Radiographers’ communication and social skills during mammography Objectives of this presention

• To make radiographers aware of women's experiences in mammography

• To suggest ways how to improve women’s wellbeing and confidence during mammography examination

Content of this presentation • Relationship with the patient: a major issue for the woman for the radiographer for adherence to the screening programme • Pain caused by mammography • Compression • Optimizing women’s mammography experience • Conclusion • References • More reading about the topic Hi Hello My name is Lara. I’m a My name is Vera. I’m a mammography radiographer trainer and radiographer and I will during this presentation I guide you through this will give some presentation complementary information and suggest some complementary activities in order to go deeper into the subject. Hi I’m Sandy. I’m a radiographer student and during this presentation I will raise some questions. Think of the response you would give before discovering the responses given by Lara and Vera A major issue for the woman

For the woman Stressful situations because mammography is expected to be: • Painful • Embarrassing • Awkward position during mammography • Anxiety until you get the results A major issue for the radiographer

For the radiographer To give the woman confidence means • Better collaboration for positioning the woman and her breast • Better image quality • Less musculoskeletal discomfort • More pleasure with performing mammograms • Better compliance of the women with the programme of early BC detection A major issue for the screening programme

• Underline the relevance of mammography screening in early detection of breast cancer

• Focus on carrying out a first real positive mammogram experience for the patient

 Increase adherence for next screenings Conceptual framework of perception of mammography discomfort

Poulos A., & Llewellyn G.(2004) Pain caused by mammography

• Some women feel slight or moderate pain while other women find it acutely painful. About two-thirds of the women experience pain during the mammography (B. Hafslund 2000); • Pain is mainly caused by the compression of the breast, by pulling or tugging the skin, by pushing the edges and corners of the detector in the rips; • In practice we observe that women do respond differently to those pain stimuli. Pain caused by mammography

• Looking at the published literature we observe a wide variation both in the reported frequency of pain and in the degree of pain felt by women. This is mainly due to a large variability of study design (Davey B., 2006). Pain caused by mammography

• Risk factors associated with pain experience during mammography can be divided into three main areas:

 Breast tenderness  Pain expectation  Breast thickness  Previous painful mammography  Breast volume  Anxiety level  Lack of control Biological Psychological Radiographer’s technical skills • Height of the Radiographer’s attitude concerning: detector  Pain • Application of Staff related  Information given about the compression procedure and the time it takes • Encourage the client to ask questions Pain caused by mammography

• 25-46% of women who did not re-attend to the mammography screening programme cited pain as the main reason. (Whelehan et al. 2013)

 Special attention should be given to first-time attenders How to decrease the pain experience ?

• To adapt the detector height precisely at the inframammary fold in order to have an optimal balance of forces (Branderhorst et al 2016) Misalignment of the detector

• To inform women in advance about compression and adapt compression to the woman’s experience; • To get women side-tracked by conversion.

 More research is needed How to decrease the pain experience ?

• A Cochrane Review was published in 2008 by Miller D, Livingstone V and Herbison GP. The review describes the following interventions:  Verbal information   Written information   Premedication with acetaminophen (paracetamol)   Breast Cushion   Patient controlled Breast Compression   Reduction in breast compression 

 Evidence of an efficient intervention /  No evidence of efficiency Interventions for relieving pain and discomfort • Important developments of the equipment have been studied since that Cochrane review:  Rigid or flexible compression paddles have no influence on pain experience (Broeders MJ et al 2015);  Pressure-standardized compression reduces pain experience without affecting absorbed glandular dose or image quality (de Groot J.E. et al 2015);  Radiolucent positioning sheets increase the pain experience (Timmers J. et al 2015)

Compression of the breast

• During mammography the breast is compressed between the breast support plate and the compression paddle  deformation of the breast into a more uniform thickness  Reduces motion artefacts  Reduces geometrical unsharpness  Reduces dose  Reduces tissue superposition  Reduces X-ray scatter

Compression of the breast

• Usually we compress the breast until it is taut and getting pale • It’s worth to compress as long as breast thickness is decreasing • It’s crucial to take into account the pain feeling of the patient • During acquisition, the compression force is measured but  No clear guidelines about the force to be applied  Applied compression force variation is related to habits and experience of the radiographers (Mercer et al 2015)

