key: cord-277528-t0tglg0a
authors: Tay, Yi Xiang; Sng, Li Hoon; Chow, Hwei Chuin; Zainuldin, Muhammad Rahizan
title: Clinical placements for undergraduate diagnostic radiography students amidst the COVID-19 pandemic in Singapore: Preparation, challenges and strategies for safe resumption
date: 2020-08-18
journal: J Med Imaging Radiat Sci
DOI: 10.1016/j.jmir.2020.08.012
sha: 
doc_id: 277528
cord_uid: t0tglg0a

Abstract Introduction The COVID-19 pandemic resulted in the suspension of clinical training for undergraduate radiography students in Singapore. Coordinated preparation plans and strategies between the university and hospitals were needed to safely resume clinical placements within national and hospitals’ risk control measures against COVID-19 transmission. Methods Singapore Institute of Technology (SIT) and the Radiology Department of Singapore General Hospital (SGH) had collaborated to meet requirements for safe resumption of clinical placements. SIT prepared students by emphasising compliance to all risk measures, addressing concerns of risk transmission, meeting learning objectives, and reassessing infection control competencies. In tandem, SGH prepared an orientation program and used technology for open communication among faculty, clinical educators and students which included monitoring of well-being and rapid dissemination of updates. Of note, SGH reorganised operating procedures and physical spaces to meet national standards of safe physical distancing, restricted movement between treatment areas and teams, and rosters to remain committed to the supervision and education of students. Results Clinical placements resumed 3 months following suspension. Clinical educators faced the challenge of the need for balance between increasing clinical load and student supervision. A solution was frequent engagement and support by faculty, with educators and students via video conferencing platforms. Students’ well-being was frequently checked. There was less variation in cases which simulation training made up for some of the learning objectives. Conclusion Adaptation and commitment to continue active and quality clinical education while ensuring students' safety were vital during a pandemic. Clinical training within stringent precautionary measures may shape the era of the new norm.

redefined strategy and priorities to mitigate the crisis. 54

'Circuit Breaker' measures 56

It is important to put into context how SIT and SGH prepared the students for the 57 challenges and designed strategies for safe resumption of clinical placements. Like many 58 parts of the world when the World Health Organisation (WHO) classified the COVID-19 virus 59 outbreak as a pandemic on March 11th, 2020 (15), Singapore went into a 'partial lockdown', 60 which was termed as 'circuit breaker' on April 7 th , 2020 (16). 61

National circuit breaker measures included mandatory wearing of masks at all times 62 in public spaces, banning the gathering of people from different households, practising social 63 distancing of one metre and registering entry at community places for contact tracing (16) (17) . 64

In HCIs, new precautionary measures, such as segregation of healthcare workers by teams 65 or by physical boundaries (7) , movement restriction between teams or HCIs restricting 66 contact between personnel (18- 19) , twice-daily temperature recording and safe physical 67 distancing (where possible) (7) , were added to existing good hygiene practices, such as 68 hand washing and the use of protective personal equipment (PPE) (7) . 69

On 16 th March 2020, the MOH began an online dialogue session with HCIs and SIT 70 on a feasibility plan to resume healthcare students' clinical placement progressively. 71

Following a few iterations, a plan was finalised. It included priority placements for final and 72

penultimate year students to ensure graduation would not be affected and no-go areas that 73 were considered high risks of COVID-19 transmission (7), such as emergency departments 74 and COVID-19 designated wards. MOH and HCIs needed the assurance that students 75 would strictly adhere to the national and HCIs' risk control measures. Safe resumption had 76 also seemed possible, contingent on the availability of on-site clinical educators (CEs). 77

Preparations from SIT 78 J o u r n a l P r e -p r o o f

The assurance of strict compliance to national and HCIs' risk control measures came 79 in the form of a clinical practice information package for submission to MOH. This 80 communique was developed for all SIT Health and Social Science (HSS) students in 81 preparation for their clinical placement resumption and had all elements of risk control 82 measures for students' compliance. A pre-clinical briefing was also conducted to reinforce 83 the importance of risk control measures in place, allay students' concerns and address any 84 gaps in understanding of the need for strict compliance. A survey was conducted to obtain 85 an overview of Year 2 and 3 radiography students' concerns to resume clinical placement 86 during DORSCON Orange, using a web-based platform (Qualtrics, Provo, UT). A total of 87 forty-five year 3 students (81.8%) and 46 year 2 students (82.1%) had completed the survey. 88

As a requirement to meet MOH's and HCI's protocols for infection control measures 89

including the use of PPE at workplace, SIT embarked on a refresher training course to build 90 on radiography students' competency in these areas. Onsite face-to-face 'refresher' session 91 was not possible due to campus closure in the pandemic state, and hence, was converted to 92 an online session. Students performed the infection control procedures guided by training 93 material and a competency checklist. Performance was recorded and submitted to SIT's 94 infection control team for assessment of the competencies. All Year 2 and 3 radiography 95 students successfully obtained the competency. 96

