key: cord-0768969-1r8t8yxv
authors: Tay, Yi Xiang; Cai, Sihui; Chow, Hwei Chuin; Lai, Christopher
title: The needs and concerns of clinical educators in radiography education in the face of COVID-19 pandemic
date: 2020-10-19
journal: J Med Imaging Radiat Sci
DOI: 10.1016/j.jmir.2020.10.004
sha: b1b9aa99529c9bbf8aeba6cf44e59a62f0adf705
doc_id: 768969
cord_uid: 1r8t8yxv

nan

It has been more than 8 months since Singapore reported its first COVID-19 case on January 23 rd , 2020 1 . Since then, there have been more than 57, 000 cases and have resulted in 27 deaths in Singapore from the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which was first detected in Wuhan, China 2 . Having experienced SARS outbreak in 2003 which resulted in 33 deaths including healthcare worker, the feeling of déjà vu was vivid 3 . Risk measures were implemented and strengthened progressively as the situation escalated, both globally and in Singapore.

Initially, public health interventions were raised to contain the first COVID-19 wave, allowing schools and most businesses in Singapore to remain open 4 . However, despite the measures to contain the outbreak, community cases increased, and infections began to surface in the population of foreign workers housed in dormitories across the island 4 . In response, nationwide strict restrictions in the form of a "circuit breaker" was instituted by the Singapore government -resulting in closure of schools and all non-essential businesses, forcing majority of the population to be confined to their homes 4 . In tandem, education of healthcare professionals was also affected, including the clinical training of radiographers 5 .

Like nursing, midwifery and many allied health education programmes, clinical training is an important cornerstone of radiographer education -equipping students to safely and competently transit into complex healthcare environments 6, 7 . During clinical training, students are supported by clinical educators who are usually registered professionals who facilitate clinical education alongside clinical and J o u r n a l P r e -p r o o f academic colleagues 8 . Collectively in Singapore, a clinical educator may be a radiographer formally appointed by an academic institution or have education and training role recognised within their job role. Formal appointed clinical educators differ from the latter as they are primarily responsible for signing off competency and evaluation, based upon standards provided by academic institutions. Nonetheless, all clinical educators are expected to support students in the workplace to gain appropriate experience and skills. Similar to Singapore, many countries have undertaken drastic measures to prevent further spread of the virus. This has substantially affected clinical training where clinical placement are suspended or clinical exposure has significantly reduced 9 .

Thus, it is important to ensure that clinical educators are successful at responding to this challenge of maintaining high-quality clinical training amid the pandemic. This paper aims to provides insights on the needs and concerns of clinical educators in the face of the COVID-19 pandemic. Drawn from the first-hand experiences as clinical educators from one of the tertiary hospitals in Singapore, this paper examined the ways in which clinical educators faced during the health crisis while facilitating the clinical radiography teaching. This will serve as a springboard for other educators who must overcome the massive and rapid change made during this period to continue to facilitate and improve clinical training.

The SARS epidemic posed many challenges in radiography service, but valuable lessons learnt enabled progression in many areas, including clinical education 10 .

Lessons from SARS could be translated to COVID-19 -innovations and contingency J o u r n a l P r e -p r o o f plans that allowed clinical teaching to continue without actual patient contact 11 . As majority of the young clinical educators did not experience the uncertainties and damaged caused by the 2003 SARS outbreak, many could not relate to the painful chapter of the outbreak. Inevitably, it was difficult for some to stay calm when this new and unknown bug emerged in Wuhan and subsequently imported into Singapore.

The clinical educators' ability to deal with disruptions were first tested at our hospital when international students' clinical training was disrupted at the onset of the outbreak. Such a decision not only cause the students to suffer financial losses, but also loss of opportunities of acquiring additional competencies gained in a foreign healthcare system 7 . Nevertheless, it was clear that such decisions were deliberated and never made lightly with priority and emphasis on the health and well-being of all students, staff and patients. However, as all the overseas students were selffinanced, the potential of additional emotional and psychological challenges had to be considered 12 One of the ways of support for the clinical educators came in the form of encouragement from notes of appreciation and gifts from the public, and the hospital senior managements to all frontline heroes -showing how much their efforts were valued through these gestures of care and appreciation. Moreover, as highlighted in the editorial by Gibbs 20 , the pandemic has driven teamworking of radiographers, supports motivation and improves psychological well-being. Coupled with encouragement among colleagues, there was a sense of safety and togetherness 19 .

