Radiography (2008) 14, 323e331

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

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

Lisa Booth*
School of Medical Imaging Sciences, St. Martins College, Bowerham Road, Lancaster LA1 3JD, UK Received 16 January 2007; revised 23 May 2007; accepted 1 July 2007 Available online 24 September 2007

KEYWORDS
Diagnostic radiography; Radiographer-patient communication; Transactional analysis

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 inuence 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 inuence it. An open coding approach was used to analyse the data. Results: Four attitude categories were identied as inuencing 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 inuenced 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. 2007 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.

* Tel.: 44 1524 384 580; fax: 44 1524 844 590. E-mail address: l.booth@ucsm.ac.uk 1078-8174/$ - see front matter 2007 The College of Radiographers. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.radi.2007.07.002

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L. Booth they might inform the patients care. Voice-tone is even and precise and the radiographers manner is calm and reassuring.2

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 ndings of a previous observation study2 which demonstrated that categories of radiographer behaviours were identiable through Transactional Analysis.

Free Child
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 ctional statements sometimes made about the room, the equipment, the examination, the radiographer, or even the patient.2

Background
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.

Adapted Child
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 condence 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 condence seen with Controlling Parent behaviours, Adapted Child behaviours include mumbling and appearing slower and inhibited.2 Although radiographer behaviour ts broadly into these ve categories, a small majority of radiographer-patient interactions can be categorised as Parental in nature (52.6%),1,2 which reects 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 identied 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 identies 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 ve 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 patients capacity of understanding.10 Behaviours that are arguably part of

Controlling Parent
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 patients contribution; there is no use of the patients name; information giving takes the form of verbal commands; there are no explanations about the procedure; and a patients 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

Nurturing Parent
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 thats great, which are used to reinforce appropriate behaviour/movements. There is commonly social conversation about the non-medical aspects of the patients care; and as well as task-orientated touch, there is evidence of expressive touch and terms of endearment such as love or dear.2

Adult
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

The radiographer-patient relationship 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 identied 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 difcult 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 inuence it.

325

Procedure
The interviews were audio-taped, as it was considered that writing responses down would have been distracting to the participants.13 Audio-taping also gave credibility to the ndings, as the tape could be replayed for accurate transcription. The transcriptions were analysed by the interviewer and another experienced researcher to ensure consistency, reliability and validity of the ndings. Two interviews took place, one in each trust, at times that were mutually convenient for the radiographers and the interviewer. A week prior to the interviews the volunteers were given consent forms, along with a description of ve communication styles that had been identied from earlier observations1,2 (these descriptions are outlined earlier in this paper); the name of each communication style was omitted from these descriptions, as it was thought that these might inuence the participants responses. At the beginning of each interview the purpose of the interview was explained and permission to use the tape recorder conrmed. It was explained again that any responses would be kept strictly condential and it was also explained that although the interviewer had a number of issues to cover, the purpose of conducting the interviews was to allow the radiographers to raise any issues they felt were relevant. Consent forms were handed back to the researcher at this point. One interview lasted 60 min, and the other lasted almost 90 min. The interviews began with a grand tour question15 Have you read the descriptions of the communication styles? What do you think? The decision to keep the rst question openended and non-directive was a deliberate attempt to avoid interview bias, which is where an interviewer inadvertently encourages particular responses from their participants, through subtle verbal/non-verbal behaviours.14 The openended nature of the question therefore encouraged participants to begin speaking, but the conversation that then took place between the participants meant that there was very little need for further input from the interviewer. Furthermore, the non-directive nature of the question meant that the content of these conversations was not affected by the interviewers agenda.15 However, the researcher was interested in the participants attitude towards all ve communication styles, therefore, if the grand tour question did not elicit a conversation about these, the interviewer would encourage conversation by asking a more direct open-ended question e.g. What about communication style 5? (in this case communication style 5 refers to Free Child). Although more directive, the open-ended phrasing of the question meant responses were still valid, as participants were articulating their own experiences, rather than conforming to a pre-determined set of categories that had been decided on previously by the researcher.15 All participants appeared to contribute equally, perhaps due to the informal nature of the interviews, or because the participants knew each other and the interviewer. There was some concern that the relationship, between the interviewer and the participants, might have created a response bias, where participants respond to questions in a way that gives a favourable impression, a response

