinations (Makely, 1990). However, whilst an ongoing dialogue can put a patient at ease, it also can lead to a feeling that the sonographer is being distracted from their work. Therefore it is necessary to maintain a balance in the level of communication during the scan.
Some of the most important points to consider when communicating with patients include the delivery of information in an unhurried, honest, balanced, friendly and empathetic fashion which can lead to greater patient satisfaction (Persutte, 2001; van Dulmen, 2002). It is also vital that information be provided at a pace suitable for the patient, allowing ample time for the patient to react and interact. This is especially true where there is an inability of a patient to fully understand the situation (Persutte, 2001).
It is essential to explain procedures during the examination itself, such as why particular positions are important. In addition, patients should always be involved in decisions that involve them (Knoll, 2008; van Dulmen, 2002). A cheerful and professional attitude and communicating unforeseeable delays can also have a positive effect on patient experience whilst in the ultrasound department (Knoll, 2008). The friendly and supportive treatment of patients by staff is no longer just a matter of courtesy, but may prevent litigation in justified cases simply because of the excellent communication and service provided to the patient (Makely, 1990).
All healthcare professionals interact with a diverse and multicultural group of patients. Whilst not usually seen as a challenge, problems can arise if there are communication issues (Singels & van Haastrecht, 1998). A multicultural society demands intercultural approaches and training for successful communication, leading not only to less inappropriate requests but also better understanding of healthcare professionals by patients and vice versa, ultimately resulting in a better informed patient and greater patient satisfaction. The outcome is improvements in the quality and accessibility of healthcare services (Singels & van Haastrecht, 1998). However, communication may be difficult if there is a language barrier which can lead to miscommunication about medical procedures, patient history or symptoms (Teutsch, 2003; van Ewijk & Grifhorst, 1998). Miscommunication can result in patient stress and anxiety and possibly a less accurate diagnosis. In such situations, adaptation of communication style is required for dealings with patients across cultures (Teutsch, 2003). As mentioned above, sonographers routinely deal with difficult patients. Under these circumstances the sonographer must also adapt their communication style in order to help the patient understand the situation and put them at ease as much as possible. This can assist the sonographer to obtain the images necessary to complete the examination.
As experts in ultrasound image interpretation and diagnosis, sonographers are not routinely trained in the prognosis of pathology and treatment or strategies for communicating a differential diagnosis (Milne & Spuur, 2009). Very often, sonographers do however communicate the results of an ultrasound scan to the patient following an examination (Milne & Spuur, 2009). In ultrasound it can be difficult to break bad news to a patient and therefore the difficulties faced by doctors communicating prognoses may be equally relevant to sonographers (Simpson & Bor, 2001).
Since ultrasound scanning is carried out as a real-time examination, patients may be able to interpret for themselves the non-verbal cues and body language of the sonographer during the scan (Bowman & Squibb, 2001). Such cues include facial expressions, posture, touch, proximity and eye contact. If verbal and non-verbal communication signals are contradictory this can cause confusion or misinterpretation and at this point a patient may well question the sonographer on their findings. Therefore communication between sonographer and patient is important during the study (Milne & Spuur, 2009).
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It may be difficult not to communicate with a patient during an investigation and it seems that many sonographers believe that the intimate nature of an ultrasound scan and the associated non-verbal communication makes a requirement of not informing a patient of the result an impossible task (Bowman & Squibb, 2001; Milne & Spuur, 2009; Simpson & Bor, 2001). The willingness of sonographers to communicate findings might vary since they could fear a patient's or their own reactions to a patient's emotional distress (Bowman & Squibb, 2001). Sonographers may also fear not knowing the answers to questions that a patient may ask (Simpson & Bor, 2001). Other fears include the repercussions of providing the wrong diagnosis, legal action, loss of credibility with medical practitioners and causing unnecessary patient anxiety or hysteria (Milne & Spuur, 2009).
It appears that there is much variation associated with the communication of a differential diagnosis by sonographers. An Australian study by Milne & Spuur (Milne & Spuur, 2009) reported that there was no apparent consistency in the practices of patient communication. Many sonographers were reported to work with no constraints on how much information can be communicated to the patient but many sonographers were also apprehensive to discuss a differential diagnosis with a patient.
