Sonographers’ level of autonomy in communication in Australian obstetric settings: Does it affect their professional identity?

Abstract

Introduction

Unlike the United Kingdom, policies in Australia prevent sonographers from exercising autonomy in their level of communication with pregnant patients in the event of adverse findings. The organisational structure makes the sonographer dependent on the sonologist because sonographers do not have the authority to provide the official report. The emotional labour on sonographers is increased as they struggle to provide patient-centred care, given the limits put on their communication during the ultrasound examination. The aim of this study was to explore Australian sonographers’ views on communicating adverse findings, including their level of autonomy in communicating with patients and how this influences their sense of professional identity.

Methods

Following a national survey, seven purposively selected participants, who were qualified to perform obstetric ultrasound examinations, completed follow-up interviews. The interviews were thematically analysed with iterative comparison to the survey results. Three case studies show sonographers differed in their ‘communicator type’ due to geographical location and workplace setting.

Results

The case studies illustrate a sonographer’s communication role, and level of autonomy is negotiated/renegotiated depending on the needs and expectations of each workplace. Their communication practices varied due to the sonologist (radiologist/obstetrician) policy on sonographer/patient communication, presence and support in the clinical setting. A strong professional identity and level of autonomy came from the construction of attributes that were built over time based on multiple factors, including previous experience, geographical location, critical incidents, training and supportive work environments.

Conclusion

The sonography profession demands autonomy and a strong professional identity free of hierarchical barriers within a collaborative model of care.

Introduction

Sonographers employ a combination of ‘simultaneous complex skills’ (p. 76)¹ while interacting with and caring for a pregnant patient throughout an ultrasound examination. They are in a trusted and sometimes difficult position² because of the strong psychological attachment between mothers and their unborn child³ and the stressful possibility of identifying an adverse finding. These circumstances demand the development of a strong rapport between the sonographer and the patient to reduce anxiety and provide patient-centred care.⁴

Patient expectations

With access to the internet, pregnant patients now have a greater awareness of what can be expected from an ultrasound examination, and therefore expect direct and immediate communication from the sonographer on the status of their unborn baby’s health.⁵ Normal results reduce parents’ anxiety, however, a prenatal adverse finding is highly stressful for both patients and sonographers.^2,6

In difficult situations, patients expect professionalism from healthcare practitioners, which includes respectful and supportive communication at all times.⁷

Sonographers in Australia

In Australia, sonographers may work in a multidisciplinary team or as a sole practitioner, depending on the practice setting. For example, in a remote setting, it is commonplace for a sonographer to work independently with the reporting sonologist offsite. However, in metropolitan locations, it is more common for several sonographers to work concurrently with a sonologist and, in most cases, the sonologist and sonographer are reliant on each other’s skills and expertise.⁸ In Australia, the official report must be completed by a sonologist who is a physician specifically trained and qualified in ultrasound; in the case of obstetric examinations, it can be an obstetrician or radiologist.^9,10 According to the Royal Australian and New Zealand College of Radiologists (RANZCR), the role of the sonologist and sonographer is clearly defined:

The sonologist performs the ultrasound examination either by him/herself or in conjunction with a sonographer, who is a dedicated ultrasound technologist. The study is interpreted by the sonologist, who issues a specialist medical opinion in the form of a written report.¹¹

This statement demonstrates that RANZCR positions the radiologist as the leader of the ultrasound team, with sonographers in a dependent and secondary role as a technologist.¹² This perception of sonographers as ‘technologists’ does not acknowledge the postgraduate education and training required to provide sonographers with the skills to capture and interpret images and provide a preliminary written report on which sonologists depend to provide their official report. In contrast, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) acknowledge through their guidelines there must be a collaborative and multidisciplinary approach to a mother’s care during pregnancy.¹³ This is reinforced by the Australian perinatal guidelines for care in the event of stillbirth and perinatal death.¹⁴ The guidelines include the need for positive patient–sonographer interactions to assist a pregnant patient’s recovery from these traumatic events.

The sonographer’s dependence on sonologists is officially recognised in both the organisational and medically dominated hierarchical structure of Australia’s healthcare system, in which the sonographer is not expected to work independently of a sonologist and does not have the authority to provide the official report to a referring practitioner.^15,16 In addition, the sonologist has the power to set protocols regarding communication practices between sonographers and patients,¹⁷ however, these are highly variable and often ambiguous depending on the reporting sonologist and the practice setting.^9,18 This creates difficulties for Australian sonographers as frontline practitioners as they do not have any formal authority or control in their interactions with pregnant patients and other healthcare professionals, such as referrers. Our research suggests it is challenging for a sonographer to provide patient-focused care^9,18,19 and put the needs of the mother first when they are prohibited from discussing findings with a pregnant patient.

