key: cord-0788895-uuovj96r
authors: Ng, Curtise K.C.
title: A Review of the Impact of the COVID-19 Pandemic on Pre-registration Medical Radiation Science Education
date: 2021-08-04
journal: Radiography (Lond)
DOI: 10.1016/j.radi.2021.07.026
sha: 1b1c1b40e9900e5e9b34b4edee5a60e86cc22a6c
doc_id: 788895
cord_uid: uuovj96r

Objective The COVID-19 pandemic has changed traditional ways to provide pre-registration medical radiation science (MRS) (medical imaging and radiation therapy) education. This literature review explores the published pre-registration MRS education curriculum adaptations implemented in response to the pandemic and effects of the adaptations on stakeholders. Key Findings Eleven articles were identified through a systematic literature search. The included articles covered the pre-registration MRS curriculum adaptations implemented in response to the pandemic in 12 countries of five continents. Through changing content delivery and assessment modes from face-to-face to online, non-practical classes and academic assessments could continue without significant interruptions. However, cancellation/postponement of practical classes and clinical placements was common during COVID-19 lockdown. Simulated learning was used by some institutions to replace some practical classes and placements. Among the stakeholders of MRS education (students, academics and clinical educators), the students were most affected. The main impacts were negative psychological effects and learning experiences. For the academics, they had common concerns about online learning quality and assessment integrity. Conclusion This review of the early publications in the first year of the pandemic provides an illustration of the MRS curriculum adaptations implemented in five continents covering both English and non-English speaking countries and their effects on the stakeholders as yet. It is expected that more articles on this area will be published over time and hence allowing a more comprehensive review in the future. Implications for Practice The included articles show provision of wellbeing support, good planning of online content delivery based on sound pedagogical approaches, implementation of computer-based simulation tools suitable for home-based learning environment and use of authentic online assessments would address the impacts on the students and academics.

In December 2019, cases of coronavirus disease 2019 (COVID- 19) were first reported in Wuhan, China. Since March 2020, the COVID-19 has become a global pandemic and caused significant impacts on everyone. 1 In response to the pandemic, restrictions of gathering and movement have become standard strategies for infection control. 2 These have subsequently changed traditional ways to provide pre-registration medical radiation science (MRS) (medical imaging and radiation therapy) education for ensuring continuity and supply of medical radiation practitioners (MRPs) (diagnostic radiographers and radiation therapists).

