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Managing the Unmanageable: A Qualitative Study Exploring Sonographer
Experiences of and Training in Unexpected and Difficult News Delivery
Authors
Natasha Kate Hardicrea*, Senior Research Fellow, Email: n.hardicre@bthft.nhs.uk; Telephone:
01274383428. ORCiD: 0000-0002-3639-5556
Jane Arezinab, Ultrasound Lecturer, Email: J.Arezina@bthft.nhs.uk; Telephone: 01133439623.
Alison McGuinessc, Consultant Sonographer, Email: Alison.McGuinness@nhs.net.
Judith Johnsond,a,e, Lecturer, Email: J.Johnson@leeds.ac.uk.
Affiliation
aYorkshire Quality and Safety Group, Bradford Institute for Health Research, Bradford Royal
Infirmary, Bradford, BD9 6RJ, UK.
bFaculty of Medicine and Health, Specialist Science Education Department, Leeds Institute of
Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
cUltrasound Department, Mid Yorkshire Hospitals NHS Trust, Pinderfields General Hospital, Aberford
Road, Wakefield WF1 4DG, UK.
dSchool of Psychology, University of Leeds, Leeds, LS2 9JT, UK.
eSchool of Public Health and Community Medicine, Faculty of Medicine, University of New South
Wales, Sydney, Australia.
Acknowledgements
The research is supported by Society and College of Radiographers. We wish to acknowledge all the
ultrasound professionals who participated in both phases of the research study, in particular those
that agreed to be interviewed, thus enabling us to undertake this part of the study. We also wish to
thank Dr. Anne-Marie Culpan for her input in developing the bid for the grant of which this is a part.
Declaration of Interests statement
Declaration of interest: none.
Corresponding author address and contact details
*Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Temple Bank
House, Bradford Royal Infirmary, Bradford, UK, BD9 6RJ. Telephone: +447534005061. Email:
Natasha.Hardicre@bthft.nhs.uk
Funding
The author(s) declared receipt of the following financial support for the research, authorship, and/or
publication of this article: This project was supported by the College of Radiographers as part of a
College of Radiographers Industry Partnership Scheme Research Grant, entitled ‘‘Delivering difficult
news during fetal ultrasound examinations; Would training and psychological support minimise the
negative impact on sonographers and improve the patients experience’’.
Citation Details
https://doi.org/10.1016/j.radi.2020.09.015
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Abstract
Introduction Ultrasound is used to diagnose pregnancy complications such as miscarriage and fetal
health conditions. Within the UK, findings identified during ultrasound examination are delivered by
sonographers as standard. However, little is known about the experiences of sonographers when
delivering unexpected news (DUN), the impact this has on them, or their preferences for training on
news delivery.
Methods Qualitative interviews were completed with fourteen sonographers and were analysed
using an inductive thematic approach. Key themes were identified.
Results Participants said that obstetric ultrasound often involves ‘managing’ the patient encounter,
including: navigating (unrealistic) patient expectations; handling their own responses to unexpected
findings; and managing interaction by moderating emotional expression and communication
practices to deliver patient-centred and empathic care. Persistent uncertainty of outcomes,
prognosis and patient reactions, alongside high workloads, and frequent siloed working, makes DUN
challenging for sonographers. DUN was experienced as emotionally burdensome, and sonographers
employed personal coping strategies to reduce stress/burnout. However, the greatest mitigation for
stress/burnout was support from peers, though accessing this was challenging. Peers were also
described as key sources of learning, especially through observation.
Conclusion Challenges associated with DUN are an enduring experience for sonographers.
Facilitating regular ongoing support and training would enable sonographers to cope with negative
aspect of the role, including the emotional burden of DUN.
Implications for Practice Long patient lists are prioritised to deal with high demand for services.
However, sonographer wellbeing needs to be a key priority to avoid stress and burnout. This means
facilitating protected time to access support from colleagues, multidisciplinary working where
possible, and regular access to training to support DUN. Training focusing on communication
practices, alongside dealing with emotional burdens of the role would be beneficial.
