Radiographic Practice Research Articles

An observational study based on the interaction between the paediatric patient and radiographer

BackgroundThe practice of paediatric radiography requires a completely different skill set to that of adult radiography. Often, obtaining a paediatric patient's cooperation is the most difficult aspect of the role. Ensuring that a child cooperates for the examination can make positioning easier, thereby potentially providing a more diagnostic image. AimThe aim of this study was to observe the interaction between the paediatric patient and the radiographer and to uncover techniques used by the radiographer to help alleviate any fear or stress that the child might have had. MethodA direct observational method was conducted, after both the radiographer and the child's guardians provided full written consent. The actions of the radiographer and resultant reactions from the child were recorded on an observational checklist designed for paediatric examinations. ResultsSeventy-nine patients aged between three months to fifteen years and thirteen radiographers with no specific paediatric training other than experience were observed. Examinations observed included lower limb, upper limb, pelvis, abdomen and chest projections. The data gathered were the result of radiographer actions when interacting with both happy and sad children. ConclusionsSuccessful methods of alleviating a child's fear and anxiety whilst in the X-ray room included the use of child friendly equipment such as colourful lead protection and posters on the wall, a simple explanation of what the equipment is before moving it, offering rewards such as stickers and praise and showing the child their image after the examination. When time was short and the workload was high, it was observed that radiographers were less likely to spend time calming the child down and instead were more focused on completing the examination as quickly as possible.

Evidence-Based Practice in Radiography: Attitudes, Beliefs, Knowledge and Practices of Radiographers in Ghana

Background: Evidence-based practice (EBP) has been identified as a standard in healthcare and the principles and practice of EBP are widely promoted and increasingly accepted by various professional bodies. Radiographers are therefore aware of the need to change attitudes and develop skills necessary for the integration of EBP into clinical practice. Aim: The main purpose of this study was to describe the attitudes, beliefs, knowledge and practices of radiographers with regard to evidence-based practice in Ghana. Methods: Nationwide survey done resulted in a response rate of 92.1% representing 199 participants. Participants completed a questionnaire designed to determine attitudes, beliefs, knowledge and practices, of their profession. Descriptive statistics was used to show the responses in tabular and graphical formats. Results: Most respondents (56.6 %) disagreed that strong evidence was lacking to support their practice. Only 39% of the respondents agreed that they had knowledge of medical search engines e.g. MEDLINE, Cochraine etc. 43% of the respondents reported using professional literature in clinical decision-making five or fewer times per month. The primary barrier to implementing EBP was lack of time. Conclusion: Radiographers showed positive attitudes and beliefs towards EBP. However, lack of resources, knowledge gap and skills was a challenge for its incorporation into practice. There is therefore the need for training of radiographers in Ghana into EBP.

An introduction and implementation of problem-based learning for radiography positioning training

The knowledge of radiological technologists is expected to increase with medical development. However, it is impossible to impart all knowledge in a limited time frame. Problem-based learning (PBL) is a learning methodology to solve it. In the PBL, students can gain problem-solving abilities by acquiring necessary knowledge from clinical cases and applying them during practice. We here report to implement the PBL in radiography practice. This practice opened a course at 2nd semester of third-grade students in our school. The practice flow includes presentation of clinical case and a survey of necessary knowledge, group work, radiography, reflection through practice, and deliberation of different cases. The clinical case was the radiography of an emergency patient. The evaluation items were about knowledge, skill, and attitude. By the PBL practice, students could realize a clinical scene, and discover considerable points unwritten in textbooks.

Endodontic radiology, practice, and knowledge of radiation biology, hazard, and protection among clinical dental students and interns

Objective: To evaluate the practice and knowledge of endodontic radiology as well as assess the knowledge of radiation biology, hazard, and protection among clinical dental students and interns. Materials and Methods: Cross-sectional study of clinical dental students and interns at University of Benin and University of Benin Teaching hospital respectively. Data was collected using a questionnaire which covered practice and knowledge of endodontic radiography, knowledge of radiation biology, hazard, and protection. Data was analyzed using Statistical Package for Social Sciences (SPSS) version 17.0. Result: Seventy participants were included in the study, 40% were final year students and 24.3% house officers. Majority (95.7%) agreed that they exposed radiographs as part of endodontic treatment. Only 18.6% knew that the apices of teeth should be 3mm from the border of the X-ray film, while 24.3% knew that 3mm of periapical bone should be visible on X-ray. Less than half (31.4%) knew that paralleling technique was the technique of choice for endodontic radiography and this was statistically Significant in relationship to the status of the of the respondents. A few (4.3%) of the respondents had knowledge of new horizons in endodontic imaging. Half of the respondents knew that damage by X-rays is mainly due to formation of free radicals. The most frequently reported radiation hazards was reduced salivary flow, while the least reported was rampant caries. Most knew how to protect patients, themselves, and other persons while exposing radiographs. Conclusion: There is need for inclusion of endodontic radiography in the undergraduate curriculum to ensure proper and correct radiographs during endodontic procedure.

