European radiographers’ challenges from mammography education and clinical practice – an integrative review

Insights into Imaging, Mar 2017

Objectives This study aims to identify European radiographers’ challenges in clinical performance in mammography and the main areas of mammography that require more and better training. Methods An extensive search was performed to identify relevant studies focused on clinical practice, education and training in mammography published between January 2010 and December 2015 in the English language. The data were analysed by using deductive thematic analysis. Results A total of 27 full text articles were read, evaluating their quality. Sixteen articles out of 27 were finally selected for this integrative review. The main challenges of radiographers’ mammography education/training can be divided into three groups: training needs, challenges related to radiographers, and challenges related to the organization of education. The most common challenges of clinical performance in mammography among European radiographers involved technical performance, the quality of practices, and patient-centeredness. Conclusions The introduction of harmonized mammography guidelines across Europe may serve as an evidence-based tool to be implemented in practice and education. However, the variability in human and material resources as well as the different cultural contexts should be considered during this process. Teaching Points • Radiographers’ awareness of their professional identity and enhancing multiprofessional cooperation in mammography. • Radiographers’ responsibilities regarding image quality (IQ) and optimal breast imaging performance. • Patient-centred mammography services focusing on the psychosocial needs of the patient. • Challenges: positioning, QC-testing, IQ-assessment, optimization of breast compression, communication, teamwork, and patient-centred care. • Introduction of evidence-based guidelines in Europe to harmonize mammography practice and education.

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European radiographers’ challenges from mammography education and clinical practice – an integrative review

European radiographers' challenges from mammography education and clinical practice - an integrative review Eija Metsälä 0 1 2 3 Nicole Richli Meystre 0 1 2 3 José Pires Jorge 0 1 2 3 Anja Henner 0 1 2 3 Tiina Kukkes 0 1 2 3 Cláudia Sá dos Reis 0 1 2 3 0 Oulu University of Applied Sciences , Kiviharjuntie 8, 90220 Oulu , Finland 1 Haute Ecole de Santé Vaud , Av. de Beaumont 21, 1011 Lausanne , Switzerland 2 Metropolia University of Applied Sciences , Mannerheimintie 172, PO BOX 4033, 00079 Metropolia , Finland 3 Tartu Health Care College , Nooruse 5, 50411 Tartu , Estonia Breast cancer; Mammography; Education; Clinical practice; Europe Introduction image processing, and imaging display [14, 15]. Due to the emphasis on patient-centeredness as an important component of screening process quality, it was chosen as the framework for deductive thematic analysis in order to widely cover the aspects of breast cancer screening quality. In this integrative review, the quality of breast imaging service was also considered from the viewpoints of staff education (radiographers), technical quality, and the quality of practices. The aim of this study was to identify European radiographers’ challenges in clinical performance in mammography and the main areas of mammography that require more and/or improved training. The following search questions were set: 1. What are the most common challenges of mammography training for radiographers? 