Challenges faced by SIT and redefining strategy 97

The survey findings revealed that half of Year 3 and Year 2 students (51% and 54% 98 respectively) had concerns about resuming clinical placement amidst the current COVID-19 99 situation. The concerns were similar between the two cohorts, with the risk of contracting the 100 virus as the top concern. Students feared contracting the virus at clinical placements and 101 during travels on public transport between placement site and home and passing it on to 102 their family members. The clinical coordinators reassured the students that they would not 103 be placed in high risk areas, and there was no evidence to suggest that a healthcare worker based on their home address. Written logs of radiographic examinations signed-off by the 107 supervising radiographer were used as patient log sheet records for contact tracing. This 108 was simultaneously used as evidence in the form of a portfolio to support the completion of 109 competencies. SIT worked with SGH on the surveillance of students' health by sharing a 110 weekly report of temperature monitoring. 111

The second concern was on the potential problem in meeting the learning objectives 112 due to the limited number and types of cases encountered. The lower caseload for students 113 was further exacerbated by the removal of high-risk areas as placement sites. In order to 114 support students and address their concerns, faculty supervisors used video-conferencing 115 platforms for students to check in on their progression at midway and end of placements and 116 provided pastoral care. However, in this COVID-19 pandemic, it was clear that ensuring 117 placements for all students was a challenge as HCIs had introduced new temporary rules to 118 limit placement capacity. Working with limited placement options, SIT redesigned the 119 structure of clinical placement by halving the duration of each placement to allow splitting of 120 the cohort into two groups with students taking turns at placements. Despite the reduction, 121 students could still fulfil AHPC's registration requirement of 1200 clinical hours. Simulation in 122 skills-based labs at Philips Medical Asia Pacific Centre, Singapore, replaced the reduced 123 duration of placements to ensure meeting learning objectives. In addition, academic modules 124 were repositioned in the curriculum to fill in the 3-month suspension of clinical placements. 125 SIT faced another challenge when allocating students to sites. Where work was 126 performed in smaller rooms, such as an X-ray examination room, HCIs allowed only one 127 student to adhere to the safe physical distancing measure. SIT was also cognisant of the 128 reduced manpower at SGH and other HCIs due to temporal segregation of COVID-19 129 designated wards from the other wards (7) , which meant the CEs (usually the more 130 experienced ones) at these wards could not supervise students. It was also possible that a 131 CE could be burdened by increased workload as a result of rising cases of transmission in 132 J o u r n a l P r e -p r o o f the community and the urgent need for a quick turnaround (19) . The clinical coordinators 133 worked with each HCI partner to recalibrate the CE-to-student ratio. At many sites, the ratio 134 reduced from 1:2 or 1:3 to a ratio of 1:1. The division of the cohort into two groups helped in 135 making the ratio of 1:1 feasible. 136

To meet compliance of precautionary measures in the 'circuit breaker' period, 138 preparations to resume placements at SGH leveraged in the use of technology, reorganising 139 training areas and orientation programme. To prioritise students' safety while on placement, student rosters were planned to 161 avoid assignment to areas deemed high-risk such as emergency department, intensive care 162 unit/high dependency and COVID-19 designated wards. They were also not allowed to work 163 with dedicated scanners for isolation and high-risk cases, such as the mobile radiography Small group size also facilitated safe physical distancing and prevented overcrowding. 173

Measures had also been put in place to ensure safe distancing at the different social 174 spots within the hospital campus such as food outlets and staff rest areas. Students were 175 reminded to practice social distancing, even at mealtimes. In short, mealtime socialising and 176 team building were prohibited during this period (21) . 177

An orientation programme serves as an important element to welcome students to 178 the department. In this period of uncertainty and potential fear, the orientation programme 179 When a radiographer was reported in the press to have contracted the virus while 196 working at a satellite facility (22), there was concern on the volatility of students' emotions -197 fear, panic, stress, and/or anxiety (10) . To allay their concerns, messages were sent through 198 the chat group to reassure students that the clinical environment was still safe and that their 199 health had been of utmost priority. In this time of crisis, CE could help to support students in Since the COVID-19 crisis began, temperature recording has been seen as a liability 202 by many staff. There were instances that students had forgotten to perform and record their 203 temperature on their rest day. To mitigate this, students were required to send text 204 messages indicating their temperature and time of submission to S3 through the WhatsApp 205 chatgroup. A team leader was appointed from the group of students to ensure temperature 206 recording compliance. Faculty supervisors were also kept in the loop for surveillance 207

As the situation was constantly evolving, WhatsApp was also used to manage rapid 209

sharing of accurate and critical updates, such as daily COVID-19 instructions issued by the 210 hospital disease outbreak taskforce. To minimise the impact of information overload and 211 misinformation, summaries were curated to highlight essential points relevant to their clinical 212 placement during their orientation. 213

