the meaning of critical thinking in diagnostic radiography

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The meaning of critical thinking in diagnostic radiography

Affiliations.

1 Department of Allied Health Professions, Midwifery and Social Work, School of Health and Social Work, University of Hertfordshire, UK. Electronic address: [email protected].
2 School of Education, University of Hertfordshire, UK. Electronic address: [email protected].
3 School of Education, University of Hertfordshire, UK. Electronic address: [email protected].
PMID: 34261613
DOI: 10.1016/j.radi.2021.06.009

Introduction: The development and application of critical thinking skills is a requirement and expectation of higher education and clinical radiographic practice. There is a multitude of generic definitions of critical thinking, however, little is understood about what critical thinking means or how it develops through a course. Diagnostic radiography students struggle with demonstrating this skill to the desired expectation, and, in higher education it is assumed that students have an implicit understanding of what is required in relation to this expectation. This study explores radiography students' understanding and perceptions of the meaning of critical thinking in diagnostic radiography.

Methods: The research framework sits within the interpretive paradigm and was designed as a longitudinal study conducted over a three-year study period. Semi-structured face-to-face interviews were employed as the means of gathering context-rich information from diagnostic radiography students (n = 13) who were purposively selected to participate in the study.

Findings: Three themes were constructed following the analysis and interpretation of the interview data. The themes were logical thinking involving analysis and evaluation, the process of decision-making, and reflection and metacognition.

Conclusion: As participants progressed from year one to year three, they recognised that critical thinking comprised not only of cognitive skills but affective skills too. They attributed their developing understanding of the meaning of critical thinking to clinical placement learning, understanding written feedback, and the expectations of professional practice. Based on these findings a definition of critical thinking applicable to diagnostic radiography was developed.

Implications for radiography education and practice: Understanding the meaning of critical thinking in relation to academic requirements and clinical placement learning is essential for diagnostic radiography students if they are to succeed in both settings.

Keywords: Cognitive skills; Critical thinking; Decision-making; Radiography; Reflection.

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DOI: 10.1016/j.radi.2021.06.009
Corpus ID: 235908378

The meaning of critical thinking in diagnostic radiography.

A. Ramlaul , D. Duncan , J. Alltree
Published in Radiography 11 July 2021
Medicine, Education

5 Citations

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Published: 24 May 2023

Embracing critical thinking to enhance our practice

Luis Martí-Bonmatí ORCID: orcid.org/0000-0002-8234-010X 1

Insights into Imaging volume 14 , Article number: 97 ( 2023 ) Cite this article

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Miguel de Cervantes, the great Spanish writer, once wrote that those “who read much and walk much, go far and know much" [ 1 ]. The same is true in medicine; reading and gathering experience are the main pillars on which one should develop the knowledge of solving clinical problems in the ever-changing field of healthcare. If properly done, these newly acquired skills will continuously enhance our critical thinking strategies with which we try to identify the best possible improvements in the clinical pathway of radiology. As gaps in knowledge are always present, medicine is rooted in consolidated knowledge based on validated scientific studies and clinical experience reproducibility and accuracy [ 2 ]. This represents our best approach to evidence-based decisions. Medical knowledge must be well-established before it can be considered as the basis for decision making and patients guidance in daily practice.

The practice of critical thinking helps us understand the disease manifestations and the related processes and actions that might be relevant to prevent, diagnose and treat diseases. To critically appraise the way we perform evidence-based practice, we must combine best quality research with clinical expertise. This link between exploration and practice will allow radiologists and related disciplines to impact the way medicine is practiced.

These concepts are the cornerstones of Insights into Imaging , and it is my privilege as editor-in-chief to describe in this editorial how the journal, and each author, can contribute quality through critical thinking, and hence improve the way we practice radiology by re-shaping our understandings.

It is universally recognized that, in medical imaging, strong levels of evidence are needed to assess the results of the different possible actions and to guide decisions (i.e., to demonstrate a sufficient causal relationship between a specific diagnostic criterion and a disease grading, or a given radiological intervention versus another option in a given condition) toward the most effective or safe outcome considering the benefit of patients and value-based healthcare pathways. Consequently, solid levels of evidence are required to assess the results of different possible actions derived from imaging findings. And, in doing so, we continuously generate more data in our diagnostic and therapeutic activities, whether they are processes or outcomes. This new information will then be transformed into new evidence, real world evidence. In this way, the observed relationship between action and outcome generates causality course actions that will improve our understanding of the best clinical pathways, eliminating the many confounding thoughts that we unconsciously carry during the process of learning and implementing our clinical practice.

Socratic inquiry and Skepticism as foundation. Critical thinking can be understood as the process of analyzing and questioning existing and established knowledge with the intention of improving it. Previous knowledge, either eminence- or evidence-based, should continuously be critically reconsidered and reevaluated for the benefit of the patients, as knowledge is always changing in Precision Medicine. In the real world of medical imaging, this critical thinking must be focused on the evaluation of the effectiveness and clinical impact of all those processes in which images are involved, from the acquisition with different modalities to the processing of the data, from the biological correlation of radiomics as an image biomarker to the therapeutic orientation, and finally in image-guided interventional treatments. Developing critical thinking helps to improve any medical discipline by asking ourselves how to establish better and more precise processes based on existing accumulated evidence, how to recognize and control the biases when approaching a clinical problem, and how to adapt the new clinical information in service of the best solutions. Socratic inquiry and a skeptic attitude can be used to consolidate the best knowledge and construct new associations to be more efficient and to approach excellence in our daily work. Critical thinking is therefore necessary to improve both clinical practice and research in radiology, avoiding disruptive uncertainties and wrong assumptions.

These “questioning and solving” skills require learning, practice, and experience [ 3 ], but mainly a recognition of the many uncertainties we do have despite the important scientific advances. Precisely, a good example of the importance of critical thinking is its contribution to Precision Medicine through medical imaging data and information. In daily practice, we should ask ourselves why should we accept a reliable diagnostic method that fails 15% of the time, or an appropriate treatment that is not effective in almost 25% of patients? As scientists, we can improve these clinical decisions in the daily practice. Artificial intelligence (AI) solutions integrating different imaging, clinical, molecular, and genetic data as inputs are being implemented as a suitable pathway to solve clinical problems. The design and methodology of these AI algorithms must allow for their explainability and critical thinking evaluation before they are implemented in clinical practice [ 4 ].

In summary, critical thinking develops evidence-based knowledge, provides continuous improvements, and avoids spurious technical and clinical misconceptions. Insights into Imaging is dedicated to manuscripts with a clear critical approach, focusing on excellence in clinical practice, evidence-based knowledge and causal reasoning in radiology. Science is based on long-lived critiques and authors are encouraged to systematically identify, analyze, and solve problems by identifying inconsistencies and correcting errors.