Keywords:
Ultrasound, Communication, News Delivery, Breaking Bad News
Introduction
Pregnancy complications are common: around one in five pregnancies involve miscarriage or
stillbirth1-3 and in one in 20, a variation from expected development is identified which could signify
the presence of a fetal health condition.4,5 Ultrasound is regularly used to identify and diagnose
these complications and while news delivery practices vary internationally, in the UK these findings
are delivered by sonographers as standard.6 A large number of studies have now investigated the
experiences of expectant parents when receiving news of complications via ultrasound.7-12
Together, these studies have suggested that receiving this news is experienced by parents as a
journey. This journey begins with generally positive expectations of ultrasound scans followed by
shock after the finding, the need to make decisions regarding further testing or pregnancy
management and eventual adaptation to their new and unexpected situation.8 They have also
highlighted key areas where practice changes can be made to improve the experience of expectant
3
parents, such as the provision of written information, signposting to relevant support organisations
and reducing the length of time between any investigations and the receipt of the results.8
While there is now a large literature base exploring the experiences of expectant parents when
receiving unexpected news via ultrasound, there has been much less research conducted into the
experiences of the healthcare professionals who conduct ultrasound scans. Only two qualitative
studies have investigated the experiences of sonographers in delivering unexpected news13, 14 and
just one of these was conducted in a country where news delivery was a standard practice for the
sonographers who participated.14 This study was conducted two decades ago in the UK and found
that the instant availability of ultrasound findings, the unpredictability of parents’ reactions and the
challenges in arranging ongoing care made delivering news in ultrasound settings particularly
challenging.14 In addition to these qualitative studies, there have been a small number of recent
quantitative survey studies in sonographers.15, 16, 17 Consistent with findings from studies in
expectant parents, these have suggested that sonographers believe a policy of immediate disclosure
of findings is a feature of patient-centred care,8, 17 but that delivering news in this way is challenging
when guidelines are unclear or support from other healthcare professionals is lacking.15, 16
There is a need for further qualitative research to better understand the experiences of UK
sonographers in relation to news delivery for three main reasons. First, in most countries, news
delivery practices among sonographers varies between practitioners, organisations and type of
complications found.13, 18, 19, 20 However, this landscape may be changing and in some countries such
as Australia, there is now a growing debate around the standardisation of news delivery practices
and whether a UK-style model may be more beneficial.13,16,20 A better understanding of the
experiences of UK sonographers regarding news delivery could inform this debate, but the situation
for UK sonographers has changed since the last qualitative study in this area was conducted two
decades ago: the Fetal Anomaly Screening Programme (FASP) has been introduced, which changed
the way scans are delivered in pregnancy in England (with equivalent organisations in Scotland and
Wales); the policy of news delivery as a standard practice has been formalised in professional
guidelines6; and recent technological advances in ultrasound equipment design and technology have
improved image quality, resulting in an increase in the number of anomalies and fetal conditions
being detected.21 As such, current information regarding the experiences of UK sonographers who
deliver news as standard is needed to inform this debate and shape the nature of policies around
news delivery practices as they are developed internationally.
Second, recent surveys of sonographers suggest that they report high levels of stress and burnout
internationally.22,23 Indeed, a recent UK study found that 89% of sonographers could be classed as
suffering from a possibly minor psychiatric disorder and 80% were experiencing exhaustion, one
aspect of burnout.24 Alongside this, sonography vacancy rates are also high in several countries
including the UK, Canada, Australia and New Zealand,25,26,27 with UK vacancy rates varying between
around 10-20%.25,28,29 News delivery is experienced as stressful for sonographers and has been
identified as one factor which could be contributing to these higher stress and burnout levels,24 but
there is a lack of information regarding how, when and why news delivery is experienced as
stressful. There is also a need to understand the factors which can mitigate the stress linked with
news delivery. A deeper understanding of these issues could help develop news delivery
interventions in sonographers which could also have the potential to reduce stress levels and
support workforce engagement.