Assessment of Compliance to European Commission on Quality Criteria for Diagnostic Paediatric Radiography in Southern Nigeria

Background: Quality and safety have become bedrocks for efficient and successful medical intervention throughout the whole world. Objective: To assess for quality screening practice in paediatric radiography; compliance with European Commission guide lines for diagnostic paediatric radiography in Southern Nigeria. Materials and Methods: University Teaching Hospitals and private health centres in Southern Nigeria were screened through questionnaires and on-site observation of paediatric radiography practices. The questionnaires contained the recommended parameters of EC in respect of skull, chest and abdominal radiography imaging. Results: They revealed that radiography device (RD) usage had good scores in all medical institutions. Nominal focal spot value (NFSV), tube filtration (TF), Film-focus distance (FFD) had good scores only in public hospitals. Automatic exposure control (AEC) had good scores only in private health centres. Quality assurance was good for public hospitals. Most of X-ray machines were manufactured 31 years ago and installed about 37 years ago. Conclusion: University Teaching Hospitals had fair compliance to EC recommendations than private health centres. The poor compliance was probably due to lack of proficient radiography technologists, lack of adequate information necessary in carrying out paediatric radiography, use of obsolete equipment or lack of incentives.

A Need Assessment for Prevention of Work-Related Stress Experienced by Radiographers in Ghana

Background: The various components within the radiography practice pose different injury risks to radiographers in the course of performing diagnostic imaging examinations such as positioning patients in bed or on x-ray tables and lifting of heavy objects. These identified situations have a significant role in the development of RSS in radiographers Aim: This study aimed to establish whether radiographers at the study site experience Repetitive Stress Syndrome (RSS) in order to outline possible techniques to reduce the risk of RSS. Method: This was a descriptive survey and 68 radiographers consented to participate in the study. A structured questionnaire assessing demographic characteristics, radiographers’ awareness about distress, work schedule and problems associated with musculoskeletal injury were completed. Data were entered into a database using Statistical Package for Social Science (SPSS) version 17.0 and graphs and tables presented using Microsoft Excel. Result: It was observed from the study that majority of the Radiographers (52%) had practiced between one to five years. Forty eight percent of the respondents had no awareness of any kind of distress. Some of the radiographers (39%) had experienced multiple symptoms of distress in their workplaces. Conclusion: The study identified lack of awareness about several stress syndromes among the radiographer at the study site. The symptoms of distress among the radiographers were mostly pain and weakness. Other practices that influenced the occurrence of stress among the participants were frequent transferring and positioning of patients.

Breast compression – An exploration of problem solving and decision-making in mammography

ObjectiveBreast compression decreases radiation dose and reduces potential for motion and geometric unsharpness, yet there is variability in applied compression force within and between some centres. This article explores the problem solving process applied to the application of breast compression force from the mammography practitioners' perspective. MethodsA qualitative analysis was undertaken using an existing full data set of transcribed qualitative data collected in a phenomenological study of mammography practitioner values, behaviours and beliefs. The data emerged from focus groups conducted at six NHS breast screening centres in England (participant n = 41), and semi-structured interviews with mammography educators (n = 6). A researcher followed a thematic content analysis process to extract data related to mammography compression problem solving, developing a series of categories, themes and sub-themes. Emerging themes were then peer-validated by two other researchers, and developed into a model of practice. ResultsSeven consecutive stages contributed towards compression force problem solving: assessing the request; first impressions; explanations and consent; handling the breast and positioning; applying compression force; final adjustments; feedback. The model captures information gathering, problem framing, problem solving and decision making which inform an ‘ideal’ compression scenario. Behavioural problem solving, heuristics and intuitive decision making are reflected within this model. ConclusionThe application of compression should no longer be considered as one single task within mammography, but is now recognised as a seven stage problem solving continuum. This continuum model is the first to be applied to mammography, and is adaptable and transferable to other radiography practice settings.