Radiographer experience: predictable compression force

Predictable compression force judgement (rules of thumb) for each of the main categories of patients encountered (Nightingale J.M. et al 2015) Compression of the breast

How much compression is good? The more, the better? Compression of the breast

• Higher compression force is not necessarily associated with better quality!  Low association between compression force and radiation dose (Waade G.G et al 2017);  Contradictory results concerning correlation between compression force / compression pressure and early detection of cancer (Moshina N, 2017; Holland K. et al 2016)  The distribution of pressure differs greatly between breasts (Dustler M. et al 2012) Optimizing women’s mammography experience

• Patient centred care • Gender • Communication • AIDET protocol Patient centred care

• Consider the woman as a unique person, with her cultural values: • What does early screening, prevention concept mean for her? • Beliefs, religious, ethnic, geographic, socioeconomic factors play a role in feeling pain and discomfort and in understandings

• Language: Use pain scales to assess pain. If possible, contact an interpreter prior to the examination Patient centred care

• Explore the patient’s experience of illness and pain: • Expressive vs non-expressive • Always offer feed-back on the whole experience and the pain experience

• The radiographer should adopt listening behaviour in relation to the women concerns and give time to discuss important questions. It’s a major factor to increase future adherence to the screening programme

• Give teaching or educational information about the all procedure: before, during and after the mammography Gender

One of my male colleagues told me that he isn’t supposed to do an internship in mammography… Isn’t this strange? Gender

• Mammograms are mostly produced by female radiographers in all countries, as it is supposed to guarantee a better acceptance by the women. In some countries male radiographers are totally excluded from mammography. This could change because of radiographer shortage. Actually we don’t really know if the gender of a radiographer would have an impact on the attendance rate of a breast cancer screening programme. Studies conducted in Ireland (Fitzpatrick P. et al 2008), Nigeria (Okeji et al 2012) and Australia (Warren-Forward et al 2017) will give you an overview of women’s perception in these three countries. Communication

• Mnemonic protocols may be an interesting way to increase communication skills. The AIDET protocol is one example. It would be a good exercise to adapt the principles of this protocol to the mammography patient. You may compare your findings with the proposition of the paper published by Leisa Arnold in 2016 AIDET protocol

• AIDET is a customer service initiative developed by the Studer Group, a healthcare consulting company • AIDET is acronym that stands for:  Acknowledgement  Introduction  Duration  Explanation  Thank you

https://www.studergroup.com/aidet AIDET protocol • Acknowledgement: The goal is to establish trust by showing empathy. The radiographer cares about the patient’s well-being. Greet the patient by her name, keep eye contact, smile… • Introduction: The goal is to reduce patient anxiety by sharing with the woman the skill set of the people who will be caring for them. Introduce yourself with your name and your profession… • Duration: The goal is to reduce patient anxiety by establishing the time expectation. Give an accurate time expectation for the imaging procedure… • Explanation: The goal is to engage the patient in their care. Explain step-by- step what to expect next … • Thank you: The goal is to build loyalty. Thank the patient for the collaboration during the imaging procedure Scott J. 2012 Conclusion

• The mammographers’ attitude is a key factor in making an unpleasant experience acceptable! References I

• Arnold L. Patient Care, Communication, and Safety in the Mammography Suite. Radiol Technol. 2016;88(1):33M-47M. • Branderhorst W, de Groot JE, Neeter LM, van Lier MG, Neeleman C, den Heeten GJ, et al. Force balancing in mammographic compression. Med Phys. 2016;43(1):518. • Broeders MJ, Ten Voorde M, Veldkamp WJ, van Engen RE, van Landsveld-Verhoeven C, t Jong-Gunneman MN, et al. Comparison of a flexible versus a rigid breast compression paddle: pain experience, projected breast area, radiation dose and technical image quality. Eur Radiol. 2015;25(3):821-9. • Davey, B. (2007). "Pain during mammography: Possible risk factors and ways to alleviate pain." Radiography 13(3): 229-234. • Dustler M, Andersson I, Brorson H, Frojd P, Mattsson S, Tingberg A, et al. Breast compression in mammography: pressure distribution patterns. Acta Radiol. 2012;53(9):973-80. • Edwards S, Chiarelli A, Ritvo P, Stewart L, Majpruz V, Mai V. " Satisfaction with initial screen and compliance with biennial breast screening at centers with and without nurses. "Cancer Nursing. 2011 Jul-Aug;34(4):293-301. doi:10.1097/NCC.0b013e3181f96bef. • Fernandez-Feito, A., et al. (2015). "Face-to-face Information and Emotional Support from Trained Nurses Reduce Pain During Screening Mammography: Results from a Randomized Controlled Trial." Pain Manag Nurs 16(6): 862-870. • Fitzpatrick P, Winston A, Mooney T. Radiographer gender and breast-screening uptake. Br J Cancer. 2008;98(11):1759-61. References II