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Third, whilst there has been only limited research into the experiences of sonographers regarding
news delivery in a broad sense, there have been even fewer studies focused on how sonographers
can be better supported to learn news delivery skills. Only three studies have been conducted in this
area.15,24,30 Two of these were quantitative studies in qualified staff which suggested that
sonographers value news delivery training courses but believe these could be improved.15,24 The
third was a qualitative study, but this was in a sample of UK pre-qualification sonography trainees
rather than qualified practitioners.30 This study focused on trainees’ experiences of news delivery
training as part of their post-graduate qualification. It found that trainees most appreciated the
opportunity to observe the practices of qualified sonographers while they were on placement, with
classroom learning supplementing this. The study suggested that trainees welcomed input from
service user representatives (i.e., speakers from SANDS, the Stillbirth and Neonatal Death Society)
but sometimes received conflicting guidance and recommendations and felt confused about which
words and phrases were best to use.30 Whilst this study identified useful recommendations to help
shape ultrasound training courses, there is currently a gap in knowledge regarding sonographers’
preferences for post-qualification education.
In order to address these issues, the current study conducted qualitative interviews with qualified
sonographers, which aimed to explore two key aspects around sonographers’ practise of delivering
difficult or unexpected news: their experience of delivering news and the impact this has on them,
and their experiences and preferences around training for delivering unexpected news (hereafter
referred to as DUN).
Methods
Within this study, an inductive, pragmatic approach was taken, whereby analysis was data-driven
and interpretive. The research sought to go beyond individual accounts of experiences to identify
‘underlying ideas, assumptions, and conceptualizations’ 31 from the corpus of data (and thereby
multiple participants), whilst remaining grounded in the data generated from within individual
accounts.
Ethical approval
Ethical approval for this research was granted by the School of Psychology Research Ethics
Committee at the University of Leeds, England (reference: PSC-175 05-December 2017).
Sample
Fourteen participants took part in the study. There were 13 female and one male sonographers with
a mean age of 51. One participant was from a nursing/midwifery background, one had not had a
previous profession and all other participants (n=12) were from a radiography background.
Experience since qualification ranged from three years to 39 years (with a mean of 22 years).
Thirteen participants were from eight regions within England and one was from South Wales.
This study was part of a wider research project. Sonographers who had participated in the first
phase of the wider project (the completion of an online survey exploring sonographer experiences of
unexpected news delivery, training and wellbeing) who had agreed to be contacted regarding the
second phase (n=65), were invited to participate by email. All participants were sent a participant
information sheet, interview guide, consent form and debrief sheet.
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Data collection
In-depth semi-structured qualitative interviews were conducted via telephone by authors JA and
AMcG. The interview guide (see Appendix 1) was developed through iterative discussion amongst
authors JJ, AMcG and JA and informed by relevant literature on the topic. Study information was
sent in advance of interviews. Written informed consent was provided by all participants.
Data Analysis
Interviews were audio-recorded, transcribed and anonymised. Transcripts were analysed
independently by authors JA and NH. In addition, NH listened to all audio recordings to become
familiar with the data. Analysis used an inductive thematic approach.32 Coding involved reading and
rereading the transcripts, identifying key ideas (about experiences of DUN and training) emerging
from the data, and sorting these ideas into categories according to similarity and difference. These
initial categories were then expanded and/or reduced to create themes and sub-themes. Emerging
codes and themes were discussed by NH, JA and JJ to reach consensus.
Results
The main themes that arose from the interviews with sonographers were i) managing the patient
encounter, ii) managing themselves, and iii) the importance of relationships with peers. Table 1
shows each theme (and sub-theme), a summary of key ideas associated with each, and illustrative
participant quotes. Each of the themes were connected to both experiences of actually DUN and the
training sonographers had had, alongside preferences for training and support to improve the
process of DUN and reduce the impact this has on sonographers. In general, sonographers felt that
their job was poorly understood by those not working within obstetric ultrasound, including the
negative impacts of high workloads and DUN. Obstetric ultrasound was described as the most
difficult area to work in because it is complex, emotionally demanding, and requires managing
multiple people and situations simultaneously. This was experienced most intensely within the
patient encounter.
Managing the Patient Encounter
The patient encounter was the key focus of sonographers’ experiences of DUN because this was the
space where they actually had to deliver difficult and unexpected news to parents. Sonographers
described having to actively manage situations and this often started as soon as the patient
encounter began, prior to the identification of problems and the moment of disclosure. Much of the
patient encounter was about trying to manage expectations, especially about the purpose of the
scan and the potential for identifying problems. In general, and consistent with other qualitative
work in this area, sonographers felt that expectant parents did not have a good understanding of the
diagnostic purpose of scans (especially mid-pregnancy anomaly scans) and so were unprepared
regarding the potential to detect problems.14,15 This made DUN more difficult. Consequently,
sonographers tried to prepare parents at the start of the scan by explaining what was going to
happen and to let them know that complications may be detected. All sonographers reported this
being slightly easier during early pregnancy, when patients were more likely to be experiencing
symptoms and so were more likely to anticipate problems.