Research from therapeutic radiographers: An audit of research capacity within the UK

Research from Allied Health Professionals (AHPs) is anecdotally known to lag behind that of other professions. The developing research landscape within other therapies and internationally led us to question how UK practice in therapeutic radiography was developing. The aim of the survey was to audit research capacity across therapy radiography in the UK. MethodAn electronic survey was sent to Radiotherapy Service Managers (RSM) and research leads in each of the radiotherapy centres in the UK. An adapted version of the ‘Auditing Research Capacity’ tool (ARC© tool) was used as the basis of the questionnaire. ResultsA total of 45 RSM responded to the survey (67% response rate) and 30 Research radiographers (RR) (45% response rate). A total of 51 RR were in post equating to 40.3 whole time equivalents and averaging 1 RR per centre. Variation was evident in the commitment to the development of a research culture identified by practices such as linking research to the business planning cycle, inclusion of research in recruitment and advertising materials, or having a nominated therapeutic radiographer lead on research for the department. Over a third of responding centres did not have a research strategy and training for RRs was limited; specifically in areas such as writing funding bids, writing for publication and the research and governance process. ConclusionA number of short and long-term strategies are proposed that should enhance a positive research culture and improve research capacity for therapeutic radiography led research. These include utilisation of the existing infrastructure provided by the National Institute for Health Research, a lead or co-ordinator for research activity with a remit to motivate others. Development of links and networks, and the development of a research strategy linked to wider Trust research priorities. The research strategy should include mentoring or developing appropriate research skills for those engaged in research (including higher degree qualifications). RSMs should also encourage peer-reviewed publications, and conference presentations from all staff to ensure research results are disseminated to the wider profession.

The influence of experience and training in a group of novice observers: A jackknife alternative free-response receiver operating characteristic analysis

PurposeThe study evaluates the pre- and post-training lesion localisation ability of a group of novice observers. Parallels are drawn with the performance of inexperienced radiographers taking part in preliminary clinical evaluation (PCE) and ‘red-dot’ systems, operating within radiography practice. Materials and methodsThirty-four novice observers searched 92 images for simulated lesions. Pre-training and post-training evaluations were completed following the free-response the receiver operating characteristic (FROC) method. Training consisted of observer performance methodology, the characteristics of the simulated lesions and information on lesion frequency. Jackknife alternative FROC (JAFROC) and highest rating inferred ROC analyses were performed to evaluate performance difference on lesion-based and case-based decisions. The significance level of the test was set at 0.05 to control the probability of Type I error. ResultsJAFROC analysis (F(3,33) = 26.34, p < 0.0001) and highest-rating inferred ROC analysis (F(3,33) = 10.65, p = 0.0026) revealed a statistically significant difference in lesion detection performance. The JAFROC figure-of-merit was 0.563 (95% CI 0.512,0.614) pre-training and 0.677 (95% CI 0.639,0.715) post-training. Highest rating inferred ROC figure-of-merit was 0.728 (95% CI 0.701,0.755) pre-training and 0.772 (95% CI 0.750,0.793) post-training. ConclusionsThis study has demonstrated that novice observer performance can improve significantly. This study design may have relevance in the assessment of inexperienced radiographers taking part in PCE or commenting scheme for trauma.

Factors influencing the development and implementation of advanced radiographer practice in Australia - a qualitative study using an interpretative phenomenological approach.

IntroductionThe purpose of this study was to explore the factors influencing the implementation or the lack of implementation of advanced practitioner role in Australia.MethodsThis study uses an interpretative phenomenological approach to explore the in-depth real life issues, which surround the advanced practitioner as a solution to radiologist workforce shortages in Australia. Research participants are radiographers, radiation therapists and health managers registered with the Australian Institute of Radiography (AIR) and holding senior professional and AIR Board positions with knowledge of current advanced practice.ResultsIn total, seven interviews were conducted revealing education, governance, technical, people issues, change management, government, costs and timing as critical factors influencing advanced practice in Australia.ConclusionsSeven participants in this study perceived an advanced practice role might have major benefits and a positive impact on the immediate and long-term management of patients. Another finding is the greater respect and appreciation of each other's roles and expertise within the multidisciplinary healthcare team. Engagement is required of the critical stakeholders that have been identified as ‘blockers’ (radiologists, health departments) as well as identified allies (e.g. emergency clinicians, supportive radiologists, patient advocacy groups). The research supports that the AIR has a role to play for the professional identity of radiographers and shaping the advanced practice role in Australia.