In direct contrast to the position of Australian sonographers, in the UK the sonographer practitioner role allows for independent practice, including reporting, and open communication. This role has been introduced with the support and encouragement of the Consortium for the Accreditation of Sonographic Education (CASE) standards,²⁰ the Society and College of Radiographers (SCoR) and the British Medical Ultrasound Society (BMUS)²¹ to reduce patient waiting lists and support professional advancement.²² The sonographers’ autonomous role in the UK has demonstrated an improvement in patient outcomes²³ and developed a strong professional identity despite sonography not yet being recognised as a profession in the UK.

Shaping professional identity

Establishing a professional identity is an evolving process with multiple factors contributing over time to influence an individual’s occupational status and sense of self.^24,25 Within healthcare, the attitudes of both co-workers and patients contribute to the shaping of professional identities.²⁶ The process and development are dynamic and contribute to understanding a person’s position and role within a workplace team, and this is true for a sonographer in an ultrasound department. Sonographers work as a team in the maternity model of care; however, the shift to patient-centredness within the healthcare system²⁷ requires patients to be involved in all clinical decisions.²⁸ Determining patients’ involvement and the level of communication they receive from a member of the multiprofessional team may affect sonographer autonomy and team dynamics if they are excluded by sonologists from making clinical decisions on communication.²⁹ Sonologist control over communication policies affects sonographers’ autonomy in their interaction with patients, therefore, this may impact a sonographer’s sense of their own professional identity and the sonography profession as a whole.

A profession is generally defined as requiring a high degree of control, confidentiality and autonomy in the service provided for a client,^30,31 based on a specialised body of knowledge recognised by society.³⁰ Sonographers in Australia are highly educated with specialised post-graduate qualifications and are required to participate in continuing professional development through professional bodies to maintain compulsory accreditation.³² Sonographers therefore use their higher level of interpretive skills to autonomously decide on the diagnostic images used for reporting by a sonologist, however, the level of autonomy exercised, particularly in communicating with patients, is limited resulting in inconsistency of their role.

Aims

Australian sonographers have variability in their level of communication autonomy with our research identifying different sonographer ‘communicator types’: ‘Limited’, ‘Variable’ and ‘Open’. This paper will use a case study approach to further investigate these ‘communicator types’ and identify if, and in what way, they influence a sonographer’s sense of professional identity.

The specific aims of this paper are to:

1. Explore the influences affecting the level of communication autonomy of each ‘communicator type’ using three case studies.

2. Understand how the degree of autonomy informs the sonographer’s sense of professional identity and how this impacts their role and recognition in the obstetric ultrasound model of care.

Method

Research design

The data reported in this paper are drawn from one component of a larger project that used a mixed methods research design (survey, interviews) to investigate Australian sonographer communication practices in obstetrics. A full description of the research design and methodologies used in the overall project has been published elsewhere.⁹ This paper consists of the qualitative findings describing sonographers’ professional identity from the perspective of exercising a degree of autonomy in communicating with pregnant patients.

Sample, participants and recruitment strategy

An invitation to participate in the survey was advertised in the Australasian Sonographers Association (ASA) weekly online newsletter for five weeks in April–May 2018. Respondents (n = 249) were fully qualified or student sonographers who self-identified as currently performing obstetric ultrasound. From the survey respondents who indicated agreement for a follow-up interview, seven were purposively selected because of the variety in their workplace settings and location, to further explore their views on the sonographer’s role and autonomy in communicating directly with pregnant patients and how this shaped their sense of professional identity. This was done using a semi-structured interview format.

Data preparation and analysis

Interview data were thematically analysed using NVivo software Version 12, 2018 (QSR International, Melbourne, Australia) including discussion and refinement by all authors with an iterative comparison with the open-text survey responses.