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Managing Uncertainty
Almost everything about the patient encounter was uncertain: sonographers often did not know
what the scan would show (the exception being when they were asked to confirm a finding already
identified by a colleague); when they were DUN they did not know how the patient/family would
respond – to them or to each other; and when anomalies were detected, there was frequently
uncertainty around prognosis. Because so many aspects were uncertain, sonographers felt like it was
difficult to know how best to manage the situation – what works in one situation did not necessarily
work in another. This caused apprehension and anxiety for all sonographers and contributed
strongly to some sonographers’ experiences of stress and burnout.
Managing workload and environment
All sonographers described having very high workloads, which contributed to the negative impact of
DUN – it was described by one sonographer as a kind of emotional ‘repetitive strain injury’. This was
especially true when scanning in early pregnancy where DUN was more common. Sonographers said
that system pressures – target driven and high workloads – were challenging for multiple reasons.
Firstly, it reduces time to spend developing a relationship with patients – this makes it more difficult
to DUN should this be necessary. Secondly, it reduces time available to spend with patients after
DUN. Thirdly, higher frequency of DUN is tiring for sonographers; it makes taking breaks challenging,
which was seen as a key resource for managing emotions and the negative impact of DUN.In
agreement with Simpson and Bor,14 our study suggests that allocating more time in the day to
accommodate unexpected news delivery, alongside allowing sonographers opportunities to recover
from difficult patient encounters, would be beneficial for practitioners.
Alongside workload, the environment and context within which sonographers work was not under
their control but frequently had an impact on DUN and how the situation was managed afterwards.
For example, sonographers said that having only one entrance and exit to scanning rooms was
particularly problematic after delivering news of pregnancy loss. Participants reported that it felt
insensitive to expect patients-experiencing-loss to walk past couples still waiting to be scanned.
Simpson and Bor, found that difficulty contacting a doctor to refer patients on to was a key factor
impacting sonographer experiences of DUN.14 Although not limited to referrals to doctors, proximity
to other services was also influential on experiences of DUN within our research. Being able to refer
families to additional services immediately after the scan was felt to be beneficial for both patients –
who would receive continuity of care – and for sonographers, who felt that they were entrusting
patients to the care of another healthcare professional rather than just ‘discharging’ them from their
care.
Managing Themselves
Much of the work that sonographers engaged in was emotional and communication management.
Detecting unexpected findings, including serious problems, triggered physical and emotional
responses in sonographers. These needed to be managed to communicate findings effectively.
Therefore, maintaining control of the situation required maintaining control of oneself.
Sonographers described managing the emotions they were feeling, managing the expression of
those emotions, and communication with others as being central parts of the job.
Communication
Communication (both verbal and non-verbal) was central because it was the means of DUN.
Sonographers suggested that whilst word choices were important – unlike findings from other
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studies,14 clarity was considered crucial, for example – the manner of delivery was critical to how
news was received. However, because patient reactions were variable and could be difficult to
predict, effective communication started before news delivery when sonographers first met
patients. Sonographers described continually reading and assessing patients from first introduction
and throughout the scan, alongside being responsive and guided by the ways in which patients
behaved and the words they said. Simpson and Bor14 proposed that there is the potential for
sonographers to misjudge patient reactions and assume that DUN has been handled well if patients
do not visibly demonstrate distress. However, our findings do not suggest this to be the case.
Instead, because patient reactions were used as a means of tailoring communication to deliver
patient-centred care, non-response from patients was described as difficult to manage. Many
sonographers assumed that their communication had not been successful because non-response
was often associated with not understanding and sonographers frequently took responsibility for a
patient’s understanding of the situation, assuming it was wholly related to their skill in
communicating news.
