Figures
Abstract
Introduction
Paediatric patients are a vulnerable population that require additional care by healthcare professionals. Quality managing these examinations ensures that effective and quality care is provided to individual patients, whilst encouraging consistency within the medical imaging department. This study explored radiographers’ perspectives on quality management strategies of general radiographic paediatric examinations using a paediatric imaging reflective checklist.
Methods
A quantitative descriptive research design with qualitative questions was used through a purposive sampling method from both public and private Australian diagnostic imaging qualified radiographers who had experience in paediatric imaging examinations. The paediatric imaging service reflective tool consisted of 65 items in total. Data analysis entailed Microsoft Excel version 16.16.6 and Jamovi version 2.3.21 for the closed-ended questions and for the open-ended responses a thematic analysis.
Results
The participation rate was 13.2% and the most significant findings were: lead shielding was still being used at their organisation, despite recent recommendations to suspend its use; access to paediatric patient related information resources is limited; there was no involvement of families and communities regarding policy development or quality improvement measures as advocated in literature; and there was a need for enhanced specialised paediatric education, training and protocols.
Citation: Caruana K, Hayre C, Makanjee C (2023) Radiographers’ perceptions on the quality of managing general radiographic paediatric examinations through the use of a reflective tool. PLoS ONE 18(12): e0295603. https://doi.org/10.1371/journal.pone.0295603
Editor: Aloysius Gonzaga Mubuuke, Makere University College of Health Sciences, UGANDA
Received: August 30, 2023; Accepted: November 25, 2023; Published: December 7, 2023
Copyright: © 2023 Caruana et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Data cannot be shared publicly because of the small sample size and is re-identifiable. Data are available with permission from the University of Canberra Human Research Ethics Committee (contact via humanethicscommittee@canberra.edu.au) for researchers who meet the criteria for access to confidential data.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Enhancing the quality and safety of healthcare delivery requires a strong emphasis on continuous improvement of organisations and individuals, organisational support and resources as well as systematically adjusting policies in accordance with best evidence-based practice [1, 2]. In order to accomplish this, it is crucial to identify the barriers and factors that impact the quality of care delivered within healthcare services [2, 3]. There is an ongoing plea to enhance the quality of medical imaging services that have expanded in resources as a result of the development and availability of technology, resulting in an increased use of ionising radiation-based examinations [2, 4, 5]. A quality management system should be adopted within medical imaging departments to improve task efficiency and safety, providing quality services whilst maximising effective care and patient satisfaction whilst maintaining appropriate radiation doses [6, 7].
Unlike their adult counterparts, paediatric patients are a vulnerable population and present with their own challenges to the medical imaging department, whereby efforts need to be made to provide effective and quality services with a great attention to childhood specific diseases and potential risks [8, 9]. The fundamental challenge of imaging paediatric patients lies in determining the appropriate radiation dose, whilst maintaining acceptable image quality [10]. In addition, radiographers are expected to perform complex tasks whilst maintaining a high standard and sustaining quality and safety for patients which includes the paediatric population in a contemporary context [11, 12]. Thus, the input and skill of radiographers plays a crucial role in justification and optimisation of radiation dose and the achievement of diagnostic images, which is pivotal for the treatment and management of paediatric health conditions [10, 13]. Radiographers are, however, limited in advancing their knowledge in paediatric imaging with their currently being no postgraduate qualification in Australia [14]. Literature also acknowledges the dearth of recognition regarding paediatric imaging as a specialty or professional registration for paediatric radiographers [14, 15].
Achieving a high level of quality imaging services requires consideration of objective and subjective factors by radiographers, as well as the involvement and collaboration of multiple stakeholders within and external to the organisation [9, 16]. It entails aspects of the medical imaging procedure being considered such as patient access to the department, assessing the child’s needs, staff-related elements, and the performance of the examination [17]. Quality managing medical imaging examinations allows inconsistencies amongst organisations, for example, human or equipment factors, to be mitigated and controlled whilst providing patient-centred care [6, 7]. Such variations include differing needs for each child, as well as organisational challenges including child-appropriate protocols, specialised equipment and environment, appropriate radiation protection and quality management [9].
