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Managing the unmanageable: A qualitative study exploring sonographer experiences of and training in unexpected and difficult news delivery



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.
Managing the Unmanageable: A Qualitative Study Exploring Sonographer
Experiences of and Training in Unexpected and Difficult News Delivery
Natasha Kate Hardicrea*, Senior Research Fellow, Email:; Telephone:
01274383428. ORCiD: 0000-0002-3639-5556
Jane Arezinab, Ultrasound Lecturer, Email:; Telephone: 01133439623.
Alison McGuinessc, Consultant Sonographer, Email:
Judith Johnsond,a,e, Lecturer, Email:
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.
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:
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
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.
Ultrasound, Communication, News Delivery, Breaking Bad News
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
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.
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).
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
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).
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.
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.
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.
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
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 (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
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
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 patients 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
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.
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.
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
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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... Fathers' attendance was seen as a demonstration of their commitment to their family and to facilitate involvement with the pregnancy [19,25,28,[29][30][31][32][33][34]. For health workers however, these views sometimes conflicted with their role in providing a medical assessment and potential diagnosis [35][36][37]. It also sometimes conflicted with parent's autonomy in terms of whether attending ultrasound was seen as a choice, or a decision to be made [17,18,21,22,[38][39][40][41][42]. ...
... (England) [18] Some providers were concerned that the clarity of the ultrasound image meant that all complications should be visible and identified [39]. Some feared the potential for consequences for both the mother, and for their professional security, if abnormalities were missed [36,39,76]. In some LMIC contexts, concerns were also expressed about the lack of appropriate training and the potential for this to result in missed complications or misdiagnosis [38,39,76,80]. ...
... Some reported deep shock and distress on hearing this news [17,65,67,69,73,[86][87][88][89]. Both service users and healthcare professionals reflected on how this shock could be compounded by couples' expectations that the scan appointment is a happy event that would provide confirmation of wellbeing [24,36,65,83]. The difficulty in getting the balance right in preparing couples for potential consequences of the scan was also discussed by healthcare professionals. ...
... Fathers' attendance was seen as a demonstration of their commitment to their family and to facilitate involvement with the pregnancy [19,25,28,[29][30][31][32][33][34]. For health workers however, these views sometimes conflicted with their role in providing a medical assessment and potential diagnosis [35][36][37]. It also sometimes conflicted with parent's autonomy in terms of whether attending ultrasound was seen as a choice, or a decision to be made [17,18,21,22,[38][39][40][41][42]. ...
... (England) [18] Some providers were concerned that the clarity of the ultrasound image meant that all complications should be visible and identified [39]. Some feared the potential for consequences for both the mother, and for their professional security, if abnormalities were missed [36,39,76]. In some LMIC contexts, concerns were also expressed about the lack of appropriate training and the potential for this to result in missed complications or misdiagnosis [38,39,76,80]. ...
... Some reported deep shock and distress on hearing this news [17,65,67,69,73,[86][87][88][89]. Both service users and healthcare professionals reflected on how this shock could be compounded by couples' expectations that the scan appointment is a happy event that would provide confirmation of wellbeing [24,36,65,83]. The difficulty in getting the balance right in preparing couples for potential consequences of the scan was also discussed by healthcare professionals. ...
... Breaking bad news is increasingly undertaken by many radiologists and sonographers, including breast imagers and in fetal ultrasound [21,22]. Specific communication training will be of benefit to both doctor and patient. ...
... This can be difficult and traumatic for the person delivering the news and their well-being also needs to be considered [21]. This important aspect of radiology is not typically included in radiology training programmes. ...
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Optimised communication between patients and the imaging team is an essential component of providing patient-centred and value-based care. Communication with patients can be challenging in the setting of busy radiology departments where there is a focus on efficient and accurate diagnosis. Traditionally, most results are provided directly to the referring clinician. However, the importance of direct communication between the radiologist and patient is increasingly relevant, particularly in the context of face-to-face settings such as rapid assessment and ultrasound clinics, and interventional radiology, as well as in written form through electronic patient portals. Artificial intelligence tools may improve efficiency, allowing more time for radiologists to communicate directly with patients. There is a need for dedicated training in communication skills for imaging professionals. This review considers the topic of patient communication in the setting of imaging departments and discusses the ways that communication skills may be improved through training and through harnessing emerging digital technologies that may enhance the quality of communication.