To foster this, Insights into Imaging welcomes critical thinking papers and will incorporate a new “Critical Relevance Statement” in all their publications, where authors are asked to summarize in one sentence the question they are trying to answer and the improvement they are providing to the issue at hand.

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De Cervantes M (1986) The adventures of don Quixote de la Mancha. New York, Farrar, Straus, Giroux

Martí-Bonmatí L (2021) Evidence levels in radiology: the insights into imaging approach. Insights Imaging 12(1):45. https://doi.org/10.1186/s13244-021-00995-7

Article PubMed PubMed Central Google Scholar

Ho YR, Chen BY, Li CM (2023) Thinking more wisely: using the Socratic method to develop critical thinking skills amongst healthcare students. BMC Med Educ 23(1):173. https://doi.org/10.1186/s12909-023-04134-2

Cerdá-Alberich L, Solana J, Mallol P et al (2023) MAIC-10 brief quality checklist for publications using artificial intelligence and medical images. Insights Imaging 14(1):11. https://doi.org/10.1186/s13244-022-01355-9

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To the Insights into Imaging ’s Office for their help in preparing this editorial.

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Medical Imaging Department and Biomedical Imaging Research Group, Hospital Universitario y Politécnico La Fe and Health Research Institute, Valencia, Spain

Luis Martí-Bonmatí

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Martí-Bonmatí, L. Embracing critical thinking to enhance our practice. Insights Imaging 14 , 97 (2023). https://doi.org/10.1186/s13244-023-01435-4

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DOI : https://doi.org/10.1186/s13244-023-01435-4

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An exploration of the meaning and development of critical thinking in diagnostic radiography

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The purpose of this study was primarily to explore the conceptualization of critical thinking development in radiologic science students by radiography program directors. Seven research questions framed three overriding themes including 1) perceived definition of and skills associated with critical thinking; 2) effectiveness and utilization of teaching strategies for the development of critical thinking; and 3) appropriateness and utilization of specific assessment measures for documenting critical thinking development. The population for this study included program directors for all JRCERT accredited radiography programs in the United States. Questionnaires were distributed via Survey Monkey©, a commercial on-line survey tool to 620 programs. A forty-seven percent (n = 295) response rate was achieved and included good representation from each of the three recognized program levels (AS, BS and certificate). Statistical analyses performed on the collected data included descriptive analyses (median, mean and standard deviation) to ascertain overall perceptions of the definition of critical thinking; levels of agreement regarding the effectiveness of listed teaching strategies and assessment measures; and the degree of utilization of the same teaching strategies and assessment measures. Chi squared analyses were conducted to identify differences within each of these themes between various program levels and/or between program directors with various levels of educational preparation as defined by the highest degree earned. Results showed that program directors had a broad and somewhat ambiguous perception of the definition of critical thinking, which included many related cognitive processes that were not always classified as attributes of critical thinking according to the literature, but were consistent with definitions and attributes identified as critical thinking by other allied health professions. These common attributes included creative thinking, decision making, problem solving and clinical reasoning as well as other high-order thinking activities such as reflection, judging and reasoning deductively and inductively. Statistically significant differences were identified for some items based on program level and for one item based on program director highest degree. There was general agreement regarding the appropriateness of specific teaching strategies also supported by the literature with the exception of on-line discussions and portfolios. The most highly used teaching strategies reported were not completely congruent with the literature and included traditional lectures with in-class discussions and high-order multiple choice test items. Significant differences between program levels were identified for only two items. The most highly used assessment measures included clinical competency results, employer surveys, image critique performance, specific course assignments, student surveys and ARRT exam results. Only one variable showed significant differences between programs at various academic levels.

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Published: 22 August 2024

Complementary use of cardiac magnetic resonance and 18 F-FDG positron emission tomography imaging in suspected immune checkpoint inhibitor myocarditis

Jieli Tong 1 , 3 ,
Nikolaos Vogiatzakis 1 ,
Maria Sol Andres 1 ,
Isabelle Senechal 1 ,
Ahmed Badr 1 ,
Sivatharshini Ramalingam 1 ,
Stuart D. Rosen 1 ,
Alexander R. Lyon 1 &
Muhummad Sohaib Nazir 1 , 2

Cardio-Oncology volume 10 , Article number: 53 ( 2024 ) Cite this article

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Immune checkpoint inhibitor (ICI) myocarditis is an uncommon but potentially fatal complication of immunotherapy. Cardiac imaging is essential to make timely diagnoses as there are critical downstream implications for patients.

To determine the agreement of cardiac magnetic resonance (CMR) and 18 F-fluorodeoxyglucose Positron Emission Tomography (FDG-PET) in patients with suspected ICI myocarditis.

Patients with suspected ICI myocarditis, who underwent CMR and 18 F-FDG-PET imaging at a single cardio-oncology service from 2017 to 2023, were enrolled. CMR was performed according to recommended guidelines for assessment of myocarditis. 18 F-FDG-PET imaging was performed following 18 h carbohydrate-free fast. Imaging was analysed by independent reviewers to determine the presence or absence of ICI myocarditis.

Twelve patients (mean age 60 ± 15 years old, 7 [58%] male) underwent both CMR and 18 F-FDG-PET imaging. Three (25%) met the 2018 Lake Louise Criteria for CMR diagnosis of myocarditis; 4 (33%) had evidence of myocardial inflammation as determined by 18 F-FDG-PET. Amongst those with positive 18 F-FDG-PET, mean standard uptake value (SUV) was 3.5 ± 1.7. There was agreement between CMR and PET in 7 cases (CMR and PET positive ( n = 1), CMR and PET negative ( n = 6)) and discordance in 5 cases (CMR positive and PET negative ( n = 2), CMR negative and PET positive ( n = 3)).

Both CMR and PET provide complementary clinical information in diagnostic of ICI myocarditis. CMR informs on myocardial oedema, whilst 18 F-FDG-PET provides information on glucose metabolism reflecting monocyte and lymphocytic activity. Future studies should investigate the role of hybrid PET-CMR for the timely diagnosis of ICI myocarditis.

Introduction

Immune checkpoint inhibitor (ICI) therapy has revolutionised the management of several cancers [ 1 ]. Despite the clinical effectiveness of these therapies, there are associated immune-mediated adverse events (ir-AEs) which can involve multiple organs. Cardiovascular manifestations include accelerated atherosclerosis [ 2 ], and myocarditis which has an estimated incidence of 1–2% [ 3 ] but reported fatality rate of 25 to 40% [ 4 , 5 ]. Increasingly, milder elevation of troponin levels has been associated the use of ICIs [ 6 , 7 ]. Given the severity of this complication and impact on downstream therapeutic decisions, timely diagnosis is essential in order to guide subsequent clinical management.