2. What are the biggest challenges for radiographers from the viewpoints of (1) technical performance, (2) quality of practices, and (3) patient-centeredness in the breast imaging service? Materials and methods The PICOs in search questions 1 and 2 The PICO for question 1 The PICO for question 2 Population: radiographer Intervention: mammography education Context: Outcomes of Interest: challenges Population: radiographer Intervention: breast imaging service Context: Outcomes of Interest: challenges of technical performance quality of practices patient-centred services Evidence review strategy to identify the dimensions than the effect of the phenomenon. It aimed to identify challenges in training and practice in the field. The studies that did not achieve the JBI levels of evidence for effectiveness 1–3 and the levels of evidence for meaningfulness 1–3 were excluded. Also, the studies receiving two or more ‘hardly or not at all satisfies assessment criteria’ scores in the STROBE checklists were rejected. However, these evaluation methods were consistent, i.e., a study that got two or more ‘hardly or not at all satisfies assessment criteria’ scores, rarely reached the JBI level 3. In case of a mismatch in quality evaluations, a consensus was discussed (Table 2). The shortened version of the STROBE checklist was used due to the need to include studies with several types of designs Critical assessment of the reporting of the studies Assessment criteria of the studies. 3. The design is clearly stated. 4. The setting is clearly described. 5. For independent and dependent variables, confounders are clearly identified and consistently implemented or something else should be added here. Description of the selected studies Challenges in mammography education Challenges of mammography practice Fig. 1 The selection process of the studies Potential papers (N=299) Medline (n=96) Pro Quest (n=68) Science Direct (n=37) EBSCO Host (n=58) OATD database (n=38) Hand search (n=2) Potential papers at the title level (N=48) Medline (n=19) Pro Quest (n=3) Science Direct (n=18) EBSCO Host (n=5) OATD database (n=1) Hand search (n=2) Potential papers at the abstract level (N=27) Medline (n=5) Pro Quest (n=1) Science Direct (n=13) EBSCO Host (n=5) OATD database (n=2) Hand search (n=1) Papers included in the integrative review after evaluation of the full text (n=16) Papers excluded after evaluation at the title level (n= 251) Papers excluded after evaluation of the abstract (n=21) Papers excluded after evaluation of the full text (n=11) handling [5, 24, 31], screen-film combination [24], viewing conditions [24, 25], breast compression, interprofessional working [24, 25, 27–31, 37, 38], the use of positioning sheets [35], and the implementation of quality control (QC) programs [24, 26, 31] (Table 4). In the selected studies, there were nine types of challenges associated with the quality of practices in mammography, comprising the following areas: positioning especially in MLO projection [25, 26, 31, 35]; image contrast [5]; artefacts [25]; the variations in image quality using screen-film, CR and DR systems [33]; the implementation of dose reference levels (DRL) [34]; (a lack of) the implementation of repeat/reject analysis [31]; image processing [26]; image labelling and documentation [25]; and the variability of strategies for image quality evaluation [32] (Table 4). Challenges of mammography practice associated with the patients comprised: (1) the provision of seamless and multiprofessional diagnostic services emphasizing the importance of staff skills and attitude to the quality of breast screening experience [36], (2) a lack of the possibility for the staff to use enough time with the patient due to the heavy workload [ 31], (3) promoting breast screening adherence in radiographer’s work [33], and (4) the use of compression force [29, 30, 35] (Table 4). Discussion Challenges of mammography education g to am re c on in :g iiann rsay adn om rfow ired rsep reen in tr se e ld e sc iran lan cen IeQ itaon ltab cuo teh teh tfo itio is rov inm rfo h sea to .re c a R im ex com ichw ircn tra fu k dd sT p a e tu a ian tis eh id e ie re sa t w rce rev p w eaxm unG ignn itaon rse ree thon taad y .irse G 4M tia nn accn w -m la db ann 024M r8om iitrcap tiraao trsae rraogm raev6 iccenh tllcee tiseo o u = f p C b p o T c q r e g iv n e l f ir cn f ed o e te o h ilv . o ,no s’ a b d i e e t nd to e n p c s i o n r t r t m e e n e s s d n co id h e h n e n e :rsseu fcnod irapgo tirenv iragodp tireceop irecenp iiangn tirevn ea an rad teh ra p ex tra teh d an o ev fo ra an rpo rep c w b d e ng )a ec n ? tseg raphg ig f n s s a s a o a e e igb io im tsc rom itcc end teh rsad trsea saep rfe rap tren e e b e lp f e r g a o -c a n in th ic y t ta