There is a plethora of literature offering in-depth knowledge regarding safety culture, which entails areas such as radiation safety, effective communication and adopting a paediatric-centred approach. Such research entails aspects of the importance of radiation protection and dose to paediatric patients, as well as delivering paediatric specific care and communication to provide better healthcare outcomes for children [5, 10, 18, 19]. This literature also delves into the advantages of quality programs and the essential characteristics for their success [2, 6, 7, 10, 11]. However, there is a lack of information in relation to the quality management of paediatric imaging [2, 6], with there being no research that investigates all aspects of general radiographic paediatric examinations within a single study. Furthermore, there is no study that allows radiographers to reflect on such practice and identify areas of improvements to enhance the paediatric service.
In order to be consistent amongst individual radiographers and organisations, we must reflect on the quality of managing paediatric examinations [20]. Such reflection allows healthcare professionals to learn from experiences as well as identify areas of improvements through critical thinking, self-awareness and evaluation [21, 22]. The aim of this study is to establish radiographers’ perspectives on the quality of paediatric medical imaging services using a paediatric medical imaging-centred reflective tool.
Materials and methods
A quantitative research design with qualitative aspects was adopted for this study to acquire radiographers’ insights into quality managing paediatric imaging services. A purposive sampling technique was used to recruit qualified diagnostic radiographers with experience in general radiographic paediatric examinations, involving the assistance of study participants in obtaining additional participants [23]. This sampling method was used to target eligible participants whilst aiding the researcher with recruitment. Ethics approval was received from the Faculty of Health Research Ethics Committee (HREC), University of Canberra (HREC 4780), whereby this study is a part of a larger project investigating paediatric imaging [24]. The data collection process began in July 2022 and ended in March 2023. Written or verbal informed consent was obtained from participants who agreed to participate in the study. The content of the consent form was approved by the HREC prior to dissemination of the questionnaire. If verbal consent was given, documentation was included in the researcher’s notes.
The paediatric-centred reflective tool was developed from a published person-centred reflective tool [25]. The first section entailed 15 items on participant demographic and professional background information. Section two required respondents to indicate “Yes” or “No” and a comment section on aspects of access to services, efficiency of task performance, patient care and wellbeing, ethical considerations, staff related elements and quality management. The “Yes / No” responses allowed an understanding of general radiographic paediatric examinations to be obtained [26], whereby radiographers reflected on all aspects of these examinations. Open-ended questions were also used in section two, providing an option for participants to identify new issues not captured in the closed-ended questions [27]. This consisted of a “Recommended action plan” and “Other comments” section for each item, which allowed for participants to outline what is currently being performed at their organisation as well as to provide additional suggestions or comments for further improvement [25, 27].
To ensure content validity, the research instrument was piloted by two clinical radiographers and two academic radiographers [23, 28]. The feedback was incorporated into the study prior to its dissemination. Internal consistency of dichotomous data was determined by the use of McDonald’s omega [29, 30], as depicted in Table 1. Similar to Cronbach alpha, McDonald’s omega is expressed as a number between 0 and 1, with optimal values ranging between 0.7 and 0.95, thus, indicating internal consistency of the instrument [29, 31, 32].
Results
In this section, the demographic data, followed by the checklist item responses and thematic analysis is depicted. An overall response rate was 13.2% (n = 60) of the 453 potential participants recruited for this study. Dedicated paediatric organisations were targeted, with only 4 responses provided and as a result, non-paediatric organisations were approached which consisted of the 56 remaining participants. Additionally, 60% were from the Australian Capital Territory, with 35% of participants from other states across Australia and the remaining 5% identifying two different locations which indicated multiple places of employment. The majority of participants (80%) were employed in a metropolitan institution and 18% at a regional/rural area, with 70% in the public sector and 25% employed at a private organisation. Their employment status varied, 61% being full-time, 15% part time and 7% employed on a casual basis. The age range was between 21 to 66 years and the mean age was 31.3 years. The majority of participants (75%) had an undergraduate bachelor’s degree, few (18%) had a master’s qualification and none with a specialised paediatric qualification. Slightly higher than half of the participants (55%) had ≤ 4 years’ experience in paediatric imaging and the remaining varied between 5 to 46 years in experience.
