Pediatr Radiol (2012) 42:139146

DOI 10.1007/s00247-011-2271-4

COMMENTARY

Ethics and teamwork for pediatric medical imaging

procedures: insights from educational play therapy
Clare Delany & Melati Conwell

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

goals and values, and to negotiate purposeful and agreed

process and outcomes. In pediatric imaging settings, the
team may include a consultant, nurse, registrar, medical
imaging technologist, educational play therapist (EPT),
parents and the child. Although the common goal to act
in a childs best interests is well recognized, there has been
little research about the nature of the health team
interactions, the capacity to respond and overall team
functioning required among all the players to achieve this
goal [5]. In this paper, we focus on specifying the meaning
of best interests of a child undergoing a medical imaging
procedure, such as an radiograph, CT, nuclear medicine,
MRI or US, through the experiences of an EPT (equivalent
to a child life specialist), reflecting on the impact of health
care teamwork for the child and family.
MRI is an example of a common and increasingly utilised
specialist medical imaging procedure that requires children to
keep still for long periods in a confined space and be exposed
to loud noises [6, 7]. A number of medical imaging
procedures involve the insertion of a needle for intravenous
contrast agent [8]. The underlying ethical principles guiding
the conduct of medical imaging are to ensure that the
conduct of the procedure benefits the child and, at the same
time, minimises associated harms. Overall benefit includes
achieving a clear and clinically useful image; respecting a
childs developing autonomy, including their right to have
their opinions taken into account [1, 2, 9]; fostering a childs
sense of control over and preparedness to undergo the
procedure, and respecting the parents wishes and needs as
the childs guardian and support person [2].
Using MRI as an example, potential immediate harms
for children undergoing a scan include feelings of claustrophobia, fear of the machines, the noise and pain
associated with the injections [6, 8]. From a longer-term
perspective, if the child experiences pain or stress once,

140

their distress is likely to escalate or at least be ongoing on

subsequent occasions [10]. Conversely, having a wellmanaged experience where the child feels in control and
develops positive associations can lay the groundwork for
future positive and efficiently conducted experiences. A
childs response to a stressful or uncomfortable experience is
influenced by their age, developmental level, copying style
and previous experience [8, 1012]. Children experience
greater distress when their coping strategies are not matched
to the actual probability of controlling the environment [10].
Coping strategies include trying to alter the external
environment, as a primary method; or using secondary and
internal methods, such as to emotionally and cognitively
modify their interpretations of the environment [10].
The role of play and other developmentally appropriate
interventions is well-established in the literature [8, 13]. A
key goal of such interventions is to ensure a level of
integration between the childs coping style or their
developmental behavioural tendencies under stress and the
particular procedure they are undergoing [10]. Techniques
used by EPTs that aim to achieve this integration include an
emphasis on language that derives from and supports an
individual childs perspective and the use of play that enables
a child to act out and develop a sense of primary and/or
secondary control over the situation. The underpinning
theoretical framework is the idea that child-appropriate
language and make-believe provide a necessary and strategic
scaffold from which children learn to think about and exert
control and mastery within their environment [14].
Acting in a childs best interests when they are
undergoing a medical imaging procedure, therefore, encompasses the provision of developmentally appropriate and
consistently used language and play. It also means paying
attention to treatment and assessment-related trauma and
anxiety and recognizing that if a child perceives or
experiences the medical imaging procedure as painful and
anxiety-provoking, their distress can become a significant
and continuing burden for the child, for those who care for
them and for those who conduct the procedures.
Several studies have examined methods for decreasing
the anxiety and distress associated with the conduct of
imaging procedures in pediatric settings [6, 8, 15, 16].
Carter and colleagues [6] have categorized these methods
as play-based therapy (using play and medical toys as a
way of explaining the procedure); desensitization (using
gradual exposure to the equipment to adjust and develop
coping strategies) and cognitive behaviour therapy (using
psychological-based strategies of visualization, behaviour
rehearsal and reinforcement to empower children).
Hallowel [8] found that a key factor in achieving a
successful and low-stress MRI procedure was the integration and collaboration between members of the family and
the health team. These studies provide some evidence of