Recently published guidelines recommend the diagnosis of ICI myocarditis with pathohistological or clinical methods [ 8 ]. Cardiac imaging in the form of echocardiography and cardiac magnetic resonance imaging (CMR) are the recommended imaging modalities in the diagnosis of ICI-associated myocarditis [ 8 ]. However, clinical studies have demonstrated intermediate diagnostic performance of CMR in the diagnosis of ICI myocarditis using the 2018 modified Lake Louise criteria [ 9 , 10 ]. 18 F-fluorodeoxyglucose (FDG) positron emission tomography (PET) imaging is a highly sensitive imaging test for the detection of inflammatory heart disease such as sarcoidosis and myocarditis [ 11 , 12 ]. 18 F-FDG PET imaging has been used in the diagnosis of ICI myocarditis with varying results [ 13 ], and could identify patients with early stage disease in case reports [ 14 , 15 ]. Current international guidelines do not recommend PET in the diagnostic workup [ 8 , 16 ].

Data on both CMR with 18 F-FDG PET imaging in the diagnosis of ICI myocarditis is lacking. The purpose of this study was to investigate the role of both modalities in the diagnosis of ICI myocarditis, and determine diagnostic agreement between CMR and 18 F-FDG PET imaging in patients with suspected ICI myocarditis.

Study design and population

In this retrospective, single-centre observational cohort study at Royal Brompton Hospital, cancer patients with suspected ICI myocarditis, and had partially met the 2022 ESC Cardio-Oncology Guidelines’ [ 8 ] definition of ICI myocarditis, were enrolled. Patients were included in the study if they were 18 years old and above, were currently receiving ICI therapy for the treatment for cancer, and had both CMR and 18 F-FDG PET imaging performed in the diagnostic process of ICI myocarditis between January 2017 and April 2023. The study was approved by the institutional review board at Guy’s and St Thomas Hospital National Health Service Foundation Trust and the United Kingdom Health Research Authority.

Definitions and data collection

Patients were identified if they met the inclusion criteria. Patients’ demographics including age and gender, and modifiable cardiovascular risk factors were captured. Cancer-specific variables such as type of primary malignancy and ICI received, and date of commencement were included. Corresponding clinical data including cardiovascular (CV) symptoms, cardiac biomarkers, electrocardiogram (ECG) readings were obtained to accurately phenotype the patients.

CMR imaging was performed on a 1.5T or 3T magnet including ECG gating, breath-holding, using recommended guidelines [ 17 ]. Following localising scans, long axis 2, 3 and 4 chamber and short axis images of the left and right ventricle were obtained. Exam protocols included cine balanced steady state free precession imaging for left ventricular functional and mass assessment and T2-weighted imaging employing either T2 short tau inversion recovery or spectral attenuated inversion recovery techniques. Pre-contrast T1 and T2 maps were performed, and T1 and T2 values were measured. Late gadolinium enhancement (LGE) images were performed 10 to 15 min after a gadolinium-based contrast agent. The CMR images and data were interpreted by experienced cardiologists who was accredited by the SCMR and/or EACVI and reviewed again by an independent reader. CMR findings were reported in line with recommendations for reporting CMR scans [ 18 ].

18 F-FDG PET

Patients were instructed to take low-carbohydrate, high-fat, high-protein diet for 24 h followed by a minimum of 6 h fasting before PET scan examinations according to previously published cardiac FDG-PET/CT guidelines [ 19 ]. 250 MBq of FDG was administered intravenously and imaging was acquired 60–90 min following injection. The scans were performed on an integrated whole-body PET system (GE Discovery ST 4, GE Healthcare, Amersham, UK) and 3D list mode data was acquired with ECG gating as a dedicated Cardiac PET-CT scan to assess for myocardial inflammation. A low-dose CT was acquired for attenuation correction. Standardized uptake values (SUV) were obtained in the regions were obtained. The images were read by an experienced radiologist, and reviewed again by an independent radiologist who was blinded to the clinical data of the patients.

Statistical analysis

Continuous data were tested for normality with the Shapiro-Wilk test. Normally distributed continuous data are presented as mean ± standard deviation (SD) while non-normally distributed continuous data are presented as median. A P -value < 0.05 was considered significant. Analyses were performed with IBM SPSS Statistics for Windows, version 23.0 (IBM Corp., Armonk, N.Y., USA).

Patient characteristics

Twelve patients who fulfilled the inclusion criteria were identified from the centre’s Cardio-Oncology registry. This cohort had a mean age of 60 ± 15 years old and 58% were male (Table 1 ). All patients had metastatic disease with a range of primary malignancies including melanoma ( n = 2), urological ( n = 2), colorectal ( n = 2), and renal, breast, gynaecological, lung, head and neck cancers, and sarcoma (1 case each) (Table 1 ). All patients were receiving either single or dual ICIs when ICI myocarditis was suspected. The most common ICI were Programmed Cell Death Protein-1 (PD-1) inhibitors such as Durvalumab, Nivolumab and Pembrolizumab ( n = 9). Cytotoxic T lymphocyte associated protein-4 (CTLA-4) inhibitor Ipilimumab ( n = 5) and Programmed cell death ligand-1 (PD-L1) (Enfavolimab and Atezolizumab ( n = 3)), and Relatimab, a Lymphocyte activation gene-3 (LAG-3) inhibitor ( n = 1). Combination ICI with Nivolumab and Ipilimumab were used in 4 instances (Table 1 ). The median number of days between CMR and PET imaging was 10 (6.5–42.5) days. Corticosteroid therapy was not initiated before CMR or PET imaging and were only initiated after both scans were performed.

Cardiovascular (CV) symptoms, electrocardiogram (ECG) and blood test results

All of the patients in this study were clinically stable and did not require emergent treatment. Half of the patients ( n = 6) were asymptomatic on presentation. Three of these patients had asymptomatic elevation of cardiac biomarkers, 1 patient had new onset pericardial effusion on echocardiogram, and 1 other patient had an incidental decline of left ventricular ejection fraction on echocardiogram. Amongst those with symptoms, 3 patients presented with heart failure symptoms, 2 patients had arrhythmias, and 1 had recurrent syncope. Three of the cases had abnormal ECG findings such as premature ventricular complexes and/or new T-wave inversion. Three (25%) had sinus tachycardia. More than one third of the cases had an elevated high-sensitive troponin I (hs-Trop I) or Troponin I levels. The mean hs-Trop I was 41 ± 52ng/L and the mean Troponin I level was 17 ± 7ng/L (Table 1 ). Coronary cause for troponin elevation was excluded with the use of computed tomography imaging of the coronary arteries (CTCA) in 2 out of the 5 patients with elevated troponins, and there was no evidence of acute coronary syndrome in these cases. All of the cases had an elevated B-type Natriuretic Peptide (BNP) or N-terminal pro B-type natriuretic peptide (NT-proBNP) level. The mean BNP was 122 ± 96ng/L (Table 1 ).