Ionising radiation: legislation and risks

Ionisation legislation ensures a safe environment in which to work and receive treatment and requires that those involved in the radiographic process must be appropriately trained for the type of radiographic practice they perform. This article looks at ionising radiation legislation from the dental nurse's perspective

WE-A-12A-01: Medical Physics 1.0 to 2.0, Session 2: Radiography, Mammography and Fluoroscopy

Medical Physics 2.0 is a bold vision for an existential transition of clinical imaging physics in face of the new realities of value-based and evidencebased medicine, comparative effectiveness, and meaningful use. It speaks to how clinical imaging physics can expand beyond traditional insular models of inspection and acceptance testing, oriented toward compliance, towards team-based models of operational engagement, prospective definition and assurance of effective use, and retrospective evaluation of clinical performance. Organized into four sessions of the AAPM, this particular session focuses on three specific modalities as outlined below. Radiography 2.0: The development of electronic capture in recent years has changed the landscape and spurred reinvestment by healthcare providers. The radiography presentation will explore how the diagnostic medical physicist must adapt to these changes to support radiographic imaging, and how she/he can add value in radiography practice over the next 5-10 years. Topics of discussion include new metrology of evaluation, new models of clinical engagement, and effective integration of new technologies. Mammography 2.0: Mammography has been an interesting testing ground on the effectiveness of close involvement of medical physicists with equipment in the past twenty years. The outcomes have clearly shown major improvements in image quality and significant reduction in the average glandular dose. However, the medical physicist's role in mammography has been largely focused to annual surveys and with limited input on operational issues with image artifacts, optimal mammographic acquisition mode and problems with image quality. This mammography presentation will address why and how medical physicists must be prepared to address the new models of practice that include new metrics of performance and the integration of new technologies (DBT, syncretized mammograms, contrast mammography, breast CT) into clinical practice. Fluoroscopy 2.0: Physics support of fluoroscopy should be operationally as opposed to compliance focused. Testing protocols must address new hardware, acquisition methods, and image processing. Future available tools are discussed. Proper configuration of acquisition parameters (focal spot size, voltage and added filter, tube current, pulse width, pulse rate, scatter removal) as a function of patient size from the neonate to bariatric patient is key to providing diagnostic image quality at properly managed radiation doses. Learning Objectives: 1. Appreciate the limitations of the currently available tools and techniques in clinical medical physics in radiography, mammography, and fluoroscopy, and ways to improve upon current deficiencies. 2. Appreciate the changing environment of imaging practice and the need for the medical physicist to be an expert consultant and educator in a capacity that extends beyond the annual survey of equipment. 3. Understand the status of the rapidly changing environment in breast imaging from planar imaging to tomosynthesis and possibly to breast CT. 4. Identify appropriate configuration of acquisition parameters as a function of patient size to manage radiation dose and ensure diagnostic image quality.

Teleradiology quality assurance -- lessons learnt.

Quality assurance in radiography is an important process in identifying weaknesses in radiographic practice. Understanding where improvements can be made helps to keep the focus on those aspects of radiologywhere intervention can improve image quality. Quality assurance of radiographic images is also feasible for teleradiology platforms, andwithinMedecins Sans Frontieres (MSF) all radiographic images sent for teleradiology are evaluated for quality (Fig. 1). Analysis of the image quality has proved useful in guiding the planning and prioritisation of radiology services withinMSF. The lessons learnt may also useful for other users of radiography in resource-limited settings. Comparing computed radiography images with those of film and chemistry, it is clear that computed radiography images are consistently of significantly higher quality [1]. This observation suggests that wherever possible, transitioning to computed radiography imaging can improve image quality compared to film and chemistry. This is partly because computed radiography technology can compensate for variables such as exposure and film processing. MSF sites that demonstrate better quality with computed radiography imaging have also had radiographer training as a part of the computed radiography installation. Good radiographic technique is a fundamental factor in improving image quality, and radiographer training, whether with computed radiography imaging or film and chemistry, results in better image quality. Wherever possible within MSF, radiographer training is prioritised and then regular visits are planned for continuation of training. A point of discussion at MSF is whether to continue utilisation of referral radiology facilities where the image quality has proved to be consistently poor. If MSF is not in a position to upgrade equipment or provide an investment in radiographer training, it should be considered whether it might be detrimental to patient outcomes to consult images that are very poor in diagnostic quality. Further, MSF has learnt a few other lessons along the way. The teleradiology platform itself must be user-friendly and not require complex processes that require too much time or too many steps. If it’s not straightforward, clinicians might find other avenues to ask for advice. Conversely, feedback to volunteer radiologists is very important in maintaining their interest and in respecting their time and investment in the outcome of the patient. Practically, this has been a difficult point for MSF to promote among field clinicians because their high workload, remote conditions and competing priorities leave less time for follow-up with consultants than clinicians would otherwise like. Last, we have found that radiologists’ reports should attempt to help with a differential diagnosis as much as possible beyond just reporting radiologic findings in order to provide the most benefit to clinicians.