The reduction in the number of cases across the department and manpower crunch 214 carried the risk of reduced clinical exposure and practice. There was a need to ensure 215 learning outcomes and progression were not compromised. This was mitigated through 216 broad, but essential learning outcomes written by SIT. Furthermore, the student's learning 217 contract related to the placement area was developed in collaboration with the CE to 218 encourage student-centric learning. This allowed understanding of expectations and ensured 219 that no students were missing out on learning (23). Using the learning contract, the CE 220 engaged students regularly to discuss learning progress. While the students were excluded 221 from handling patients with COVID-19, CEs continued to create learning opportunities for 222 them by sharing the department's policies and procedures on the management of COVID-19 223

patients. This included an overview of the pre-procedure room and patient preparation, 224 scanning techniques and infection control prevention and practices through case-based 225

With a smaller educator-to-student ratio, more manpower was needed to supervise 227 students. While it was stressful to divide the work between managing patients and students, 228 it was important that educators understood the importance of clinical education. Throughout 229 the clinical placement, there were increased support, feedback and assistance provided to 230 the students from both stakeholders (faculty and CE) than in pre-COVID situation. 231

The widespread of COVID-19 presented a massive test on the global healthcare and 233 education system with the initial suspension of clinical training of undergraduate radiography 234 students and the uncertainty surrounding the epidemiologic data of . 235

However, it was critical to resume clinical placements for a timely graduation, thereby 236 producing safe and competent diagnostic radiographers to meet manpower shortage (25). It 237 was also vital for safe resumption of clinical placements. The paper had described the 238 preparatory steps taken by the university and HCI to integrate and increase the awareness 239 of precautionary measures as part of training and the strategies to overcome implementation 240 challenges without compromising essential learning outcomes. 241

Maintaining students' psychological well-being was key to a positive clinical learning 242 experience. Our survey finding that infection risk was the biggest concern among students at 243 clinical placements highlighted the need for strategies such as frequent check-ins on their 244 mental health and emotional well-being. Sustaining mental health in the midst of an 245 extremely disrupted curriculum was also raised in a perspective paper (10) . Similarly, high 246 stress levels were also found in radiology education (26). Our strategy in using WhatsApp shown to be a valuable approach for technical skills training, patient communication, 267 managing complex cases and increasing confidence and motivation in students (31-32). In 268 addition, the use of virtual platforms for teaching and learning during COVID-19 could be a 269 potential approach to augment learning outcomes (11). However, there were no prior plans 270 in place on using virtual technology to maintain the education of Singapore student 271 radiographers during an outbreak. This serves as a timely reminder for us to exploit 272 technology-enhanced learning in the clinical setting in the future. 273

Although the local radiography students may be limited by the availability of 274 alternative technology-enhanced learning experiences compared to other allied healthcare 275 professionals (28), CE can still contribute to a meaningful student learning experience by 276 being positive role models themselves (2). Building a positive educator-student relationship 277 may be challenging within the COVID-19 situation as CE may experience additional burden 278 and stress with increasing workload and smaller teams. This was highlighted as SGH's 279 challenge in managing smaller CE-student ratio where more manpower was needed for 280 student supervision and assessment. While it might be arguable that students may benefit 281 from a 1:1 ratio model where CE could focus solely on the student, a paired-student model 282 J o u r n a l P r e -p r o o f would provide peer-assisted learning (33) . However, there has been no clear advantages 283 between the CE-student ratio models (33) , hence the strategy to develop a strong belief 284 among CE in the value of clinical education was more important than standardising ratio 285 models. A partnership between SGH CE and SIT with close communication was key to 286 support CE in ensuring that students had met all expectations and competencies for entry 287 level clinical practice (34). Embracing students as members of COVID-19 teams would help 288 build a positive relationship (35). 289

The first batch of penultimate senior year students had recently completed a 290 placement during the 'circuit breaker' period. A survey is ongoing to measure how successful 291 the preparation and strategies implemented had been in terms of providing fulfilling learning 292 experience amidst the restrictions imposed onto the clinical placements. 293

Despite the uncertain COVID-19 situation, clinical placements are essential 295 components for graduation and therefore, safe resumption of undergraduate diagnostic 296 radiography clinical placements was needed. SIT's strategies to assure SGH and other HCIs 297 include raising students' awareness to mandatory adherence to strict national and HCI's 298 regulations by creating an information package, a pre-clinical briefing and a survey to 299 address any concerns. SIT also conducted an infection control and PPE use refresher 300 training and ensured close communication with CEs in the allocation and supervision of 301 students. SGH emphasised on a more comprehensive orientation package to students on 302 protocols for risk control measures within SGH, including team and temporal segregation 303 and even lunch etiquette in line with safe distancing. SIT and SGH have collaborated in 304 many aspects of clinical placements, namely managing students' well-being, meeting 305 learning outcomes and adhering to national and HCIs' risk control measures through the use 306

of WhatsApp, open communication among students, educators and faculty, and continuous 307 SIT support for CE. All strategies were planned with learning outcomes in mind. Where 308 learning outcomes might not be achieved in COVID-stricken placements, these were 309

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