Professional Behavior in Sonographers: A Literature Review of Current Standards in the Profession From an Educator’s Perspective

Abstract

Objective:

Professional behaviors are integral elements in the definition of professionalism. Determining which of these behaviors meet professional standards and how they equate to professionalism in sonographers is critical for educators to prepare students for clinical experiences.

Materials and Methods:

A review of peer-reviewed literature and qualitative extraction explored professional behaviors in sonography. Professional standards published by organizations representing sonographers were also examined for professional behavior standards.

Results:

Two peer-reviewed studies were found that explored professional behaviors in sonographers. The existing professional performance guidelines focused on defining clinical competencies for successful diagnostic medical imaging and used only generalized descriptions of professional expectations related to communication, analytical skills, and ethics.

Conclusion:

Specific professional behaviors have rarely been identified in the existing literature, which limited this data extraction. Qualitative themes associated with professional behaviors in the literature included social conduct, appropriate appearance, and ethical conduct. More research is needed to assist educators in promoting professional behaviors.

Keywords

Education professionalism professional behavior and diagnostic medical sonographers

As organizations representing sonographers continually revise performance standards across all imaging occupations, it is also essential to update standards related to professional behavior. Regarding professionalism and the obligation to keep professionals competent, respectable, and focused on achieving the best patient outcomes through diagnostic imaging, it is vital to address which behaviors need to be introduced and reinforced for sonography students. Professionalism broadly applies to complex systems and the organization of skilled workers into a recognized group that are able to proficiently perform a specific set of tasks.¹ Professional behaviors within this group are defined and reinforced through experiences and compared to behaviors demonstrated in similar professions,¹ such as occupations in nursing and medicine.

This literature review was designed to explore professional behaviors through peer-reviewed publications and professional standards, published by organizations representing sonographers. This review was conducted through an educator’s lens to define these behaviors contextually to sonography. It also addressed challenges regarding professional behavior sonography educators should consider in addressing workplace diversity, belonging, and inclusion. Some inductive questions were How do we apply professional behavior standards consistently and fairly while embracing social change? How do we educate future sonographers when a universally accepted list of professional behaviors may not exist?

Materials and Methods

This literature review explored peer-reviewed literature and standards of professional behavior, in sonography, to discover if gaps or inconsistencies existed in those standards, from an educator’s perspective. The method used was guided by the framework of a qualitative systematic review.² This allowed for the qualitatively extracted data to be analyzed and synthesized, from literature related to professional behaviors and further develop them into common themes.

Literature was retrieved using the university’s library and full-text digital databases such as EBSCO, ProQuest, CINAHL, and Google Scholar. Key search terms included “professional behavior” or “professionalism” followed by the preposition “in” relative to “ultrasound,” “sonography,” and “medical imaging.” The criteria for inclusion were that peer-reviewed articles be published in the past 5 years, have full-text sources, and be written in English. Literature was excluded if it did not address professional behaviors or if the determinant of professionalism focused on clinical competencies, over behavioral expectations. Literature was selected by relevance to sonography and professionalism, as well as by convenience.

Existing standards for professional behavior and organizational position papers were retrieved from organizations representing sonographers, such as the American Echocardiography Society (AES), the American Institute for Ultrasound in Medicine (AIUM), the Society for Diagnostic Medical Sonography (SDMS), and the Society for Vascular Ultrasound (SVU). Accrediting or licensing organizations, associated with sonography, were excluded from retrieval, as were organizations that did not include sonographers, in the context of professional behavior. Because of author familiarity, program-specific student conduct and professionalism standards published by the host university³ were used as a baseline to compare with other program guidelines, specific for sonography students. Only one program-specific guideline for professional behavior was found using the search criteria.

Professional behaviors are qualitative data and subjective in interpretation. First, they necessitate description, followed by categorization along similar themes for qualitative systematic review.² This method was designed to explore whether professional behaviors were consistently identified and specifically addressed the sonography profession.

Results

Seven peer-reviewed articles and one program-specific policy were retrieved. However, only two pieces of literature were found that explored professionalism in sonography (see Table 1) and demonstrated the limitations in professional behaviors, associated with sonographers.^4,5 Two excluded studies involved sonographers but focused on identifying the clinical scope of practice⁶ and addressing clinical preceptorship⁷ programs.

Table 1.

The Published Sources Used for the Qualitative Extraction of Data for the Literature Review.

