Assessment Of Patient Attitude To The Involvement Of Students In Radiographic Examinations In Hospitals
Patients’ consent to being part of the education of Medical Radiography is often taken for granted hence formal consent is not always sought during teaching and patients are sometimes not aware that they are going to be used for teaching activities. Some students of Radiography are not even aware of patients’ right to privacy when they come for radiographic examinations. This study aims to assess the reaction or attitude of patients to the involvement of students in radiographic examinations. A survey was conducted using a manual questionnaire tailored to suit the purpose of this study; data collected from patients from the three university teaching hospitals in Enugu namely UNTH, NOHE and ESUTH (N=99) was statistically analyzed.
The results show that 22.2% of the patients have been examined by student radiographers without the supervision of a radiographer. Also 47.5 percent of the respondents are would be afraid to be examined by student radiographers without supervision, while 34.3% would be embarrassed if they are examined by students of the opposite gender. This indicates that students should be well supervised during radiographic examination of patients and that care should be taken to ensure patient privacy to avoid embarrassment.
Table of Contents
- Title page
- Table of Contents
- List of Tables
- List of Figures
- 1.0 Background of study
- 1.1 Statement of problem
- 1.2 Purpose of study
- 1.3 Significance of study
- 1.4 Scope of study
- 1.5 literature review
- 2.1 The patient
- 2.2 Attitude
- 2.3 Measuring attitudes
- 2.4 Assessment of patient attitudes to the involvement of students in radiographic examinations
- 2.5 Effects of student involvement on radiographic examinations
- 2.6 Importance of patient and student education
Research Design and Methodology
- 3.0 Research design
- 3.1 Target population
- 3.2 Sample size
- 3.3 Sampling procedure
- 3.4 Instrument and method of data collection
- 3.5 Data analysis and presentation
Discussion, Conclusion and Recommendations
- 4.0 Discussion
- 4.1 Conclusion
- 4.2 Recommendation
- 4.3 Limitations of study
List of Tables
- Table 1; Age of respondents
- Table 2; Sex of respondents
- Table 3; Marital status of respondents
- Table 4; Level of education of respondents
- Table 5; Attitude of patients to student involvement in radiographic examinations
- Table 6; Chi-square test on whether respondents’ feeling of embarrassment is sex dependent
- Table 7; Chi-square test on whether fear of student involvement is dependent on hospital
- Table 8; Chi-Square test on whether respondents’ feeling of embarrassment is age dependent for each sex
- Table 9; Respondents’ reasons for being afraid of student involvement in radiographic examinations
- Table 10; Respondents’ reasons for not being afraid of student involvement in radiographic examinations
List Of Figures
- Figure 1; A compound histogram showing frequency and percentage distribution of the ability of respondents to differentiate between a student radiographer and radiographer.
- Figure 2; A compound histogram showing frequency and percentage distribution of respondents’ previous experience with unsupervised Students in the radiology department
1.0 Background of Study
A patient is any recipient of health care services. The patient is most often ill or injured and in need of treatment 1. Being a patient does not take away one’s right to privacy and comfort at the hospital during treatment. In fact, due to the physical, emotional, and mental state of patients, it is very important that their privacy is respected, and their comfort guaranteed.
Therefore, every examination or treatment in the hospital should be in the patient’s best interest, because the patient is the main reason for the existence of the hospital. Training of new health care professionals such as doctors, radiographers, nurses, etc, is part of the process of improving health care delivery, which in turn is beneficial to the patient.
Therefore, in order to train health care providers and also improve on the standard of health care delivery, real life situations are required. This is where the patient becomes very important in the education and training of health care professionals.
However, the patient’s rights to privacy should be respected and it is ethical for patient’s consent to be sought before they are used for teaching or demonstration for students. On the contrary, patients are sometimes not aware of any teaching activities 2.
Students are now becoming actively involved in patient care in order to gain clinical experience. This seems to be a symbiotic relationship because as students gain more clinical experience, patient care is enhanced due to combined efforts from both the health care professional and the students.
Students of Radiography require high level scientific training for proper understanding and efficient application of the modern technology involved in the discharge of health care.
Therefore, clinical postings for students of radiography require that they visit teaching hospitals regularly, and are present in the examination room in order to gain practical knowledge of how radiographic procedures are carried out.
Student presence, and furthermore, participation in carrying out radiographic procedures are very important to their training as professional radiographers. However, while this is of great benefit to the students it may not go down well with some patients who have reservations about students being around while they are being examined.
While some patients may not have a problem with having students participate in general radiographic investigations, they may not want students participating in special or intimate examinations such as hysterosalpingography (HSG), micturating cyctourethrography (MCU), gynaecography, mammography, etc
It is worthy of note that the hospital exists solely because of the patient, and as such, every aspect of healthcare delivery should be geared towards patient.