This provided much-needed encouragement for the clinical educators to work even harder, to remain unfazed and to press on for the education of the future radiography profession.

As the clinical educators prepared to welcome the return of radiography students in their penultimate year, it was essential to understand the perspectives from these students who had to recover lost ground after missing months of clinical experience while dealing with the threat of delayed graduation 21 In fact, many COVID-19 era publications surfaced, advocating the importance on reporting students' perspectives 16, [23] [24] [25] . These publications were also timely as many of our current students were Generation Z (born in 1997 or later), and educators (baby boomer/generation X and millennial); preventing a "culture clash" as a result of generational difference in medical education 4 . Generation Z consists of active problem solvers, independent learners and learners who are better technological integrated, but with increased risk of suffering from psychological distress 4 . Indeed, these characteristics of Generation Z students will certainly affect how clinical educators provide education in the COVID-19 pandemic.

In the radiography profession, clinical placement is crucial to develop knowledge and skills acquired theoretically -allowing students to consolidate knowledge, socialising into the radiographer role and acquiring values 26 . In a commentary on the perspectives of student radiographers in Singapore, the students highlighted their need to put theories into practice to bridge the gap between the two 24 . This phenomenon of theory-practice gap had been identified across multiple healthcare disciplines and might have implications on professional competence and future progression from student to novice professional 27 While clinical placements had resumed, the duration, movement and rotation were reduced. The return of students for clinical placement was also staggered and numbers of students kept to minimal. This was in line with the practices in the United Kingdom (UK), Australia, and North America where students were to learn in much smaller and stable social bubbles 28 . Modification was also made to the clinical assessment -previous summative clinical examination conducted by academic institution appointed examiner had been replaced with multiple formative assessments throughout the duration of the clinical placement. Like the medical students, radiography students must comply with strict personal hygiene, physical distancing and were not allowed to enter high-risk areas nor participate in risky, aerosol-generating procedures 4 . Clinical educators were instituted to ensure that students comply with the risk control measures, while focusing on the students' core clinical learning outcomes and competencies 4 .

These made teaching and supervising students in clinical settings more challenging than pre-COVID. In similar vein, midwifery educators who shared comparable workplace characteristics with the radiographers -mainly not possible to maintain physical distancing in the line of work but had to deliver effective education safely, echoed similar concern 7 . It was undeniable that academic institution had tried to reduce demands on the Learning can take place everywhere and COVID-19 has forced us to rethink the educational strategies for the Generation Z students. As the COVID-19 situation evolved, all non-essential appointments and elective procedures had to be deferred as part of enhanced safe-distancing measures. Radiographic examinations were reduced and impacted on the students' hands-on opportunity. Their movement were restricted, and they could only have placement in low risk areas. These posed a potential challenge to the Generation Z students who preferred hands-on experience and on-the-job-learning 36 . As clinical educators, they had to mitigate the loss in learning opportunity based on the profile of the students. The student to educator ratio of 2:1 was reduced to 1:1, and it allowed an increased direct observation of the assigned student and other teaching opportunities such as self-reflection and roleplaying 35 . With the new ratio, clinical educators were able to provide the students with more guidance, frequent immediate feedback and encouragement to learn from their mistakes -meeting the Generation Z students' learner perspectives [36] [37] . Since it was emphasis to all clinical educators at the onset that they had to jointly teach and meet service requirements, clinical educators were more prepared. With the youngest generation now entering clinical placement, clinical educators had to modify their teaching strategies to account for the learner perspectives.

Transformation includes strong mentoring relationships, collaborative work with ground radiographers, reflective activities, real-time feedback, frequent interactions, case-based learning and more importantly technology in education [35] [36] [37] . The pandemic had caught the clinical educators unprepared in the incorporation of technology into teaching, and presented a diversion from the traditional methods of teaching. Perhaps, it would be timely for clinical educators to consider creative ways such as interactive tutorials and the use of social media sites 35, 36, 44 .