Method
Approval for the research was gained from the two Trusts from which the research participants were recruited, and the research was consistent with St. Martins College Ethical Principles and Guidelines for Research Involving People. Two semi-structured, group interviews took place. The semi-structured approach allowed a number of open-ended questions to be asked in a loosely structured format, which ensured the researcher covered all issues, whilst being afforded the freedom to diverge or pursue responses in more detail.12,13 The group interview technique capitalised on the communication between the participants in order to generate more data.participants were encouraged to talk to one another, ask questions, exchange anecdotes and comment on each others experiences and points of view (p. 20)12 while the interviewer listened in and recorded these conversations.

Sample
The semi-structured interviews were conducted by the researcher with qualied general radiographers who worked in two NHS trusts. Volunteers were recruited by placing a notice that explained the purpose of the study on staff notice-boards. Exclusion criteria were: staff grade superintendent III and above, non-general radiographers and radiographers who had been involved in an earlier stage of the research. Twelve volunteers were recruited, six from each hospital trust. Eight were female and four were male. Eight were radiographer grade, two were of senior II grade and two were senior I grade. Although such a small conveniently selected sample generates ndings that cannot be generalised to the population as a whole; the aim of the research was to discover meaning about a previously un-researched phenomenon, so generalisability was not the main concern at this stage of the investigation.14

326 style known as social desirability.14 This response style is particularly relevant when anonymity from the researcher is not preserved. However, Becker (1970), cited by Saks and Allsop15 stated that .the information disclosed by participants (during interviews) is so detailed that it guards against bias by making it difcult for participants to produce data that uniformly supports a mistaken conclusion (p. 82). With this method being used to triangulate ndings from an observational study, it was possible to infer that the responses were reliable and valid, as they supported what had been observed in practice. Over-all it was perceived that the relationship between the interviewer and the participants actually added to the level of honesty, rather than detracting from it, but it was noted that participants tended to comment that it was other radiographers, and not themselves, who exhibited negative behaviour towards patients. This might be attributable to a lack of self-awareness, rather than a deliberate attempt to give a favourable impression to the researcher, as many of the comments were extremely honest, to the point that the researcher was surprised at the level of detail offered.

L. Booth communicate using the same communication style, whatever the circumstance. These responses are represented in the comments below. e some people are single mindedly one way e communication is a personality trait of their lives. However, there are other inuences on communication and the radiographers recognised their use of interactions that can be characterised as Adapted Child when faced with new examinations, examinations that they did not undertake regularly, or when dealing with new equipment e.g. e communication is down to condence e its the individuals perception of themselves.if you pick up a card and think I hate doing these, because 9 out of 10 times I have to repeat it.you wouldnt talk to the patient. They also commented on the use of Adapted Child behaviours by students, perhaps because students are faced with novel examinations/equipment more often than qualied staff; e You see it with students.theyre less sure.

Analysis
The interview record was rst transcribed verbatim from the tape recordings that had been made, the analysis of which made use of the inductive open-coding technique.12 This analysis involved identifying a question and then attempting to answer, verify, conrm and qualify that question by searching through the data (p. 78).12 Once categories and codes had been determined by the interviewer they were passed to a second researcher, along with the transcripts, to establish the reliability of the categories and codes.

Characteristics of the patient Despite their own personal characteristics and how these inuence communication, there was a general feeling amongst the radiographers that they still tried to, negotiate their approach every time a patient came through the door. They commented that they would use Nurturing Parent behaviours with elderly patients and children. However, if patients are a similar age to the radiographer, it seems that Adult behaviours are preferred, e I wouldnt use it [Nurturing Parent] on somebody my age.it could be patronising.with those patients I would be more likely to be [Adult] e I would use it [Nurturing Parent] with certain patients.old patients e Id be [Nurturing Parent] with old people, geriatrics and kids. Patient characteristics are therefore important in radiographer-patient relationships and will inuence how radiographers communicate. For example, if a patient is intoxicated, or is too familiar, then radiographers are more likely to exhibit Controlling Parent behaviours, probably because it enables them to exhibit a more dominant position in the interaction, e sometimes when the patient winds you up youre [Controlling Parent] e I nd Im [Controlling Parent] with people who are drunk, I shout over them.be rm e I become defensive and [Controlling Parent] when somebody is really forward.