Pediatr Radiol (2012) 42:139146

effectiveness of strategies aimed at decreasing anxiety for

children; increasing the successful radiologic-based outcomes of the procedures and reducing the need for general
anaesthesia [7, 10]. Other guidelines for practice [17] and
studies of interventions [8, 15, 16] have described conducive environmental features and specific roles for family
members and health professionals.
Ethical dimensions of health team functioning have also
begun to receive recognition as a framework for understanding effective team practice [18, 19] and enhancing
communication and safe care [20]. However, as Leonard
and colleagues [20] highlight, effective communication and
the necessary collaboration to achieve clinical and ethical
goals in health care are often assumed and not made visible.
Divergent perceptions of roles and differences in goals and
values may confound individual efforts to achieve a good
outcome.

Objective and methods

Our objective was to explore the ethical dimensions of
conducting medical imaging with children through the
insights of an EPT about the nature of interdisciplinary
teamwork in this area of clinical practice.
We draw from a single case study involving the work of
an EPT recording the preparation and management of the
medical imaging process for a child and their parents. The
case is drawn from a larger qualitative research project that
involves mapping, via in-depth interviews, ethical issues
encountered by allied health staff working in a major
pediatric public hospital in Australia. Ethics approval to
conduct the interviews was obtained from the hospital
ethics committee. The overall aims of the research are to:
1. Document and categorise current ethical challenges and
dilemmas in allied health pediatric practice.
2. Explore the attitudes, knowledge and practices of allied
health professionals in relation to these ethical challenges.
3. Identify and develop evidence-based approaches to
ethical decision-making and ethics education for allied
health.
Each interview is audiotaped with the consent of
participants, transcribed in full and analysed using a
thematic approach [21]. The single interview that forms
the basis for the discussion of interdisciplinary teamwork in
this paper was with an EPT with 9 years experience and
educational qualifications in teaching, early childhood
education (Author 2).
The interview illuminates the highly relational nature of
interprofessional practice [4, 22] where health care decisions made for and with children and their parents emerge
from dynamic negotiations among team members, parents

140

their distress is likely to escalate or at least be ongoing on

subsequent occasions [10]. Conversely, having a wellmanaged experience where the child feels in control and
develops positive associations can lay the groundwork for
future positive and efficiently conducted experiences. A
childs response to a stressful or uncomfortable experience is
influenced by their age, developmental level, copying style
and previous experience [8, 1012]. Children experience
greater distress when their coping strategies are not matched
to the actual probability of controlling the environment [10].
Coping strategies include trying to alter the external
environment, as a primary method; or using secondary and
internal methods, such as to emotionally and cognitively
modify their interpretations of the environment [10].
The role of play and other developmentally appropriate
interventions is well-established in the literature [8, 13]. A
key goal of such interventions is to ensure a level of
integration between the childs coping style or their
developmental behavioural tendencies under stress and the
particular procedure they are undergoing [10]. Techniques
used by EPTs that aim to achieve this integration include an
emphasis on language that derives from and supports an
individual childs perspective and the use of play that enables
a child to act out and develop a sense of primary and/or
secondary control over the situation. The underpinning
theoretical framework is the idea that child-appropriate
language and make-believe provide a necessary and strategic
scaffold from which children learn to think about and exert
control and mastery within their environment [14].
Acting in a childs best interests when they are
undergoing a medical imaging procedure, therefore, encompasses the provision of developmentally appropriate and
consistently used language and play. It also means paying
attention to treatment and assessment-related trauma and
anxiety and recognizing that if a child perceives or
experiences the medical imaging procedure as painful and
anxiety-provoking, their distress can become a significant
and continuing burden for the child, for those who care for
them and for those who conduct the procedures.
Several studies have examined methods for decreasing
the anxiety and distress associated with the conduct of
imaging procedures in pediatric settings [6, 8, 15, 16].
Carter and colleagues [6] have categorized these methods
as play-based therapy (using play and medical toys as a
way of explaining the procedure); desensitization (using
gradual exposure to the equipment to adjust and develop
coping strategies) and cognitive behaviour therapy (using
psychological-based strategies of visualization, behaviour
rehearsal and reinforcement to empower children).
Hallowel [8] found that a key factor in achieving a
successful and low-stress MRI procedure was the integration and collaboration between members of the family and
the health team. These studies provide some evidence of

