Since x-ray was discovered by Roentgen in 1895, its medical application has grown to be a fast and dynamic imaging modality. Today’s imaging department consists of an impressive array of diagnostic and therapeutic devices from x-ray machines, CT Scan, PET Scan, linear accelerator, which mainly use ionizing radiation for diagnosis and treatment of illnesses; and with the addition of ultrasound and MRI that use sound waves and magnets for diagnosis instead of x-rays. Thus, radiology is considered as the window of the healthcare institution and the radiologic technologists are the persons behind these state-of-the art machines.
In the x-ray department, one of the divisions of radiology department, the x-ray machines are used for diagnoses of illnesses. For 100 years the film-screen system has been the imaging system of choice. This system uses radiographic film, screen and wet chemistry to generate an image just like conventional photography. Every RT’s goal is to provide high quality images for accurate diagnosis; therefore each step is very critical. The RT must be equipped with knowledge and skills from anatomy, positioning and exposure techniques. One slight mistake can imperil the image and yields an unacceptable radiograph which entails repeat examination that primarily means additional radiation dose to the patient. This is one of the disadvantages of a film-screen system wherein once the film has been processed; there is no way to alter it. What you see is what you get. Fortunately, with the growing technology of imaging modalities came the introduction of digital imaging which follow the same concept as digital cameras wherein brightness and contrast of the image can be changed and images can now be cropped. Its advantage compared to film-screen is very obvious, since images can be altered, repeat examinations, oftentimes is no longer necessary.
The technology is superb and its debut has grown the curiosity of every RT whether it is efficient compared to the traditional system. And of course, it is. However, as with every other technology has its drawback. Since the new technology primarily uses computer and computer-aided equipments oftentimes do the entire job. The question lies wherein will the competence of the RT in terms of exposure technique factors be same as using the conventional way?
Several international studies stated that because of the convenience of the system, the RTs using the machine oftentimes fail to consider the standard protocols in every technique selection because images can be manipulated later. Alteration of images from time to time should not be a daily scenario because manipulation sometimes interfere accurate diagnosis.
As of the researchers’ knowledge, there are no known local related studies in the decline of RT’s competence in using CR. One of the reasons may be this modality is still in the stage of introduction in the Philippines and that its implication is not yet intensively studied. But this does not stop the researchers to seek of finding out if there is indeed a decline in RT’s competence with the new system. This study is a comparative-correlational research in determining the level of radiographic competence between film-screen system and CR on exposure technique factor selection. The main objectives of the researchers are to compare if there is a significant difference in terms of radiographic competence in the RT who uses film-screen from CR and to determine if the respondents profile and agency has a significant relationship in terms of radiographic competence. Base on the result of the study, the researchers will be able to assess the essential skills needed for the profession. Technology indeed has helped us in many ways. However, without the competence of the professional manipulating the equipment is futile. This means that the technologist who has the sole responsibility of manning the state-of-the art equipment should not rely from technology, instead technology should rely on them.
REVIEW OF LITERATURE
This study primarily aims to compare the level of radiographic competence on exposure technique factor selection between film-screen system and computed radiography (CR). Exposure technique factor selection is an important foundation for these two types of image receptor (IR) or imaging system. Image receptor is a device that converts x-rays into visible light. Competence should not vary whether the radiologic technologist (RT) is using the conventional or digital system, otherwise, it will defeat the intensive study of the exposure techniques during the undergraduate years. Furthermore, providing appropriate exposure techniques is paramount in the profession since these techniques also mean radiation dosage on the part of the patient. According to Fauber & Johnston (2012), the radiographer’s actions at the control panel directly determine the nature and the make-up of the x-ray beam. This means that the selected exposure technique factor is directly proportional to patient dose. In addition, it is the responsibility of the radiographer to learn the philosophy, factors and methods that minimizes ionizing radiation exposure to the patient (Callaway, 1996). This also means that an RT is providing quality patient care when he/she gives an adequate and necessary amount of radiation to the patient.