Results
Four categories of ndings emerged from this analysis: 1. Characteristics of the radiographer e subdivided into 1a. Personality 1b. Condence 2. Characteristics of the patient e subdivided into 2a. Age of the patient 2b. Behaviour of the patient 2c. Patient illness or injury 3. The need to produce a diagnostic image 4. The need to keep the department running

Data Interpretation
Although the research participants were provided with numeric identiers for the communication styles, rather than using the conventional labels for the reason explained earlier, the conventional labels are used in this interpretation to aid readers understanding. The characteristics of the radiographer According to the radiographers interviewed, how they communicate depends largely upon their personality. They went on to discuss that individuals tend to

The radiographer-patient relationship Conversely if the radiographer knows the patient, then they feel comfortable taking on a less dominant role in the interaction e.g. e Im not often [Free Child].but with patients who are repeat visits, because they know whats going to happen, I might be then, because I can relax with them more. A patients illness or injury also inuences how radiographers communicate. For example, Adult behaviours might be used in situations where radiographers are faced with conicting stimuli e.g. poly trauma patients. These patients are often in a lot of pain, they will require some degree of technique modication, there is usually bleeding and often there are other health-care personnel in the x-ray room. To deal with these stimuli efciently, the radiographer needs to work in a methodical and organised manner. e With accidents youve got to be [Adult]; in-out; efcient; and on the ball The radiographers went on to explain that the praising used in the Nurturing Parent style was a helpful technique when examining patients who are in a lot of pain. They use this technique to encourage patients to overcome their fear of experiencing pain, and in doing so persuade the patient to move into the desired position. e You use [Nurturing Parent] if theyre in a lot of pain; they need coaxing into doing it But it is the technical styles of communicating i.e. Adapted Child and Controlling Parent that would be used in emotionally stressful situations; e Sometimes I avoid [Nurturing Parent], because you dont feel happy being sympathetic someone who might start crying on you e Youd be [Adapted Child] with patients who are really ill and you dont know how to deal with that. This focus on the technical task protects radiographers from engaging in a potentially emotional conversations with patients and prevents, giving patients an opening that you as a radiographer wont be able to deal with. The need to produce a diagnostic image Radiographers use a range of communication behaviours to help them achieve their goal of producing a technical image. e you can use communication to get the best (image) out of the patient. For example, the radiographers interviewed stated that Nurturing Parent behaviours are used to reinforce appropriate behaviours in the patient that consequently assist in the process of producing a diagnostic image. e coaxing the patient, makes taking the x-ray easier for you.

327 Whereas they comment that they use Adult behaviours to demonstrate to a patient exactly what is required of them, to ensure that a diagnostic image is produced. e You have to say WHY it is important they dont move e sometimes, instead of modifying your technique you can interact with the patient in such a way as to get them to do something.like straightening their elbow e I nd if you show them what they need to do...

Keeping the department running Perhaps the greatest predictor of Controlling Parent behaviour is the need to keep the department running. e Youd be more likely to be [Controlling Parent] if youve got a big queue of patients, youre going to concentrate on your technical role e If youre not focussed on the technical outcome you are going to be there all day and other patients will suffer e You dont use [Adult] when its busy.I dont think you can give the patient as much information as you would if you had more time e If youre busy you will tend to move more quickly to restraining a child than if it is quiet.