• de Groot JE, Broeders MJM, Grimbergen CA, den Heeten GJ. Pain-preventing strategies in mammography: an observational study of simultaneously recorded pain and breast mechanics throughout the entire breast compression cycle. BMC Women's Health. 2015;15:26. • Hafslund, B. (2000). "Mammography and the experience of pain and anxiety." Radiography 6(4): 269-272 • Holland K, Sechopoulos I, den Heeten G, Mann RM, Karssemeijer N. Performance of Breast Cancer Screening Depends on Mammographic Compression. In: Tingberg A, Lång K, Timberg P, editors. Breast Imaging: 13th International Workshop, IWDM 2016, Malmö, Sweden, June 19-22, 2016, Proceedings. Cham: Springer International Publishing; 2016. p. 183-9. • Mercer, C. E., et al. (2015). "A 6-year study of mammographic compression force: Practitioner variability within and between screening sites." Radiography 21(1): 68-73. • Miller D, Livingstone V, Herbison P. Interventions for relieving the pain and discomfort of screening mammography. Cochrane Database Syst Rev. 2008(1):CD002942. • Moshina N, Sebuodegard S, Hofvind S. Is breast compression associated with breast cancer detection and other early performance measures in a population-based breast cancer screening program? Breast Cancer Res Treat. 2017. • Narayan MC. Culture's effects on pain assessment and management. Am J Nurs. 2010 Apr;110(4):38-47; quiz 48-9. doi: 10.1097/01.NAJ.0000370157.33223.6d • Nightingale JM, Murphy FJ, Robinson L, Newton-Hughes A, Hogg P. Breast compression – An exploration of problem solving and decision-making in mammography. Radiography. 2015;21(4):364-9. References III

• Poulos A, Llewellyn G. Mammography discomfort: a holistic perspective derived from women's experiences. The college of radiography, 2004, . DOI: http://dx.doi.org/10.1016/j.radi.2004.07.002 • Scott J. Utilizing AIDET and other tools to increase patient satisfaction scores. Radiol Manage. 2012;34(3):29-33; quiz 4-5. • Timmers J, Voorde MT, Engen RE, Landsveld-Verhoeven C, Pijnappel R, Greve KD, et al. Mammography with and without radiolucent positioning sheets: Comparison of projected breast area, pain experience, radiation dose and technical image quality. Eur J Radiol. 2015;84(10):1903-9 • Waade GG, Sanderud A, Hofvind S. Compression force and radiation dose in the Norwegian Breast Cancer Screening Program. European Journal of Radiology. 2017;88:41-6. • Warren-Forward HM, Mackie B, Alchin M, Mooney T, Fitzpatrick P. Perceptions of Australian clients towards male radiographers working in breast imaging: Quantitative results from a pilot study. Radiography (Lond). 2017;23(1):3-8. • Whelehan P, Evans A, Ozakinci G. Client and practitioner perspectives on the screening mammography experience. Eur J Cancer Care (Engl). 2017;26(3). • Whelehan P, Evans A, Wells M, Macgillivray S. The effect of mammography pain on repeat participation in breast cancer screening: a systematic review. Breast. 2013;22(4):389-94. More readings about the topic

• Clark S, Reeves PJ. Women's experiences of mammography: A thematic evaluation of the literature. Radiography. 2015;21(1):84-8. • Maruthur NM, Bolen S, Brancati FL, Clark JM. Obesity and Mammography: A Systematic Review and Meta-Analysis. Journal of General Internal Medicine. 2009;24(5):665-77.

Authors: Nicole Richli Meystre Françoise Ineichen