Competence in Radiologic Technologist
Klemp (1980) defined competence as “an underlying characteristic of a person which results in effective and/or superior performance on the job.” A competent person is imbued with the right knowledge, skills and attitude on a particular task. Other authors define competence as “a cluster or related knowledge, skills, and attitudes that reflects a major portion of one’s job, which has a relationship in the performance on the job that can be measured with well-accepted standards, and that can be improved with training and development (Parry, 1996).” In radiologic technology, for example, an newly licensed RT already possess cognitive and motor skills at an entry level, however, it can only be enhanced through proper and consistent training in a chosen specialized field during the course of his/her work as an RT.
Knowledge, Skills, Attitude
As mentioned, competence is a combination of knowledge, skills and attitudes. These components are essential as a whole because the absence of one component greatly affects ones performance. According to Dowd (1996), knowledge as part of competence includes theories and concepts which were gained as a result of the experience of performing certain tasks. Furthermore, in the field of radiologic technology he added that knowledge includes job-specific terminology, methods of organizing information and an understanding of principles and generalizations. On the other hand, Hans Reynold in 1928 defined skill as combined mental and physical qualities which make it useful to industry. Knowledge if combined with skills is important in the workplace. Furthermore, one cannot develop a skill without knowledge and at higher levels, knowledge are converted to skills (Klieme, 2004.)
The last component that determines competence is the attitude. The attitude such as beliefs, values, traits, and motives is a part of competence because it indicates the person’s response to a particular event or situation. Attitude refers to the predisposition or mental state of individuals/users towards a product, ideas, or attributes. It also implies on mental readiness on a particular object or his attributes toward an object or his preferences. (Hulse & Dowd, 1996). In the field of radiologic technology, competence does not only mean that the RT is equipped with the knowledge and skills but RT is also imbued with the right attitude and judgment to provide each patient with quality care
On Radiographic Competence
In the field of radiologic technology, one aspect of the profession requires competent skills in radiographic exposure factor technique. The said competence is essential especially in the diagnostic x-ray imaging, wherein exposure factors are the key to accurate diagnosis and providing radiation dosage to minimum level. For 100 years, film-screen technique has been the method of choice in radiographic imaging (Bushong 2009). Film-screen system uses radiographic films, radiographic intensifying screens and wet chemistry to make the image visible. Furthermore, this conventional system should adhere to the standards of the darkroom requirements. Film-screen system has the same concept as a typical conventional camera. In a film-screen technique, radiologic technologist should be certain on the exposure factors to be applied in a particular exposure because improper selection of exposure factors can lead to overexposure or underexposure of the film. Overexposure or underexposure degrades image quality and therefore, it can lead to rejection of film, thus necessitates the need for repeat examination. Repeat examination provides unnecessary dose to the patient and additional costs to the department.
On the other hand, as with the other innovations in technology, diagnostic imaging has shifted its course from conventional to digital. Computer applications are employed nowadays in diagnostic imaging modalities. An appropriate analogy that is easy for most people to understand is the replacement of typical film cameras with digital cameras: images can be taken, immediately examined, deleted, corrected, and cropped, and subsequently sent to a network of computers. Computed radiography system (CR) is an affordable solution to digital imaging. Instead of the film, CR employs an imaging plate to capture x-rays and makes it visible when the plate is scanned into a computer and digitized it. Once the image is converted to data, it can be recorded on a laser printed film or can be transmitted and stored digitally. It has special features like manipulation or enhancement of the image. Its specialized software is used to image viewing with enhanced functions similar to film-screen system, such as contrast, brightness, and zoom. (dicomsolutions.com, 2011).
Computed radiography has practical technical advantages compared with conventional techniques, such as wide contrast dynamic range, post-processing functionality, multiple image viewing options, and electronic transfer and archiving possibilities. In this system, image quality can be achieved because of the post-processing techniques that are not possible with film-screen system. This system is convenient for the technologists because the RT can compensate for exposure technique inaccuracies by adjusting the technique during post-processing phase of the image rather than that time of exposure.