Discussion
Given the relatively small sample size used in the current study and how the experience of being a radiographer is probably inuenced by individual hospital environments and clinical specialities, this study must be viewed as an exploratory investigation of factors that can inuence communication events in diagnostic radiography. These factors have been found to include: personality and condence of the radiographer; the age of the patient; the behaviour of the patient; the patients illness or injury; the need to produce a diagnostic image; and the need to keep the department running. It is unlikely that this list is exhaustive and it is possible that further investigation, that uses a sample more appropriate to the population as a whole, would reveal other factors relevant to communication in diagnostic radiography. Nonetheless, the initial data that are presented here seem to support evidence and comments within the existing radiographic literature and go some way towards understanding and identifying some of the barriers to the effective communication that is espoused in the NHS Key Skills Framework.8 It has been argued that the personal characteristics of radiographers are important for presenting a professional image and when providing good patient-care. Because of this it has been suggested that personality characteristics, particularly those that are associated with the personality construct extroversion, should form the basis of personnel selection into radiography.16 Extrovert individuals are generally socially outgoing, uninhibited and good at making and maintaining interpersonal contacts.17 Nonetheless, selection for radiography personnel remains largely subjective, perhaps because it is believed that students who perform well clinically do not always perform well academically

328 and vice versa.18 However, research in both dentistry19 and nursing20 contradict this belief, and advocate personnel selection on the basis of extroversion, nding it to be associated with improved clinical performance19 and successful academic performance.20 Similarly, Arnold18 found extroversion and good clinical performance to be related in radiography, and did not nd any evidence to suggest that extroversion and poor academic performance were correlated. The present study also seems to support the view that personality should be a consideration when selecting radiography personnel. For example, the radiographers interviewed suggested that each radiographer has a preferred style of communicating and that this preferred style is closely related to the radiographers personality. This nding is perhaps unsurprising in that the behaviours identied during the course of this investigation are based upon the theory of Transactional Analysis (TA). According to TA an individuals personality consists of three ego-states; the Parent; the Adult; and the Child. Everybodys personality is structurally alike, in that they have a Parent, an Adult and a Child, but they differ in the working arrangement of these three areas the extent to which the Parent, Adult and Child function.21 Nonetheless these functional differences mean that everybody has a personality that is unique to them which, because personality and behaviour are closely linked, results in behaviour that is relatively consistent. This perhaps explains why the radiographers interviewed discussed communication as a personality trait of their lives. However, an individuals experiences and beliefs allows them to adapt the working arrangement of their ego-states (and so behaviour)21 and it is this skill that would allow radiographers to negotiate their approach every time a patient comes through the door. Nonetheless these contrasting views highlight one of the most fundamental problems when using an interview technique, in that what people say they do and what they actually do might be quite different.14 It would be interesting therefore, to undertake further investigations to determine which is more predictive of communication in radiography; a radiographers personality or a radiographers experiences and beliefs. The outcome of such a study would determine whether or not personality should, in fact, form the basis of personnel selection into diagnostic radiography. It does seem, however, that experience is important. Radiographers can lack condence and self esteem, which manifests itself in submissive behaviour,22 such as Adapted Child.2 Condence, in particular, affects technical expertise, as well as interpersonal skills and patient care.23 The radiographers interviewed highlighted how condence in technical abilities if you pick up a card and think I hate doing these, because 9 out of 10 times I have to repeat it.you wouldnt talk to the patient; as well as condence in dealing with patients Youd be [Adapted Child] with patients who are really ill and you dont know how to deal with that, ultimately affects communication. Given the importance of condence in terms of technical/interpersonal competence, it has been argued that radiographers who lack condence should be supported and mentored during a rst-post registration year to ensure that they meet the requirements necessary to be considered competent to practice.22 Those radiographers who demonstrate high standards of competence, and possess

