Lorraine Walsh's excellent article
entitled 'Why it is difficult for sonographers to talk' in Imaging Therapy and
Practice (April 2018) got me thinking about communication in obstetric
ultrasound and the experience of scanning within the screening programme.
Why it is difficult for sonographers to talk | Society of Radiographers https://t.co/1GnArBDZmJ— JacquieTorrington (@peabodysono) April 16, 2018
Although the fetal anomaly
screening programme is highly structured, the experience of scanning is more
complicated than the structure suggests and the quality of a scan depends not
only on the skill and experience of the operator but on factors relating to the
patient. It is important that true
limitations to the scan are clearly and sensitively explained to the parents
and recorded in the notes. Antenatal
ultrasound view is frequently impeded by fetal position, maternal obesity,
fibroids or abdominal wall scarring. The
fetal anatomy may appear abnormal due to these factors and on further
investigation be found to be normal. On
occasion, a sonographer may have an uneasy feeling about the fetus but will be
unable to elucidate why. Suspicion that
an underlying abnormality is present may be based on something as subtle as the
anatomy ‘not looking quite right’. It
is always advisable to seek a second opinion in these cases as sonographers see
large numbers of normal pregnancies so if something about a fetus makes them
uneasy a supportive Fetal Medicine Consultant will take it seriously. Sometimes these ‘gut feeling’ referrals turn
out to be abnormal.
Ultrasound examinations require
high levels of concentration and analysis by sonographers. Standard 4 of the NHS Fetal Anomaly Screening
Programme 2010 Standards requires that 30 minutes should be allowed for an anomaly
scan of a single fetus; most other scans require 20 minutes. It is common for ultrasound departments to
have to fit in extra scans for which there are no available appointments. Many
departments are chronically understaffed as in the UK there is a longstanding
and worsening shortfall in sonographer staff numbers meaning that there is an
insufficient number of trained Sonographers to meet the growing demand for
ultrasound examinations. In 2014 the
Society of Radiographers conducted a workforce survey of sonographers and found
the absence rate across responding departments to be 9% and vacancy rate of
18.1%; an increase on the 2011 vacancy rate of 10.9%. 33% of sonographers were over the age of 50
and only 35% under the age of 40. 65%
of responding departments had sonographers working more than their contracted
hours to meet demand.
The increasing number of women with
a BMI of over 30 combined with excessive hours of scanning and the technical
difficulties of achieving the images required for the Nuchal Translucency
measurement has led to an increase in the number of sonographers suffering from
work related musculo skeletal disorders, particularly affecting the neck and
dominant arm and hand of the sonographer.
In response to an increasing number of inquiries from sonographers
suffering from work related musculo skeletal disorders The Society of
Radiographers has produced guidance, most recently updated in 2016 giving
advice on how to reduce the risk of developing or exacerbating problems. A recommendation for those departments
providing FASP scans is the provision of secondary monitors in the scan room,
allowing the parents a view of the scan without the sonographer having to turn
the screen for them to see. In the absence
of a secondary monitor the natural desire of the parents to see the scan can
lead to the sonographer increasing their risk of injury by adopting a poor
posture while turning the screen for the parents to see.
Additional strains are caused by
the public perceptions of ‘the scan’.
Most sonographers are very aware of the importance placed on the social
aspects of the scan and wish to make the experience enjoyable and informative
when they can. An online survey of
social and commercial aspects linked to the two NHS FASP scans conducted by the
Society of Radiographers in 2015 gathered a 49% response rate from managers of
ultrasound departments conducting FASP scans.
The high response rate to the online survey makes it likely that the
themes in the answers are general across ultrasound departments. The survey was designed to obtain information
about parental expectations unrelated to the screening of the fetus. Expectations include the mother being able to
have her partner and other adults and children accompanying her, can learn the
sex of the baby and be given pictures to take away with her. A strong theme emerging from the survey
responses are tensions between the clinical justification for the screening
scan and the parent’s expectations which leads to distraction for the
Sonographer when the requirement for concentration is very high. The presence of others apart from the partner
in the scan room can be a problem when a fetal anomaly is identified. This is particularly difficult when children
are present. In my experience, most
complaints received by antenatal ultrasound departments relate to communication
and the social aspects of the scan. My
own experiences mirror the survey findings and include the increasingly common
experience of partners attempting to covertly video recording scans. Time spent by the sonographer dealing with
disruption in the scan room without escalating tensions and precipitating
conflict and subsequent potential complaint is a distraction from the screening
scan.
All these elements create a
stressful working environment for sonographers and increase the likelihood of
abnormal appearances being missed. The
sustainable solution to this situation lies in the recruitment and retention of
trained staff and the training of new sonographers. The Society of Radiographers is conducting a
survey of departmental training needs to identify current requirements and
capacity.
What are your current #ultrasound training needs?— SCoR Members (@SCoRMembers) March 20, 2018
CoR short survey to find out current requirements and capacity. #sonographyhttps://t.co/HF9mjyACw9
The analysis of the sonographer
workforce survey identified barriers to recruitment and training with 20
responding departments reporting a lack of suitable candidates for vacant roles
and a lack of funding for training. A
variety of other themes emerged from the survey including reliance on agency
sonographers and difficulty in retaining staff once qualified.
From the analysis of both surveys a
picture emerges of a profession working under continually increasing
strain. All of this is distracting and
results in cumulative pressure, increasing the risk of anomalies being missed
by stressed Sonographers.
Under the circumstances outlined
above it is necessary to question to what extent an individual sonographer
should be held solely responsible for missing anomalies in a screening
programme. The individual sonographer
has responsibility for the safe conduct of the scan; however, under the terms
of the NHS Constitution the employing trust has the responsibility to provide
the staff with a good working environment and ensure that staff have the tools,
training and support to deliver compassionate care.
References
Department for Health. 2015. The
NHS Constitution for England.Fetal Anomaly Screening Programme programme
handbook. 2015.
NHS Fetal Anomaly Screening
Programme. 2010. 18+0 to 20+6 Weeks Fetal Anomaly Scan National Standards and
Guidance for England
Public Health England. Down’s
syndrome screening Quality Assurance Support Service (DQASS): proposed changes to the threshold for red
flag bias. 2017.
Society and College of
Radiographers (SCoR). 2015. A survey of
social and commercial aspects linked to the two NHS fetal anomaly screening
scans: an on-line survey.
Society and College of
Radiographers (SCoR). 2014. Sonographer Workforce Survey Analysis.
Society and College of
Radiographers (SCoR). 2016. Work Related Musculo-Skeletal Disorders (Sonographers)