As depicted in Table 2, ease of access to services was positively rated for the majority, except resources of information at approximately 58%. Efficiency of the task performance was exceedingly high, whereas safety in terms of radiation protective gear was approximately 66%. Patient care and wellbeing and ethical considerations received high ratings by participants, with the exception of cognitive assessment which received approximately 66%. In terms of the staff related elements, over 80% participants stated “Yes” to both paediatric specific equipment and patient satisfaction. Availability of educational support was 60%, however, professional development of staff was positively rated. The majority of participants (75%) felt there was multidisciplinary team engagement and peer debriefing. Regarding quality management, more than 75% stated there was stakeholder involvement in quality improvement measures as well as quality assurance and quality control protocols in place alongside dedicated imaging protocols. However, family and community engagement in quality management and paediatric service delivery was average (50%).
Evaluation of medical imaging services
Some participants identified gaps in terms of access to parking, including aspects of navigating as illustrated in the following quotes:
“Parking close to the hospital often unavailable during business hours around the hospital” (P2).
“Poor parking and signage located on site” (P13).
“We have poor signage to get to medical imaging” (P8).
Participants (42%) stated “No” in relation to information resources for the dichotomous question, indicating there was a scarce amount of information available. Examples consisted of:
“Resources are limited, only a website is available displaying a two minute generic video for paediatric x-rays” (P5) and in some instances
“… there is no website, education programmes or information leaflets available to patients regarding paediatric examinations” (P31).
This limitation could be overcome by:
“Having leaflets both physical and online to provide patient information on the risks and benefits associated with paediatric imaging. QR [quick response] code within examination rooms for parents/guardians to access this information” (P7).
“… has developed an app ("Okee") for this exact purpose. The app can be found through various app stores” (P21).
“Fact sheets on simple dose metrics provided in the waiting room for patients” (P2).
Issues pertaining to best practice principles and quality assurance
Despite the majority indicating that medical imaging equipment was tailored for paediatric examinations, a few participants indicated otherwise.
“None of the sites that I work at have equipment or accessories specific to paediatric patients” (P31).
“There isn’t a paediatric focus on monitoring of quality improvement, in regard to equipment” (P5).
“Low levels of paediatric focus in these area” (P6).
Participant 8 outlined that a potential reason for this could be due to financial constraints.
“Financial analysis prevents us from getting funding for specific paediatric equipment as we don’t have a specialised paediatric department and such we don’t get many patients” (P8).
Although the majority of participants stated “Yes” in relation to efficiency of task performance, the collimation applied to the body part region of interest in part of radiation safety mechanism was of concern as stated:
“Sometimes collimation is kept wider to ensure anatomy required is captured on a moving or struggling child” (P8).
“Often left slightly open, in case of pt [patient] movement” (P24).
Similarly, application of lead protective shielding appears to be discretionary as shared by Participants 5 and 9.
“Used when appropriate” (P5).
“Paediatric shielding used if appropriate” (P9).
Though most participants had knowledge on dose reference levels, some participants (7%) identified there are no such charts available for paediatric general x-ray at their organisation, as stated by the following participants.
“For CT [computed tomography] yes. Not x-ray” (P11).
“There are no charts or information sheets regarding dose reference levels for paediatric examinations at the company” (P31).
Specifically, one participant acknowledged that these charts “Don’t exist in Australia for children’s x-rays” (P39).
Surveys for patients and families, are valuable because feedback can be used “… to integrate changes to the department as they are the consumers” (P30). In this regard, Participant 31 commented:
“… I believe the company has surveys at reception available for all patients (paediatric or not) to give feedback about their experience” (P31).
Some participants stated that to strengthen feedback “greater access to feedback forms in reception for pts [patients] to fill out post exam” (P14) and “More satisfaction surveys to be completed” (P49).
Few participants also indicated patient, family and or community involvement was inappropriate because “… it is not their specialty/job?” (P37) and “… do not understand much of these processes” (P21).
On the other hand, some participants like Participant 31 stated:
“Improvements are always a good thing, and I do think that families and the community should be included in those conversations” (P31).
Support mechanisms and resources
Regarding professional development and educational support, participants were “… not aware of any company led education programmes for staff or patients” (P31) and that was “limited explicit paediatric content” (P6). If there were opportunities for education and/or professional development, it was “limited for pts [patients] & [and] students” (P18). Whereas others indicated that staff educational opportunities were “limited in regard to paediatric imaging” (P2) or “not specific to paed’s [paediatrics]” (P4).