The patient is therefore not divested of his rights to privacy and comfort because he is ill. It is important to note that the patient pays the bills for his treatment and this requires that his preferences are acknowledged whenever possible.
When patients are not comfortable in the examination room then it may be difficult for radiographic examinations to produce desired results.
A good number of studies have examined how patients feel about the involvement of medical students in clinical examinations; however, very few studies have examined how patients feel towards student involvement in radiographic examinations.
1.1 Statement of Problem
- It has been observed that some patients are not comfortable with the large number of students present in the diagnostic room, especially during special radiological cases.
- Patient discomfort due to heavy student presence may cause fear, anger, or embarrassment, leading to poor radiographic examinations, patients holding back vital information, and time wasting.
- It seems that there is inadequate patient education concerning participation of students in radiographic examinations.
- Students mostly depend on their clinical postings in order to have practical knowledge of radiographic procedures, but may be sometimes asked to leave the diagnostic room during some examinations, leaving them with less practical knowledge.
1.2 Purpose of Study
This research has the objective of determining the following:
- To determine the attitude of patients towards student involvement during radiographic examinations.
- To determine the effect of student involvement on radiographic examinations involving patients who have reservations about student participation.
- To determine the level of patient education concerning student participation in radiographic examinations.
- To determine if patients actually request that students should not be allowed to be present or participate while they are being examined.
1.3 Significance of Study
- Improvement in patient comfort and reassurance concerning student involvement during radiographic examinations.
- Improvement in student-patient relationship, thus providing satisfaction for the patient and making the clinical postings a rewarding experience for the students.
- Improvement in patient education as regards student involvement and this will make the patients more willing to help with radiography education.
- A good knowledge of patient attitude towards student involvement will help to improve on the quality of healthcare service given to patients who come to the Radiology department.
1.4 Scope of Study
This research will be carried out in the three hospitals in Enugu metropolis, where students of radiography are afforded the opportunity of clinical postings, namely: University of Nigeria Teaching Hospital, National Orthopedic Hospital Enugu, and Enugu State University Teaching Hospital, Park lane.
1.5 Literature Review
Some studies have been carried out to determine the attitude of patients to medical students’ involvement in clinical examinations. However, there seems to be a dearth of studies dedicated to determining the attitude of patients towards radiography students’ involvement in radiologic examinations.
Shlomo et al, in an informal survey among hospital and clinic physicians found that formal consent procedures are not used during teaching 3. King et al, in their work also found that patients are not always aware of teaching activities 2. Hence, according to Shier et al, it is safe to say that there is ignorance among staff regarding their obligation to patient confidentiality 4.
There is also considerable ignorance among students on the confidentiality issue 4. Many students actually think it is their right to participate in patient care, and hence find it hard to swallow when they are asked to leave or leave the consulting room reluctantly.
In 1996 the Law of Patient Rights was legislated by the Israeli parliament, defining the issues of confidentiality, consent and record-keeping 5. The statement defined six areas of importance: the provision of information, the right of refusal, proper identification, the presence of a teacher, the right to request for the presence of a third party, and the rights of disabled people 3.
Therefore, the patient being the main reason for the existence of the hospital, has the right to privacy and confidentiality irrespective of the fact that students need to be trained with real life situations
In a research conducted by Wood, it was found that recommendations in within various researches into this area have highlighted the importance of using real patients as stimuli for learning 6. A medical school in the United Kingdom also echoed this sentiment by advising that students need to practice in real life situations and not just on simulations or plastic models for clinical teaching; hospitals and clinics therefore, provide the only available opportunity for students to practice on real patients 7.
However, Abdulghani et al, identified that this can only be practicable if the patients are comfortable and willing to involve the students in clinical care 8. This can only be achieved if doctors and students understand the factors that are likely to elicit feelings of either negativity or positivity regarding medical student participation 9.Therefore patient satisfaction is of utmost importance and should be top priority during treatment at the hospital.
Devera-Sales et al, found that majority of research in this area agrees that most patients are positive about the presence of a student in clinical care 10. Prislin et al also found in their research that patient satisfaction and enablement are not impaired due to medical student involvement 11.
The issue of prior consent has been identified as an important factor that affects patient attitude to student involvement in clinical care. Most patients do not consider the issue of prior consent important with respect to teaching and some of them feel proud to be part of the teaching or advancement of medicine. However, in the same study it was found that a minority of 15% insisted on prior consent 3. Most of the patients felt that student presence had no influence on the consultation or examination, although a third objected to a physical examination without the teacher’s presence, and 4% thought that presence of students had a detrimental effect on the consultation or clinical care 3.