Pediatr Radiol (2012) 42:139146

effectiveness of strategies aimed at decreasing anxiety for

children; increasing the successful radiologic-based outcomes of the procedures and reducing the need for general
anaesthesia [7, 10]. Other guidelines for practice [17] and
studies of interventions [8, 15, 16] have described conducive environmental features and specific roles for family
members and health professionals.
Ethical dimensions of health team functioning have also
begun to receive recognition as a framework for understanding effective team practice [18, 19] and enhancing
communication and safe care [20]. However, as Leonard
and colleagues [20] highlight, effective communication and
the necessary collaboration to achieve clinical and ethical
goals in health care are often assumed and not made visible.
Divergent perceptions of roles and differences in goals and
values may confound individual efforts to achieve a good
outcome.

Objective and methods

Our objective was to explore the ethical dimensions of
conducting medical imaging with children through the
insights of an EPT about the nature of interdisciplinary
teamwork in this area of clinical practice.
We draw from a single case study involving the work of
an EPT recording the preparation and management of the
medical imaging process for a child and their parents. The
case is drawn from a larger qualitative research project that
involves mapping, via in-depth interviews, ethical issues
encountered by allied health staff working in a major
pediatric public hospital in Australia. Ethics approval to
conduct the interviews was obtained from the hospital
ethics committee. The overall aims of the research are to:
1. Document and categorise current ethical challenges and
dilemmas in allied health pediatric practice.
2. Explore the attitudes, knowledge and practices of allied
health professionals in relation to these ethical challenges.
3. Identify and develop evidence-based approaches to
ethical decision-making and ethics education for allied
health.
Each interview is audiotaped with the consent of
participants, transcribed in full and analysed using a
thematic approach [21]. The single interview that forms
the basis for the discussion of interdisciplinary teamwork in
this paper was with an EPT with 9 years experience and
educational qualifications in teaching, early childhood
education (Author 2).
The interview illuminates the highly relational nature of
interprofessional practice [4, 22] where health care decisions made for and with children and their parents emerge
from dynamic negotiations among team members, parents

Pediatr Radiol (2012) 42:139146

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.

Interview findings and discussion

A childs experience
During the interview, the EPT provided a rich description
of a childs experience and possible reactions when
attending the hospital for a medical imaging procedure.
A common scenario for a child in the scanning room
is that the child may have a team of several
professionals around, such as the technologist, nursing staff, doctors, parents and EPT could all be
present at the same time or coming and going
throughout a procedure. This can be extremely
overwhelming for the child and family along with
the staff, as each person tries to hold the attention of
the child and noise can also escalate leading to
heightened anxiety and confusion. Once the procedure has commenced there are expectations of what
the child needs to comply with for the scan to be
successful such as staying still, not talking, unable to
control their own bodys feelings, moving beds and
equipment. Once finished the child may have to wait
again in the waiting room, this may involve watching
families/staff come and go, as well as dealing with
what has just happened to them. Families often have
outpatient clinic appointments booked on the same day
with the referring doctor or possibly have more scans

