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Adoption of ultrasound by nurses: education review

P Hussain
MSc DMU DCR(R) CTCert ICTM
Senior Lecturer/Ultrasound Course Leader
The Centre for Radiography Education University of Portsmouth
E:budgie.hussain@port.ac.uk

Ultrasound is a noninvasive and a nonradiation-based safe imaging modality, utilised by an array of healthcare professionals. It is regarded as an essential diagnostic tool in the enhancement of clinical judgment, provides immediate results and facilitates appropriate referrals to hospital specialists with a reduction in hospital waiting lists, in turn leading to early treatment and in many cases saving lives.(1)
The last decade has seen a prolific development of new ultrasound techniques and procedures, coupled with great advancements in the diagnostic imaging technology, revolutionising obstetrics and gynaecology applications. At the same time we are witnessing a widespread decline in recruitment and retention of key NHS healthcare professionals, mainly radiologists and radiographers, who for many years have been the standard bearers for the provision and delivery of ultrasound services.(2,3) Certainly the escalating workload, shortage of staff and poor recruiting have contributed to a gradual adoption of ultrasound modalities by different healthcare professionals, particularly obstetricians, urologists, gastroenterologists, and recently GPs and nurses.(1)
There is no doubt that nurses play a pivotal role in the management of patient care in the NHS. This role has evolved over the last two decades with dramatic effect.4 Nurses should consider themselves ideally placed to prepare for new and more advanced skills such as ultrasound diagnosis, commensurate with the increasing demands of their professional role.(5,6)
It is now accepted that the shortage of radiologists and radiographers is no longer an excuse for the adoption of ultrasound by nurses; on the contrary, it is service-led. Furthermore, the perception by traditional providers that nurses will marginalise and dilute ultrasound services leading to unsafe practice no longer applies. Nurses contemplating adoption of ultrasound diagnosis for the enhancement of their clinical judgment are the first to acknowledge that the responsibility for adequate training rests with them.(6,7)
The Centre for Radiography Education has seen a gradual increase in the number of nurse practitioners and midwives attending the award-bearing ultrasound courses. Recently, we have acknowledged the limitations of themasters programme; it is time-consuming and fails to address the needs of nurses.
The consultations between the Centre for Radiography Education, the Royal College of Midwives, hospital managers and nurses have highlighted a requirement for a more focused course, dedicated to service provision, where nurses spend less time in academic establishments and more time in clinical practice, leading to a "competence- based" qualification.(8) The course design ensures that a large volume of the learning process is undertaken in the NHS, close to patients and resources, thus maximising learning in the clinical environment.
Because of the dynamic nature and rapidly developing technology in ultrasound applications, students' learning is designed to enhance their professional judgment and commit them to a lifetime of learning and development. Great emphasis is placed within the curriculum on more self-directed learning, especially in the practice environment, where students are allowed more control over their clinical and didactic progression. The continuing clinical training element of the course is responsible for developing nurses' skills in making an accurate diagnosis of the disease process, based upon evaluation of available evidence and critical reflection and thought, rather than the "factual overload" acquired in an academic setting.
The evolution and development of a dedicated ultrasound course for nurses is in keeping with the doctrine of the NHS plan for a more flexible team approach, encouraging the development of innovative educational programmes designed to provide immediate diagnosis, leading to early treatment of pregnancy problems. In designing the course, we have addressed the main issues of a nurse-led ultrasound service, such as the Early Pregnancy Assessment Units (EPAUs), which require skilful nurses to provide holistic healthcare for their clients.
Furthermore, we are convinced that obstetric practice and ultrasound diagnosis are inseparable; pregnant women get far more effective healthcare, including the benefits of immediate feedback on the wellbeing of the fetus in the first trimester,(9) regarded as an essential and prudent use of ultrasound.
The ultrasound course was piloted successfully in January 2001, leading to the inaugural course in November 2001. The course offers classroom lectures enforced by practical workshops, utilising both models and ultrasound clinics, to allow students to experience the complexity of dynamic imaging in laboratory conditions under the guidance of specialist tutors.
Workshops facilitate the development of ultrasound skills to a specific level of competence before and in tandem with direct patient contact. The specially designed laboratory environment ensures that patients are not used as teaching aids and that students are not distracted by the multidimensional complexity of the sick person. The use of models and simulators provides a structured approach to skills learning with tutor supervision, ensuring separate mastering of key ultrasound skills, enabling students to refine and redefine their learning process.
It also allows assessment of students' aptitude and knowledge of the subject, both in a group situation and on an individual basis. Students benefit from the constructive criticism, responsible for dismantling barriers to the tutor-student relationship, which is also essential in addressing the students' progress.
The practical workshops enable students to apply the newly acquired knowledge to their work-based practice, resulting in the improvement and further enhancement of their clinical skills.(10)
The aims of the course require that nurses learn all about first-trimester ultrasound, with an understanding of the potentials and limitations of ultrasound techniques that promote accurate diagnosis. The learning outcomes ensure enhancement of clinical judgment by a judicious use of ultrasound, and enable nurses to provide more efficient patient care.
The course also imparts knowledge and understanding, which assist nurses in correlating the ultrasound findings with clinical history and biochemical indices, such as the level of circulating serum hcG/progesterone level in the diagnosis of an ectopic pregnancy. Stage two of the course deals with the supervised practical training element, with a combination of assessment criteria leading to an award of the certificate for clinical competency.
A recent audit of the inaugural course has highlighted that nurses have benefited from the learning experience, signifying a positive impact on their professional development. The feedback from nurses indicates that the course was instrumental in:

  • Supplementing their clinical skill.
  • Enhancing their clinical judgment.
  • Increasing their confidence in making a diagnosis.
  • Improving patient care.
  • Improving patient management.
  • Reducing patient anxiety.
  • Ensuring patients receive a more efficient service.

The hospital managers were found to be supportive towards nurses pursuing ultrasound training and were keen to ensure that the course:

  • Was essential to service delivery.
  • Was focused on nurse-led ultrasound practice.
  • Had a clinical competency base.
  • Was dedicated to early pregnancy problems.
  • Was properly supervised.

Further comments from the nurses demonstrated two major limitations of the nurse-led ultrasound service:

  • Restricted access to clinical training.
  • Absence of adequate supervision.

Both these issues revolve around some antagonism within the ultrasound departments, resulting in a failure to secure supervision, exacerbated by a total absence of qualified supervision in the obstetric departments. It is essential that nurses have access to expertise in ultrasound within the hospital situation in order to pursue the continuing clinical training programme.
The traditional providers possibly see this as a "turf battle" and a threat to their jobs.(11) The issue of misdiagnosis and the misuse of ultrasound by nurses is also an issue(12) - are nurses capable of providing a comprehensive, safe and accurate first-trimester ultrasound service? The audit demonstrated that at least 50% of the nurses are near to completion of the course, having secured supervision, and are benefiting from the use of ultrasound in their everyday obstetric practice; the other half have yet to start training.
The Royal College of Midwives is in favour of role enhancement and recognises the need for a training scheme leading to accreditation of clinical competencies in first- trimester ultrasound. 
In view of this, the College has set up a working party to explore and seek consensus on an ideal short-course framework through CASE (Consortium of Accreditation of Sonographic Education), a professional body set up to ensure standardisation and monitoring of ultrasound education for all masters programmes in the UK.

Conclusion
There is no doubt that the judicious use of ultrasound will enhance the clinical judgment of nurses in the diagnosis of early pregnancy problems. 
In order to practise ultrasound safely, nurses must have access to a relevant education and supervised training programmes. The support for training should come from the traditional providers, who have a responsibility to ensure that students are supported throughout the programme of learning. It is also evident that in order for a programme to be reliable and valid, the traditional providers must be prepared to loosen their grip on the "sole occupancy" of the ultrasound empire and demonstrate a sense of duty and responsibility in recognising the benefits of a nurse-led ultrasound service. Failure to do so will lead to "turf battles" and further segregation of ultrasound services in the NHS.
In reality, we all share common problems associated with the lack of recruitment, inadequate retention and shortage of sonographers; we should make an honest effort to dismantle our "professional bunkers" and recognise and appreciate each other's skills in the delivery of an efficient healthcare service, which patients rightly deserve.

References

  1. Hussain P. Moving ultrasound in the community. Radiography Today 1994;60(691):35.
  2. Royal College of Radiologists. Clinical radiology workload and manpower survey. RCR Newsletter 1992;33:7-11.
  3. College of Radiographers. Demand, shortages, recruitment and retention, PAM manpower survey. London:Office of Manpower Economics; 1997.
  4. Wilson-Barnett J, Beech S. Evaluating the clinical nursing specialist. A review. Int J Nurs Stud 1994;31(6):561-71.
  5. UKCC. A higher level of practice. London: UKCC; 2000.
  6. Department of Health. The NHS Plan: a plan for investment, a plan for reform. London: HMSO; 2000.
  7. Jarvis P. Professional education. Kent: Croom Helm; 1983.
  8. Lester S. Beyond NVQs: accrediting professional development. ITD SW regional conference report. 1994. p.28-32.
  9. Hussain P. Fetal monitoring: the use of ultrasound. In: RCGP members' reference book 2001/2. London: Campden Publishing; 2001. p. C37-8.
  10. Bines H. Issues in course design.In: Developing professional education. Buckingham: Open University Press; 1992.
  11. Sunshine JH, Bansal S, Evans RG. Radiology performed by non-radiologists in the United States: who does it? Am J Radiol 1993;161:419-20.
  12. Stocksley M. Sonographers and abdominal scanning. Br Med Ultrasound Bull 1991;May:9.

Resources
University of Portsmouth
The Centre for Radiography Education
W:www.sci.port.ac.uk/rad
British Medical Ultrasound Society
W:www.bmus.org

Forthcoming event
11-13 Dec 2002 British Medical Ultrasound Society 34th Annual Scientific Meeting Manchester
Contact: BMUS  T:020 7636 3714
E:secretariat@bmus.org