Findings

The findings from the follow-up interviews are presented here as three case studies; this captured the thoughts and experiences of the participants from a range of practice sites and geographical locations, and to illustrate the characteristics of the three previously defined ‘communicator types’. The ‘Open Communicator’ openly discusses results; the ‘Variable Communicator’ changes their practices depending on the circumstances, and the ‘Limited Communicator’ rarely communicates findings directly to obstetric patients.⁹ These different styles reflected differences in sonographers’ understanding of their role, sense of professional identity and how multiple factors influenced the autonomy they experienced in communicating results with pregnant patients.

For anonymity, pseudonyms have been used.

Three case studies

Each of the three case studies presented is representative of the different experiences of sonographers around professional identity, degree of autonomy and communication practices. While there are similarities between the three sonographers (female, 15+ years’ experience), there are also differences in that they work with a range of reporting sonologists, and in different geographical locations and practice settings.

Case Study 1 (Chloe) is employed on a contract basis with the majority of her time working as a solo sonographer in remote parts of Australia (population < 5000). She also works a few weeks each year in a tertiary referral maternal foetal medicine (MFM) unit in a metropolitan city. Case Study 2 (Jackie) works in regional Australia in a private radiology practice. She is heavily involved in training junior sonographers.

Case Study 3 (Val) works in a metropolitan city, in an obstetrician-owned, private practice. She had her initial training in a private radiology practice.

Discussion

These three case studies illustrate that practice setting and sonologist involvement shape a sonographer’s level of autonomy in their communication practices, and in turn, their sense of professional identity. Chloe, Jackie and Val’s perception of their professional identity came from the construction of attributes that were built over time and based on multiple factors, including previous experience, training and supportive work colleagues. Their communication roles varied depending on the needs and expectations of each workplace.

The three case studies reinforce the idea that for sonographers, professional identity is difficult to define,³³ and is clearly shaped by others, especially sonologists.³⁴ All three sonographers’ roles in communication were dependent on the sonologist’s practice policy, presence and support in the clinical setting.

For the purpose of this study, the authors’ interpretation of a sonographer’s sense of professional identity was drawn from the participant’s account of their perceived level of autonomy in communicating with patients and how they viewed this in the context of their sonographer role. It was evident from participants’ accounts that their sense of professional identity was shaped by their workplace settings and relationships, with those in radiology settings feeling they had less autonomy and therefore a weakened professional identity compared to those working in obstetrician-reporting settings or as sole sonographers working remotely.

Despite working in different settings, the three sonographers intrinsically strive for patient-centred care as ‘patient advocates’. They are motivated to maintain patient wellbeing and are flexible as they adapt their communication practices to their setting. All three sonographers recognise that their communication and interactions with patients may bring about an emotional and psychological impact, particularly in the situation of an adverse outcome. Chloe points out that she maintains a high level of care in both workplace settings and has constructed meaning around her professional identity and communicator roles. She has developed and assumed a strong professional identity in both settings, however, she practices as an ‘open communicator’ remotely because she is the sole practitioner; whereas, in the MFM unit she does not need the same level of communication because of her role within a multidisciplinary team. She is comfortable with the level of her autonomy and communication role in both settings.

Jackie is a ‘variable communicator’ depending on the instruction from the reporting radiologist, stage of pregnancy and the complexity of the adverse finding. As a trainer, she imparts a strong sense of professional identity, however, her communication role is different because she lacks autonomy due to the practice’s ‘no communication’ policy. Jackie’s limited level of communication autonomy, due to control and mediation of communication with patients by radiologists, weakens her professional identity.

Val changed from a ‘limited communicator’ position in a radiology setting to an ‘open communicator’ in the private obstetrician-reporting practice where formalised protocols, training and the backup and support of sonologists existed. In this setting, the obstetricians and sonographers showed a collaborative multidisciplinary approach with respect and trust towards each other.

Navigating the different settings and responsibilities in communication appears to be an accepted part of these sonographers’ professional identity. They constantly reshape their role in communication depending on the reporting sonologist’s requirements. However, they preferred to have support from their reporting sonologist to avoid stress and pressure in these difficult communication situations with Chloe and Val explaining that working directly with their reporting obstetrician sonologists provided a supportive environment. Chloe believed her time working overseas as an autonomous sonographer had strongly influenced her professional identity because of the confidence she gained in her knowledge and communication abilities. The workplace environment with the obstetricians encouraged confidence and allowed Chloe and Val to find their own professional identity without hierarchical challenges in the organisation’s structure.^33,35 This is in contrast to Jackie who has limited autonomy to decide on her communication practices due to barriers imposed by the radiologist’s authority, which controls the sonographer/patient interaction and makes her communication role variable. Her professional identity in this model of care differs from Chloe and Val because she works for radiologists, not obstetricians. Restrictions and interprofessional boundaries like this can create a challenging and stressful workplace for sonographers,^2,9,36,37 leading to a loss of confidence, poor recognition and possibly a weakening of their professional identity.³⁸ Determining the roles of each team member in a multiprofessional context is vital to appreciate how each person contributes to patient care.³⁹ In a radiology setting, the traditional culture of medical authority adversely affects a sonographer’s professional identity⁴⁰ by limiting their professional growth whereas those working with obstetricians expressed recognition of their professional identity.