Participants identified the need for an increased amount and improved education with regards to programmes and professional development of staff.
“… exist but could be much more/improved” (P12).
For example,
“Need more CPD [continuing professional development] specific to imaging paeds [paediatrics]” (P43).
Similarly, another participant stated:
“More available paed [paediatric] specific CPD [continuing professional development] would be helpful” (P11).
Participants also expressed a greater desire for education in specific areas. These comments included:
“… regular education regarding patient communication” (P21),
“More care/training for children with disabilities” (P19) and
“… cultural awareness” (P21).
Discussion
Reflection is an important process for understanding quality assurance and improvement strategies and implementation thereof [33]. Based on the undertaking, a reflection on the quality of paediatric imaging services revealed interesting results.
Organisations must seek feedback from patients and families to identify areas of improvement and enhance the radiology service and quality [34, 35]. However, the results from the study conducted found a discrepancy amongst participants relating to the availability and completion rate of patient and family surveys. Similarly, Lee et al. [36] reported feedback forms were available, but organisations need to improve the diversity and accessibility of these to enhance, monitor and assure the quality of care. On an analogous note, Berger et al. [37] found a myriad of patient feedback forms were available, which need to be promoted and patients encouraged to complete. In addition to organisations seeking feedback from patients and families, they should be involved in the development and implementation of policies to improve safety and care [38]. It was identified, however, that participants from the study were uncertain in relation to the families and patient involvement in such policy development. Literature reinforces the importance such a perspective can provide and acknowledges that stakeholders should be involved and work collaboratively with service providers for the development of policies and quality improvement programs, leading to improved outcomes and better quality and safe health care for patients [39].
Access to medical imaging departments includes appropriate parking and signage that is clear and indicates the location of the department [17, 40]. For patients, the implications of insufficient parking are creating stress and anxiety [17]. The study conducted found such services was insufficient, which could impact the quality of the patient’s healthcare experience.
Research identifies the benefit of having specific paediatric medical imaging equipment and quality assurance programs implemented into organisations, enhancing the service delivery and care paediatric patients receive [11, 41]. In this study, most radiographers reported the equipment to be suitable for paediatric examination, however, there were no dedicated paediatric equipment and quality assurance for this specific population group. Similar to a study by Billinger et al. [42], there was a significant variation of dose reference levels between different hospitals. Currently, “There are currently no Australian national Diagnostic Reference Levels published for paediatric, or adult, general radiography examinations” [43].
There is a notable absence of specialised paediatric imaging postgraduate qualifications among the radiography participants, aligning with literature [14, 15, 24]. Contributing factors could be insufficient avenues or motivations for specialised paediatric radiographers as well as the limited recognition by regulatory boards identifying paediatric as a distinct sub speciality within medical imaging [15, 24]. Quality health care is defined as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” [44]. Therefore, education and training on contemporary paediatric imaging processes and procedures is paramount [14]. The results from the study are consistent with previous research like Alsleem and others which reported a lack of dedicated paediatric education programmes [45]. Likewise, Ewuzie concludes that a lack of these programmes could hamper the services offered to paediatric patients and must be improved [46].
An issue highlighted in this study is immobilisation aids and current best-practice principles. Christie et al. also found more than 30% of radiographers believed their training in the use of immobilisation aids for paediatric patients was poor or lacking [47]. Similarly, Satharasinghe et al. found radiographers were tending to use a larger than required x-ray field in an attempt to avoid repeating the imaging examination [48]. However, unnecessary radiation exposure to the patient can result from inadequate collimation and thus, radiographers must improve such skills to improve patient outcomes [49, 50]. In terms of using lead shielding, Cardoso et al. found uncertainty among radiographers, specifically about gonad contact shielding [51]. In this study, the use of lead shielding was discretionary. A suggestion to resolve this issue could be to review and update recent guidelines regarding lead shielding within organisations [52]. On the contrary, regulatory bodies advocate discontinuation of shielding device [53, 54]. Such use of shielding provides no significant advantage and can increase patient radiation exposure, potentially compromising the effectiveness of the imaging [55].