In radiologic technology field, competence means that the RT is equipped with the knowledge, skills, attitude and judgment to provide each patient with quality care. According to Olavidez (2005), competence is essential in the field of Radiologic Technology because RT is a fast growing profession; RT deals with human lives and most of all, the RT curriculum is not enough to prepare the students to be equipped with the skills necessary for the profession especially in the special fields of radiologic technology. For an RT to become competent, he/she should have undergone formal educational background followed by specialized training in their chosen field that takes months. As an RT, he/she should have comprehensive knowledge and skills in patient care, radiologic procedures and radiation dosage.
Exposure Technique Factors
Exposure technique factors influence and determine the quantity and quality of x-radiation to which the patient is exposed (Bushong, 2009). Kilovolt peak (kVp), milliamperage (mA), exposure time and source-to-image distance (SID) are the principal exposure technique factors. Furthermore, the said factors also affect image quality.
Milliamperage and exposure time are the exposure factors that affects the quantity of radiation. Milliampere is the measure of x-ray tube current, whereas milliampere-second (mAs) is the produce of exposure time and exposure tube current. They directly affect the optical density (OD) of the film. Optical density is the overall blackening of the film. The darker the film, the higher number of x-rays is given to the patient. The higher the number of x-rays that are the given to the patients, the greater the radiation dosage they receive. Source-to-image receptor distance also affects the quantity of the radiation. The closer the patient is to the x-ray source, the higher dosage the patient gets. For chest x-ray, the standard SID is 72 inches, while for the other x-ray examinations, the standard SID is 40 inches. Kilovoltage peak (kVp), directly affects the quality of radiation. kVp is the maximum electric potential that travels across the x-ray tube. Since kVp affects the quality of the x-ray beam, it also affects the quality of the radiographic image. Kilovoltage directly affects contrast. Contrast is the variation of densities on the film. The advantage of using higher kVp is that the patient will receive lower dosage of radiation because it will not be absorbed. However, higher kilovoltage produces more scatter radiation, thus increases the transmission of x-rays to the image receptor and degrades image quality. The best techniques to prevent scatter radiation are using beam restrictors such as collimator to filter low energy x-rays and to cut-off low energy rays using radiographic grids. By employing beam restrictors and grid will enhance image contrast because scatter radiation will be prevented. Furthermore, scatter radiation will also provide unnecessary dose to the patient.
Therefore, exposure technique factor selection is essential. To provide quality radiographs and to limit patients to radiation should be a goal for every RT. According to Bushong (2009), RTs are required to use their skills to produce the best possible image with single exposure (Bushong, 2009). Otherwise, repeat examination will provide unnecessary radiation dose to the patient. Therefore, it is necessary for the RT to be equipped with knowledge and skills to manipulate these exposure technique factors to produce desired optical density, contrast, and image detail on the finished radiograph.
RT in Film-Screen System
In conventional film-screen system, before each examination, the radiologic technologist must select the optimum radiographic technique factors- kVp, mA, and exposure time (Bushong 2009). There are many considerations to determine the value of each factor and they are complexly interrelated. Contrast and Density are the photographic factors of the radiograph and it functions to make the image visible. Visibility of image is important so that anatomical image will appear for proper diagnosis. After each exposure, there is no way to manipulate its contrast and density and that’s what makes film-screen system difficult as inadequate contrast or density entails repeat examination. Since manipulation of the image is not possible in this system, the RT should be certain with the technique factors prior to the exposure; otherwise, miscalculations can result to underexposure or overexposure. In a film-screen system, overexposure and underexposure of the image is considered unacceptable because the important structures are not visible and thus it is not a tool for proper diagnosis. In other words, image quality is dependent on exposure factors.