In a research carried out by Bentham et al, out of 148 patients only 3 objected to consulting with a medical student before seeing their doctor 12. In another study, Devera-Sales et al, found that 90% of patients were happy for medical students to be involved in their clinical encounter 10.
It seems that for some patients, student presence results in receiving more attention during consultation, having more opportunities to raise concerns (perhaps not intimate ones) and they appreciate participate in the teaching process 3. The students influence on the consultation is complex; some patients dislike it, others are not concerned by it, and still others enjoy it 3.
Patients’ preferences regarding medical student participation in the outpatient dermatology clinic and their participation in the physical examination were shown in a research work by Iqbal et al. It showed that the majority of patients (56.9%) preferred the student with the physician, while (23.5%) had no preference. Those who preferred to see the physician alone composed 19%. Student participation in the physical examination showed almost similar results. From patient preference questions administered it was noted that 51% of patients wanted time alone with the physician; 64.8% felt comfortable disclosing personal information to the student; whereas 22.9% were uncomfortable. The majority of patients enjoyed medical student interaction and felt medical students understood their healthcare needs. A total of 22.8% of patients did not feel they received more attention with medical student participation 13.
Majority of patients enjoy their interactions with the students and felt comfortable disclosing information. Some patients want to spend time alone with the physician so permission for medical student participation should be requested 13.
The issue of consent and confidentiality must be an integral part of teaching in medical schools. A clear explanation should be given to patients about the need for student participation, its advantages and disadvantages. Patients should understand that they are free to choose, and that refusal to have a student present will in no way influence their care or the doctor-patient relationship. Students must be instructed not to discuss patients in a careless manner, and should be made to understand that if a patient does not wish to be examined by him or her, no personal element is involved 3.
Generally, findings in these researches are encouraging for the future of teaching of any branch of the medical profession. However, there are some important issues to be considered before generalizing these findings to the entire patient population.
Haffling found that although the majority of the patients in most cases seem to be happy with student participation, it frequently depends on certain conditions 14. These conditions may be student based such as their age, gender or stage of training. They may be patient based such as their previous experiences with students, gender or the nature of their medical problems 9.
Previous research has indicated that patients with negative attitudes to be involved in teaching were likely to be younger 15, 16, 17, to be women 15, 17, 18, and to have stated psychological problems 15, 16, 18. They were also less willing to discuss intimate and emotional problems or to be videotaped and observed 19. O’Flynn et al, discovered that women were less inclined than male patients to discuss emotional and sexual problems and to undergo a physical examination 20. In a further study they found that 30% of patients found it difficult to talk about personal matters.
Patients’ past experiences play a vital role in how they co-operate with students. Lynoe et al, stated that patients’ beliefs are thought to be predominantly governed by past experiences with medical students 21. Hartz et al, found that patients having experience with medical students are more likely to feel comfortable in a clinical teaching environment 22.
Choudhury et al, had a different view of this this by reporting that patients with prior experience with medical student presence were more likely to be uneasy regarding future student participation in their clinical care and would request no student involvement in the future 23. Cooke et al, also found that 82% of patients that felt that student participation would not affect their quality of care had no previous experience with students 24.
13% of patients who had previous contacts with a student, and 22% who did not, would be troubled if a physical examination were to be repeated by either a doctor or a student; and 31% and 42% respectively would be uncomfortable if a student of the opposite sex examined an intimate body part 10.
Student behavior during patient care has also been implicated as a huge factor that determines how a patient feels about student presence. In a related research some patients labeled the experience with students as “thoroughly enjoyable” and “pleasant”, however, some other patients thought students to be “less confident” and “redundant” 9.
Surprisingly, Coleman et al, advocated a theory that an unconfident student may make the patient assume the role of the teacher or expert in the situation 25. On the other hand, the patient might become discouraged and apprehensive due to the student’s disposition and feel uncomfortable in their presence, and according to Benson et al, this then may prompt the patient to question the student’s ability or competence 26.
The general lifestyle or frame of mind of the patient on a particular day may affect how the patient copes with student presence. In a related research 49.8% of patients agreed that their co-operation with medical students would be affected by their mood that day 8. Some patients may feel that the presence of students may make their consultation more stressful and difficult 9. It is also worthy of note that this might be as a result of increased examination time due to teaching.
Walters et al, observed that some patients found the presence of students distressing, with one patient describing the experience as “emotional upheaval” 27. This was said to be due to either the level of the student’s competence or a perceived lack of sympathy from the student.
According to Levy et al, a lot of researches have shown that students receive more clinical exposure from patients of the same gender 28. This is much the case in gynecological, sexual and internal problems 29, 30, 31.