Title	Publication year	Authors	Study typology	Sonographer contextually linked
Evaluation of post-simulation sonographer students’ professional behavior in the workplace	2022	Bowman et al.	Quantitative case study	Yes^a
Health care professionals’ perceptions of unprofessional behavior in the clinical workplace	2023	Dabekaussen et al.	Survey	No^b
An insightful evaluation of professionalism among dentistry students	2020	Habib et al.	Cross-sectional	No^b
Professional behavior policies	2024	Indiana University	N/A, policy guide	Yes^a
Scope of Practice of Sonographers Across the United States: A Survey Study	2023	Pessin et al.	Survey research	Yes^b
Developing preceptorship programs by exploring the needs of newly qualified sonographers through the lens of experienced ultrasound preceptors	2024	Philips & Alsop	Focus group analysis	Yes^b
Assessing professionalism in health profession degree programs: A scoping review	2021	Smith et al.	Scoping review	No^b
Pilot study to identify attributes of professionalism in sonography	2021	Tinetti et. al.	Pilot study	Yes^a

Included in the literature review as pertinent to diagnostic medical sonographers.

Used to corroborate professional behavior in the discussion section of the manuscript.

The first study explored professionalism in sonographers, as the equivalent of having a universally recognized and accepted professional identity, based on the combination of learning “professional behavior and humanistic attributes.”⁴ According to that study,⁴ simulations conducted by 94 clinical assessors of 174 students demonstrated that professional behaviors were transferrable from a learning environment into clinical practice. The following paragraph described the most transferable professional behaviors:

Teamwork, professional attributes, appearance, accountability, responsibility, dependability, time management, impact on workflow, patient rapport, confidentiality and requesting assistance transferred well. These may represent the more observable components of professionalism, which performativity theory divides into theatrical and improvisational components. The theatrical component of students’ learning transferred well ensuring ‘switching on’ their professional identity by ‘looking the part’ (i.e., uniforms), and displaying humanistic attributes related to a sonographer’s professional image.⁴

Professional behaviors that did not transfer as well in students included “‘Communicating findings to team members’ and ‘showing initiative’ transferred satisfactorily but less well, and ‘dealing appropriately with patients’ questions’ proved least transferable.”⁴ Bowman et al.⁴ speculated that these behaviors did not transfer as well due to students’ insecurities, a lack of initiative, or role confusion.

Identifying specific professional behaviors in a larger sample of sonographers appeared to only exist in the pilot phase and was limited to Australia.⁵ The results of their three-phase study that surveyed both sonographers and patients revealed the following “attributes” associated with professionalism:

Written communication/instructions (Communication); patient safety (Patient care); compassion, hygiene, being neat and tidy, non-judgmental, and having patience (Personal characteristics); being willing to seek guidance and assistance when required (Self-awareness); being collaborative, reliable, and supportive (Team member); and having an openness and willingness to accept opportunities to learn, and technical skills (Technical competence, the category was renamed following iterative analysis).⁵

These authors concluded that this list of attributes was not comprehensive and that further study was needed to create applicable behavioral standards specific to sonography.⁵ A comprehensive list of professional behaviors extending beyond Australia would benefit professional organizations and sonography educators.

Only one program-specific clinical standard was discovered,⁸ as part of the literature search. However, more behavioral standards applicable to sonography students could likely be found in program-specific student handbooks and educational materials that were not readily accessible online. The Indiana University School of Medicine⁸ referenced to the Scope of Practice and Clinical Standards for the Diagnostic Medical Sonographer⁹ as the basis for their clinical standards before adding “professional and ethical standards.” In their Chapter 3, it addressed HIPAA and patient privacy expectations by “not accessing patient information or examinations unless the information is needed for educational purposes,” “may not take images out of the clinical site without permission,” and “refraining from discussing patients and patient information except as related to their education.⁸” In Chapter 4,⁸ they addressed “Communication Policy” addressing e-mails and noting text messages were “not an appropriate form of official communication” in the context of communicating with faculty. Under Chapter 6,⁸ the document outlined conduct expectations such as punctuality, “effective communication,” using “professional titles” when addressing physicians, and avoiding “controversial conversations.” In addition, in Chapter 6, they went on to address these conduct issues: “students are expected to refrain from eating, drinking, sleeping, personal reading, personal device use, excessive time to study, surfing the web, and mingling in portions of the hospital department devoted to patient and physician services.⁸” Dress code policy was addressed in Chapter 12⁸ and outlined program-specific expectations for students; also included was a list of inappropriate attire, always wearing an ID badge, adherence to grooming standards, avoidance of excessive perfumes, wearing minimal jewelry, hiding offensive tattoos, and not having long or artificial fingernails. These policies were probably necessitated by previous experiences with students and resembled policies implemented by the host university.³

