Professional Documents
Culture Documents
DOI 10.1007/s00247-011-2271-4
COMMENTARY
Received: 30 May 2011 / Revised: 1 September 2011 / Accepted: 1 September 2011 / Published online: 14 October 2011
# Springer-Verlag 2011
Introduction
A fundamental ethical principle when caring for children is
that interventions including assessment procedures should
maximize their best interests and minimize harms [1].
Acting in the best interests of a child has been defined in
general terms and includes ensuring the best interests of
children must be the primary concern in making decisions
that may affect them [2]. This general principle encompasses the ethical right of children to have procedural pain
and anxiety minimised and managed efficiently [3], or
where discomfort is unavoidable, adequate preparation to
minimize such harms. A key feature of conducting medical
imaging (i.e. radiology) procedures in a pediatric setting is
the need to bring together a range of specialist practitioners
who work together towards achieving the goal of conducting an imaging procedure and managing potential anxiety
in the child.
Edwards [4] describes work that relies on different types
of professional expertise combining towards a particular
goal as fluid and responsive object-oriented work. In the
context of conducting radiology procedures, this means that
although all practitioners are oriented towards the overall
objective of achieving an effective diagnostic outcome,
there is a need to understand differing discipline-specific
C. Delany (*)
The Childrens Bioethics Centre,
The Royal Childrens Hospital Melbourne,
50 Flemington Road,
Melbourne, Australia 3052
e-mail: c.delany@unimelb.edu.au
M. Conwell
Uniting Care Gippsland,
Melbourne, Australia
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and the child. The insights from the EPT highlight how one
professional conceives of their role to work with colleagues, parents and the child whilst maintaining a focus on
the overall purpose of maximising short- and long-term
benefits for the child. The strategies employed by the EPT
provide insight into the nature and possibilities of teamwork in a pediatric radiology context, to be dynamic,
responsive, non-hierarchical and focused on short- and
long-term best interests for the child.
Drawing from the EPTs description and from a
sociocultural perspective of examining ideas of distributed
professional expertise embedded in everyday practice, we
use the analogy of being a member of a chamber ensemble
as a useful way to conceive of multidisciplinary teamwork
in this particular clinical setting. A feature of teamwork
from this perspective is the overriding and shared goal of
understanding each others contributions. Standard hierarchical structures of authority and decision-making may or
may not be the most appropriate way to advance integration, collaboration, cohesion and harmony among the health
team, the parents and the child to achieve clinical outcomes
and ethical ideals of reducing associated pain and anxiety
for the child.
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Discussion
This single interview data affirms that working together in
the best interests of a child undergoing or preparing for a
medical imaging procedure requires a combination and
integration of methods of distraction, play and cognitivebased interventions with a focused view of the clinical and
diagnostic goal. It points to the need for an awareness of the
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potential harms for children in undergoing imaging procedures and a knowledge of how the dynamics and
collaborative practices of the team might work to minimise
such impacts. The data, comprising a single case interview,
is limited in its use as generalisable evidence. In addition, it
presents as a dominant perspective the views and interpretations of one member of the health team, the EPT. This
single professional perspective neglects the views and
interpretation of other key stakeholders, and there is a clear
need for research that includes and highlights alternative
views and experiences. However, as a single case, the
findings may be useful in providing a foundation for
building or extending understanding about theories and
practices in this clinical context [30], and to promote further
debate and discussion. We used a chamber music ensemble
example to illustrate the dynamics of interaction. Others
have suggested the need to develop distributed agency and
common intentions within team members, and to explicitly
share resources [31].
The chamber ensemble analogy is useful in so far as it
highlights a need for rethinking established hierarchical
team structures for the conduct of medical imaging
procedures for children, and may also be relevant to other
types of procedural care in pediatrics. The overriding
ethical purpose of maximising short- and long-term benefits
for a child requires a more nuanced understanding of health
care teams that moves away from the traditional basis of
hierarchies of authority (where the more medical training
you have, the more likely you are to be the key decision
maker) [32, 33]. Studies of health care teams and contexts
where leadership is distributed among health team members
have shown that good teamwork starts with a frame of
mind, or a set of attitudes and values [34]. This suggests
physically bringing together a group of professionals with
specific disciplinary skills may not be enough to achieve
the complex goals of diagnostic procedures.
The EPTs description in this interview accords with
what Beckett [35] refers to as a sense of relationality and
what Edwards [4] describes as relational agencya
capacity for working with others to strengthen purposeful
responses to complex problems. It requires all professionals involved to be able to recognize and work with others
by acknowledging and integrating discipline-specific professional resources and interpretations [4]. Translated to a
clinical setting, having a sense of agency and purpose that
also relates to other health professionals involved in the
conduct of a procedure means taking steps to understand
their motives and available resources, and then aligning all
perspectives and motives towards an expanded goal or
interpretation of what constitutes the best interests of a
child. Where an EPT may be focused on ensuring the
medical imaging procedure is a positive experience for the
child, the medical imaging technologist may be more
Conclusion
This paper has discussed the ethical and clinical goals of
conducting pediatric medical imaging procedures using the
experiences of a play therapist involved as a team member
during the procedure. Using an ethical lens and single indepth interview data, the discussion has highlighted that
medical imaging in pediatric contexts requires attention not
only to the performance of accurate imaging techniques and
knowledge of effective methods to reduce anxiety for the
child and family, but also consideration of how the team of
people involved are working together in the best interests of
a child and their family.
The interview data provides some valuable insight into
the significance of cooperation and collaboration among
health professionals during the conduct of medical imaging
procedures. We identified similarities between the conduct
of a chamber ensemble and the conduct of medical imaging
procedures for children because of the importance of
working together and recognizing how each professional,
including the parents, can both support each other and build
on the relative strengths of their contributions for an
overriding purpose. Recognising that the best interests of
the child should be the primary concern when making
decisions about treatment and assessment procedures for
them [2] means that each member of the health team is
required to contribute their own expertise and knowledge,
and also attend to the goals of collaborative and relational
practice necessary to achieve this goal. Our further
contention in the case of medical imaging is that the most
appropriate member of the health team to coordinate and set
the agenda for the conduct of the procedure should not be
based on standard hierarchical structures, but on the basis
of how to best advance the integration and collaboration
among the health team, the parents and the child to achieve
ethical ideals of reducing associated pain and anxiety for
the child.
Acknowledgement The authors would like to acknowledge the
assistance of Caroline Kennedy and Associate Professor Joce Nuttal
for valuable input in reading and commenting on this manuscript.
Kennedy, quality unit manager with the Medical Imaging Department,
Royal Childrens Hospital, reviewed the manuscript from a radiology
perspective. Nuttall, principal research fellow for the faculty of
education, Australian Catholic University, provided very useful
comments from an educational and interdisciplinary perspective.
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