Hospital-based Dose Survey, an Impetus to a National Diagnostic Reference Level in Chest X-Ray Examinations

Diagnostic Reference Levels (DRLs) are significant in diagnostic radiology. Currently, there is no established diagnostic reference level in any radiographic procedure in the Philippines. The study aimed to determine doses received by patients undergoing chest posteroanterior (PA) x-ray examinations. In addition, the study also aimed to provide an estimate of entrance surface dose for chest PA for later basis in establishing DRLs in the country. It used a dose survey to collect data. Instruments were used to measure the dose received by the subjects of the study. The result of the data gathering revealed a dose estimate of 0.15± 0.06 mGy which is lower than the reference/guidance levels set by two international organizations: (1) the European Commission (EC, 1997) and (2) the International Atomic Energy Agency (IAEA, 2007). It is also relatively lower than the doses measured in similar studies in other countries. The result of the study gives an indication of good radiography practice in the tertiary hospital where the study was conducted. It is recommended that the data in this study together with data from other studies for the same procedure conducted in the country be used in establishing a DRL for chest radiography in the Philippines. Keywords - Radiology, diagnostic Reference Levels (DRL), Entrance Surface Dose (ESD),descriptive method, Philippines

Consultant breast radiographers: Where are we now?: An evaluation of the current role of the consultant breast radiographer

IntroductionThe aim of this study is to:•Evaluate the current role of the consultant breast radiographer.•Compare current practice with the four key components for consultant practice.•Gauge the support of radiologist colleagues.•Determine the other professional commitments involved with the role.This study could be the precursor for a macro study of all consultant radiographer practice in other specialities. MethodologyMethodology used was a comparative ethnographic study. Questionnaires to the 24 consultant breast radiographers currently in post, and consultant breast radiologists, who work with them, were conducted.Data collection was a qualitative thematic approach. ConclusionConsultant breast radiographers provide high quality care to patients through excellent clinical practice, leadership and good communication.However, this study shows hospital Trusts emphasis for non medical consultants is for clinical practice first. Some radiologists are still a barrier to progression for consultant breast radiographers, and radiologists have a big influence in recruitment decisions.Consultant breast radiographer posts are well established, their numbers are increasing through recognition of the role and of their abilities and performance. Consultant breast radiographers state that becoming a consultant is the major achievement of their career, proving the Society of Radiographers' vision of the four-tier career structure has been well received by the radiography profession.

Significant change in the practice of chest radiography in Dutch ICUs

>We performed a survey under Dutch intensivists on the current practice of chest radiography in their departments. Chest radiographs (CXRs) are obtained frequently in ICU patients, despite the diagnostic and therapeutic efficacy of routine CXRs being known to be low. The discussion regarding specific indications for CXRs in critically ill patients and the safety of abandoning routine CXRs is still continuing [1].

Significant changes in the practice of chest radiography in Dutch intensive care units: a web-based survey

BackgroundICU patients frequently undergo chest radiographs (CXRs). The diagnostic and therapeutic efficacy of routine CXRs are now known to be low, but the discussion regarding specific indications for CXRs in critically ill patients and the safety of abandoning routine CXRs is still ongoing. We performed a survey of Dutch intensivists on the current practice of chest radiography in their departments.MethodsWeb-based questionnaires, containing questions regarding ICU characteristics, ICU patients, daily CXR strategies, indications for routine CXRs and the practice of radiologic evaluation, were sent to the medical directors of all adult ICUs in the Netherlands. CXR strategies were compared between all academic and non-academic hospitals and between ICUs of different sizes. A comparison was made between the survey results obtained in 2006 and 2013.ResultsOf the 83 ICUs that were contacted, 69 (83%) responded to the survey. Only 7% of responding ICUs were currently performing daily routine CXRs for all patients, and 61% of the responding ICUs were said never to perform CXRs on a routine basis. A daily meeting with a radiologist is an established practice in 72% of the responding ICUs and is judged to be important or even essential by those ICUs. The therapeutic efficacy of routine CXRs was assumed by intensivists to be lower than 10% or to be between 10 and 20%. The efficacy of ‘on-demand’ CXRs was assumed to be between 10 and 60%. There is a consensus between intensivists to perform a routine CXR after endotracheal intubation, chest tube placement or central venous catheterization.ConclusionThe strategy of daily routine CXRs for critically ill and mechanically ventilated patients has turned from being a common practice in 2006 to a rare current practice. Other routine strategies and an ‘on-demand only’ strategy have become more popular. Intensivists still assume the value of CXRs to be higher than the efficacy that is reported in the literature.