RT in Computed Radiography
In CR system, image quality is not dependent on exposure factors. Digital image is unrelated to dose, kVp becomes less important. Since, image quality is not dependent on exposure factors, image can be manipulated. In a conventional system, the film serves as both image acquisition and display medium. With CR, the image plate serves as the acquisition medium but does not display the image. Since these functions are separate in CR, the digital signal can be altered to compensate for underexposure or overexposure and an acceptable image can be displayed on the monitor (Shephard, 2003). With CR system, post-processing is possible that helps enhance image thus allowing the RT to alter image contrast and density. Since image can be manipulated or modified, underexposure or overexposure is no longer a problem with this system, because it can usually salvage variations from the optical technique, whereas technical error with a screen-film system often requires a repeat exposure (Pizzutiello, 1993; Cesar, 1997). Therefore, with CR, technical errors are eliminated because of exposure variances that are possible with salvageable results, assuming adequate kilovoltage is used (Ballinger, 1999).
On Assessment of RT Competence
In order to know the competence of a professional, assessment plays a vital role. Assessment is important so as to evaluate if the RT is still competent to do the job. Since we are in the era of rapid technology, it may come to a point that we will just put our confidence on computers rather than our competence. According to Olavidez (2005), competence is an observable ability and it can be measured against set of standards. Assessment of competence is a combined knowledge, skills, and attitudes that reflect the current work practice. Furthermore, it can bridge the gap between workplace requirements and standard.
Selection of exposure technique factor is of extreme importance because RT deals with exposing patients to radiation. Exposure technique factor is equivalent to the quality and the quantity of radiation that exits the patient, therefore, the RT should be precise in giving exposure technique factors. Providing appropriate radiation dose is necessary to prevent the patients from the hazards of the ionizing radiation, therefore prior to the exposure of the patient, accurate exposure techniques should be practiced. The issue of providing accurate techniques lies in a digital system, wherein images can be manipulated during post-processing. According to Fredrick Walker (medicalimagingmag, 2008), a radiologic technologist at Sharp Rees-Stealy in San Diego, CA, he pointed out if the image is too dark, we can manipulate the image using post-processing techniques like windowing or shadowing or to adjust contrast without having to repeat the examination. Furthermore, since image can be manipulated during post-processing, it can encourage complacency rather than accuracy with exposure techniques which can result in overexposed or underexposed images (Medicalxray, 2010). In addition, according to Enfinger (2012), that it is true that the image can be adjusted, however, it is not recommended because the raw data from the initial exposure will contain information from scatter radiation that degrades image quality even if it is manipulated later.
According to Shephard (2003), it is likely that digital imaging will replace conventional screen-film radiography in many modern medical imaging centers in the near future. It has already been stated that even if the image can be manipulated during post-processing, this should not be a practice because somehow it can deteriorate image quality which results in inaccurate diagnosis. One retrospective analysis of patients who had undergone lumbar spine radiographs for the diagnosis of osteoporosis compare diagnostic accuracy with screen-film versus digital radiography. The authors suspected that bone mineral loss could be more easily visible with screen-film imaging due to the fact that image contrast cannot be adjusted with this modality, whereas CR (and DR) images undergo digital post-processing techniques to maximize contrast. This could result in misleading results that confound diagnostic strength in osteoporosis.
Therefore, this is a challenge now for the RT to maintain their competence amidst the aid of technology. Competence of RT is the foundation of providing quality patient care by providing appropriate radiation dose for accurate diagnosis.
Synthesis
The focus of the literature and studies cited was the radiographic competence of RT between film-screen system and computed radiography and it is through this study that the researchers can identify and compare whether their competence will differ based on the image receptor that is being used. In addition, competence in exposure technique factors is essential because this will also mean radiation dose to the patient. It has already been affirmed that the concept has been there for the past few years and therefore the present study is certainly not a new concept. Nevertheless, the researchers deemed it necessary to conduct a study assessing the competence of the RT for the benefit of the institution where they belong because the researcher wants to propose a professional program that could strengthen the foundation of the RTs’. It is also important for the school to offer the programs since almost the RT from the different hospitals in Davao City are products of this institution.