In times of uncertainty, it was crucial for clinical educators to actively manage the well-being of students. The COVID pandemic would likely lead to increased distress and burnout of the students given the dramatic changes to their learning environment and plans 6, 9 . The negative well-being could lead to depression, burnout and anxiety 45 . This was of great concern as Generation Z was shown to be more prone to psychological distress than earlier generations 37 . When a radiographer working at the community care facility was reported to have tested positive for COVID-19, there was fear that the student's psychological well-being would be affected 46 . In concordance with the approaches adopted by the medical educators, J o u r n a l P r e -p r o o f clinical educators checked-in with the students through electronic communication and provided reassurance on the risk measures in the clinical environment 9, 47 . It was crucial for the clinical educators to be available on demand while providing support to normalise stress. In addition, clinical educators worked to develop a sense of belonging and safety for the students 47 . Routine instructions from the hospital disease outbreak taskforce were disseminated regularly to the students. Students were also invited to attend radiographers' continuing professional development sessions and radiographers' led tutorials -creating a community for the students in the face of physical distancing 47 . In addition, like the radiographers, students were also issued tokens of appreciation -recognising them for their dedication and hard work, supporting their esteem and well-being needs 47 .

With no silver bullet in sight to the end of COVID-19, clinical education would be subjected to further circumstances beyond our control. However, regardless of the circumstances, it is still fundamental that students need the opportunity, under supervision, to experience and learn to practice safely in a pandemic work environment. Moreover, clinical educators must now consider the new generation learners' perspective and help support their learning. The battle may be long but with creativity, resiliency and perseverance, clinical educators can adopt clinical teaching practices to meet dynamic and complex student demands complicated by the evolving pandemic. This will future proof the radiography workforce in preparation for the next global challenge, lest not having radiographers ready to meet Singapore's evolving healthcare demands.

J o u r n a l P r e -p r o o f

Six months of Covid-19 in Singapore: A timeline. The Straits Times; 2020

Updates on COVID-19 local situation

SARS in Singapore--key lessons from an epidemic

Perspectives on COVID-19 from Singapore: Impact on ESKD Care and Medical Education

COVID-19 and Health Professions Education: A 360° View of the Impact of a Global Health Emergency

Strategies to develop student support mechanisms in medical radiation sciences clinical education

Midwifery education in COVID-19-time: Challenges and opportunities

The Society of Radiographers. Practice Educators Accreditation Scheme

COVID-19: Challenges and Opportunities for Educators and Generation Z Learners

COVID-19 and medical education

The challenges of "continuing medical education" in a pandemic era

M Transnational connections, competences and identities: Experiences of Chinese international students after their return "home

Psychosocial impact of COVID-19 outbreak on international students living in Hubei province

Skills Framework for Healthcare

Future radiographers must be 'adaptable' and 'creative'; 2010

Understanding the consequence of COVID-19 on undergraduate medical education: Medical students' perspective. Annals of medicine and surgery

Stress and parenting during the global COVID-19 pandemic. Child abuse & neglect. 2020;104699. Advance online publication

The experiences of health-care providers during the COVID-19 crisis in China: a qualitative study. The Lancet. Global health

The Covid-19 pandemic: Provoking thought and encouraging change

COVID-19: consequences for higher education

Expectations of therapeutic radiography students in Wales about transitioning to practice during the Covid-19 pandemic as registrants on the HCPC temporary register

Nursing students' views on the COVID-19 pandemic and their perceived stress levels

Coping with COVID-19: Perspectives of Student Radiographers

Perspectives of medical students on local medical education during COVID-19

Dichotomy between theory and practice in chest radiography and its impact on students

Research Informed Teaching Experience in Diagnostic Radiography: The Perspectives of Academic Tutors and Clinical

Placement Educators

Challenges to medical education at a time of physical distancing

Failure of faculty to fail failing medical students: Fiction or an actual erosion of professional standards

Struggle and failure on clinical placement: a critical narrative review

The failure to fail underperforming trainees in health professions education: A BEME systematic review: BEME Guide No. 42

Struggle and failure on clinical placement: a critical narrative review

Professional Integrity and the Role of Medical Students in Professional Self-Regulation

Chinese Business Face: Communication Behaviors and Teaching Approaches

Generation Z: What's Next?

Is Medical Education Ready for Generation Z?

Several Ways Generation Z May Shape the Medical School Landscape

Clinical supervision in primary health care; experiences of district nurses as clinical supervisors -a qualitative study

Finding ways to support radiographers as teachers

Educating clinical educators: using a model of the experience of being a clinical educator

Supervision -guidance for occupational therapists and their managers

What impact do students have on clinical educators and the way they practise

An investigation of nurse educator's perceptions and experiences of undertaking clinical practice

How and why are educators using Instagram

Understanding Singaporean medical students' stress and coping

Singapore reports 741 new COVID-19 cases, including healthcare workers at Singapore Expo community care facility. ChannelNewsAsia; 2020

Leading Change to Address the Needs and Well-Being of Trainees During the COVID-19 Pandemic