INTRODUCTION
1
Clinical placements are an important component in the education of students who are training in the healthcare professions. Here, they begin to witness examinations of patients thereby gaining required experience as it concerns the hospital environment.
The co-operation of patients and their consent to involve students in their care is vital to clinical education.1
A vital part of radiography students’ education is learning through interaction and direct contact with patients. An essential example of this is in contrast-administered examinations where students learn more on the patient pathology, participate and learn the intricacies involved in radiological examinations. Thus, a key element of clinical education is a patient’s willingness and comfort level with involving a student in their ecaminations.2
It can therefore be inferred that in order for students to finally become competent in the practice of radiography after graduation, real life sessions with patients are ultimate if this is to be achieved. The patient now becomes an important tool in making sure students earn that clinical experience which qualifies them as radiographers.However, patients have their right to confidentiality.3
As a patient, he/she has a right to every consideration of privacy related to your medical care. Examination, consultations should be conducted discreetly. As long as it does not interfere with diagnostic procedures or treatments, a patient has the right to request that someone be present or not while an examination is being performed. This interferes with purpose of clinical learning of students by presenting them with real life situations. The era when radiographers/radiologists and clinical students approached patient with a sense of divine right over them are long gone. Patients now have increased awareness of their rights.3
It is therefore an ethical practice to seek for their consent and if sought, have the capacity or will to decide if students are to participate in their examinations or not. Some radiological investigations which require the administration of contrast agents are intimate. Therefore, patient privacy should be held esteem.Being a patient also leaves one with a responsibility of responding to your caregivers.3
In order to facilitate care, a patient to help the medical personnel by following their instructions and medical orders. Clinical students might be involved in a care and the patient has the obligation of following instructions.Although most patients accept that healthcare givers in training must develop their clinical skills, the presence of a student might add to the arousal that the medical environment already imposes on a patient.4
This can evoke negative/unacceptable behaviours from patients especially when the patient nurses the feeling that he/she has lost his/her privacy. The aggression of the patient might manifest in the form of defiance; refusal to co-operate with instructions given to them. This usually interferes with the examination and in general, adversely affects the clinical teaching environment. As it concerns student radiographers, it can be stated that continued exposure to uncooperative patients tend to manifest in the student as emotional exhaustion and lower level of psychological well-being.5
A patient’s willingness and comfort level with involving a student in the radiological examination may be affected by a number of factors. These range from their previous experience with radiography students, through understanding the role/responsibilities of the students, nature of the medical problem and the patient or student’s sex, most importantly.2,6,7,8
As it concerns sex as the most important factor, anecdotal evidence from male students have shown how difficult it is to obtain experience whenever it concerns female patients. In radiography, invasive examinations such as Hysterosalpingography(HSG) are often and inadvertently restricted to mainly female students. Female patients tend to be more apprehensive when they have male students around than female students in radiological examinations like HSG.
Nevertheless, previous studies carried out especially on medical students revealed a general acceptance of them as patients had a positive view of them, but specific details on assessing the level patients co-operate when students participate in intimate radiological examinations like Hysterosalpingography(HSG), Micturating Cystourethrography(MCUG), mammography has not been documented. Again, these studies have been carried out on Caucasians with the awareness that the values of this country are different from theirs; it becomes necessary to assess this major factor in clinical excellence within our locality.
1.1 Statement of problem
2
Therefore, in the light of all these, the big question remains, “If student radiographers do not witness these contrast examinations and learn the intricacies involved in such investigations, how then can they register themselves as professional radiographers?
1.2 Objectives of study
The major aims of this study are two-fold:
1.3 Significance of study
1.4 Scope of study
This research will be carried out on all patients booked for the following radiological examinations; Hysterosalpingography (HSG), Micturating Cystourethrography (MCUG), including Mammography, in the University of Nigeria Teaching Hospital (UNTH) and Federal Medical Centre (FMC), Owerri, between January and May, 2013.
1.6 Hypothesis
The racial distribution of patients, mainly ethnicity plays a major role in the perception of patients regarding the presence of students in the fluoroscopy room during their examinations.8
1.7 Literature review
Only a few studies have been carried out in the United Kingdom (UK) that has studied the level of cooperation students receive when involved in the general care of patients. The majority of such studies indicate that patients are, in general, positive about student participation.9
These previous research studies have yielded results all based on medical students’ involvement in clinical sessions and consultations. However, there has been a dearth of studies regarding the field of radiography as to the level of cooperation exhibited by patients when radiography students are present in radiographic examinations.The study conducted by Rima et al revealed that privacy was the most important factor in the patients’ reticence towards examination by the students, whilst the relative safety and comfort if a supervisor was available determined patients’ agreement.1
It showed that 67.8% approved the presence of medical students during clinical sessions.Patients’ choice as to whether or not to involve students in their examinations can be influenced by patients socio-economic characteristics a 58.2% out of the patients who gave their approval were those with better socio-economic characteristics.1
But this general acceptance notwithstanding, patients’ consent is supposed to be sought before students are involved in examinations.Physicians have always had a duty to keep their patients’ confidences. In essence, this duty means that any medical information from patient is meant solely for the physician. The AMA’s code of medical ethics have backed up this issue of patient confidentiality, the purpose of which is to ensure a full and frank disclosure of information by the patient.10
This in turn enables a full and more complete diagnosis to be made and proper treatment, administered. The Law of Patient Rights which was enacted in Israel by the Israeli parliament, highlighted extensively six areas of importance concerning patient confidentiality, consent and record-keeping.28
the areas of importance included right of patient refusal, provision of complete and accurate information, proper identification, presence of a senior medical staff, the right of a disabled patient and patient’s right to request for the presence of a third party (might be a student in this case).15
This issue of patient confidentiality nearly compromised the fact that students need to be presented with real life situations for clinical learning to be adequate and equally comprehensible. In the United Kingdom, its importance was highlighted. It was advised that students needed to use real life situations, which was patients, to effect clinical experience instead of depending on human phantoms and simulations for clinical experience.11