Professional organizations representing sonographers, such as the AIUM,¹⁰ ASE,¹¹ SDMS,⁹ and SVU¹² outlined generalized descriptions of expected professional actions based on meeting entry-level clinical competencies. The most referenced document, the Scope of Practice and Clinical Standards for the Diagnostic Medical Sonographer⁹ outlined both expected clinical competencies and general behaviors consistent with clinical competence. For example, this sentence established behavioral expectations: “Sonographers use independent, professional, and ethical judgment and critical thinking to safely perform diagnostic sonographic examinations, procedures, and associated tasks.”⁹ Four sections⁹ addressed behavioral expectations by combining clinical competencies with general behaviors necessary for sonographers to meet their scope of practice; these standards were broadly applicable in Sections 1 through 3 to communication with patients and other health care professionals, the acquisition and reporting of patient data in Section 1, self-awareness and improvement in Sections 2 and 3, and maintaining ethical standards in Section 4.

These competencies and standards published by the SDMS⁹ were a collaborative effort created by multiple organizations representing sonographers. They were referenced by the SVU¹² and the AES¹¹ in their policy statements specific to clinical competencies for vascular technologists and echocardiographers. In “Minimum Standards for the Cardiac Sonographer: A Position Paper,” skills related to safety, ethics, and communication were briefly outlined as a means to meet basic competency in echocardiography.¹¹ The AIUM¹⁰ referenced the SDMS⁹ document to address the scope of practice for sonographers and issued a separate statement on professionalism related to respecting a patient’s dignity.

Organizing the generalized behavioral standards, noted in this literature search, into common themes, such as: sonographers were expected to communicate well in written and verbal form, collaborate with other health care professionals, use critical thinking skills, adhere to a specific physical appearance and grooming standards, follow the rules and regulations ensuring patient safety, comply with hospital policies and procedures, demonstrate trustworthiness, and follow ethical guidelines.⁹ If condensed further, professional behaviors exhibited by sonographers should guide their social conduct, analytical capacity, and uniform appearance, which identifies them as unique medical imaging professionals.

Discussion

Professional behaviors appear broadly defined by professional organizations and are only explicitly identified at individual program levels. The descriptions of expected professional behaviors were likely broadly written to provide subjective interpretation and recommend desirable traits in sonographers; however, this has the potential to generate confusion. In addition, the professional organizations reviewed seemed to be primarily focused on defining entry-level clinical standards for sonographers, the education required to attain, and maintain clinical competence. It should be noted that clinical standards are not the same as behavioral standards, even if standards of behavior are implied as necessary to the delivery of patient care (i.e., “Quality patient care is provided when all members of the healthcare team communicate and collaborate efficiently.”)⁹ Which behaviors constitute efficient communication and collaboration?

Agreed-upon clinical standards of job performance and the creation of boundaries for the profession indicate professionalism in a systemic context;^1,13 however, the behaviors of those within the profession may vary in acceptance, as they are not specific. Despite its broad application, the Scope of Practice and Clinical Standards for the Diagnostic Medical Sonographer⁹ represents the closest document for establishing professional behavioral standards across all sonography specialties, as it was reviewed and endorsed by 17 different organizations associated with the performance of diagnostic medical sonography.⁹

The professional behaviors revealed in the results section were organized thematically. Behavioral standards related to social conduct, included verbal and written communication standards and collaboration with other health care professionals. Sonographer appearance was also an essential behavioral standard, addressing the necessity of uniforms, identification (ID) badges, tattoos, and basic hygiene practices. Appearance also addressed long fingernails, piercings, and other body modifications that could pose health risks due to infection. Analytical and ethical behavioral standards were also explored, as sonographers must think quickly to process large amounts of information in unpredictable, high-stress environments. These functions are to be completed while maintaining personal integrity.

Behavioral Standards Related to Social Conduct

The ability to communicate effectively, so patients understand the sonographer at every point during the interaction, is covered by the Scope of Practice and Clinical Standards for the Diagnostic Medical Sonographer;⁹ however, what is “effective communication?” Does this mean the sonographer should speak the same language as the patient in such fluency to be understood, or does it imply precise speech conveying minimum information, so that the sonographer can complete their job? Patient introductions, exam explanations, obtaining consent, and taking a patient’s medical history are task-related actions that sonographers must perform to meet clinical standards.⁹ How does a sonographer accomplish this appropriately and to what professional standard?