lle t n lit en hW ach eem from tceh auq itap l r e im u a y in b w ph t . y n a a lrou ram teh raph İtsa teh rgo a g e og in y m ifn om tlau m tiy rev am .tiy ire am av am la su m la f f e o m m o iew eg ) to te ep in tiav rv le R ahn ssse i-0 ro rs ty IQ tit e l 1 f n t o C p s . e e y d a titiliaaevnuQ .tsydu ircaennCAm li(aogodyRA ittiraeccadno tsseaaduow tliiaeaqugym itirseaeonnqu raaoghpmmm itreccnnhgno raaoghpmmm tieaenpnuqm .ititrenuuhQ .ilssaayn tr a t a , ra .s c red pg iew png iew tia tu 7 in v i m c th k re 1 ak trev ree teh tir-su isw ttsan tilen adn ttsn in3 sw yb . w a g 7 a w d ch se25m tireev tiircp isan trreh tiircp a2nd tireev lsaey rapo = in ap in fu ap in In a a n p itcaonud :t)reed2g ireopvm tilayuq tirsedom tiiaanoxm itrseonnv it)sse7hn )8DM e ta to tc ,n d e te y g . rseehw ledubo itaconu t:rfaea iticngoo ltraonn trrfehu isachn tsoodm irrfonm ltoogyh icp sh ed IQ re co )6 su an ep ap e d .s seo , acn h .s d n d d e t d lseay itaeav teohm adn titean ssodm rfreopm itedw nd teohm an ti e l p a a e itseccaw ilsaqgnu ittitaanuv lii(cacn ,il)cacnh tahpno itepnm leeavu tliitaaeuv ittitaanuv a u q IQ te and equ rew q q r P e ru a y in e a o g h e v f rrfsehom reaedhg fanhyd ,liohdn iragodp taaeud ,reyhw iittrceap ittitaan trseeo ic in 7711 irraagpdo tirayww iraagpod tehUK ieeanR trsaogP tiitifeacn ragopmm titeaopd .tsyuduQ .ilssy lraaepbm ,f5173o8 ragophm irssseopn raakndm r o r om reg nd re a v e a la t am om en n i u N in fr d a C M in th a a se m c D o v F A ) l s ) c a d r b d rn an e ng )a ec an s? te e tseg raphg ig f n s s in e in rc igb io iam tsco raom itcce eedn lsao iisnd itse fon ttreeaah llrseaegdn titrsaebn tseaeph lifraecpn tlifraopy tt-rceeenn rseaehw iltiiraaby irseecngn irssepoom .issecknh hW ach eem from tceh auq tiap T v s c t r ,tliiiittfrssayobvno tirrrsaeaeaaeknddh ittrssaeeeagonbm iiittitsngnoopuo ,tilitrsssagood ttttrfreeeeeehboh ttttilecedoy itilrseam .i)-seeonvwOmW iirreaeceonpdnm tiitissseeghnno li)senyovw c w w hw seeh rew iab abno (LM eexp ithpow -(LOM Challenges of mammography practice Table 4 Biggest challenges of breast imaging practice according to selected studies more. The result is not the desired for the patient when breast cancer is diagnosed, and the experience can be worse if the patient feels emotionally and mentally neglected or disturbed. The quality of screening can be also improved by efficient interprofessional and intraprofessional collaboration and communication [13, 24, 25]. Implications Implementation of the European guidelines for quality assurance in breast cancer screening and diagnosis are varying in European countries. All the European countries should reach the same level of observance. Undergraduate radiographer training is not sufficient regarding the quality expectations of the mammography screening programmes. CPD education in mammography should have equal demands, and it should be mandatory in all the European countries in order to harmonize the education and clinical practice in mammography. Development of mammography training and clinical practice should be considered equal to other imaging examinations performed by radiographers, and resourced to reach the highest quality of education and patient services. In addition to technical quality and the quality of practice, the patient-centred viewpoint should also be emphasized both in mammography education as well as in clinical practice. this does not exclude the main limitation of integrative reviews, namely the problem of synthesising findings of studies with disparate methodologies. Acknowledgements The European Commission support for the production of this publication does not constitute an endorsement of the contents which reflects the views only of the authors, and the Commission cannot be held responsible for any use which may be made of the information contained therein. 1. 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Eija Metsälä, Nicole Richli Meystre, José Pires Jorge, Anja Henner, Tiina Kukkes, Cláudia Sá dos Reis. European radiographers’ challenges from mammography education and clinical practice – an integrative review, Insights into Imaging, 2017, 329-343, DOI: 10.1007/s13244-016-0542-1