key: cord-350456-lter7hy2 authors: Lewis, Shantel; Mulla, Fathima title: Diagnostic radiographers’ experience of COVID-19, gauteng south africa date: 2020-09-18 journal: Radiography (Lond) DOI: 10.1016/j.radi.2020.09.009 sha: doc_id: 350456 cord_uid: lter7hy2 Introduction As of July 2020, South Africa (SA) had the fifth highest number of COVID-19 infections in the world, with the greatest contributor of these infections, being the province of Gauteng. Diagnostic radiographers in Gauteng providing chest CT, chest radiograph and MRI services are frontline workers experiencing these unprecedented times. Therefore, this study undertook to explore diagnostic radiographers’ experiences of COVID-19. Methods A qualitative approach using an asynchronous opened-ended online questionnaire was used to explore diagnostic radiographers’ experiences of COVID-19. Responses from purposively sampled diagnostic radiographers in Gauteng SA, underwent thematic analysis. Results Sixty diagnostic radiographers representing both the private and public health sector responded to the questionnaire. Thematic analysis revealed three themes: new work flow and operations, effect on radiographer well-being and radiographer resilience. Conclusion Besides experiencing a shift in their professional work routine and home/family dynamics, diagnostic radiographers’ well-being has also been impacted by COVID-19. Adapting to the “new way of work” has been challenging yet their resilience and dedication to their profession, providing quality patient care and skill expertise is their arsenal to combat these challenges. Implications for practice Understanding the impact of COVID-19 on diagnostic radiographers will allow radiology departments’ management, hospital management, professional bodies and educational institutions to re-evaluate provision of resources, training, employee wellness programs as well as policies and procedures. Note: A graphical abstract has been submitted for consideration: The stick person (non-gender, non-race) represents the radiographer, pushing up the boulder of emotions and experiences as the COVID-19 infections continue to raise in SA. Yet radiographers draw on the positives and soldier on hence the use of the super hero cape. In 1918 the Spanish flu killed approximately 300 000 South Africans in six weeks. 1 Since 1982, HIV/AIDS has claimed in excess of three million South Africans. 1, 2 South Africa (SA) also remains one of eight countries that contribute to two thirds of the total global tuberculosis (TB) infections. 3 Now, in addition to its burden of existing diseases, SA like the rest of the world, faces a novel pandemic. 4 Since 31 December 2019 when the first case of a new Coronavirus was reported the disease Coronavirus 2019 (COVID-19) caused by the severe acute respiratory syndrome Coronavirus 2 5 , has spread to 213 countries and territories worldwide. 6-7 SA reported its first COVID-19 patient on 5 March 2020 and on the 26 th March 2020 the country went into a 21 day national lockdown with 927 confirmed positive cases. 8 The aim of the lockdown was to reduce the rate of transmission and to allow health care facilities to prepare for the anticipated infection surge. 8, 9 SA's healthcare sector consists of a public and a private sector. SA's public healthcare sector is government funded but under-resourced, supporting approximately 85% of the population. The private healthcare sector, paid through medical aid schemes and individuals is well-resourced, catering for the remaining 15% population. 10 News reports indicate that the private healthcare sector may accommodate COVID-19 patients from the public health sector at an agreed price. 11, 12 Background The 2003 Severe Acute Respiratory Syndrome (SARS) Coronavirus resulted in an increased need for medical imaging services and stringent infection control practices. 19 Radiographers working through the SARS outbreak, experienced SARS as being stressful. Low staff morale, inadequate infection control and poor risk management skills were highlighted as contributing factors. However, after the outbreak, radiographers found the experience to be a valuable opportunity to reflect on their role as radiographers, radiography practice and professionalism. 