Amongst those without an elevated troponin ( n = 7), there was a suspicion of ICI myocarditis in 4 of the patients who had CV symptoms (palpitations, syncope and heart failure) while receiving ICIs. The remaining 3 patients were asymptomatic but had a decline of LVEF, development of pericardial effusion, or isolated elevated BNP levels, thus prompting the managing physicians to suspect ICI myocarditis (Table 1 ). Details of each patient’s CV symptoms are listed in greater detail under the Supplementary Material section.

CMR findings

The mean indexed left ventricular end diastolic volume (LVEDV), left ventricular end systolic volume (LVESV), mass, and left ventricular ejection fraction (LVEF) were 86 ± 21ml/m 2 , 42 ± 20ml/m 2 , 76 ± 22 g/m 2 and 56 ± 11% respectively. The mean right ventricular end diastolic volume (RVEDV), right ventricular end systolic volume (RVESV), right ventricular ejection fraction (RVEF) were 83 ± 20ml/m 2 , 38 ± 17ml/m 2 and 58 ± 9%, respectively. Three (25%) of the patients had myocardial oedema demonstrated on T2-STIR imaging. Trivial to moderate pericardial effusion was seen in 5 of the patients. In 1.5 Tesla (T) studies, 5 patients had an elevated native T1 while 3 patients had an elevated native T2. The mean native T1 was slight elevated at 1074 ± 44ms (normal 975-1065ms), and T2 values were at the upper limit of normal with 54 ± 5ms (normal < 55ms). There was a significant difference in myocardial T1 values between CMR negative and positive cases (1065 ± 19ms vs. 1086 ± 19ms, p = 0.03). However, no significant difference was seen between the 2 groups for T2 values (52 ± 5ms vs. 56 ± 4ms, p = 0.87). Late gadolinium enhancement (LGE) was seen in 8 (67%) of the cases. The LGE pattern was seen in the mid-wall (4/8), followed by subendocardial (3/8) and subepicardial (1/8) (Table 2 ).

PET-CT findings

In all of the cases, there was sufficient myocardial suppression following dietary preparation. Four (33%) out of the 12 patients had 18 F-FDG PET findings positive for myocardial inflammation. The mean standard uptake value (SUV) amongst these positive cases was 3.5 ± 1.7 (Table 2 ).

CMR and PET-CT comparison

There was agreement between CMR and 18 F-FDG PET findings in 7 patients, where 6 patients did not meet the 2018 Lake Louise criteria for myocarditis and were also negative for myocardial inflammation on 18 F-FDG PET imaging. One patient had positive CMR and 18 F-FDG PET findings for myocardial inflammation. Discordance between the two imaging techniques were seen in 5 patients: 3 cases did not meet the CMR Lake Louise criteria for myocarditis but were positive for myocardial inflammation on 18 F-FDG PET; 2 cases met the CMR Lake Louise criteria but the respective 18 F-FDG PET scans did not demonstrate inflammation (Table 3 ).

In concordant positive study ( n = 1), the mean T1 and T2 values were elevated at 1102ms and 58ms respectively. Myocardial oedema was demonstrated on T2-STIR imaging and LGE was present. The maximum SUV on 18 F-FDG PET was 2.4 (Table 4 ). Amongst those with concordant negative studies, the mean T1 and T2 values were 1114 ± 23ms and 50ms respectively. There was no myocardial oedema demonstrated on T2-STIR sequence, although LGE changes were identified in all 6 studies (Table 4 ). Discordant studies which were positive for myocarditis in CMR, but negative on 18 F-FDG PET, had mean T1 and T2 values were 1078 ± 18ms and 55 ± 6ms respectively. Myocardial oedema on T2-STIR sequence and LGE were present in 1 case each (Table 3 ). Discordant studies ( n = 3) which were negative for myocarditis in CMR but positive on 18 F-FDG PET, had mean T1 and T2 valves of 1017 ± 24ms and 54 ± 8ms respectively. The mean maximal SUV in these cases was 6.2 ± 6.1. Myocardial oedema on T2-STIR sequence and LGE was detected in in 1 case each (Table 4 ).

Impact of imaging results on management

ICIs were stopped in patients who demonstrated myocardial inflammation on 18 F-FDG PET imaging. They were also treated with intravenous and subsequently oral steroids. Amongst those with negative studies on 8 F-FDG PET imaging, they were deemed not to have ICI myocarditis and did not receive steroidal treatment. This group of patients also continued on their cancer immunotherapy.

Cardiovascular immune related adverse events are uncommon but carry significant mortality and morbidity [ 20 ]. Diagnosis of myocarditis can be made through detection of early tissue responses in the form of myocardial oedema, vasodilatation and myocyte necrosis, and replacement fibrosis later on [ 21 ]. Endomyocardial biopsy (EMB) has been recommended as a gold standard in diagnosis with its ability to provide histopathological diagnosis [ 22 ]. While confirmatory when positive, EMB has a sensitivity of 45% for the diagnosis of myocarditis [ 23 ], and EMB is an invasive test with a small risk of serious complications [ 24 ].

In this study, we found important differences in CMR and PET for the assessment of patients with ICI myocarditis. One important aspect to consider for the interpretation of these findings is that CMR and PET evaluate myocardial inflammation in different approaches. CMR can be used to assess for myocardial oedema as a surrogate from inflammation, whereas PET assesses myocardial inflammation as a result of increased metabolic activity from cardiomyocytes with active inflammation.

CMR may be helpful in the diagnosis and monitoring of cardiovascular damage in cancer patients [ 25 ], and for the diagnosis of myocarditis or monitoring for disease progression. In the European of Society (ESC) 2022 Cardio-Oncology guidelines, CMR and echocardiogram had a Class I recommendation for the diagnosis of ICI myocarditis, and the 2018 modified Lake Louise criteria was a major criterion for its diagnosis in the guideline [ 8 ]. The strength of evidence for myocarditis was increased if myocardial oedema was present with markers of inflammatory myocardial injury on the CMR study [ 8 , 26 ]. The 2018 modified LL criteria outperformed the original criteria in the diagnosis of acute myocarditis with a significant improvement of sensitivity and specificity (88% and 96%) respectively [ 27 ]. These criteria require both the presence myocardial oedema seen on T2-weighted imaging, and that of fibrosis in T1, extracellular volume (ECV) and LGE imaging [ 28 ].