141

booked on the same day. The childs coping ability may

be less resilient than earlier in the day. All these factors
impede on the child and familys experience for medical
imaging procedures. Once the child has finished their
hospital visit they have their journey home while
attempting to process what has happened to them.
Typical behaviors for children who are under stress or
in an unfamiliar environment is that regression may
occur. This can manifest in daily behaviors such as
wetting the bed, baby talk, being non attentive or
being frightened and withdrawn. By preparing children for their visit to a hospital or treatment the child
can have some control of their world and daily
experiences in a new and sometimes frightening
place. Through EPT involvement and explanation of
procedure with child focused props, families can be
talked through the process of what is required of a
scan or injection. Children and families learn coping
strategies and what role they can play in their care.
Families and children generally feel empowered after
these preparation sessions, having a better understanding of what is expected by all involved.
Preparation session with an EPT is preferred before
the date of the childs appointment, allowing unrushed time for the child and family to process the
information and have positive reinforcement at home.
The play therapist described her role in preparing and
assisting a child through the experience of a medical imaging
procedure as one to educate and empower children, families
and other members of the health team to decrease both short
and long term effects of pain, stress and emotional and
physical trauma associated with single or ongoing procedures
including general anesthetics, medical imaging and surgery.
A good outcome, according to the play therapist in the
interview, was when the child and others were so absorbed in
their roles that the conduct of the procedure fades into the
background:
Everyone works together, we gave the child a bit of
preparation, good distraction, other health team members
could focus on what they were doing. They can do their
thing, youre doing your thing, the nurse wasnt even
needed, she was hanging back which, again, is really
good. They know when to step in. The parents were
totally focused with doing the I spy (game of distraction
where children are encouraged to locate objects in a
book) [23] because Ive involved them in that, it was
done in a split second. The child didnt even know.
Preparing family members and assessing their readiness
and ability to cope with a procedure is a large part of the
EPTs work:

142

My decision about readiness of the child (to undergo

an MRI without a GA) is really based on how they
react and how they cope with what Im showing
them, so I try and ring up and get background
information if I can, with the family first, so Ive
got something to come in with.
The specific description of the play therapy role in the
context of other health team members also involved
recognizing the boundaries and limits of their roles and
how the process of teamwork can quickly dissipate if there
is not a clear understanding of roles and purpose among
team members. An important professional value articulated
by the EPT during the interview was the goal of achieving a
positive and empowering experience for the child and a
level of trust in their relationship. This extended to ensuring
the child associated a positive experience with the EPT.
When this professional goal was not shared by other team
members, who had concerns about achieving an outcome or
were aware of time pressures, the EPT was required to
recalibrate her own professional values involving a particular type of relationship with the child, with values held by
other members of the health team. In the following quote,
the play therapist indicates some uncertainty about joining
with other team members if that role involved being part of
a potential negative experience for the child:
I have issues with my own boundaries of, if youre in
a procedure and I might be holding a childs arm,
resting and then the child starts to struggle and your
hands theredo I clamp my hand down or do I not
clamp my hand down because I dont want to be seen
in my role as part of this procedure going really badly,
I dont want to be involved but when do I walk away?
I cant leave the child
And when do you say stop? As a play therapist, how
much power do you have to say, really, this cannot go
on, this needs, I think we need time out for all
involved and sometimes Ive been able to do that
because Ive built up that relationship here but if its
someone that you dont know or if youre in a
different area, thats say once off, you dont have that,
you dont feel empowered enough to do that so
therefore youre going to harm the child through their
participation in this experience.
This example also highlights the challenges of, on the
one hand, drawing from ones own individual professional
values to dictate and shape practice and find a moral
solution, and on the other hand, of finding a collaborative
solution that can integrate differing ethical and clinical
values. Such challenges are magnified when there are
hierarchical professional team structures that result in