In literature, communication is a major component in healthcare related contexts in terms of confidence and skills in ensuring benefit-risk information is communicated clearly [56, 57]. In order to achieve an effective exchange of information, compassion, recognition, acknowledgement and unprejudiced acceptance of diversity must occur [56]. An interesting finding were barriers faced with paediatric patients with intellectual disabilities [57, 58]. Enhancing radiographer’s education and skill to ensure they are better equipped to address these barriers would improve the paediatric radiography services offered by organisations [46, 57, 58]. In this study, participants also expressed a desire for improved cultural competence, allowing individual patient needs to be addressed and reduce health disparities amongst diverse populations [59, 60].
Another aspect of communication entails patients desires for written resources of information to be made available to them regarding paediatric imaging, such as rationale for ordering specific imaging examination [61]. This could include hospital-endorsed internet sites and take-away printed material to retain and use for reference [61]. However, Bray et al. reported children were frequently not given or assisted in accessing healthcare information, despite the desire to do so prior to a medical procedure [62].
A unique contribution of this study is the clinically based paediatric-centred quality management reflective tool. The findings of this study could be used as a baseline for a similar study of this nature, including validation of the effectiveness of the reflective tool as a part of a quality improvement strategy within a clinical setting. This would aid in identifying strengths and weaknesses in the delivery of paediatric medical imaging services. The outcomes inform and contribute towards existing quality improvement endeavours at an organisational level, such as, devising appropriate action plans, timelines, and/or strategies. For example, prioritising the professional development of staff in paediatric specific education and communication aspects as well as investing in dedicated paediatric equipment and instrumentation. By addressing these implications, healthcare organisations can improve and ensure a high quality of care services, thereby contributing to better health outcomes for paediatric patients.
Despite the strengths of the study, there are some limitations. Specifically, the low participant response rate was as a result of professionals experiencing burnout due to post COVID-19 fatigue, high workplace demands and the eligibility criteria to participate in the study. This limits the generalisability of the results. Additionally, most of the participants had less than 4 years’ experience and not all states were included. Future studies could engage a larger population through use of a medical imaging team-based approach and involve practice managers, quality and safety management officers and target medical imaging practices across all states.
Conclusion
This tool enabled participants to reflect on their own practice and provided valuable insights into the challenges and opportunities to enhance the paediatric imaging services at an individual and organisational level. It emphasises the importance of addressing issues associated with equipment, quality assurance and best practice principles. Additionally, communication, patient involvement and educational support must be improved to enhance the quality of care provided to paediatric patients. However, these results lack generalisability due to the restricted response rate. Further research and action are needed to address these identified gaps and enhance the overall quality of paediatric radiology services.
Supporting information
S1 Checklist. A quality management checklist for paediatric imaging examinations.
https://doi.org/10.1371/journal.pone.0295603.s001
(PDF)
References
- 1. Furnival J, Boaden R, Walshe K. Conceptualizing and assessing improvement capability: a review. Int J Qual Health Care. 2017 Oct 1;29(5):604–611. pmid:28992146
- 2. de Almeida RP, da Silva CA, da Silva Gama ZA. Framework for health care quality and evidence-based practice in radiology departments: A regional study on radiographer’s perceptions. J Med Imaging Radiat Sci. 2022 Dec 1;53(4):648–658. pmid:36184270
- 3. Kisembo HN, Nassanga R, Ameda FA, Ocan M, Kinengyere AA, Abdirahaman SO, et al. Barriers and facilitators to implementing clinical imaging guidelines by healthcare professionals using theoretical domains framework: a mixed-methods systematic review protocol. BJR Open. 2021 Mar 16;2(20210004):1–7. pmid:35855474
- 4. Nunes AM, Ferreira DC. The health care reform in Portugal: Outcomes from both the New Public Management and the economic crisis. Int J Health Plann and Manage. 2019 Jan;34(1):196–215. pmid:30109900
- 5. Bárdyová Z, Horváthová M, Pinčáková K, Budošová D. The importance of public health in radiology and radiation protection. J Public Health Res. 2021 Mar 12;10 (3). pmid:33709644
- 6. Papp J. Quality management in the imaging sciences e-book. 6th ed. Elsevier Health Sciences; 2018. p. 3–10.