However, CMR findings in ICI myocarditis can be variable and less predictable [ 29 ]. There was lower rate of late gadolinium enhancement (LGE) and lower sensitivity of the Lake Louise criteria in ICI myocarditis than viral myocarditis [ 30 ]. In an international registry of patients with ICI myocarditis, elevated T2-weighted short tau inversion recovery (STIR) was only present in 28%, LGE was seen in 48% of patients, while 42% of the cases did not even have an abnormal T2-STIR or LGE [ 9 ]. Timing of when CMR was performed was also crucial to diagnosis. It was demonstrated in the same study that LGE increased from 22 to 72% ( P < 0.001) if the CMR was performed beyond day 4 of the onset of symptoms [ 9 ]. Myocardial characterisation with the use of parametric mapping has been found to aid in the diagnosis of ICI myocarditis. In another study of 136 patients with ICI myocarditis, abnormal T1 and T2 values were seen in 78% and 43% respectively, and T1 mapping had an impact on prognosis [ 10 ]. However, T1 mapping is non-specific and can be elevated by a variety of cardiac conditions that result in changes in the myocardial architecture [ 31 ].

18 F-FDG PET is increasingly used in the evaluation of myocarditis. Although its use is not recommended in the current guidelines for cardio-oncology [ 8 ], some studies have shown promising results in diagnosing other types of myocarditis. In one study, the sensitivity and specificity of PET was 74% and 97% compared to CMR [ 11 ]. 18 F-FDG PET could be considered as an alternative non-invasive imaging modality in stable patients with contraindications to CMR or in those with suspected concomitant systemic autoimmune disease [ 32 ]. However, 18 F-FDG PET imaging’s performance in ICI myocarditis is limited. In a study of 31 patients with treated suspected ICI myocarditis who underwent 18 F-FDG PET studies, there was low sensitivity and negative predictive value demonstrated, although the majority of patients had already been initiated on corticosteroid therapy which may have inadvertently blunted the FDG signal [ 13 ]. Attempts have been made with the use of novel tracers in PET studies to identify early ICI myocarditis. 68 Ga-DOTA(0)-Phe(1)-Tyr(3)-octreotide ( 68 Ga-DOTATOC) [ 33 ] and 68Ga-FAPI PET-CT [ 34 ] have been studied in small studies and shown to be useful in detecting inflammation in early stages of ICI myocarditis. Larger studies need to be performed to understand the clinical application in this this cohort of patients.

To our knowledge this is the first study to compare CMR and PET imaging for the diagnosis of ICI myocarditis. Whilst there was agreement in several cases, this study provides a signal that both CMR and 18 F-FDG PET-CT provide complementary information for the non-invasive diagnosis of ICI myocarditis. CMR allows for accurate assessment of morphology, function, and tissue characterisation by providing information on myocardial oedema and fibrosis [ 35 ]. Whereas PET-CT may provide quantitative assessment of myocardial inflammation. Combining the strength of both modalities may provide complementary clinical information in challenging cases. Future studies should consider hybrid PET-CMR imaging, which can provide complementary information in just a single scan, reduce the number of imaging studies needed, and allow for quicker diagnosis and treatment for patient in order to guide subsequent clinical management.

Limitations

The authors acknowledge the limitations of a small sample size, in a retrospective, single-centre cohort study. The small sample size reflects the rarity of myocarditis as a complication of ICI. We also note that endomyocardial biopsy was not performed in all of the cases. However, sampling errors can occur with use of EMB. An EMB is also an invasive procedure with the potential for complications. The benefits of an EMB in the diagnosis of ICI myocarditis in this cohort of largely asymptomatic patients with mild troponin elevation are questionable. Thirdly, the CMR protocols used in this cohort were heterogeneous. We agree that a standardised CMR protocol would have improved the accuracy in diagnosing myocarditis. Furthermore, since the patients underwent two distinct imaging tests, it is likely that there were some potential diagnostic challenges which may have introduced selection bias of the difficult cases into this study. Finally, the CMR and PET scans were not performed on the same day, which may have introduced biological variability into the findings presented.

Diagnosing ICI myocarditis is challenging, especially in cases with mild symptoms and biomarker elevation. Non-invasive imaging modalities are increasingly used in diagnosis. This is the first study to describe CMR and 18 F-FDG-PET in suspected ICI myocarditis, and it demonstrates the presence of some agreement between both modalities. This suggests that CMR and PET provide complementary clinical information in the diagnostic process. Larger studies will be required to test this hypothesis further, and also evaluate the role of hybrid PET-CMR imaging in the diagnosis of ICI myocarditis.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

Cardiac magnetic resonance

Cytotoxic T lymphocyte associated protein-4

Endomyocardial biopsy

High-sensitive troponin I

Immune checkpoint inhibitors

Immune related adverse event

Lymphocyte activation gene-3

Programmed Cell Death Protein-1

Programmed Cell Death ligand-1

18 F-fluorodeoxyglucose positron emission tomography

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Jieli Tong, Nikolaos Vogiatzakis, Maria Sol Andres, Isabelle Senechal, Ahmed Badr, Sivatharshini Ramalingam, Stuart D. Rosen, Alexander R. Lyon & Muhummad Sohaib Nazir

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Tong, J., Vogiatzakis, N., Andres, M.S. et al. Complementary use of cardiac magnetic resonance and 18 F-FDG positron emission tomography imaging in suspected immune checkpoint inhibitor myocarditis. Cardio-Oncology 10 , 53 (2024). https://doi.org/10.1186/s40959-024-00250-0

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J Med Radiat Sci
v.70(4); 2023 Dec
PMC10715334

A model to facilitate critical thinking of radiography students

Tracey pieterse.

1 Department of Anatomy and Medical Imaging, School of Medical Sciences, The University of Auckland, Auckland New Zealand

Annie Temane

2 University of Johannesburg, Johannesburg South Africa

Charlene Downing

Associated data.

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Introduction

Critical thinking is a much‐needed skill required by radiography students, across disciplines, when they graduate. The facilitation of critical thinking is a task that radiography educators are faced with in order to produce graduates who can apply these skills in the clinical setting, for the best care of the patient. The development of critical thinking skills is challenging, and currently there is no radiography‐specific model which has been implemented and evaluated as a framework of reference for radiography educators. The aim of this article is to present a critical thinking model as a framework of reference that was implemented and evaluated by diagnostic radiography educators.

A theory‐generating qualitative, exploratory, descriptive and contextual design was used for the development of a model to facilitate critical thinking skills of diagnostic radiography students in a South African setting.

A theory‐generation model to facilitate critical thinking skills for radiography students was developed. The model was implemented and evaluated by radiography educators. Three themes emerged from the evaluation of the model after implementation. The results indicated the implementation of the model provided a platform for radiography educators to collaborate and purposefully tailor activities to incorporate critical thinking into their teaching.

Conclusions

Through the implementation of the model, radiography educators felt empowered by using a framework of reference to facilitate critical thinking skills of radiography students.