This study is similar to the other studies cited in this section because it stated on the effects of digital imaging on the radiographic competence of the RTs. Furthermore, previous studies dealt with the effects of image manipulation on image quality and it indirectly link to the competence of the RTs.
Conceptual Framework
In this view, the researchers attempted to assess the level of radiographic competence of the RTs in terms of knowledge, skills and attitude. Through assessing the competence of the RTs, the researchers are able to determine the level of radiographic competence; their strengths and weakness of radiographic techniques. On the other hand, the researchers identified the factors that can affect their competence, such as the respondents’ demographic profile in terms of age, sex, number of years in service and educational attainment and the profile of institution such as agency and its classification are also considered.
To have a vivid picture of the study, Figure 1 served as the research paradigm
SCHEMATIC DIAGRAM
Independent Variables Dependent Variables
Factors
Respondents’ Profile
Age
Number of years in service
Agency
Private
Public
Image Processing
Film-Screen System
Computed Radiography
Level of Radiographic Competence
Knowledge
Skills
Attitude
Figure 1
Schematic Diagram showing the relationship between the independent and dependent variables
STATEMENT OF THE PROBLEM
The study aims to compare the level of radiographic competence in using a film-screen system and computed radiography on exposure technique factor selection; specifically it aims to answer the following questions:
What is the respondents’ profile in terms of:
Age
Number of years in service
What is the agency of the healthcare institutions in terms of:
Private
Public
What is the level of the respondents’ radiographic competence in using film-screen system on exposure technique factor selection in terms of:
Knowledge
Skills
Attitude
What is the level of the respondents’ radiographic competence in using computed radiography on exposure technique factor selection in terms of:
Knowledge
Skills
Attitude
Is there a significant relationship between the respondents’ profile and the level of radiographic competence in terms of:
Knowledge
Skills
Attitude
Is there a significant relationship between the agency of healthcare institution and the level of radiographic competence in terms of:
Knowledge
Skills
Attitude
Is there a significant difference in the level of radiographic competence between film-screen system and computed radiography in terms of:
Knowledge
Skills
Attitude
HYPOTHESES
There is no significant relationship between the respondents’ profile and the level of radiographic competence in terms of:
Age
Number of years in service
There is no significant relationship between the agency of the healthcare institution and the level of radiographic competence in terms of:
Public
Private
There is no significant difference in the level of radiographic competence between film-screen system and computed radiography in terms of:
Knowledge
Skills
Attitude
DEFINITION OF TERMS
Accuracy- refers to the degree of conformity of a measured or calculated value to its actual or specific value.
Computed Radiography- is an affordable solution of digital imaging system that uses a photostimulable phosphor as the image receptor.
Digital Radiography- an all-digital technique in which x-ray absorption is quantified by assignment of a number to the amount of x-rays reaching the detector; this is also called as cassetteless system.
Exposure- measure of ionization produced in air by x-rays or gamma rays.
Exposure Factor Selection. It is the factor set by the radiographer (kVp, and mAs) to produce visibility of structures in the radiograph.
Film Screen System- is the conventional image receptor that uses radiographic film, radiographic intensifying screen and wet chemistry to visualize the image in the radiograph.
Image receptor- is a device that converts x-ray beam into visible image.
Level of Radiographic Competence- refers to the measure of the level of competence of the radiologic technologist in achieving goals and objectives in providing quality radiographs with minimum radiation dose to patients.
Private hospital- is a hospital owned by a profit company or a non-profit organization and privately funded through payment for medical services by patients themselves.
Public hospital- is a hospital which is owned by the government and receives government funding.
SIGNIFICANCE OF THE STUDY
This study seeks to determine if there is a significant difference on the level of the respondents’ radiographic competence in exposure technique factor selection between film-screen system and computed radiography; and to determine if there is a significant relationship on the level of radiographic competence between respondents’ profile and agency.