Sometimes sonographers felt that no communication was the most appropriate response to
patients. Knowing when to be silent and give people time to digest difficult news and information
was also considered crucial. This was more difficult for less experienced sonographers but got easier
over time. Empathic and genuine communication was considered ideal and some sonographers said
that their own life experiences contributed positively to this. All sonographers suggested that
training in communication skills would be useful both pre- and post-qualification. It was also felt that
students and newly qualified staff would benefit from having access to key phrases about certain
aspects of the work (e.g. purpose of scan and disclosing intrauterine death). This appears to be
consistent with sonographer experiences even when disclosure of news practices are different and
sonographers are not necessarily required to DUN routinely.13,15 This suggests that guidance that
provides direction to sonographers regarding processes for DUN would be useful regardless of the
context within which sonographers are doing so. Moreover, the UK National Institute for Health and
Care Excellence (NICE) guidelines for early pregnancy loss33 recommend news delivery training for all
healthcare professionals working in this setting. Currently, there is no evidence-based way to meet
this requirement. A multidisciplinary group in the UK have created a consensus document to begin
to meet this need.34 However, further research and development of evidence-based communication
training for sonographers would be valuable.
Managing Emotions & Emotional Expression
Consistent with previous studies,13,14,30 we found that detecting and disclosing unexpected and
difficult news caused physical and emotional responses for sonographers, during the patient
encounter and afterwards. Many sonographers described experiencing an ‘adrenalin rush’, panic,
and increased heart and breathing rates when discovering problems. These responses were
considered barriers to effective communication which needed to be managed before disclosing
news to patients. Consequently, the job demands the sonographer to feel and behave differently,
predominantly in not expressing felt emotion, and conveying unfelt emotion. Within the patient
encounter, this frequently included pretending that one did not feel the panic or upset that they did
and expressing a sense of calm that was not felt. Participants said that when DUN they frequently
felt like they were walking a fine line between empathy – which can be a facilitator of good
8
communication – and over-identification – which can be problematic for both sonographer well-
being and communication with patients. However, some patient stories deeply affected
sonographers and they struggled not to find situations upsetting. Whilst expressing this upset to
patients was sometimes considered acceptable, all sonographers felt that taking this upset into the
next patient encounter was inappropriate – in part because they wanted to provide good care to all
expectant parents, but also because patient expectations demanded such an approach.
Feelings of guilt and responsibility for causing patient suffering were also experienced and these
were enduring emotions after patient encounters. This is consistent with findings of other studies,
which suggest that sonographers feel a heavy burden of responsibility for patients,13 not only for
how they feel but also what they do, including at times whether people proceed with their
pregnancy.14 Even though all sonographers in our study knew that they were not responsible for
pregnancy outcomes, feeling responsibility for patient distress through disclosing unexpected news
was described as emotionally exhausting, physically draining and sometimes unrelenting (especially
when working in early pregnancy assessment clinics). This was described as a major cause of stress
and burnout. Managing emotions was therefore not only important for delivering good patient care,
but also for maintaining their own wellbeing.
Strategies for managing emotions include ‘compartmentalising’, acting in ways consistent with
patient expectations rather than personal experience, and emotionally distancing from patient
situations. However, these sometimes conflicted with one another. For example, being emotionally
distant was sometimes helpful to protect sonographer wellbeing, but empathy and authenticity
were considered by sonographers to be key aspects of good communication with patients. This
required sonographers to carefully balance competing priorities – their own mental and emotional
wellbeing, the wellbeing of the patient/families within this encounter, the experience of
patients/families next on the list, and the system’s requirements to work quickly and effectively to
manage a high workload due to service demand. Sonographers frequently prioritised patient
wellbeing, followed by the needs of the service, often to their own detriment. As a means of dealing
with these pressures sonographers frequently relied on informal support from peers.
Relationships with Peers
One characteristic of obstetric sonography frequently described as challenging was lone working:
both as a sonographer who is scanning patients, and as a profession where lone working is common.
Working and interacting with other sonographers was a key source of both training and support, yet
many sonographers worked alone and got minimal time to work with or talk to colleagues. Those
that did, reported this being extremely valuable for their continuous professional development and
as a coping mechanism for the difficult aspects of the job. Moreover, sonographers appeared to feel
disconnected from other healthcare professionals within maternity services and distinct from the
rest of a patient’s care pathway. Consequently, sonographers rarely received feedback, either about
their work or patient outcomes and this meant that they did not know whether what they had done
was ‘right’. All sonographers we spoke to, wanted more opportunity to work with others throughout
their careers because exposure to the ways other people do things was considered extremely
beneficial.