This has a positive outcome on the student because the desired communication skills and attitudes are developed, particularly in the intimate examinations of men and women.12
Witt et al noted that cooperation of patients can be determined by treatment-related factors such as personality trait and patient attitude. These factors could affect the patients’ perception towards involvement of students in examinations. Patient attitude are a critical link between these influences.13
Patient satisfaction also influences a patient’s general perception of privacy throughout the examination.14
This means that lack of privacy is not measured only in terms of student presence. Lin et al in their research revealed how significantly associated patient satisfaction is with how they perceived privacy in examinations. Results obtained showed that privacy level decreased significantly when patients’ personal information is overheard by a third party, which in this context refers to the student radiographer. The patient is the reason for the existence of the hospital and they are also the reason for which the whole medical team is employed. Satisfaction of the client should be considered before the importance of student involvement. The ethics of practice is always compromised.15
Shlomo et al confirmed this claim with results from their survey. This showed that no consent procedures are set aside to obtain patient consent for them to be used in teaching students. Shier et al, summarized it by inferring that healthcare givers are ignorant that they have an obligation to patient by ensuring their confidentiality.16
There is greater acceptance of student involvement in clinical/radiographic examinations once there is no direct contact between students and patients. Yousef et al in a short research revealed that once it involves only reading patients’ files, observing doctors performing examinations, patients were quick to give consent.17
paediatric patients showed higher acceptance of students while obstetrics/gynaecology patients (especially females) and students appeared to affect the degree of acceptance of students by patients. It was also argued how presence of students affected quality of health care. From this study, 436 patients (46.8%) believed that presence of students during examinations improves the quality of healthcare.17
Mol et al, in a literature review of 16 studies that examined patients’ satisfaction regarding the presence/participation of a medical student during an examination in a general practice setting, found that the benefits reported by patients included a longer examination time, more thorough examination and better patient education.18
this study also noted how frequently good patients felt about contributing to student education.18
Majority of patients who agreed to participate in student-involved examinations did so because they wanted to or felt obliged to make contributions to medical education.19
Ghandi et al highlighted this in a study involving 72 patients who participated in a medical examination, in which was reported that 82% found the experience positive and 90% would encourage others to participate in the future.19
in these studies, negative comments were uncommon; Cooke et al showed that only 3% of patients had a negative view about presence or involvement of students,20
O’Flynn et al, also inferred that patients were favourable towards medical students.21
It is suggested that patients’ unwillingness to co-operate with student involvement may be because of the more invasive and intimate nature of the examination. Although these studies provide an insight into patient attitudes to passive medical student involvement, that is, simply observing patient interactions with qualified medical personnel, they may have differing views towards active medical student involvement in their healthcare, that is, the performing of examinations by students themselves under the supervision of qualified professionals.
In radiography, the invasive nature of most radiological examinations, such as HSG, MCUG among others make this determinant very sensitive in the field. Not many studies have investigated patients’ attitude towards medical students performing invasive procedures. Grabber et al asked 150 patients for their opinions regarding student involvement in clinical procedures as part of their training. They found that patients’ willingness was low for highly invasive procedures.
Additionally, few studies have examined the demographic characteristics of patients who may be unwilling to allow a student to participate in their healthcare. Results across the few existing studies investigating the effect of the patient’s age on unwillingness to co-operate in a clinical setting with small sample sizes for younger age groups that may not be representative of the views of the general population.2, 22
With regard to ethnicity, a United States (U.S) study by Adams et al revealed that this demographic characteristic could influence patients’ cooperation once medical students are involved in examinations.6
In this study, it was shown that non-white patients in an ambulatory care setting were less likely to perceive a benefit from the participation of medical students in their care compared to Caucasian patients. Non-Caucasian respondents also experienced greater concern if they were examined by a medical student alone, without supervision from a qualified professional.Similarly, another research by Simons et al has suggested that previous contact with medical students in a clinical setting may increase patient willingness for subsequent medical student participation in their care.2
Favourable previous experiences with students might increase willingness to cooperate, but although patients may seem happy about it, it frequently depends on certain conditions.23
these conditions may be student-based; sex of the student and level of training of the student or patient based; patients sex, previous experiences with students, understanding role of students and nature of medical problem.2,6-8,24
Patients who have had previous contact with students will not always want future student involvement in their sessions.25
the reason for this might be due to a student based factor which is the behavior of the student predominantly.24
a student present during clinical examinations, as perceived by patients, might be thought to be less confident. A lack of sympathy perceived by the patient can also contribute to a future reluctance to participate or co-operate towards student involvement in examinations, as revealed by Walters et al.26
this attitude by patients support the claim held by Lynoe et al in a study were it was stated that all patients’ beliefs are predominantly as a result of past experiences with students whom they had come in contact with.27
Choudhury et al, had a different view of 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.29
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.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 day30
. Some patients may feel that the presence of students may make their consultation more stressful and difficult24
. It should be noted that this might be as a result of increased examination time due to teaching.To the best of the researcher’s knowledge following the reviewed literature, most of these previous research studies were centered and carried out on Caucasians. None of such has been done to determine patient cooperation with involvement of students among the Nigerian population. There is also no conclusively documented literature concerning patients and their cooperation during radiological examinations when radiography students are to participate. All other reviewed literature was mostly also done on medical students. Therefore, this work is to establish the level of cooperation students receive from patients when they find themselves in the hospital setting, which maybe when students go for clinical placements and relate findings with the racial distribution of the patients to determine if the patient’s race can affect the patients’ cooperation positively or negatively.