L. Booth skills more usually seen with experience, could be encouraged and supported in a similar way. The aim of this support would be to maximise future career potential and government initiatives such as the NHS Plan,24 The NHS Career Framework25 and the NHS Key Skills Framework,8 seem to support such a move, although the associated costs and implications for the training and education of diagnostic radiographers would need to be considered before such a programme could be rolled out nationally. Although radiographer characteristics are important, radiographers are, in fact, only one element of a much more complicated process. Interactions between radiographers and patients are interpersonal exchanges, where the radiographer and the patient are reacting emotionally to one another,26 as such the patient also contributes to the style of communication used. The radiographers interviewed acknowledge this, stating that they tried to negotiate their approach. Negotiating how best to talk to patients is a commonly talked about feature of healthcare interactions,26 and age of the patient has been found to be one factor that does inuence practitioner talk.27 For example, facilitative behaviours such as coaxing and praising (associated with Nurturing Parent behaviours), are more often seen when health practitioners are dealing with older adults27 and the current research also demonstrated a preference for Nurturing Parent behaviours when dealing with this patient group. An explanation for this is offered by the work of Levinson et al.,26 where it was demonstrated that practitioners feel more warmth and enthusiasm for older patients, than they do towards younger patients. Levinson et al.26 went on to argue that this nding disputes any concerns that ageism is undermining quality of care. However, the sample of 66 doctors (predominantly male) and 660 patients (predominantly female), that was used in the study, allowed for an inherent bias that favoured the elderly patient, in that the mean age of the sample was 60 years old. Studies that look specically at inequality in health care certainly consider ageism to be a signicant problem.28,29 Nowhere is this more evident than in the referral rates for diagnostic procedures. For example, in 2003 only 79% of patients aged 61 and over were offered brain imaging after stroke, compared to 97% of patients aged 60 and under.28 It is therefore more likely that the communication seen with older adults is not because they are viewed more positively by practitioners, but is actually because they think older people are more likely to misunderstand instructions and explanations, due to age-related cognitive failure.30 This stereotype actually leads to older adults being treated in a Nurturing Parent-Child fashion and is a phenomenon known as the rescue game, where the helper actually takes over the task and consequently takes away the patients control (p. 146).4 These Nurturing Parent behaviours are accepted in health care as they appear to reconcile the caring approach practitioners are expected to adopt alongside the technical functions they are actually performing.31 Whereas Nurturing Parent behaviours might be accepted in diagnostic radiography, the behaviours demonstrated during emotional interactions are more difcult to reconcile. It has been said that in order to deal with an oncology/ terminally ill patient, radiographers need to acknowledge what the patient is going through.have empathy, listening skills and the ability to discuss life and death topics should

The radiographer-patient relationship they arise.32 The reality is that radiographers use Controlling Parent/Adapted Child behaviours to distance themselves from these patients. Murray and Stanton32 reported that this is because diagnostic radiographers nd dealing with oncology patients stressful; partly because they are unable to deal with the strong emotions that are experienced; and partly because they fear doing psychological harm to the patient. Only 15% of oncology patients, whose condition merits psychiatric intervention, are ever referred to professionals who might be able to help them.33 In medicine, clinicians also use Controlling Parent behaviours to avoid engaging with the patient i.e. they divert conversation topics, use closed/leading questions and avoid making eye contact.32,34 Some doctors do, however, acknowledge that their communication skills are inadequate and have handed-over their responsibility to specialist nurses, but evidence suggests that these nurses are using the same distancing techniques.34 The consequence is that poor communication exists between practitioners and patients and between practitioners themselves. That is, the assumption is often made by each practitioner, that another practitioner must have relayed the relevant facts (about tests and treatments, to a patient) at the appropriate time,34 because of the distancing techniques that are being employed; practitioners do not check whether this is in fact the case, as evidenced by Chesson et al.35 who found that although 82% of patients had been told why a radiological investigation was necessary, 64% did not know which investigation they had actually been referred for. The emotional reactions experienced by practitioners working in these stressful situations include; feelings of failure; powerlessness; frustration; and grief36; as well as a fear of death and dying (thenatophobia).37 These emotional reactions are not exclusive to practitioners who work in oncology, they have also been seen in practitioners who deal with prolonged resuscitation/recovery, burn victims, trauma victims, and children in neonatal intensive care.38 The outcome is generally the same with practitioners exhibiting a desire to avoid involvement with the patient, in an attempt to avoid the strong emotions that are associated with that persons care.34 Although these distancing techniques are used to protect the practitioner from experiencing stressful emotions, there is a growing body of evidence that suggests such techniques actually lead to occupational burnout.32,34 The rst symptoms of which are; desensitisation to patients needs; and distancing oneself from potential stressors at work. Eventually these symptoms start to affect personal relationships outside of the work environment.38 Burnout affects almost 25% of health practitioners39 and is associated with high levels of staff absenteeism and turnover.40 If radiographers are to be encouraged to engage with these emotional situations, it is advocated by Murray and Stanton32 that training and support needs to be made available to radiographers. This training should include learning to ask for help and recognising when help is needed, as without this skill distancing techniques will continue and burnout is highly probable. Distancing techniques and practitioner-centred communication have also been found, in previous studies, to be a consequence of technical priorities i.e. the need to produce a diagnostic image.41 However, the present study implies that this might not actually be the case.