Pediatr Radiol (2012) 42:139146

different levels of power and authority. These are often

invisible but keenly felt by those professionals who are
adjunct or allied to the key diagnostician or technician. If
the EPT decided to stop, they may also influence parents
willingness to continue with the procedure. This may be
interpreted by others on the team as an unnecessary
disruption to the wider clinical goal to obtain good quality
images or to complete a procedure. Other members of the
health team may argue that the best interests of the child are
served by pressing ahead with the procedure and completing the imaging, e.g. so that an important diagnosis can be
obtained or treatment commenced.
The point of contention here is the interpretation of best
interests as an immediate clinical and diagnostic goal
related to the procedure, or as a longer-term goal of
empowering the child and minimising their anxiety for this
and future diagnostic imaging events. Both interpretations
of best interests are ethically valid. The dilemma is in
deciding, in a time-pressured clinical moment, whose
interpretation and perspective matters. From an ethical
perspective, this decision requires identification and then
consideration of how to minimize harms and maximize
benefits arising from each possible interpretation of the
possible actions and responses.
The EPT alluded to these differing interpretations when
she suggested a poor outcome was more likely when there
was a degree of unfamiliarity among other members of the
team or a level of misunderstanding about timing of
interventions or professional roles:
I find that if things dont go well it is either because I
havent worked with particular nurses or doctors
before and they dont understand my role, or its
something that theyve asked me to come in ad hoc
and when you come it is too late? [after the
examination has already started] and you might
already have a distressed child.
A key feature to emerge from this description of the
conduct of a medical imaging procedure is the need for
each health team member and the childs parents to
collaborate to reduce the childs anxiety prior to and during
the procedure. Such health team dynamics are complicated
by the nature of a pediatric hospital environment as a
complex setting involving teams of different disciplines,
separate departments that specialize in particular procedures
and conditions, and a range of organizational and departmental cultures and boundaries. This results in fluid
formations of different combinations of disciplines to
achieve particular treatment and management outcomes.
Viewing this environment through an ethical lens means
seeing each health professional, acting as a moral agent,
having a particular discipline-based view of their obligations to the child and family, based on their specialized

Pediatr Radiol (2012) 42:139146

knowledge and skills, of what is best for the young child. If

the ethical perspective is widened to include the ethics of
interprofessional collaboration, the scope of moral obligations expands for each team member to include the need to
understand the skills and expertise of others and more
specifically, as described by Edwards [4, 22], a need to
develop capacities to work with the expertise that others
offer. Understanding others perspectives necessarily begins
with a level of certainty and agency concerning ones own
professional goals, skills and responsibilities. This type of
reflection about practice takes time and a commitment to
understanding and responding to competing or alternative
professional goals. For EPTs, this means taking responsibility for adequately preparing and informing children and
their parents. It also means actively developing professional
relationships and providing resources and education to
other members of the health team. In a clinical pediatric
radiology setting, moral agency is understood as individuals
acting responsibly and professionally in their own work, in
addition to actively developing a web of interconnectedness
with others [24].
An added complexity in the pediatric setting is the
reliance on parental participation [25]. Parents bring their
own perspectives and values of what is in the best interests
of their child based on their experience of caring for the
child at home [2629]. This may include their own
anxieties about their personal hospital experiences with
procedures, e.g. if they are needle phobic or have had
their own bad scan experience.
Our analysis of this complex, dynamic and fluid
environment led to the analogy between the function of a
health team including parents in a pediatric imaging setting
and the collaborative and careful listening and awareness of
each musicians role in a chamber ensemble. In both
settings, each person has an important and specific role to
contribute to achieve the overall quality of the sound/
experience. Importantly, each person in a chamber ensemble does not need to know how to play other instruments,
but they do need to be aware of how to integrate their own
sound with others for an agreed musical quality and
outcome. This type of collaboration, applied to pediatric
imaging, has implications for how parents can be involved,
including the significance of prior education to enhance
their successful collaboration with the health team.
The EPTs vision and overriding goal was to place the
childs developmental age and associated needs as the
overriding procedure quality to be achieved. To achieve
this, there was a need to be aware of the clinical goals and
contributions of each of the team members and, to use their
skills to complement the skills of other team members, to
ensure contributions (including the dynamics and the
timing) from each of the health professionals and the
parents worked towards the overriding goals and outcomes

