The view from here: A sonographer's view of scanning in the Fetal Anomaly Screening Programme.

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?
CoR short survey to find out current requirements and capacity. #sonographyhttps://t.co/HF9mjyACw9

— SCoR Members (@SCoRMembers) March 20, 2018

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)