... Training programs focused on fundamental skills are required to help rural women develop their technical ability and support their engagement in entrepreneurship. The training programs should be initially structured around the trainees' felt needs before shifting to their unfelt but crucial requirements (Hardicre et al., 2021). Women-specific technologies should be created in order to meet the technical needs of rural women. ...
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The purpose of this study was to investigate how rural Ugandan women entrepreneurs fulfill their business ambitions in pursuit of starting and expanding their enterprises. The study captured the case of one woman's story to entrepreneurship in the remote Kabale area. To investigate several social and economic facets of rural Ugandan women entrepreneurs, a qualitative approach was used. The findings indicated that rural women entrepreneurs in Kabale District, Maziba Subcounty, Rugarama Parish, Kagarama Cell face four major connected challenges and two major opportunities. This study is one of the few studies in response to calls for greater research on rural women entrepreneurs, especially in developing nations, and for demonstrating the significance of context in influencing individual womenentrepreneurial choices. The case provided a deeper knowledge of rural women entrepreneurs and laid the groundwork for future study on rural development, entrepreneurship contextualization, and rural women empowerment. women business owners in Kagarama Cell.
Purpose/methods: This systematic review aims to provide an overview of strategies available for healthcare professionals (HCPs) to effectively communicate unexpected news in pregnancy, specifically for the most common pregnancy complications. Three medical databases and grey literature were searched until March 2023 using subject headings and keywords. Snowball techniques were also used. The articles were reviewed at each stage of screening independently by two separate authors. Qualitative, quantitative and mixed methods studies were included. Recent findings: Forty-three studies were included and grouped according to the gestational age of the pregnancy complication - miscarriage, increased risk screening, foetal conditions, stillbirth. The main key points for communication were outlined at each specific complication and eventually the six common themes that emerged from all the categories were included in the acronym PRICES (Preparation - Referral - Individualized care - Clarity - Empowerment - Sensitivity). Summary: Given the negative impact of failed communications both in pregnancy outcomes and patients' experience, we advocate that communication training for HCP providing pregnancy care should be mandatory, and skills should be updated at regular intervals. Tools like our acronym PRICES can be used during teaching HCPs how to communicate more effectively.
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Introduction Despite widespread recognition that communicating unexpected news during obstetric ultrasound examinations is challenging, there is a dearth of research investigating how to teach evidence-based communication to sonographers. Communication Coaching is a supportive, positive method that has previously been associated with improvements in communication, patient satisfaction, and reduced burnout in clinicians. However, to date, no study has coached sonographers. This study explored stakeholders’ views on a proposed Communication Coaching intervention and used these data to adapt the intervention for use with qualified obstetric sonographers. Methods Semi-structured interviews were conducted with people who have a vested interest in unexpected news delivery and thematic analysis was conducted on the data. Eight sonographers, six people with lived experience of receiving unexpected news and six representatives from third-sector organisations who support expectant parents were recruited (18 women; 2 men, aged between 21 and 75 years). Results Participants viewed the planned Communication Coaching intervention favourably and suggested adaptations. The two main themes were (1) the practicalities of coaching, and (2) content. The first theme had four subthemes: (a) brief and flexible structure, (b) online modality, (c) sensitive and positive coach and (d) organisational awareness. The second theme had three subthemes: (a) specific language and behaviour recommendations, (b) adaptable to different service-users and situations and (c) confer relevant emotional skills and techniques. Conclusions Communication Coaching could be a feasible and acceptable intervention for qualified sonographers if specific, limited adaptations are made as recommended by the stakeholders. Further evaluation of the intervention in practice is necessary.