Critical thinking is a much‐needed skill required by radiography students when they graduate. A theory‐generating qualitative, exploratory, descriptive and contextual research design was used for the development, implementation and evaluation of a model to facilitate critical thinking skills of diagnostic radiography students.

An external file that holds a picture, illustration, etc.
Object name is JMRS-70-369-g001.jpg

Internationally across health care, several studies report on the need to produce graduates with the ability to think critically. 1 , 2 Radiographers are required to actively use critical thinking skills to make sound clinical judgements, and the radiography curriculum falls short if it is not designed in such a way to instil these skills in the undergraduate years. 2 However, literature relating to critical thinking skills within radiography has indicated diagnostic radiography students' ability to think critically is below the desired level. 3 , 4 In addition, barriers to critical thinking persist throughout radiography student's clinical placement as students are trained in a protocol‐driven environment. 5 , 6 This results in poor critical thinking and clinical reasoning in the clinical environment and ultimately has a negative impact on the health outcomes of the patient 3 due to a reduction in the application of knowledge and limited clinical efficiency. 7

Educators are responsible for forming critical thinking skills of students during their student years. 8 This can be done through designing the curriculum by structuring teaching to include a wide variety of experiences that challenge learned knowledge and by creating tasks that are specifically aimed at developing critical thinking skills. 9 Therefore, in addition to knowledge, educators need to instil critical thinking skills to assist students to navigate a variety of clinical situations effectively. 10 Through this, students will be able to display critical thinking skills in the clinical environment for accurate clinical reasoning and to work effectively as part of the healthcare team for the best care of the patient. 11

Critical thinking is a challenging skill to master, 11 , 12 and there is no clarity on how educators teach it within the healthcare profession. 13 In addition, research on critical thinking in radiography is limited, 3 , 14 despite the vital need for these skills in the profession. 2 Although a number of critical thinking models exist in health care, there is a need for the implementation of a radiography‐specific model to facilitate critical thinking as the definition of critical thinking differs for each profession. 8 , 15 Radiography educators need to be empowered to incorporate critical thinking skills within the radiography curriculum. This will meet the needs of professional boards who require graduates to demonstrate critical thinking skills 2 as well as the healthcare team who relies on sound clinical decision‐making for the best care and outcome of the patient.

Problem statement

Radiography educators are tasked with the challenge of incorporating critical thinking into their teaching to transfer these much‐needed skills to radiography students. Currently, there is no specific model that has been implemented and evaluated as a framework of reference to facilitate critical thinking skills in diagnostic radiography education.

The aim of this article is to present a model that was developed and implemented as a framework of reference for diagnostic radiography educators to facilitate critical thinking skills of diagnostic radiography students.

Study design

A theory‐generating qualitative, exploratory, descriptive and contextual design was used in the study. 19 , 20 A model is a symbolic/diagrammatic representation of a theoretical relationship, achieved through words, pictures, diagrams, mathematical notation or physical structures. 21 The implementation of the model was evaluated using a phenomenological approach through a focus group discussion in May 2021. Thematic analysis of data took place through Tesch's descriptive method of open coding as described by Creswell & Creswell. 22

The ethical guidelines and research process were approved by the University of Johannesburg Research Ethics Committee and Higher Degree Committee (REC‐01‐116‐2016). The four pillars of bioethics, namely respect for autonomy, non‐maleficence, beneficence and justice 16 were adhered to throughout the research process.

Trustworthiness

Lincoln and Guba's model of trustworthiness was used to ensure credibility, transferability, dependability, confirmability and authenticity, respectively. 17 , 18 Credibility was ensured through prolonged engagement, persistent observation, triangulation and member checking. Dependability was ensured by providing a description of the research methodology, the code–recode method of data analysis, the use of an independent coder and an audit trail of the research process. Confirmability was achieved by ensuring reflexivity, using verbatim quotes, and an audit trail and authenticity was ensured through fairness by prolonged engagement, informed consent, member checking, reflexivity and the use of an independent coder.

The development of the model

The model (Fig. 1 ) was developed using the four steps identified from Chinn and Kramer's theory‐generation method. 20 The steps include a concept analysis, relationship statements, a description of the model and an evaluation of the model by a panel of experts. 20 By focusing on the identification and interpretation of critical thinking concepts within radiography, relationship statements were constructed, and a conceptual framework was created to assist in the development of the model for the facilitation of radiography students' critical thinking skills. For this study, critical thinking was defined as ‘the radiography student's ability to analyse, evaluate and problem‐solve in a clinical scenario in order to make a judgement based on evidence for the best outcome of the patient’.

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Object name is JMRS-70-369-g002.jpg

Model to facilitate critical thinking skills of radiography students.

A model to facilitate critical thinking skills of radiography students

The relationship phase.

The relationship phase is critical as the radiography educator and radiography student's relationship begins with a dynamic interactive process of engaging through the creation of a positive environment. The relationship phase of the model forms the foundation through the mobilisation of resources, mutual respect and trust and gives the radiography student confidence by empowering them. In the relationship phase the radiography student is provided with a safe learning environment that encourages active participation in classroom activities which are goal oriented through collaborative discussions, questioning and feedback.

The working phase

During the working phase, the radiography educator purposefully sets out a variety of learning activities to facilitate problem‐solving, reasoning and reflective skills of radiography students (Table 1 ), as they are exposed to learning new knowledge and link this to existing knowledge. Most of the facilitation is done during the working phase. Engagement occurs through a variety of teaching and learning activities purposefully set out by the radiography educator. These activities are carefully designed to promote problem‐solving, reasoning and reflection of radiography students. The activities will assist radiography students to think logically and make a judgement by analysing and evaluating evidence within context.

Activities used during the model implementation for the facilitation of problem‐solving, reasoning and reflection.

1. Facilitating problem‐solving through problem‐based learning.
1a) Simulation
1b) Using triggers
1c) Case studies
1d) Example‐problem‐based‐learning (EPBL) and Plan‐Do‐Check‐Act (PDCA).	:
2. Facilitating reasoning	,
2a) Metacognition	by considering:
2b) Inquiry‐based learning (IBL)
3. Facilitating reflection	which began with a shared starting point that triggered an opportunity for reflection and included the following steps as a guideline:

In the model (Fig. 1 ), as the radiography student progresses, guidance from the radiography educator is needed much less as the radiography student becomes more independent and self‐directed in the termination phase. The radiography student has developed the skills needed for problem‐solving, reasoning and reflection in the final phase, and this leads to the outcome of the model where the radiography student becomes a critical thinking radiography student before they graduate.