It was found that in cases of pelvic and rectal examinations a significant number of females would prefer only female students to be present, but male patients in the same conditions did not have as much significant preference as to the gender of the patient 14. In the same study both young males and females were cautious about student involvement in intimate examinations.
Therefore, it may not be correct to consider age, gender and type of examination as separate entities that can influence patients’ attitude to student involvement in their care, but acknowledge that a relationship exists between these issues that can vary from patient to patient 9.
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A lot of studies have been carried out to determine the attitudes of patients to student involvement in clinical examinations. However, there seems to be an almost complete dearth of studies carried out to determine patients’ attitudes to student involvement in radiographic examinations in the Radiology department.
Patients are the main reason for the existence of any hospital so their privacy and rights to confidentiality must be respected irrespective of the fact that radiography students, as part of their learning process, need to be involved in carrying out radiographic examinations. The level of student involvement in radiographic examinations in any hospital varies according to the learning and competence of the student. In any case, however, it is important that patients are used as stimuli for learning 6.
This research shows the attitudes of patients to student involvement in radiographic examination in the afore-mentioned hospitals. The target population had more people (56.6%) that fell within the age group of 18 – 38 years and female respondents (61.6%) were more than the male respondents (38.4%). A large percentage of the patients (83.8%) could tell the difference between student radiographers and radiographers. This may have been as a result of the fact that the majority of the respondents are educated and were aware of this difference between teaching and non-teaching hospitals.
A significantly large number of the patients (77.8%) have not been previously examined by student radiographer without supervision, while 22.2% have been previously examined by an unsupervised student.
Although there was a higher percentage of patients (52.5%) who for various reasons would not be afraid to be examined by a student radiographer without supervision, a significant percentage (47.5%) indicated that they would not be afraid. This might also be because the patients had no knowledge that they were students 41. Some of the patients indicated that they expected to be handled by students because they were in a teaching hospital.
In this research, the main reason behind patients’ fear of student involvement in radiographic examination is the students’ limited knowledge of health conditions. In some other studies conducted in some developed countries, the main reason for such fear is privacy concerns 3.
There were other factors which elicited fear in patients such as students are rough (5.1%) and students are not careful (16.2%). These are general perceptions which people have about students no matter the area of study. This then means that some patients may always be afraid of student involvement irrespective of the student’s abilities.
However, it was found that all the patients (100%) would feel more comfortable if the student was supervised by a radiographer. There was a strong indication among patients who were not afraid of student involvement that students listened to them better. They also indicated that the reason for this was that students wanted to learn and so tended to listen better to patients. They also opined that students were caring and kind, and this corroborates with results obtained in previous studies. It was discovered while collecting the data that some patients enjoyed being examined by students and some of them believed they were contributing to medical knowledge 10.
It was gathered in general that 34.3% of the patients would be embarrassed if they were examined by students of the opposite gender, while 65.7% would not. However, on splitting these figures 60% of the females within 18 -38 years of age would be embarrassed if they were examined by a student of the opposite gender, while none (0%) of the male patients in the same age group would be embarrassed to if they were examined by students of the opposite gender. It is obvious then that the feeling of embarrassment depends on the age and sex of patients. Younger women tend to be embarrassed by involvement of student of the opposite gender 3.
All the patients (100%) believed that students should participate in radiographic examinations and their major reason was to pass on the knowledge of medical radiography to the students who would take on the profession in the future.
Although a large number of the patients (91.9%) had never requested that students should be sent out as they were being examined a few of the patients (8.1%) had previously requested that students should not be present during their radiographic examination.
It was gathered that most patients in all the three hospitals where this research was carried out could tell the difference between a student radiographer and a radiographer.
Although a majority of the patients would not be embarrassed when they are examined by students of the opposite gender, a large percentage of those who would be embarrassed in such situation are mostly women that fall within the age group of 18 – 38 years of age.
It was also gathered that all the patients believe that students should be allowed to participate in radiographic examination of patients, however some of the patients (22%) were averse to students examining them without supervision because they believe students have limited knowledge of their health condition.
Results from this study suggests that students should be educated properly on how to conduct themselves before patients to avoid being seen as rough or not careful to avoid eliciting the feeling of fear in the patients.
A good number of the female patients will feel more comfortable if someone else is present during radiographic examination, especially physical ones, so effort should be made as much as possible to ensure that a female student or radiographer is present during such examinations.
It is necessary to respect patients’ privacy by informing unsuspecting patients that students may be involved in their radiographic examination. This is to avoid fear or embarrassment.
Limitations of Study
This research had more data from patients who came for general radiographic examinations with very few patients for special radiographic examinations such as Hysterosalpingography. Hence, results from this study may not reflect a holistic view of all the variables studied.