Introduction Following recommendations of the Francis report (2013), healthcare professional groups have formalised restorative supervision within practice in order to maintain emotional well-being among staff and provide quality of care for patients. There is a scarcity of research available on how professional supervision is utilised as a restorative device within current practice for sonographers. Methodology An online cross-sectional, descriptive survey was used to gain qualitative details and nominal data on sonographer experiences of professional supervision. Themes were developed through thematic analysis. Results A total of 56% of participants did not identify professional supervision as part of their current practice; 50% of participants felt emotionally unsupported within their work. The majority felt ‘unsure’ of how professional supervision would affect their working day; however, they highlighted that a restorative function would be valued equally as professional development functions of practice. The barriers to professional supervision as a restorative function demonstrate that an understanding of what sonographer needs are should be considered in approaches to professional supervision. Conclusion This study found that participants identify professional supervision in its formative and normative functions more commonly than its restorative functions. It also found that sonographers are found wanting of emotional support, with 50% of sonographers feeling unsupported and identifying a restorative supervision need to their working practice. Implications for practice The need to establish a system that supports the emotional well-being of sonographers is highlighted. This should help with retention of sonographers in a career where burnout is evidenced.
Résumé Objectifs Analyser les attitudes et le vécu d’un panel d’échographistes lors de l’annonce d’une anomalie fœtale, découverte soit en échographie de dépistage, soit en échographie diagnostique. Les objectifs secondaires étaient: 1) D’identifier les facteurs compliquant l’annonce 2) D’explorer les différentes pratiques des échographistes lors de l’annonce par l’analyse de leur savoir-faire et de leur savoir-être 3) D’identifier les ressources utilisées par les échographistes pour améliorer la qualité de l’annonce. Méthode Etude qualitative mixte basée sur des observations de consultations d’échographie et sur des entretiens semi-dirigés, auprès d’échographistes exerçant dans une maternité d’Ile-de-France. Résultats Les résultats mettaient en évidence un ressenti très inconfortable des échographistes lors de la découverte d’une anomalie. Les difficultés ressenties et les pratiques médicales face à l’annonce étaient différentes entre les échographistes dépisteurs et diagnostiqueurs. L’incertitude du pronostic fœtal semblait être un facteur compliquant une annonce pour les échographistes diagnostiqueurs. La disponibilité de l’échographiste et son comportement étaient des qualités mises en avant par les soignants. Si l’expérience professionnelle était considérée comme essentielle pour améliorer la qualité de l’annonce, suivre une formation à l’annonce semblait être un atout majeur pour mettre en œuvre les bonnes pratiques. Conclusions L’annonce d’une anomalie fœtale est un exercice difficile, impactant le vécu et l’attitude des échographistes. Certaines pratiques professionnelles sont à encourager quand d’autres sont à remettre en question. Une relation de confiance entre le soignant et la patiente est renforcée en partie par la qualité de l’annonce mais aussi par l’accompagnement, la rigueur et l’humanité du soignant.
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Ultrasound is a diagnostic tool with many advantages, however, concerns over operator wellbeing have arisen in the last 20 years. Many sonographers experience burnout, which has the potential to cause financial loss for radiology clinics, and for sonographers, suboptimal examinations, high turnover and a reduced ability to communicate with patients. The aim of this narrative review was to explore, identify and categorise the causes of burnout in the sonography profession, and to identify burnout prevention and control strategies. A literature search was conducted through Central Queensland University library, accessing the following electronic databases; Wiley Online Library, Gale Academic, Ovid, Sagepub, CINAHL, Elsevier Science Direct, PubMed and ProQuest. Eight articles were reviewed. This study identified two key themes contributing to sonographer burnout: delivering adverse news and increased workload. Twelve causes of burnout were identified, with exposure to adverse news and time constraints the most commonly identified causes. In addition, other causes identified included managerial pressures to perform more scans/tasks within a short‐time frame, followed by the constant exposure to adverse news and the burden of delivering it to patients. Recommendations include considering reducing the required number of scans per week by increasing appointment times, counselling and skills training for adverse news delivery and use of technical assistants to perform soft tasks. Current literature relating to sonographer burnout appears isolated to the obstetrics domain with further study required on sonographer burnout in other fields of sonography, including burnout because of lack of career progression.