329 Different styles of communication seem to be used, by diagnostic radiographers, as strategies for achieving a diagnostic image. This is highlighted by the comment you can use communication to get the best (image) out of the patient. It is worthwhile noting that the behaviours associated with this diagnostic success are those that are synonymous with patient-centred care e.g. Free Child behaviours were identied as being useful when examining children; Nurturing Parent behaviours were preferred when examining older adults; and Adult behaviours were found to be effective in explaining to patients what was required of them. These responses raise an interesting notion; radiographers are consciously choosing styles of communicating that are based on their desire to achieve a diagnostic image. These types of interactions are known as ulterior transactions, where the overt behaviours appear to depict one message, but the covert message is actually another.4 Although these types of messages are often associated with psychological game playing,42 the fact that radiographers are consciously choosing one style of communicating over another suggests they are more likely to be manoeuvres.4 Choosing styles of communication, to control patient behaviour, was a feature of Hewisons study.31 Here it was argued that nurses use Overt Power (Controlling Parent) to simply tell patients what to do, and Terms of Endearment (Nurturing Parent) to persuade patients to undertake tasks. Hewison25 also went on to say that although Adult interactions do not appear to be overtly controlling, they do in fact Control the Agenda, in that the questions asked have a limited range of responses which ensures the patients participation. For example, the question will you be able to get up on the table? gives the impression that the patient is being included in a decision, but in fact they are being told that they have to get onto the table. Using communication to achieve patient adherence has been a part of health care research since the late 1970s.43 Communication has been found to contribute to the success of drug/dietary regimes43,44 and attendance for appointments,45 and the ndings of the present study suggest that communication is also important for achieving diagnostic success. Successful imaging results in a reduction in repeat/reject rates, which in turn would reduce the radiation dose to the patient. Advantages that merit further investigation. Therefore patient-centred behaviours seem to be correlated with diagnostic accuracy, but radiographers adopt more practitioner-centred behaviours i.e. Controlling Parent, when faced with time pressures and keeping the department running smoothly. It is possible that focussing on the technical task, asking closed/leading questions, using monosyllabic responses and making little eye contact, reduces the amount of conversation that takes place with the patient. The perception being that these conversations add to the time it takes to complete examinations. As early as 1978 it was proposed that radiographers have two roles in caring for patients; a technical role and a psychosocial role.46 Since this time there has been much speculation as to how time-pressures might affect the importance radiographers attach to these roles, although it has always been presumed that the technical role would dominate.47 This is perhaps not surprising when the environment in which a radiographer works is

330 considered. This environment, coupled with an education and research base that is dominated by science and technology, ensures an almost unilateral emphasis on the technical aspects of the radiographers role. Although this role ideal might be quite different to a radiographers personal beliefs, it has the potential to be the overriding inuence on their behaviour. Nowhere is this more evident than in the following quote taken during the interviews: If youre not focussed on the technical outcome you are going to be there all day and other patients will suffer. Evidence suggests that this has not always been the case. The ndings of Reeves and Unett,48 some eight years ago, suggested that although speed and efciency were considered to be important in radiography, they were not as important as good communication skills. However, the radiographers interviewed in the present study suggested that communication becomes less important when departments are busy. When time pressures dominate; speed and efciency are more important qualities. This change has possibly emerged due to remote management styles47 and an ever increasing emphasis being placed on as many patients in as shortest time possible.49 If communication is to be central to effective working within the NHS,8 more work is needed to determine the impact of increased patient-throughput on communication e.g. delivering the 18 week patient pathway, and how these in turn affect patient understanding, memory, recall, satisfaction and adherence with diagnostic radiography regimes.