Results and Discussion

Due to COVID‐19 lockdowns, the activities in the working phase were adapted to be delivered in an online format using online teaching and learning software platforms, including simulation software. Limited opportunities existed during clinical placement visits to offer students face‐to‐face learning activities. The model was implemented and evaluated by radiography educators at a comprehensive university over three phases. Phase one took place immediately after a workshop informing participants of how the model should be implemented. Phase two of the evaluation took place after 1 month of implementation of the model, and phase three after 3 months of implementation of the model.

Six participants took part in the evaluation of the model implementation. This took place as a focus group discussion that was conducted online over Zoom. Table 2 summarises the demographics of the participants who took part in the model's evaluation after a full 3 months of implementation.

Focus group participants' demographics.

	Participants (P)
	P1	P2	P3	P4	P5	P6
Gender	Female	Female	Female	Female	Female	Male
Age	40	58	44	41	31	38
Highest qualification	Master's Degree	Master's Degree	Master's Degree	Master's Degree	Master's Degree	BTech Degree
Radiography education experience	14 years	15 years	8 years	4 years	3 years	2 years

The question asked of participants was ‘ How did you experience the implementation of the model to assist you in facilitating critical thinking skills of radiography students? ’

The central storyline which emerged after implementing the model was that it promoted a greater consciousness about teaching methods being underpinned by an educational philosophy. Online teaching posed challenges, but also great opportunities to encourage critical thinking in a creative and interactive way. Using different teaching methods to promote critical thinking is a disciplined process that should be scaffolded from the first year of study to the fourth year in radiography education.

Three themes emerged from thematic coding:

Theme 1: The model's implementation contributed to a greater level of consciousness about teaching methods already being underpinned by an educational philosophy
Sub‐theme A: When the model was implemented, participants became more conscious and reflective of their own teaching methods and engaged in peer collaboration

Participants found they were collaborating about their teaching approaches by discussing their various teaching approaches, creating teaching activities together and sharing their experiences with each other during team meetings and casual conversations. Participants also said they thought about their teaching approaches more carefully and purposefully, recognising what worked and what did not work well. Participants felt empowered when they realised the teaching methods, they were already using had a pedagogical underpinning. Pedagogical awareness enlightens educators about their teaching methods. This awareness allowed participants to evaluate their teaching approaches and refine their teaching methods.

With reflection, I did realise it's a lot of things we do already … but we don't necessarily know, we don't have that education background. (P3)

We actually do all these things, it's just that we didn't possibly have the right words or know that we were already implementing. (P5)

It is common for radiography educators with little to no educational background to take on academic teaching activities directly from a clinical environment. They rely on their professional experience and thus implement what is known as a “signature pedagogy”. 28 Säde‐Pirkko and Asko 29 confirmed that educators develop their teaching identity over time by constantly evaluating their teaching methods.

Participants felt they were consciously thinking about their teaching style. They considered how to purposefully change their teaching style and utilise the model to facilitate critical thinking.

I do this, but then I, after, after our session I'm like, how can they do this right. (P1)

I give them topics … and they [students] had to think about how to bring across the justification of why you would do this modality over that one and all those kind of things. (P2)

The model provided a platform to create a positive environment and improve relationships with radiography students. Open conversations enabled radiography students to feel comfortable enough to share thoughts and ideas during classroom discussions.

I really was interested to know how they [students] were … the ones that told me how they were, now I noticed on the online platform. They are the ones that put up their hands or say something, because they feel they can talk to me. (P1)

I think something that um, made the relationship better was ‐ when you share things, mistakes you've made or things that you've done, then all of a sudden they're like ‘oh right, right’ … ‘oh they're humans’ and we're [radiography educators] also radiographers … that sharing of experiences makes it a stronger relationship. (P2)

Educators contributing their own personal stories and clinical experiences make the classroom authentic as part of a sharing culture to foster engagement, mutual respect and trust. 30 Collaborative conversations enable students to feel comfortable enough to share thoughts and ideas. 5 Students who have a positive relationship with the educator are more motivated and therefore have higher educational aspirations and better academic success through intellectual development. 31

Sub‐theme B: Adjustments to teaching and learning methods encouraged critical thinking and problem‐solving competency

Participants found themselves purposefully designing activities with careful thought. Participants used questioning as a way to encourage radiography students to think critically and justify their thinking.

I phrase questions differently – just changing the questions alone, I think it makes them think about different aspects. (P3)

They [students] would ask a question … and we would respond with a question … but then after a while, I think they [students] enjoyed us asking them question upon a question, because then the the one even said “oh thank you for telling me I went and read that up” (P1)

Quality thinking is encouraged when students become self‐directed to find their own answers to questions, guided by the facilitator. 32 This teaching method helps students become creators of knowledge rather than consumers of knowledge, promoting their problem‐solving and critical thinking skills. 33

Participants used the model as a guide to give radiography students more responsibility in their learning, by assigning them teaching and learning activities. A variety of tasks were used to improve radiography students' engagement during teaching sessions.

I assign the students that are going to be giving tuts [tutorials] to us. (P6)

I tried role‐play … I have been trying flipped class … [when] it's one of them [students] presenting then they tend to be able to ask more questions. They tend to not be afraid to try and respond when the student is asking questions. (P4)

According to Theobald et al., 30 a knock‐on effect of student engagement is an improvement in graduate outcomes by encouraging class attendance and participation. Students find collaborative engagements conducive to learning and help increase their understanding, encouraging inclusiveness in the cohort. 34

Participants used questioning techniques to motivate radiography students to think about their answers and the justification behind their answers. This led to radiography students taking more responsibility for their learning and becoming reflective and independent thinkers.

I always ask them “so what does it mean? So you've written it, but what does it mean?” For example, like central ray or anode heel effect, but what does it mean to you … practically what does it mean to you … (P5)

Questioning techniques are associated with increased student motivation as students take charge of their learning by taking responsibility and becoming authors of their answers. 35 This approach to teaching assists students in developing their own understanding through knowledge discovery and interaction, which fosters independent learning. 28

Theme 2: Online teaching posed challenges, but also great opportunities to encourage critical thinking in a creative and interactive way

Multiple challenges were faced in teaching online during the COVID‐19 pandemic, but participants used them to develop new teaching methods, embracing the available opportunities.

Sub‐theme A: Participants faced challenges with online teaching

Participants felt detached from their students during online teaching and learning. Radiography students seemed to be less motivated to participate during online sessions as opposed to face‐to‐face classes.

You know, you have a class of 90 students, for example, and only 40 students consistently attend the lectures. We don't know when the students are actually listening to the class, if they actually are, so you know that has been quite a challenge. (P3)

You know, you say, “so what do you see” … and you get nothing. (P2)

Cavinato et al. 34 found that 33% of students are less willing to answer questions during a Zoom session, 30% are less willing to participate in class activities online, and 36% are less willing to ask questions as opposed to face‐to‐face lectures. Moving to online teaching caught participants off guard, and all software tools available to participants may not have been fully utilised. Mardiana 32 identifies this as a problem caused by the rapid move to online teaching, meaning educators did not have enough time to equip themselves with the knowledge of available online tools and how best to utilise these to increase classroom interaction.