Essential communication with patients, such as sonographers introducing themselves,¹⁴ is related to the concept of presence in clinical settings. Presence is crucial in establishing an empathetic role for the sonographer,¹⁵ giving patients full attention through body language and verbal acknowledgment via active listening.¹⁴ Introductions are a common courtesy that informs patients who the individual performing their test is and the first step in instilling trust. The failure to establish the nature of the sonographer-patient relationship erodes trust, and the patient may feel disrespected or neglected from the onset of the interaction.⁵

Cultural considerations regarding communication between sonographers and patients also need to be addressed. Some cultures value group medical decisions/interactions more than others, communicating as a family,^16,17 and some cultures, such as the Amish, limit interactions between men and women.¹⁸ Sonographers should recognize these cultural differences and how they could impact patient interactions; it may be considered rude to address only the patient and not acknowledge others present.

It is also vital that sonographers understand language barriers and obtain approved human- or computer-based interpreters to relay important information to patients.¹⁹ Reliance on family members to interpret is discouraged, and obtaining an interpreting service is necessary for accurate communication and avoiding issues with medical liability, due to misinterpretation of critical aspects of procedures.¹⁹ Even if the sonographer is fluent in the patient’s native language, issues with dialect/accent could also create communication errors.¹⁹

Explaining the diagnostic test properly is another professional behavior that needs to be emphasized by educators and clinical preceptors. Like basic introductions, explaining the diagnostic examination performed on patients is necessary to instill trust,¹⁹ demonstrate competence,⁴ and provide informed consent.^17,20 Patients have the right to know what is being done to them, who is performing the test, and for what purpose;¹⁷ patients also have the right to refuse testing, which should be respected by the sonographer.²⁰ Students need to understand these legal boundaries, including the importance of not revealing test results to patients or engaging in comments that fall into diagnosing medical conditions.⁴ While sonographers recognize pathology and describe it in diagnostic terms, interpreting medical images is not allowed, and should be the duty of the interpreting physician.⁹

The use of profanity, vulgarity, and the discussion of taboo subjects such as politics, sex, and religion were regarded as unprofessional behaviors.⁸ This may challenge many sonographers personally and professionally, as using some profanity²¹ and discussing previously controversial topics such as sexual identity²² may seem rather common and reflects a cultural shift. Despite social trends being in constant flux, sonographers should follow a conservative, respectful approach to language and avoids unintentionally offending others.⁵ Patients appreciate conversations that make them feel comfortable and well-informed, as their anxiety levels are likely elevated.⁵ Swearing and the use of profanity have been described as stress and pain relief,²¹ which explains why health care professionals need to be reminded not to engage in it. Discussing the care of other patients or gossiping about hospital politics is also regarded as unprofessional behavior;^4,5 the former is also considered a HIPAA violation²³ in the United States and illegal.

Communication standards related to e-mail and smartphones are also worth addressing,^3,8 particularly if they interfere with patient care delivery or the ability to communicate with peers and superiors. Any distraction would hinder effective communication by negating personal presence, with smartphones emerging as addictive elements²⁴ and may necessitate a ban. Smartphones present a significant risk for HIPAA violations due to their audio and video recording capabilities and pose security breaches for hospital information technology (IT) departments, if those phones connect to the hospital’s Wi-Fi network.²³

Behavioral Standards Related to Appearance

Sonographers are expected to adhere to basic hygiene practices and not report to work disheveled or improperly dressed in school and clinical environments.⁵ For sonographers and students, wearing hospital scrubs or business casual attire under a white lab coat is considered professional. Sonographers should be identifiable via ID badges; students should be identifiable by logos on their lab coats indicating their status and which school they represent to avoid confusing patients and staff.⁸ Clinical environments also require ID badges to be worn at all times while on the premises for security reasons.⁸

A common issue related to professional appearance is students who wear piercings or have visible tattoos. As culture evolves, these once stigmatized practices have become normalized in society, and many younger individuals display multiple facial piercings and tattoos as a form of artistic expression; it has also been suggested that body modification is a form of trauma therapy.²⁵ In some African, Asian, Native American, and Pacific Islander cultures, tattoos and other body modifications are a rite of passage;²⁵ these body modifications are considered a part of their identity and if challenged, could constitute discrimination based on race and culture. Body modifications remain a source of social stigma as older generations may view piercings or tattoos as frightening,²⁵ holding more conservative views of professional appearance.