L. Booth

Acknowledgements
The author would like to thank Professor D. Manning for his assistance with managing the data and Professor H. Leathard for her help in putting together this paper.

References
1. Booth L. The communication strategies of diagnostic radiographers: a transactional analysis approach. Ph.D thesis. Lancaster University; 2002. 2. Booth LA, Manning DJ. Observations of radiographer communication: an exploratory study using Transactional Analysis. Radiography 2006;12(4):276e82. 3. Williams KB, Williams JE. The assessment of transactional analysis ego-states via the adjective checklist. J Pers Assess 1980; 44(2):120e9. 4. Steiner C. Scripts people live: transactional analysis of life scripts. 2nd ed. New York: Grove Press; 1990. 5. Emrich K. Helping or hurting? Interacting in the psychiatric milieu. J Psychosoc Nurs 1989;27:26e31. 6. Rowe J. Self awareness: improving nurse-client interactions. Nurs Stand 1999;14(8):37e40. 7. Parissopoulos S, Kotzabassaki S. Orems self-care theory, transactional analysis and the management of elderly rehabilitation. ICUS Nurs Web J 2004;17:11. 8. The NHS Knowledge Skills Framework and related development review. London: Department of Health; 2003. 9. Dieppe P. Soundbites and patient-centred care. BMJ 2002; 325:605. 10. Stewart M. Towards a global denition of patient-centred care. BMJ 2001;322:444e5. 11. Kendall S. Do health visitors promote client participation? An analysis of the health visitor-client interaction. J Clin Nurs 1993;2:103e9. 12. Pope C, Mays N. Qualitative research in health care. 2nd ed. London: BMJ Books; 2000. 13. Polit DF, Hungler BP. Nursing research, principles and methods. 4th ed. JB Lippinncott Co; 1991. 14. Lo-Biondo-Wood G, Haber J. Nursing research; methods, critical appraisal, and utilisation. 5th ed. Mosby; 2002. 15. Saks M, Allsop J. Researching health; qualitative, quantitative and mixed methods. Sage; 2007. 16. DeCann R. What is a good radiographer? Radiogr Today 1985; 51(597):127e32. 17. Hill RL, Simon B. Transactional analysis, a better patient approach. Focus Crit Care 1984;11(3):11e6. 18. Arnold M. The importance of personality in the performance of diagnostic. Radiography 1997;3(2):83e98. 19. Smithers S, Catano VM, Cunningham DP. What predicts performance in Canadian Dental Schools. J Dent Educ 2004;68(6): 598e613. 20. Fladeland DMY. Nursing programme success, personality and learning style. University of Minnesoda, 1995 [PH.D]. 21. Harris TA. Im OK e youre OK. London, England: Arrow Books; 1969. 22. Jackson C. Assessment of clinical competence in therapeutic radiography: a study of skills, characteristics and indicators of future career development. Radiography 2007;13(2): 147e58. 23. McCabe C, Timmins F. Teaching assertiveness to undergraduate nursing students. Nurse Educ Pract 2003;3(1):30e42. 24. Department of Health, The NHS Plan. London: Department of Health; 2000. 25. A Career framework for the NHS version 2. London: NHS Modernisation Agency; 2004.

Conclusion
This study has yielded several insights into the factors that inuence communication in radiography. It demonstrates that, although radiographers attempt to adapt their communication to suit individual patients, internal factors such as personality and condence, as well as external factors such as producing a diagnostic image and departmental pressures, play an important part in radiographer-patient interactions. These factors need to be considered when attempting to improve communication in diagnostic radiography, and when attempting to implement the NHS Key Skills Framework, as this study demonstrates that education/training will not be enough. For example, support is needed for radiographers who are working in emotionally stressful situations, if distancing techniques are to be avoided. Post-registration training needs to be considered for those radiographers who lack condence, and consideration needs to be given to staff-patient ratios, if radiographers are to consider communication to be as important as speed and efciency. It is also possible that personality characteristics should form the basis of personnel selection in radiography, although further research is recommended. It would also be interesting to investigate further the inuence of departmental pressures and practitionercentred behaviours and how these might ultimately affect patient satisfaction/adherence. The ndings of the present study also suggest a correlation between patient-centred styles of communication and diagnostic success and this too warrants further investigation.