Dose Assessment for Some Industrial Gamma Sources with an Application to a Radiation Accident

Accidents involving industrial radiography are the most frequent cause of severe or fatal overexposure to workers and the public. On May 5, 2000, a radiation accident happened at a construction site in a gamma radiography practice at the village of Meet Halfa-Egypt. The accident was a severe overdose of non-radiation workers due to external exposure of Ir-192. This paper provides a methodology for calculating doses and dose rates from the most commonly used industrial γ-sources: 192Ir, 60Co, 134Cs, 137Cs and 131I. For this purpose, MCNP computer code based on Monte Carlo technique is used. The applied method helps firstly in studying and analyzing the doses from the above mentioned sources. Secondly, it provides a lead container design in a trial to reduce the dose rate within the permissible. Computer models were used to simulate the 192Ir Meet Halfa accident. To verify these models, the calculated doses were compared with a well-known empirical formula to convert source activity into dose rate and then the models were applied at different distances to analyze the factors that affect the deposited dose in the human body to find out the dose received by the victims.

An Early X-ray Tube

The ABC of the X Rays (1) by William Henry Meadowcroft (1853-1937). Meadowcroft was Thomas Edison’s secretary and biographer (Edison was an early x-ray investigator). The text is an elementary exposition of x-rays, x-ray tubes, and suitable power sources. Practical Radiography (2) by Henry Snowden Ward (18651911) and William A. Anthony. Ward was editor of a British photography journal, The Photogram, which featured a section on radiography. Not surprisingly, his book deals with equipment and techniques for taking radiographic exposures. Roentgen Rays and Phenomena of the Anode and Cathode (3) by Edward Pruden Thompson. Thompson was an electrical engineer and patent attorney in New York. His text is a compendium of approximately 200 synopses of seminal papers exploring electrical and radiant phenomena (including publications of Faraday, J.J. Thomson, Crookes, Tesla, Hertz, Lenard, Edison, and Roentgen). The X Ray or Photography of the Invisible and Its Value in Surgery (4) by William James Morton (1845-1920) and Edwin W. Hammer. The only text authored by a physician, it contained sections on medical, surgical, and dental radiography (with a brief speculative chapter on the “curative action of the X ray”). Even the use of radiographs as legal evidence was addressed. It is the only one of the volumes that mentioned radiation toxicity, but it made no recommendations regarding radiation safety.

Bernstein's theory of pedagogic discourse as a theoretical framework for educators studying student radiographers' interpretation of normality vs. abnormality

PurposeTo acknowledge the tacit rules underpinning academic practice of undergraduate radiographers in determining normality vs. abnormality when appraising skeletal images. MethodologyTwelve students were interviewed (individually) using in-depth semi-structured questions. Interviews were mediated through a PowerPoint presentation containing two digital X-ray images. Each image was based on a level of expertise; the elementary (Case 1) and the complicated (Case 2). The questions were based on regular ‘frames’ created from observing tutor–student contact in class, and then validated through a group interview.Bernstein's theory of pedagogic discourse was then utilised as a data analysis instrument to determine how third year diagnostic radiography students interpreted X-ray images, in relation to the ‘recognition’ and ‘realisation’ rules of the Educational Theoretical Framework. ConclusionBernstein's framework has made it possible to specify, in detail, how issues and difficulties are formed at the level of the acquirer during interpretation. The recognition rules enabled students to meaningfully recognise what trauma characteristics can be associated with the image and the demands of a detailed scrutiny so as to enact a competent interpretation. Realisation rules, made it possible for students to establish their own systematic approach and realise legitimate meanings of normality and abnormality. Whereas obvious or visible trauma generated realisation rules (represented via homogenous terminology), latent trauma authorised students to deviate from legitimate meanings. The latter rule, in this context, has directed attention to the student issue of visioning abnormality when images are normal.