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Introduction The aim of this study was to evaluate and report normal sonographic FHR values among low-risk singleton women across the three trimesters of pregnancy and determine FHR role in gestational age prediction. Method A prospective cross-sectional study of 2727 low-risk singleton pregnant women was undertaken. FHR measurements were obtained by a consultant radiologist and three experienced sonographers using transabdominal approach from January 2019 to December 2020. Two FHR measurements were taken for each participant. The fetal lie and presentation were also documented in the first trimester. Data were analysed using SPSS version 24 (IBM, Armonk, NY, USA). Result The maternal mean ± SD age was 25.8 ± 6.5 years and mean FHR for first, second and third trimesters were 151 ± 16, 145 ± 6 and 125±6 bpm respectively. The mean ± SD gestational age were 10 ± 2, 19 ± 3 and 34 ± 2 weeks for the first, second and third trimester respectively. Using ANOVA, there were statistically significant differences in FHR across the three trimesters (p ≤ 0.05). A positive correlation existed between maternal age and FHR (r = 0.57, p ≤ 0.05). Conclusion This study has established normal values for FHR in first, second and third trimester respectively. Referring physicians, radiologists, sonographers, obstetricians and gynaecologists may consider FHR of (135–167) bpm (139–151) bpm and (119–131) bpm as normal FHR ranges for the first, second and third trimester respectively. This study has also revealed the possibility of gestational age prediction using FHR with the equation [Gestational Age = 87.8 – (0.47) FHR]. Implications for practice This paper provides the most up-to-date sonographic FHR recommendations for fetal management. More importantly, findings from this study also suggests that ultrasound practitioners can use FHR measurements as a reliable alternative for fetal dating.
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Background Studies indicate there is a need to improve the delivery of unexpected news via obstetric ultrasound, but there have been few advances in this area. One factor preventing improvement has been a lack of consensus regarding the appropriate phrases and behaviours which sonographers and ultrasound practitioners should use in these situations. Aims To develop consensus guidelines for unexpected news delivery in Early Pregnancy Unit and Fetal Anomaly Screening Programme NHS settings. Methods A workshop was conducted to identify priorities and reach consensus on areas of contention. Contributors included interdisciplinary healthcare professionals, policy experts, representatives from third-sector organisations, lay experts and academic researchers ( n = 28). Written and verbal feedback was used to draft initial guidance which was then circulated amongst the wider writing group ( n = 39). Revisions were undertaken until consensus was reached. Results Consensus guidelines were developed outlining the behaviours and phrases which should be used during scans where unexpected findings are identified. Specific recommendations included that: honest and clear communication should be prioritised, even with uncertain findings; technical terms should be used, but these should be written down together with their lay interpretations; unless expectant parents use other terminology (e.g. ‘foetus’), the term ‘baby’ should be used as a default, even in early pregnancy; at the initial news disclosure, communication should focus on information provision. Expectant parents should not be asked to make decisions during the scan. Conclusions These recommendations can be used to develop and improve news delivery interventions in obstetric ultrasound settings. The full guidelines can be accessed online as supplemental material and at .
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Expectant parents report negative experiences of receiving unexpected news via ultrasound. There is a need to improve communication in this setting, but a lack of understanding on how to achieve this. This systematic review aimed to synthesise findings from qualitative studies exploring experiences of expectant parents or healthcare professionals when a fetal abnormality or unexpected finding was identified via ultrasound. MEDLINE, EMBASE, CINAHL and PsycINFO were searched using three blocks of terms (fetal abnormalities; ultrasound; experiences). Qualitative studies exploring the disclosure of pregnancy complications during ultrasound examinations were included and analysed using meta‐ethnographic synthesis. The review was conducted according to PRISMA and eMERGe guidelines. The review identified 28 studies. News delivered via ultrasound can be viewed as a journey involving five phases (expectations of ultrasound scans; discovery; shock; decisions and planning; adaptation). How well this is navigated depends upon the extent to which information needs and support needs are met. Ultrasound is a uniquely challenging situation to communicate difficult news as there is the potential for news to be communicated immediately. Care quality could be improved by the provision of written information and the use of correct terminology to describe abnormalities.
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Background Previous studies suggest there is a need to improve the delivery of bad and challenging news in obstetric ultrasound settings. However, no research has explored the experiences of trainee sonographers when learning how to deliver challenging news. Understanding this could identify gaps in current provision and inform future training interventions. Aims To explore the experiences of trainee sonographers when learning how to deliver challenging news. Methods Semi-structured interviews were conducted with trainee sonographers ( n = 7) from four training centres to explore their experiences and preferences for news delivery training. Results Learning how to deliver difficult news was a journey where trainees developed their confidence over time. Most learning occurred in clinical settings, but classroom teaching complemented this. Trainees appreciated the opportunity to observe clinical practice and to hear from patient representatives. However, quality of teaching varied between centres and trainees reported uncertainty regarding the specific language and behaviours they should use. They described building their own personal protocol for news delivery through the course of their training. Discussion An ultrasound-specific news delivery protocol which details the words and behaviours sonographers can employ could help reduce uncertainty in trainees. Trainees may also benefit from receiving structured feedback on their news delivery performance.