Communicating a differential diagnosis may alleviate patient anxiety and stress both during an ultrasound examination and whilst awaiting consultation with a physician. It may also increase patient satisfaction with the provision of the ultrasound service (Persutte, 2001) as well as prevent a sonographer's response to a question becoming cryptic or ambiguous in order to avoid revealing information (Milne & Spuur, 2009). It may be important to implement time to communicate the results to the patient during the examination since this may reduce stress for sonographers (Simpson & Bor, 2001). It is apparent that clear guidelines are needed to direct sonographers wishing to impart differential diagnoses in order to keep the patient well informed without causing undue distress (Milne & Spuur, 2009).
In addition to patient communication, sonographers also routinely communicate with other health professionals including consultants, surgeons, radiologists, nurses and colleagues within the ultrasound department including administration staff as part of the healthcare team. Good communication with all members of the department ensures a committed, supportive and faithful team and a pleasant working environment (Hegan, 2003). In difficult situations, communication with colleagues may help with conformation to ethical guidelines, patient feelings and thoughts and to build on personal experience and experiences of colleagues (Persutte, 2001). It is important to collaborate with colleagues and members of the wider healthcare team including other disciplines in order to ensure an adequate continuity of care for patients. Much emphasis must also be placed upon patient confidentiality and privacy when communicating with colleagues before, during and after an examination (Knoll, 2008).
The sonographer-patient relationship is unique in that the sonographer acts as a diagnostic aid between the patient and physician (Persutte, 2001) and is responsible for communicating the results of a study to the referring physician. Of equal importance to verbal communication, written communication is primarily used to communicate the results of an examination. Should a patient return to the ultrasound department at a later date the report should allow the sonographer to clearly reconstruct an examination without reference to memory or other colleagues and identify what was done and said at the time of the examination. Sonographers are likely to review a report at a later time when the details of the study are no longer fresh in their minds (Nagy et al, 2008) or may be asked to interpret a colleague's scan. Therefore abbreviations are only appropriate if they are widely used and not derogatory (Hegan, 2003). The results must be clear not only to referring physicians and sonographers but to other members of the healthcare team, since sometimes a receptionist or secretary is asked to convey or obtain the results via telephone. Communicating the results in this way also emphasises the importance of patient confidentiality when conveying the findings.
It is of the highest importance to communicate both normal and abnormal findings to the referring physician in a way that is of the most use to them (Persutte, 2001). Decisions about major and sometimes invasive treatment are based on the findings of an ultrasound investigation (Gordon et al, 2005) and therefore there must be excellent communication between those who interpret the results of the examination and the sonographers that acquire them (Nagy et al, 2008). Sometimes the physician interpreting the results is isolated from the ultrasound department by geographic distance and there is a lack of opportunity for physicians and sonographers to confer issues relating to examination results. Direct verbal interaction sometimes allows in-depth explanation of a sonographer's perspective (Nagy et al, 2008). An ultrasound examination must be interpreted in a real-time fashion and the diagnostic value of any one particular image cannot be determined without interpreting it. An ability to recognise and image pathology appropriately is fundamental to the training of a sonographer and if significant pathology is not identified during a real-time scan, it is unlikely to be documented on static images. Due to the dynamic nature of an ultrasound examination the sonographer is sometimes in the best position to answer questions relating to the results of an investigation (Persutte, 2001).
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Frequent communication between physicians and sonographers is also crucial for implementing change to scanning protocols or raising image quality control issues (Nagy et al, 2008). It is also important for communicating referral requirements. For instance some ultrasound investigations require a patient to be fit for surgery. This communication is necessary to reduce inappropriate referrals and increase the efficiency of an ultrasound service.
Effective communication is imperative for the delivery of high quality patient care (Persutte, 2001) and therefore it is as vital as speed and efficiency in the field of ultrasound (Booth, 2008). It is of the utmost importance to maintain a good level of communication with patients, physicians, colleagues and the wider healthcare team in order to deliver an excellent level of continuous care to patients as well as a high quality and timely diagnostic service (Nagy et al, 2008).
Sonographers are faced with many challenges when communicating with patients and must overcome communication barriers in order to successfully complete ultrasound examinations. The sonographer is uniquely involved in the physical, mental and emotional welfare of the patient as well as the communication of results to the referring physician. Consequently there should be an emphasis not only on verbal patient communication skills but also written communication skills for report-writing.
Many changes have occurred in the healthcare systems of many countries in the last two decades. Patients are more informed about healthcare, asking more specific questions than in the past and expecting and demanding more information and interaction with healthcare professionals (Makely, 1990). The work of sonographers is also becoming more technical and sophisticated and with this change comes a need for increasing independence. It has been suggested that there may be a need for policy change to provide clear guidelines for sonographers to communicate a differential diagnosis to patients as experts in their field (Milne & Spuur, 2009).
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