Based on the results of this study, the researchers can identify the strengths and weaknesses of the RTs and if it shows significant decline in the competence of the RT in the CR system, the researchers will propose an enhancement program for the professionals. The said program will also be a part of the Continuing Professional Education (CPE), and it will be added to the CPE units needed to renew RT licenses. This study will be most helpful to the radiology department of the hospital to enhance Health Care Delivery by limiting radiation dose to the patients. Furthermore, determining the attitude toward the imaging system will help the department to reevaluate the mental and the emotional state of the RT’s. Mental and Emotional state of the RT are important since they are dealing with patients. It is the responsibility of the RT to render quality patient care by providing appropriate radiation dose.
Furthermore, this study will also be of most helpful to the schools offering radiologic technology as to intensify the foundation of the students in terms of exposure technique factors. Based on the result of the study, there may be a need to revise the curriculum to further intensify the skills of the RT students. Computed Radiography is not a part of the standard RT curriculum, and it may be one factor that affects the decline of competence on the part of the professional as well as the students.
Chapter 2
METHODOLOGY
This portion discusses the research design used, the research locale where the study will be conducted, the description of samples and the sampling technique, the instrument used, the details of procedure and the statistical analysis to answer the research problem.
Research Design
The study will employ a comparative-correlational research. To determine the difference between the level of competence in film-screen system and computed radiography, comparative study will be used. Furthermore, to determine the relationship between the respondents profile and agency between the levels of the radiographic competence, correlational design will be employed.
Setting
The study will be conducted from the selected hospitals in Davao, Digos and Tagum City employing either film-screen system and computed radiography. The hospitals using film-screen system are the following: Alexian Brothers Health and Wellness Center, Km. 4, McArthur Highway, Matina, Davao City; Davao Regional Hospital, located at Apokon, Tagum City 8112 and Davao Del Sur Provincial Hospital which is located at Lapu-lapu St. Digos, City Davao Del Sur. On the other hand, the hospitals using the computed radiography system are the following: Davao Doctors Hospital (DDH), E. Quirino Ave., Davao City; Southern Philippines Medical Center (SPMC), J.P Laurel Ave., Bajada, Davao City and Davao Medical School Foundation and Hospital (DMSF), Medical Drive, Bajada, Davao City.
Participants
The respondents of the study are the Registered Radiologic Technologists and Associate X-ray Technologists coming from the selected hospitals in Davao City employing a film-screen and computed radiography system. Moreover, the qualified respondents should be at least six months in service at the time of the evaluation.
Measures
The research assessment is composed of four parts. The first part of the assessment consists of questions pertaining to the profile of the respondents and hospital.
The second part consists of questions on the respondents’ level of knowledge on exposure technique factor selection. The questions are specifically structured in such a way that assesses the respondents’ acquired knowledge on technique selection. Based on the results, the attitude in terms of respondent’s response in both film-screen and CR system will be categorized as follows depending on their mean score:
Points Obtained Qualitative Description
30-25 Very High
20-24 High
15-19 Moderately High
10- 14 Low
13- 0 Very Low
INTERPRETATION
The aforementioned assessment form that will be used as instrument of the study is constructed and designed by the researchers as to measure the basic knowledge in exposure technique factor selection regardless of the imaging system used. Its validity and reliability was attested by experts of the field.
Moreover, the third part of the assessment is an actual evaluation wherein the respondents are observed during x-ray examination. They will be assessed in the actual selection of the exposure technique factor and the outcome of the image. The said assessment is a point system; the appropriate the RT performs in technique factor selection and the acceptable the image, the higher the points. Based on the results, the level of radiographic competence in terms of respondent’s skills will be categorized as follows depending on their mean score:
Points Obtained Qualitative Description
10 Very high level of radiographic skills
7-9 High level of radiographic skills
4-6 Moderately low level of radiographic skills
1-3 Low level of radiographic skills
Low level of radiographic skills means that the respondents were not able to perform the appropriate exposure techniques and came up with an unacceptable radiograph. Moderately low level of radiographic skills me
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