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Background: Sonographers report high levels of burnout. For those working in obstetric ultrasound, one frequently cited stressor is the delivery of bad or difficult news. Training in news delivery may reduce sonographer stress levels, but no studies have investigated sonographer experiences of this training. Aims: To investigate sonographer experiences of difficult news delivery training and preferences for training techniques, and to assess whether news delivery training is associated with lower burnout and higher wellbeing. Methods: A cross-sectional survey measured occupational characteristics, news delivery training experiences and preferences, burnout (on two dimensions of exhaustion and disengagement) and general mental wellbeing. Results: Ninety sonographers (85 female; mean age = 47) responded. The majority of participants thought training in difficult news delivery had improved their practice. Preferred training techniques were observation of clinical practice and receiving service-user input. Eighty per cent of participants were experiencing exhaustion, 43.3% were experiencing disengagement and 88.9% could be classed as having a minor psychiatric disorder. Having received difficult news delivery training was associated with lower levels of disengagement, even when other variables were controlled for. Discussion: News delivery training is perceived to be effective by sonographers and may help to reduce sonographer burnout levels.
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Purpose: To assess the effectiveness of news delivery interventions to improve observer-rated skills, physician confidence, and patient-reported depression/anxiety. Method: MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Register of Controlled Trials databases were searched from inception to September 5, 2016 (updated February 2017). Eligible studies included randomized controlled trials (RCTs), non-RCTs, and controlled before-after studies of interventions to improve the communication of bad or difficult news by physicians, medical students, and residents/interns. The EPOC risk of bias tool was used to conduct a risk of bias assessment. Main and secondary meta-analyses examined the effectiveness of the identified interventions for improving observer-rated news delivery skills and for improving physician confidence in delivering news and patient-reported depression/anxiety, respectively. Results: Seventeen studies were included in the systematic review and meta-analysis, including 19 independent comparisons on 1,322 participants and 9 independent comparisons on 985 participants for the main and secondary (physician confidence) analyses (mean [SD] age = 35 [7] years; 46% male), respectively. Interventions were associated with large, significant improvements in observer-rated news delivery skills (19 comparisons: standardized mean difference [SMD] = 0.74, 95% CI = 0.47-1.01) and moderate, significant improvements in physician confidence (9 comparisons: SMD = 0.60, 95% CI = 0.26-0.95). One study reported intervention effects on patient-reported depression/anxiety. The risk of bias findings did not influence the significance of the results. Conclusions: Interventions are effective for improving news delivery and physician confidence. Further research is needed to test the impact of interventions on patient outcomes and determine optimal components and length.
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Several rare diseases are regularly identified during the prenatal and perinatal periods, including dysmelia. How these are communicated to parents has a marked emotional impact, but minimal research has investigated this. The purpose of this study was to explore parent experiences and preferences when their baby was diagnosed with dysmelia.Twenty mothers and fathers were interviewed. Data was analyzed using thematic analysis. The overriding emotion parents experienced was shock, but the extent of this was influenced by several factors including their previous experience of disability. Four key needs of parents were identified, including the need for signposting to peer support organizations, for information, for sensitive communication, and for a plan regarding their child’s care. Parents wanted immediate information provision and signposting to peer support, and for discussions regarding possible causes of the dysmelia or termination (in the case of prenatal identification) to be delayed until they had processed the news.