9
Training and CPD
Like Thomas et al,13 who proposed that tacit knowledge passed down by other sonographers was the
key means of learning, the importance of peer learning was emphasised by all our participants. This
was achieved primarily through observation but also through role-play and mentoring. Opinions
about role play were divided, though most people felt it could be valuable if done well.
Sonographers emphasised the benefit of scenario-based training with supportive role-play and
discussion as a key part of this. It was felt that training as a team would be useful because learning
with colleagues instead of strangers would be a more supportive environment. Reflective practice
was promoted as a means of developing professionally and also coping with difficult aspects of the
job. Whilst this can be done individually, many sonographers felt it would be beneficial to discuss
reflections with colleagues and/or a mentor – doing so would enable sonographers to get insights
from others and also provide debrief opportunities. Importantly, all participants suggested that
training in DUN should start pre-qualification and continue throughout their career. This is
consistent with sonographers working within and outside the NHS.13-15, 24, 30 At present, the
postgraduate diploma which qualifies sonographers in the UK, is only a year in duration and this may
limit the capacity of pre-qualification courses to offer training in communication and skills around
DUN, alongside the technical aspects of sonography. However, some universities are now offering a
three-year undergraduate degree course, and this could offer more scope for robust,
comprehensive, and assessed training in all aspects of sonography practice. Moreover, although
research suggests that many sonographers do receive some form of post-qualification training (of
which the majority report it improved their practice), 24 there are currently no evaluations of training
interventions for communication in sonography. 35 Research evaluating interventions to improve
sonographers experience and skills in communication and DUN would be beneficial.
Proposed means of training remained consistent regardless of a sonographer’s level of experience
and this centred around observation (both observing others and being observed by others),24
professional and patient feedback about what works and what is less helpful/effective, and
opportunity to practice. Learning through both watching and doing was considered vital. Some
sonographers suggested that until you have actually delivered news to expectant parents, you did
not understand the magnitude of the task.
Support
Other sonographers were key sources of support – often informally, through opportunistic
encounters.15 This was, in part, because of proximity (e.g. being in the same team and using shared
spaces during break times), but also because they felt only ‘insiders’ ‘get it’. There was a strong
sense that only those doing the job really understood what it was like and this was why
sonographers chose to speak to other sonographers when trying to manage the negative aspects of
the job, such as DUN. Support tended to operate in informal networks, though most participants
would like it to be more formalised and supplemented with support from other disciplines. This is
consistent with findings from almost twenty years ago,14 suggesting that although there have been
multiple changes to UK sonography practice – for example, introduction of the Fetal Anomaly
Screening Programme, the formalised policies of news delivery as standard practice,6 and increase in
capability to detect anomalies and conditions due to technological advances21 – little has changed to
improve the support for sonographers.
Conclusion
Challenges associated with delivering unexpected news appears to be an enduring experience for
sonographers working in obstetric ultrasound, regardless of expectations about the role of
10
sonographers in routinely DUN. Variability of (previously unknown) clinical findings, alongside the
variability of patient expectations, is unlikely to change because it is an inherent aspect of the work.
However, the organisation of work, such as reducing workloads where possible, building in time for
breaks and additional time to spend with patients when DUN, and multidisciplinary working to
integrate sonographers into maternity services, could reduce work-related stress. More formalised
protocols for delivering news have also been proposed as a solution for improving experiences of
delivering (and receiving) unexpected news, especially for less experienced sonographers. The UK
consensus guidelines for the delivery of unexpected news in obstetric ultrasound: The ASCKS
framework has the potential to meet this need. 34
Facilitating ongoing support and evidence-based training for sonographers would enable them to
cope with the negative aspects of the job, including the difficulties associated with managing
emotions and emotional expression. Proposed mechanisms include protected time to spend with
colleagues and ongoing training incorporating observation of colleagues, scenario-based training,
and reflective practice. Multidisciplinary input, including feedback from patients, would also be
helpful – ‘closing the loop’ would help people manage the uncertainties of the job and would
facilitate a sense of ‘closure’ that is frequently missing from obstetric sonography.
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