Participants felt significant frustration and demotivation with online teaching due to the inability to see their radiography students face‐to‐face stating they felt alone in the teaching session.

Ya, because you are speaking to this black screen – and only five students. And you know, it's only those students all the time that will respond. (P4)

with the online, it is so much harder to do these kinds of things … when you can't see somebody. (P2)

Notably, not all students have the same accessibility or funds to fully facilitate the move to online learning. 36 In addition to a lack of digital infrastructure, students are also faced with family responsibilities, health and mental wellness issues, as well as food and financial insecurities. 34 These are some of the issues that may have plagued radiography students during online teaching sessions. It can be surmised that due to family demands or data restrictions, students may have no option but to turn off their video cameras to attend lectures. Cavinato et al. 34 found that 39% of students cited some of these reasons affected their ability to fully participate in online classes.

Sub‐theme B: Different opportunities arose from online teaching

Although challenging, the move to online platforms meant participants became creative and innovative in their teaching approach, finding new ways to engage radiography students in their teaching sessions.

But what I did use in, in, during lectures, was the polls that you can do. So, then I'd ask a question, and have like a couple of responses. And then they [students] like doing that because that's anonymous … So polls are much better … You need to be innovative… I think innovation is key. (P2)

You have to come up with all these weird and wonderful things to get them [students] engaged. (P5)

Considering the known barriers students face related to online learning means educators can find strategies in their teaching to overcome these barriers. 34 , 37 Van Wyk et al. 38 described this as ‘disruptive innovation’. Disruptive innovation was first described in education when the speed of technology increased rapidly, forcing educators to engage with and implement technology in their teaching approaches. 38

Participants became creative in their delivery of content and questioning techniques to overcome the barrier of disengaged radiography students. Participants used technology to assist in the model's implementation by asking questions on WhatsApp and using tools in the online learning management system.

What I did was, I would put up activities of a WhatsApp group. And, and then they could respond. (P3)

it is quite inspirational to take something that is challenging … I think it can be quite inspiring to see when something works. You know, like now you've tried something and it's, it inspires you to do more. (P2)

Creating online resources to assist radiography students find information, adding frequently asked questions and posting reminders assists those who do not have a natural motivation but need guidance to become motivated as they succeed. 39 Misra and Mazelfi 40 found WhatsApp to be a beneficial form of communicating with students, since it is freely available and allows instant communication with multiple students at once. Although remote learning is a challenge for students with limited resources, many students have access to WhatsApp, which is easily integrated into teaching small topics or sharing images and videos. 38

Participants said radiography students interacted with each other more when they prepared their own content to deliver to their peers.

As soon as I put another student to be the one teaching it sort of prompted them to speak more to differ with the student more. (P6)

they [students] lecture the first term … they've prepared all of the lectures … they did it incredibly well. (P2)

the confidence, it differs when it's someone else that's presenting other than you, the lecturer. (P4)

Giving students self‐directed tasks increases their autonomy and motivation to engage with the group. 41 Mpalyani et al. 42 acknowledge that self‐directed learning is known to motivate students, with the result of promoting lifelong learning. In line with this, Misra and Mazelfi 40 agree that students who can work independently become motivated and cognitively strong.

Through the model's implementation, participants increasingly collaborated with each other to discuss ideas and teaching methods. Participants recognised this as a positive outcome of the model implementation process that was unexpected. Participants also felt the model allowed them to purposefully engage with radiography students through various teaching techniques.

They [students] think that whatever you are saying is always right, but I mean we [are] also in a learning process together with them [students]. (P4)

one more thing about this model [implementation] … that I think we would like, speak to each other more like “what are you going to do or what have you done?” (P1)

Vilppu et al. 28 recognised collegial collaboration plays a vital role in education by creating a community for discussion around teaching techniques and enabling educators to feel less isolated in their pedagogical journey. Positive engagement with students is aligned with academic success through the creation of an environment of open communication. 38

Theme 3: Applying different teaching methods to promote critical thinking is a developing disciplined process, which should start in the first year of study and continue through to the fourth year of study

Participants indicated that the model implementation process needs to be scaffolded from year one to year four and should be considered a long‐term process in order to gain maximum benefit.

Sub‐theme: Critical thinking development

Participants found the model's implementation gave them a foundation through which they could develop radiography students' critical thinking skills. They indicated the need to work together to strategically implement teaching and learning activities throughout the curriculum, specifically aimed at each year level to purposefully scaffold the teaching of critical thinking from the first year to the fourth year to maximise the benefit of the model's implementation.

But for the first years we really had to be like focus on getting the concepts right, the foundation right or else they're gonna struggle. (P5)

I haven't in first year given a full scenario. I'm going to do it now, because I thought – build it up slowly. (P3)

I feel like it's too soon to leave them … I feel like it's a process … so if we're starting now consciously, so next year the second years are going to be in a different phasẹ (P1)

When you move on first to fourth year, you have to consider the level of students, and how we implemented it. (P3)

According to Kirmizi et al., 43 critical thinking skills should be developed from the start of an education programme. In order to understand and base decisions on evidence, students should receive new information that can be connected to previous knowledge in line with constructivist learning approaches. 44 Careful curriculum coordination is integral in developing critical thinking skills by scaffolding learning throughout the programme. 45

Through the implementation of the model, participants guided radiography students towards self‐directed and independent learning.

I send them questions ahead of time, so they can prepare and come prepared for discussion … students have to then also engage in, in creative thought to think beyond what they normally know and [think] lateral. (P3)

I've asked them [students] to go away and reflect on kind of, their clinical practice related to what we've been doing. (P2)

Learner‐focused approaches to teaching are known to encourage students' critical thinking by discovering knowledge on their own. 28 Self‐directed learners are more successful in achieving learning outcomes. With the introduction of online teaching during the COVID‐19 pandemic, self‐directed learning will become increasingly relevant. 46

Limitations

The impact of COVID‐19 meant that many of the face‐to‐face teaching strategies in the implementation of the model could not take place. Instead, face‐to‐face activities were re‐designed in an online format utilising the online learning platform. Additionally, the workshop to assist radiography educators to implement the model had to take place online rather than face to face.

The development of critical thinking skills before radiography students graduate is necessary to ensure the best outcome for the patient in a radiography setting. Through a theory‐generation process, a model was developed for implementation to assist diagnostic radiography educators in the facilitation of critical thinking skills of radiography students.

Conflict of Interest

The author declares no conflict of interest.

Data Availability Statement

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An Exploration of the Meaning and Development of Critical Thinking in Diagnostic Radiography

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