- 7. Dodwad SS. Quality management in healthcare. Indian J Public Health. 2013 Jul 1;57(3):138–143. pmid:24125927
- 8. International Atomic Energy Agency. Radiation Protection and Safety in Medical Uses of Ionizing Radiation. IAEA safety standards series No. SSG-46. 2018:1–318. Available from: https://www.iaea.org/publications/11102/radiation-protection-and-safety-in-medical-uses-of-ionizing-radiation
- 9. Thukral BB. Problems and preferences in pediatric imaging. Indian J of Radiol Imaging. 2015 Oct;25(4):359–364. pmid:26752721
- 10.
Makanjee C. The Frequently Forgotten Pediatrics: Their Safety in the Clinical Setting. In: Hayre CM, Cox WAS, editors. General Radiography: Principles and Practices. CRC Press; 2020. p. 113–135.
- 11. Lötter M, Richardson I, Reid L. Development and Evaluation of a Quality Assurance Programme for a Radiology Department. Doctoral dissertation, University of Limerick. 2022. Available from: http://hdl.handle.net/10344/7050
- 12. Kruskal JB, Eisenberg R, Sosna J, Yam CS, Kruskal JD, Boiselle PM. Quality improvement in radiology: basic principles and tools required to achieve success. RadioGraphics. 2011 Oct 4;31(6):1499–1509. pmid:21997978
- 13. Matthews K, Brennan PC, McEntee MF. An evaluation of paediatric projection radiography in Ireland. Radiography. 2014 Aug 1;20(3):189–194.
- 14. Hardy M. Paediatric radiography: is there a need for postgraduate education?. Radiography. 2000 Feb 1;6(1):27–34.
- 15.
Erondu OF. Chapter 2: Challenges and peculiarities of paediatric. In: Erondu OF, editor. Medical imaging in clinical practice. Croatia: InTech; 2013. p. 23–35.
- 16. Venkataraman V, Browning T, Pedrosa I, Abbara S, Fetzer D, Toomay S, et al. Implementing shared, standardized imaging protocols to improve cross-enterprise workflow and quality. J Digit Imaging. 2019 Oct 15;32:880–887. pmid:30756266
- 17. Hyde E, Hardy M. Patient centred care in diagnostic radiography (Part 2): A qualitative study of the perceptions of service users and service deliverers. Radiography. 2021 May 1;27(2):322–331. pmid:33039253
- 18. Donnelly LF. Fundamentals of pediatric imaging. 3rd ed. Academic Press; 2021, p. 1–9.
- 19. Kadom N. Engaging patients and families in pediatric radiology. Pediatric Radiology. 2020 Oct;50(11):1492–1498. pmid:32935240
- 20. Broder JC, Cameron SF, Korn WT, Baccei SJ. Creating a radiology quality and safety program: principles and pitfalls. RadioGraphics. 2018 Oct;38(6):1786–1798. pmid:30303786
- 21. Bass J, Sidebotham M, Creedy D, Sweet L. Midwifery students’ experiences and expectations of using a model of holistic reflection. Women and Birth. 2020 Jul 1;33(4):383–392. pmid:31296473
- 22. Mann K, Gordon J, MacLeod A. Reflection and reflective practice in health professions education: a systematic review. Adv Health Sci Educ. 2009 Oct;14:595–621. pmid:18034364
- 23. Brink H, van der Walt C, van Rensburg G. Fundamentals of Research Methodology for Health Care Professionals. 4th ed. Juta and Company (Pty) Ltd; 2018, p. 19–181.
- 24. Makanjee CR, Tsui JK, Treller M, Francis K, Issa A, Hayre C, et al. Australian student radiographers’ experiences and perspectives in general paediatric medical imaging examinations. Radiography. 2023 May 1;29(3):604–609. pmid:37075490
- 25. Makanjee CR, Bergh AM, Xu D, Sarswat D. Creating person-al space for unspoken voices during diagnostic medical imaging examinations: a qualitative study. BMC Health Serv Res. 2021 Dec;21:1–12. pmid:34511105
- 26. Leavy P. Research design: Quantitative, qualitative, mixed methods, arts-based, and community-based participatory research approaches. Guilford Publications; 2017. p. 38–189.