The radiographer-patient relationship

26. Levinson W, Frankel RM, Roter D, Drum M. How much do surgeons like their patients? Patient Educ Couns 2006;61(3): 429e34. 27. Zandbelt LC, Smets EMA, Oort FJ, Godfried MH, Haes HCJM. Determinants of physicians patient-centred behaviour in the medical specialist encounter. Soc Sci Med 2006;63: 899e910. 28. Fairhead JF, Rothwell PM. Under investigation and under treatment of carotid disease in elderly patients with transient ischaemic attack and stroke: a comparative population study. BMJ 2006;333:525e7. 29. Haight BK, Christ MA, Dias JK. Does nurse education promote ageism? J Adv Nurs 1994;20:382e90. 30. Moss J. The impersonalisation of radiological technology. Can J Med Technol 1988;19(2):55e65. 31. Hewison A. Nurses power in interactions with patients. J Adv Nurs 1995;21:75e82. 32. Murray N, Stanton M. Communication and counselling oncology patients-are diagnostic radiographers adequately supported in the role. Radiography 1998;4(3):173e82. 33. Ford S, Falloweld L, Lewis S. Doctor patient interactions in oncology. Soc Sci Med 1996;42(11):1511e9. 34. Falloweld L, Jenkins V. Effective communication skills are the key to good cancer care. Eur J Cancer 1999;35(11):1592e7. 35. Chesson RA, McKenzie GA, Mathers SA. What do patients know about ultrasound, CT and MRI? Clin Radiol 2002; 57(6):477e82. 36. Meier DE, Back AL, Morrison SR. The inner life of physicians and care of the seriously ill. The patient-physician relationship. JAMA 2001;286(23):3007e8. 37. Chaiken EJ, Thornby JI, Merril J. Cating for terminally ill patients: a comparative analysis of physician assistants and

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medical students attitudes. Pers Phys Ass Edu 2000;11(2): 87e94. Badger J. Understanding secondary traumatic stress. Am J Nurs 2001;101(7):26e32. Garrosa E, Bernado MJ, Youxin L, Jose LG. The relationship between socio-demographic variables, job stressors and burnout and hardy personality in nurses. An exploratory study. Int J Nurs Stud 2008;45(3):418e27. Duquette A, Kerouac S, Balbir BK, Ducharme F, Saulnier P. Psychosocial determinants of burnout in geriatric nursing. Int J Nurs Stud 1995;32(5):443e56. Dowd SB. The radiographers role: part scientist part humanist. Radiol Technol 1992;63(4):240e3. Karpman S. Fairy tales and script drama. TAB 1968;7(26):39e43. Ley P. Communicating with patients: improving communication satisfaction and compliance. London: Nelson Thomas; 1997. Marks DF, Murray M, Evans B, Willig C, Woodall C, Sykes CM. Health psychology: theory research and practice. 2nd ed. London: Sage; 2005. Lyon R, Reeves PJ. An investigation into why patients do not attend for out-patient radiology appointments. Radiography 2006;12:283e90. Fengler K. The patient-care gap. Radiol Technol 1978;49(5): 599e600. Kabler C. Can a radiographer survive on technology alone? Radiol Technol 1986;58(1):19e21. Reeves PJ, Unett EM. Trauma radiography: speed and efciency. J Diagn Radiogr Imaging 1999;2(4):151e8. Delivery of the 18 week patient pathway and beyond: a strategy for imaging workforce. London: The National Diagnostics Imaging Board; 2007.

38. 39.

40.

41. 42. 43.

44.

45.

46. 47. 48. 49.