Critical incidents and experiences also play a significant role in developing an individual’s professional identity and affect them in their future communication actions. Interaction and socialisation through personal experience forces individuals to continually renegotiate their identity.²⁶ This was evident with Val recalling a foetal death she discovered during a third-trimester scan, which she had never experienced before, and it gave her insight on how to communicate bad news to mothers in the future. This reinforces the findings of Johnson et al. (2012) who describe a constant reshaping of one’s professional identity throughout one’s working life due to different experiences.⁴¹

Several of the survey participants in the major project associated with this paper (see Methods) referred to the dichotomous position of sonographers; that is, working in a medically dominant and hierarchical health system while feeling that they should meet patient expectations within a patient-centred care model. Such a situation creates stress and challenges for a sonographer as they try to satisfy everyone. This dichotomy was evident in all three case studies with Jackie and Val explaining how they regularly changed their approach because ‘each situation was different’ and Chloe working remotely without a sonologist available to attend the examination. This ambiguous and often chaotic boundary in communication ultimately limits the sonographer’s level of autonomy and confidence, resulting in stress and pressure in the workplace.

Sonographers have a universally accepted role allowing considerable latitude and responsibility in diagnosing adverse outcomes during a scan,⁴² even though RANZCR policy describes them as ‘technologists’ which infers an inferior position. In contrast, RANZCOG¹³ states in its guiding principles that collaboration ‘with mutual trust and respect for each profession’s perspective and way of thinking’ will ensure quality ‘woman-centred care’. RANZCOG recognises this can only be achieved with ‘open, honest and unbiased communication with the woman, her partner or support person and other maternity carers’¹³, as was evidenced in the case studies with obstetricians recognising the sonographer role. The paradox of these policies reinforces Palmer and Short’s conclusion that the overall Australian healthcare system’s ‘model of care’ does not align well with the ‘reality’ of everyday practice.⁴⁰

A limitation of this study is that the participants included in the case study comparison were purposively drawn from survey respondents who volunteered for a follow-up interview; this was done to further explore the themes previously identified as informing three ‘Communicator Types’. As such, the participants included were limited to female sonographers with over 15 years’ experience and therefore consideration is not given to male or inexperienced sonographers. Further qualitative research is needed to understand if the experiences of the three case study participants are representative of Australian sonographers working in obstetric settings, and also to include the experiences of pregnant patients in their interactions with sonographers in these settings.

Conclusion

This study has shown that there are differences in a sonographer’s sense of professional identity due to workplace settings, experiences, geographical location and sonologist background. These influences impact a sonographer’s level of autonomy and ability to practice patient-centred care. The recognition of a sonographer’s role as the frontline practitioner in diagnosing and interacting with a pregnant patient demonstrates that sonography is a profession which demands a strong identity free of hierarchical barriers. Therefore, urgent attention is needed by all professional bodies associated with ultrasound in obstetrics to address the contradictory policies currently operating in Australia and encourage uniformity of practice across all settings; this will be an important first step needed in the process of giving sonographers full autonomy to provide patient-centred care.

Consent

Written consent was obtained from all the participants.

Contributors

Kate O’Loughlin revised the article critically for important intellectual content and gave final approval of the version to be published.

Jill Clarke revised the article critically for important intellectual content and gave final approval of the version to be published.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethics approval

The University of Sydney Human Research Ethics Committee granted ethics approval (Ethics Approval Number 2017/932). University of Sydney, Sydney, Australia.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Guarantor

Samantha Thomas made substantial contributions to the conception and design of the study, as well as the acquisition, analysis and interpretation of the data and drafting the article.

ORCID iD

Samantha Thomas https://orcid.org/0000-0001-9453-1790