143

for the child. One key difference between the controlled

environment of a chamber ensemble interpreting a piece of
music and the hospital environment is the unpredictable
nature of the pediatric practice setting where time,
diagnostic and logistical pressures and constraints add a
layer of complexity and urgency to team functioning.
When one member of the ensemble is off key, the role of
the EPT was described as a refocusing of the participants
energies to the overall purpose:
Its really difficult when parents anxieties are coming
out and their concerns are coming out and they say,
for example, I really dont like to look at blood, and I
am thinking, actually were not talking about blood,
were focusing on the boyso that is very difficult. I
find that challenging because youre trying to also redirect the parent and get them to cope, to support their
child who is having a procedure done or an IV that
youre so close to finishing but the parents are going
on a tangent so, ethically, Im with that child or meant
to be advocating for the child but you still have that
parent that youre meant to be supporting and getting
through that as well, and where and when do you say
stop to them.
The chamber ensemble analogy recognizes that each
player needs to watch the others, responding accordingly to
changes in tempo and expression. This requires a strong
sense of professional identity, agency and confidence from
each member within the group, whilst at the same time,
knowing enough about the expertise of others to achieve a
cohesive approach:
So in medical imaging, I know when to step in
because theyll look at me and give me a nod of []
we need you now, or I know by their actions that
they dont need me at all, theyre handling the
situation really well so I just step back. So its about
that give and take that you dont own what you do
as a play therapist. You want to be able to give those
skills across to other colleagues so that when youre
not there, theyre utilising it and I think you need to
respect it enough that if somethings going well, you
dont need to jump in.

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

144

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

Pediatr Radiol (2012) 42:139146

focused on the positioning and accuracy of the image, and

the doctor may be focused on the clinical outcome.
Working relationally means recognizing, understanding
and combining different perspectives to achieve an expanded but realistically achievable goal of an accurate image
and a positive experience for the child.
Clarke and colleagues [18] suggest that a conceptual
framework for understanding ethical dimensions of interprofessional teamwork needs to include overriding principles in addition to attending to established forms of
knowledge, patterns of behaviour and procedures to be
followed. Effective teamwork that has the needs of the child
as its central focus requires principles and practices that
apply not only to individual health professionals, but also
include the function of the team and the role of the
organization in supporting and promoting the work of the
team. Edwards [4] describes six specific changes in
practices required to achieve relational agency in professional team collaborations:
1. Focusing on the child in the wider context to enable a
wider view of accumulated risk and development of
both short- and longer-term goals.
2. Having a clear purpose of the work and being open to
alternatives including discussions about purposes and
implications of actions to help practitioners recognise
and cross professional boundaries.
3. Understanding ones own professional values as a basis
for negotiating practices with other professionals.
4. Knowing how to know who or how to access other
specialist knowledge, expertise and systems.
5. Adopting a principled or pedagogical stance to be
explicit about ones own professional values and
methods.
6. Being responsive and open to fellow professionals and to
the goals and expertise of patients (children and parents).
In practical terms, these types of changes require team
members to establish collaborative communication among
each other and with parents, and to develop strategies to
acknowledge and resolve conflicting goals and agendas.
This may involve developing guidelines of collaborative
practice to enable each person to have a sense of how their
role relates to others, to ensure there is some consistency of
language and processes among team members and to
establish procedures for involving appropriate members of
the health team to prepare and inform children and their
parents prior to and during medical imaging procedures.
This type of collaboration should encompass evidencebased techniques for minimising a childs discomfort [610,
15, 16]. It also requires the organization to be committed to
learning from past and present practices, to create and
develop tools for collaboration and to devise processes and
clinical procedural pathways for knowledge sharing [4].

Pediatr Radiol (2012) 42:139146

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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