- 27. O’Cathain A, Thomas KJ. “Any other comments?” Open questions on questionnaires–a bane or a bonus to research?. BMC Med Res Methodol. 2004 Dec;4(1):1–7. pmid:15533249
- 28. Heale R, Twycross A. Validity and reliability in quantitative studies. Evid Based Nurs. 2015 Jul 1;18(3):66–67. pmid:25979629
- 29. Stensen K, Lydersen S. Internal consistency: from alpha to omega?. Tidsskrift for den Norske Laegeforening: Tidsskrift for Praktisk Medicin, ny Raekke. 2022 Aug 23;142(12). pmid:36066232
- 30. Goodboy AK, Martin MM. Omega over alpha for reliability estimation of unidimensional communication measures. Ann Int Commun Assoc. 2020 Oct 1;44(4):422–439.
- 31. Tavakol M, Dennick R. Making sense of Cronbach’s alpha. Int J Med Educ. 2011;2:53–55. pmid:28029643
- 32.
Creswell JW, Creswell JD. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. 5th ed. Sage publications; 2018. p. 215–280.
- 33. Shaw EK, Howard J, Etz RS, Hudson SV, Crabtree BF. How team-based reflection affects quality improvement implementation: a qualitative study. Qual Manag HealthCare. 2012 Apr;21(2):104–113. pmid:22453821
- 34. Lexa FJ, Berlin JW. The architecture of smart surveys: core issues in why and how to collect patient and referring physician satisfaction data. J Am Coll Radiol. 2009 Feb 1;6(2):106–111. pmid:19179239
- 35. Kapoor N, Yan Z, Wang A, Wickner P, Kachalia A, Boland G, et al. Improving patient experience in radiology: impact of a multifaceted intervention on national ranking. Radiology. 2019 Jan 22;291(1):102–109. pmid:30667330
- 36. Lee R, Baeza JI, Fulop NJ. The use of patient feedback by hospital boards of directors: a qualitative study of two NHS hospitals in England. BMJ Qual Saf. 2018 Feb 1;27(2):103–109. pmid:28754814
- 37. Berger S, Saut AM, Berssaneti FT. Using patient feedback to drive quality improvement in hospitals: a qualitative study. BMJ Open. 2020 Oct 1;10(10):1–8. pmid:33099495
- 38. Newman B, Joseph K, Chauhan A, Seale H, Li J, Manias E, et al. Do patient engagement interventions work for all patients? A systematic review and realist synthesis of interventions to enhance patient safety. Health Expect. 2021 Aug 25;24(6):1905–1923. pmid:34432339
- 39. Carman KL, Dardess P, Maurer M, Sofaer S, Adams K, Bechtel C, et al. Patient and family engagement: a framework for understanding the elements and developing interventions and policies. Health Aff. 2013 Feb 1;32(2):223–231. pmid:23381514
- 40. Rousek JB, Hallbeck MS. Improving and analyzing signage within a healthcare setting. Appl Ergon. 2011 Nov 1;42(6):771–784. pmid:21281930
- 41. Okpaleke MS, Nweke CB, Ugwuanyi DC, Ikegwuonu NC, Chiegwu H. Challenges of paediatric radiography in selected hospitals and radio-diagnostic centres in Anambra State, Nigeria. J Biomed Invest. 2022 Jun 24;10(2):23–36. Available from: https://journals.unizik.edu.ng/index.php/jbi/article/view/1511
- 42. Billinger J, Nowotny R, Homolka P. Diagnostic reference levels in pediatric radiology in Austria. Eur Radiol. 2010 Jan 22;20:1572–1579. pmid:20094888
- 43. Earl VJ, Potter AO, Perdomo AA. Effective doses for common paediatric diagnostic general radiography examinations at a major Australian paediatric hospital and the communication of associated radiation risks. J Med Radiat Sci. 2022 Dec 1;70(1):30–39. pmid:36453696
- 44. Lohr KN, Schroeder SA. A strategy for quality assurance in Medicare. N Engl J Med. 1990 Mar 8;322(10):707–712. pmid:2406600
- 45. Alsleem H, Davidson R, Al‐Dhafiri B, Alsleem R, Ameer H. Evaluation of radiographers’ knowledge and attitudes of image quality optimisation in paediatric digital radiography in Saudi Arabia and Australia: a survey‐based study. J Med Radiat Sci. 2019 Dec;66(4):229–237. pmid:31697039
- 46. Ewuzie OC. A need for specialized education in pediatric radiography in Nigeria. Int J Med Health Dev. 2019 Jul 1;24(2):85–88.