19 Seventeen years later, the COVID-19 pandemic has had a similar impact on medical imaging services. Chest computed tomography (CT), lung ultrasound, magnetic resonance imaging (MRI) and chest radiographs, performed by radiographers, play a pivotal supportive role in the diagnosis, management and treatment of COVID-19. [20] [21] [22] [23] [24] [25] As a result, medical imaging departments had to introduce new work flow and operations. Measures included the use of personal protective equipment (PPE), social distancing and stringent equipment sanitization. Staff allocations were also amended to mitigate spread among staff while ensuring continued service. Infection of staff would mean that the workload on remaining staff would increase. [26] [27] [28] [29] [30] [31] Besides these changes to the working environment, enforced lockdown protocols resulted in furloughs, loss of jobs, reduced work hours and children needing to be schooled at home. [32] [33] [34] Adjusting to this new way of work and life has resulted in emotional, physical, financial and mental stress. [35] [36] [37] [38] [39] The impact of these multitude of changes needs to be explored. Therefore, this study undertook to explore diagnostic radiographers' experience of COVID-19. The study was conducted in Gauteng, SA. [20] [21] [22] [23] [24] [25] Method A qualitative approach using an open-ended online questionnaire was used to explore Gauteng's diagnostic radiographers' experiences of COVID-19. 40 Diagnostic radiographers (hereafter referred to as radiographers) employed in Gauteng, SA were purposively sampled. 40 Demographic data was obtained and answers to a single J o u r n a l P r e -p r o o f question: "How has your experience been during COVID-19?" underwent thematic analysis. Radiographers' responses were read and reread to obtain a general sense of the information; the data was coded and categorised and then themes were generated. Due to COVID-19 restrictions preventing face to face interviews, telephonic or video calls could have been used, but considering changes to radiographers' work and home life, the option to have an online open-ended questionnaire was favoured. Asynchronous qualitative online, open-ended questionnaires are not commonly used for qualitative research 41 but were selected for use in this study so as not to burden participants in time-locked obligations. 42 Radiographers choosing to participate in the study could do so at any time they found suitable without being burdened by contact at a specific time. Also invitations to participate in the study asked radiographers to share their experiences in as little or as many words as they liked. Written responses allow for self-reflection and focused answers. 43 Measures of trustworthiness included member checking and reflexivity to ensure credibility. 40,44 Themes were shared with radiographers that participated in the study to establish if it portrayed the truth value of their experience of COVID-19. 40,44 The authors kept research diaries of their own to allow continuous reflection. 40, 44 Dependability and transferability of the study was ensured by a detailed description of results along with providing direct quotations from participants. 40,43,44 Confirmability of a study is ensured by an audit trail. 40,44 Questionnaire responses from the study is preserved to allow for independent auditing. 44 Ethical clearance and consent to conduct the study were obtained (REC-524-2020). Diagnostic radiographers were invited to participate in the study through email and messaging applications as well as through the head of radiology departments. Data collection continued until data saturation was achieved. Sixty radiographers from Gauteng's public and private sector responded to the questionnaire. Both sectors were represented in the study with 31 radiographers working in public hospitals, 27 working in private hospitals and the remaining 2 radiographers working in both public and private hospitals. The study information letter outlined the purpose of the study as well as provided the opportunity for radiographers to express their experiences of COVID-19 without The demographic data of participants is presented in Radiographers' responses to the question ""How has your experience been during COVID-19?" were read and reread to obtain a general sense of the data. The data was then coded and categorised yielding three themes: New work flow and operations, effect on radiographer well-being and radiographer resilience. Medical imaging departments' operations were affected by the decrease in imaging referrals at the onset of the lockdown. 49 Even though it has been viewed as an opportunity to address "overuse and overdiagnosis" 50 , the reduction in imaging referrals, has resulted in some radiographers in the private sector experiencing pay cuts: J o u r n a l P r e -p r o o f "…since the lockdown patients were advised not to come to the hospital unnecessarily and with that in private sector, we were affected economically. Less patient=less profit to the company then salaries we cut off" R34 Radiographers' experiences confirm the introduction of new work flow and operations as well as the need to conform to new changes. [26] [27] [28] [29] The quotes below convey radiographers' experiences of the changes: "During this pandemic we've also had to work extended hours at the hospital (12 hour shifts for 7 days and then 7 days off which I feel also adds to the exhaustion." R10 "…So my experience has been okay and at times difficult as we divided ourselves into teams" R7 Comparably, worldwide medical imaging departments have adapted operations to mitigate cross-contamination and staff shortages. [26] [27] [28] However, an 84 hour work week as indicated by R10, despite the time off, constitutes prolonged working hours. Prolonged working hours raise concern of health and safety as well as increasing the risk of respiratory disease. 