Objective To identify factors influencing sonographers’ practices in communicating adverse obstetric findings and to understand their views on the need for standardized national policies and guidelines. Methods Qualified and trainee sonographers who currently perform obstetric sonography were invited to complete a survey through the Australasian Sonographers Association. Closed-ended questions sought information on the demographic profile of the participants and their experiences on a range of issues related to workplace practices and policies. Open-ended questions allowed respondents to elaborate on workplace interactions and their views on the communication roles of sonologists (radiologists and obstetricians) and sonographers. Results The practice setting, the background of the sonologist, the type of adverse finding, and the trimester in which a patient is scanned have an impact on the level of difficulty for sonographers in obstetric communication. These findings highlight a lack of uniformity of sonographer and sonologist communication with patients due to limited training, lack of formalized departmental policies, inadequate support, and communication practices by radiologists. As a result, respondents strongly supported the development of a standardized national policy. Conclusion In the current environment of patient-centered care, sonographers are in a challenging position as they do not have policies supporting them as independent health care professionals, autonomously deciding on the best approach to communicate findings with their patients. This may lead to anxiety and stress if they lack control over the interaction. More support from sonologists in a radiology setting is needed. These findings should encourage professional bodies to address these issues by working collaboratively and to recognize the importance of the sonographers’ role and their unique position with pregnant patients.
Introduction/purpose: Despite the clinical importance of patient-centred care in the sonographer/patient interaction in obstetric ultrasound, there has been very little current research in Australia on sonographer and sonologist communication practices in the event of an adverse finding. This study sought the views, experiences and practices of Australian sonographers, particularly in relation to adverse findings, with consideration of the implications for their professional role and practice. Methods: Qualified and trainee sonographers who perform obstetric ultrasound were invited to complete a survey through the Australasian Sonographers Association. Using qualitative methodology, the authors developed themes on a range of issues related to sonographer and sonologist communication practices and roles from responses to three open-ended questions within the survey. Result: Analysis of 249 responses revealed three distinct 'Communicator types'. 'Open Communicators' confidently practice open and direct communication; 'Limited Communicators' perceived barriers preventing them from openly communicating; 'Variable Communicators' indicated various challenging 'grey areas' which created inconsistent communication practices. Variables, such as the complexity of an adverse finding and a reporting sonologist's role, attitude and level of control they exercised over sonographer communication, all influenced respondents' communication practices. Respondents believed professional bodies should agree on a standardised policy regarding sonographers' roles. Discussion: This paper highlights the complexity of the sonographer/patient interaction and outlines the difficulty in providing true patient-centred care in obstetric ultrasound. Conclusion: The need for a collaborative, patient-focussed policy, which defines and recognises the role of the sonographer in the event of obstetric adverse findings, will improve the current model of care.
Introduction/Aim Sonography as a profession has developed through the evolution of ultrasound technological advancements over 50 years 1. The traditional role of a sonographer was technical with image taking, similar to radiography, followed later by a sonologist diagnosis and report. However, with the advent of real time scanning a sonographer must now identify, image and diagnose adverse findings whilst performing the scan. A sonographer's professional identity develops over time 2. Many factors are critical in shaping this identity and it is an ongoing process as a result of multiple discourses with patients, sonologists, sonographers, the social environment, education and other professional interactions 3. Sonographers’ concept of their professional role has changed over time with many believing they are more autonomous and active in patient communication. However, a sonographer's role within the Australian obstetric model of communication with pregnant patients is ambiguous 4,5. Our aim for the study was to: • Explore the role of sonographers in communicating findings directly with pregnant patients • Understand sonographers’ perception of their own professional identity • Investigate the processes that shape a sonographer's sense of self Method An online survey of Australasian Sonographer's Association members (n=249) with experience in obstetric ultrasound and follow up interviews with six sonographers. Results Sonographers believe they have an important role in maintaining a pregnant patient's trust. Open communication about the results at the time of the scan was preferred by most sonographers, however, there were some sonographers who did not want to take on the responsibility of communication and believed it was the sonologist's role. The professional culture of medical authority affects a sonographer's sense of self and professional identity. Most sonographers want empowerment and autonomy in the team. Variations in professional identity varied due to a number of factors which include the sonographer and sonologist relationship, training in how to communicate findings, lack of national policies and guidelines. and critical incidents. Sonographers found communication stressful without support from sonologists and professional bodies. Conclusion There is confusion within the profession of what a sonographer's role entails and the sense of their true professional identity. A collaborative approach by professional bodies to break down the barriers of interprofessional tensions will improve acceptance of a sonographer's important but complex role in obstetric communication.