Piercings, long fingernails, and jewelry present safety and hygiene issues as hospital environments are at risk for deadly bacteria, such as methicillin-resistant staphylococcus aureus (MRSA).²⁶ Limiting piercings is considered an acceptable compromise for students after explaining the risks involved in exposure to hospital bacteria and other potential dangers.⁸ Literature exploring infection control measures recommended that students and employees avoid having excessively long or artificial fingernails due to their increased risk of contamination since bacteria colonize fingernail beds.^26,27 Adhering to universal precautions, isolation measures and hand hygiene are critical behavioral standards in clinical environments.⁸

Behavioral Standards Related to Analytical Skills

Analytical skills entailed the sonographer’s ability to process patient information and quickly react to unpredictable health care environments.¹¹ It also entailed reporting faulty equipment and potential safety issues with patients.⁹ Analytical skills are the sonographer’s self-awareness and situational awareness, the combination of mental agility and the capability to use common sense to solve complex problems. Critical to student progression to full-time entry-level employees is the sonographer’s need to work independently and with minimal supervision.⁷ Sonographers who lack confidence in their abilities will progress much slower toward independence and may also undermine the trust that physicians have placed in sonographers, to perform their duties. How student sonographers handle adversity is vital to their future in the profession, and possessing mental discipline with emotional maturity should not be underestimated as desirable professional behavior.⁵

Behavioral Standards Related to Ethics

Ethical behavior was mentioned in all professional performance standard documents. The professional expectation is that sonographers are honest, report their findings accurately, and promptly to physicians, as well as considering the safety of patients.^9,11 Sonographers are advocates¹³ that are temporarily responsible for patient welfare, during diagnostic imaging and must report their findings promptly and accurately to physicians, nurses, and other sonographers, while remaining within their scope of practice.⁹ Dishonest behaviors that hinder diagnostic imaging and reporting results are detrimental to patient care and not conducive to a professional environment.

What individual behavioral traits should sonography programs and medical imaging facilities look for in sonographers? Compassion, empathy, a willingness to learn from adversity, technical feedback, emotional maturity, and reliability are usually mentioned in the literature exploring professionalism.⁵ Developing confidence in sonographers and their ability to operate independently from supervision is also a concern mentioned by clinical preceptors.⁷ To develop confidence and proficiency in conducting an examination, sonographers will need to receive feedback from clinical preceptors.⁷ If students or new sonographers lack patience or the ability to receive constructive feedback, this represents a self-defeating behavioral trait.

Literature exploring professionalism and clinical performance standards mentions ethical and trustworthy behavior, as a desirable characteristic for sonographers.^4,5 Sonographers and students in clinical may be tempted to falsify patient reports or falsely report time spent performing clinical duties, demonstrating unethical, even illegal behavior.²⁸ Nearly all academic institutions hold a zero-tolerance policy for academic integrity violations,^3,8 usually aligned with employer expectations when hiring trustworthy, honest individuals.

Measuring the success of teaching empathy remains an issue,¹⁵ as are measuring honesty, resiliency, integrity, self-reflection, and the desire for improvement; usually, professionals who fail to demonstrate these traits are terminated or are encouraged to pursue different career paths. It is again incumbent upon educators to understand their students’ motivations to learn sonography and their character traits to avoid such issues with professionalism.⁶

Limitations

Systematic review options were limited to conduct qualitative analysis. As a result, there was a lack of pertinent peer-reviewed literature describing qualitative data vis-a-vis professional behavior. A meta-analysis, based on this paucity of data, was impossible, and quality assessment of data sources was not performed. It was also impossible to review every sonography program’s student handbook, due to accessibility and time constraints. A more systematized review of sonography program standards could hypothetically generate similar results to a large-scale survey distribution exploring desirable professional behaviors in student sonographers.

Conclusion

This review was not intended to challenge existing clinical standards outlined by professional organizations but to help identify specific professional behaviors that embody the sonography profession. Transitioning from broad descriptions of desirable professional behaviors for sonographers to more specific behavioral standards is essential for fortifying the profession. Further research is warranted to identify and define professional behaviors that the sonography profession exemplifies, particularly within North America. First, it is necessary to survey clinical preceptors, clinical coordinators, and supervisors/managers to identify desirable professional behaviors while identifying the most prevalent unprofessional behaviors. Second, once professional behaviors have been identified and placed into appropriate categories, a discussion should be held by professional organizations with the goal of universal agreement on what is acceptable and what is not acceptable professional behavior. Third, once the behavioral standards are codified, implementation should occur so that these standards will appear alongside existing clinical performance standards. These steps are necessary to transition from a subjective, eminence-based system of determining professional behavior to an evidence-based system better representative of an elite, respected medical profession, by combining clinical competencies, and behavioral standards commensurate with sonography. Education is critical to instilling professional behavior in students, and it is necessary to reinforce it once students transition from didactic to clinical settings.⁴

Footnotes

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Robert C. Moody

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