54, 55 J o u r n a l P r e -p r o o f Radiographers shared their experience of medical imaging departments implementing stringent infection control measures that affected work flow and operations. [26] [27] [28] 56 Their responses ranged from having access to sufficient PPE to lack of PPE; lack of disinfectants as well as delayed testing and provision of results. 60 Radiographers' experiences of infection control measures are shared through these direct quotes: "… At least we have PPE." Radiographers routinely wear gloves and practice handwashing in daily practice however now continuous use of masks and face shields was described as "stifling" and as "not being able to breathe properly". 34 Radiographers describe being sad, terrified, confused, stressed, scared, exhausted, anxious, overwhelmed, frustrated, uncertain and panicked. Their "roller coaster" of mixed emotions has stirred up an "emotional war" draining them emotionally, physically, financially and mentally. [33] [34] [35] Seeing patients out of breath, deteriorate, being ventilated and dying; in the same way, seeing colleagues falling ill and some dying, take a toll on radiographer's mental health. Radiographer's mental health is marauded even further by not being able to see family and friends coupled with the anxiety of contracting and transmitting the disease. [33] [34] [35] There is also the notion that healthcare workers are not human and therefore should cope. 28 These descriptions are reflected in the following quotes: Yet some radiographers report being told that "staff" are overreacting. During the SARS epidemic radiographers were motivated through the crisis by reassurance. 57 "I, for one know that at work, we were often told "staff is overreacting" so I fought this and I felt a lot of emotional and mental strain on myself" R51 Not being considered frontline workers, a concern echoed by professional bodies impacts allocation of resources as well as radiographers' well-being: [58] [59] [60] [61] [62] [63] [64] "It has been rather negative, as we do not get proper personal protective equipment (PPE), we are not recognized as Frontline workers, and we are not considered by our hospital." R48 "Very nerve wrecking. It's a learning curve so you have to be on guard all the time. Being a radiographer, you are essential but not considered total frontline. With everyone testing the waters it's difficult to have proper guidelines." R15 There was also concern about the volumes of COVID-19 information. Information overload coupled with misinformation and conspiracies results in psychological distress. 65, 66 "At the beginning there was very limited factual information about the virus itself and an overload of information about different theories/conspiracies about covid-19 and this has in turn resulted in so much confusion and difficulty to find the path of how to deal with the situation and find a way forward. There were many arguments and different opinions of how one should go about doing things." 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The piece was The novel coronavirus (COVID-2019) outbreak: Amplification of public health consequences by media exposure Analysts are tracking false rumours about COVID-19 in hopes of curbing their spread Reality shock in radiography: fact or fiction? Findings from a phenomenological study in Durban Reducing the burden of injury in high-risk communities The burden of trauma at a district hospital in the Western Cape Province of South Africa The lived experiences of radiographers in Gauteng. The SA Radiographer Thematic Review of Social and Occupational Factors Associated With Psychological Outcomes in Healthcare Employees During an Infectious Disease Outbreak J o u r n a l P r e -p r o o f Moreover, they face mental, physical, emotional and financial challenges. However, honing the positives, they have initiated strategies towards resilience. Thank you to all the radiographers working in the frontline, who shared their experiences during this pandemic.The authors would like to acknowledge Maxine Maistry, first year WITS undergraduate Fine Arts student, for graphically representing this study.