- 47. Christie S, Ng CK, Dos Reis CS. Australasian radiographers’ choices of immobilisation strategies for paediatric radiological examinations. Radiography. 2020 Feb 1;26(1):27–34. pmid:31902451
- 48. Satharasinghe D, Niroshan N, Jeyasugiththan J. Awareness of paediatric radiological protection and imaging parameters among group of Sri Lankan radiographers. Radiat Prot Dosimetry. 2023 Apr;199(6):533–539. pmid:36897047
- 49. Su YT, Chen YS, Yeh LR, Chen SW, Tsai YC, Wu CY, et al. Unnecessary radiation exposure during diagnostic radiography in infants in a neonatal intensive care unit: a retrospective cohort study. Eur J Pediatr. 2023 Jan;182(1):343–352. pmid:36352243
- 50. Okeji MC, Anakwue AM, Agwuna K. Radiation exposure from diagnostic radiography: an assessment of X-ray beam collimation practice in some Nigerian Hospitals. Internet J Med Update-EJOURNAL. 2010 Jul;5(2):31–33.
- 51. Cardoso CE, Bezzina P, Portelli JL. Gonad contact shielding in digital radiography: A questionnaire survey. Eur J Radiol. 2023 Jan 1;158(110620):1–9. pmid:36521379
- 52. Fahim S, Tom F, Dwight M, Marcia S. “To Shield or Not to Shield?” Frontline Radiographer’s Perspective. J Med Imaging Radiat Sci. 2022 Dec 1;53(4):S15–16.
- 53.
British Institute of Radiology, Institute of Physics and Engineering in Medicine, Public Health England, Royal College of Radiologists, Society and College of Radiographers & the Society for Radiological Protection. Guidance on using shielding on patients for diagnostic radiology applications. London: British Institute of Radiology; 2020. Available from: https://www.bir.org.uk/media/414334/final_patient_shielding_guidance.pdf
- 54. Australian Society of Medical Imaging and Radiation Therapy. Position Statement: Gonad Shielding; 2020. Available from: https://www.asmirt.org/asmirt_core/wp-content/uploads/2464.pdf
- 55. Marsh RM, Silosky M. Patient shielding in diagnostic imaging: discontinuing a legacy practice. AJR Am J Roentgenol. 2019 Apr;212(4):755–757. pmid:30673332
- 56. Chau M. Cultural diversity and the importance of communication, cultural competence, and uncertainty in radiography. J Med Imaging Radiat Sci. 2020 Dec 1;51(4):S17–22. pmid:32439284
- 57. Portelli JL, McNulty JP, Bezzina P, Rainford L. Radiographers’ and radiology practitioners’ opinion, experience and practice of benefit-risk communication and consent in paediatric imaging. Radiography. 2016 Dec 1;22:S33–40.
- 58. Tracy J, McDonald R. Health and disability: Partnerships in health care. J Appl Res Intellec Disabil. 2014 Dec 22;28(1):22–32. pmid:25530571
- 59. Abrishami D. The need for cultural competency in health care. Radiol Technol. 2018 May 1;89(5):441–448. Available from: http://www.radiologictechnology.org/content/89/5/441.short pmid:29793905
- 60. Makanjee CR, Allen M, Lee J, Gyawali J, Hayre C, Lewis S. Diagnostic radiography students’ perspectives on cultural competence and safety. Radiography. 2023 Mar 17;29(1):S96–102. pmid:36935246
- 61. Thornton RH, Dauer LT, Shuk E, Bylund CL, Banerjee SC, Maloney E, et al. Patient perspectives and preferences for communication of medical imaging risks in a cancer care setting. Radiology. 2015 Mar 24;275(2):545–552. pmid:25803490
- 62. Bray L, Appleton V, Sharpe A. ‘If I knew what was going to happen, it wouldn’t worry me so much’: Children’s, parents’ and health professionals’ perspectives on information for children undergoing a procedure. J Child Health Care. 2019 Dec;23(4):626–638. pmid:31431048