The common changes include teaching delivery mode (from face-to-face to online) and cancellation / postponement / replacement of activities such as practical classes and clinical placements. [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] Although these changes have a certain basis such as education literature about online and simulated learning, their rapid implementation implies many of these were not planned in advance. 2, 12, 13 After more than a year of the onset of the pandemic, COVID-19 is still not under control worldwide. It may take several years to end it. 14 Sustainable strategies for providing quality pre-registration MRS education that is able to meet fitness for practice, fitness for purpose and fitness for award requirements need to be determined. 5, 15 Literature reviews about the adaptations of learning and teaching approaches for undergraduate radiology and nursing educations have been published elsewhere. 16, 17 However, apparently, such review has not been available for the MRS profession yet. It is timely to review the literature about the COVID-19 impact on the pre-registration MRS education as a first step to determine the sustainable strategies for the 'new normal'. The purpose of this literature review is to explore the published articles to answer the question "What were the pre- process. 21 The year range chosen should cover all articles about the COVID-19 published in journals as yet. 14 The search statement used was ("Radiography" OR "Medical Radiation Science" OR "Medical Imaging" OR "Radiation Therapy" OR "Radiotherapy") AND ("Education" OR "Training") AND ("COVID" OR "Coronavirus"). The selected keywords were based on the review purpose but not specific to the pre-registration curriculum adaptations in response to the pandemic and their effects on the stakeholders for minimising potential omissions of the relevant articles. Inclusion criteria were the articles written in English, published within the peer-reviewed journals and focussed on the pre-registration MRS education curriculum adaptations in response to the COVID-19 and / or the effects of the changes on the stakeholders. Conference abstracts and review articles were excluded as information provided in the former tended to be incomplete and the latter could only provide secondary information. 22, 23 J o u r n a l P r e -p r o o f After duplicate articles were removed from the database search results, the remaining articles were screened via a three-stage process (by evaluating 1. titles, 2. abstracts, and 3. full texts) against the exclusion criteria (conference abstracts, review articles, published before 2019, not written in English, not from peer-reviewed journals, not focussed on the pre-registration MRS education curriculum adaptations in response to the COVID-19 and / or the effects of the changes on the stakeholders). Each non-duplicate article identified through the database searching was included until a decision on its exclusion could be made (Fig. 1) . 24 As the COVID-19 emerged less than two years ago, it was expected that not many relevant original research papers had been published. It was decided to use a narrative approach for this literature review. Hence, editorials and commentaries were included to provide a more holistic illustration of the adaptations implemented and their effects. 17, 25 All references cited in the included articles were checked for identifying additional, relevant papers. Quality assessment tool for studies with diverse designs (QATSDD) was used to assess quality of the included papers. The QATSDD was chosen because it could evaluate the quality of studies with diverse research approaches (e.g. quantitative, qualitative, mixed methods, etc.) with good reliability and validity. 26 The included papers were categorised into low (<50%), moderate (50%-70%) and high (>70%) qualities based on their QATSDD's quality assessment scores expressed as percentages. 24 half of its second and third year students worried about having the clinical placements during the pandemic due to increased chances of COVID-19 infection at the clinical centres and during travelling, and transmitting the COVID-19 to family members. 9 The SIT's students also expressed concerns about the reductions of clinical placement lengths and case volumes which affected their clinical competence development, and expected that the SIT should adjust corresponding case report assignment requirements accordingly. 11 To address these students' concerns, the SIT's academics and clinical educators worked collaboratively to provide special arrangements for resuming the placements. These included provisions of online refresher infection control training and enhanced clinical placement information packages prior to the placements, better placement site allocation for shortening travel time, daily twice temperature monitoring, reduction of educator-student ratio to 1:1 with dedicated clinical educators, removal of placements in emergency department (ED) and intensive care unit (ICU), change of assessment mode from summative to multiple formative, uses of simulated learning in physical MRS laboratories to address any clinical competence gaps and WhatsApp Messenger (Facebook, Inc., California, USA) for enhancement of communication between the students and the educators, and provision of wellbeing support. 8, 9 However, the resumption of clinical placements also increased pressure faced by their clinical educators due to handling backlog of cases and supervising the students at the same time, and failing underperforming students affected by the reduction of clinical exposure. Recognitions from public and hospital management, and supports from the academic institution, clinical educator workshops and experienced educators were considered essential to address these issues. 10 For other countries such as UK, 27 cancelled / postponed their medical imaging and radiation therapy placements during the lockdown but allowing their nuclear medicine students who started the placements before the lockdown to continue. 4 Remote access to computer-based simulation (CBS) software was arranged for their radiation therapy students as a replacement for some clinical placements. 5 The adaptation of the placement arrangement did not need their regulatory body approval provided that the learning outcomes of the course remained unchanged. 4 An online questionnaire survey study involving 274 USA MRS academics showed more than 70% of the participants felt comfortable with modifying their clinical placement arrangements in response to the lockdown. Nearly all (92.7%) of the respondents suspended the placements and about half (48.9%) used the simulated learning to replace them, leading to a median clinical hour reduction of 150 hours in one semester. 12 For the online questionnaire survey study involving 1,277 MRS students from 12 countries of five continents by Rainford et al., 7 they indicated that the majority of students in many countries were removed from the clinical placements at the early stages of the pandemic based on anecdotal evidence but their survey finding showed nearly half of their participants J o u r n a l P r e -p r o o f were required to complete the clinical training between January and June 2020 for maintaining the future MRS workforce numbers. About two thirds of the participants indicated various levels of concern about having the placements during the pandemic and their levels of concern were associated with their domestic and health circumstances. The students who had the underlying health conditions or lived with family members having the underlying conditions expressed higher levels of concern while the final year students and recent graduates were statistically significantly less likely to have any worry (p<0.05). This was because the underlying health conditions such as cancers and chronic lung diseases were risk factors for severe COVID-19 illness. About one fifth of the participants indicated that they were unconfident in using personal protective equipment and dissatisfied with placement arrangement communication. Also, half of them expressed a concern about completion of clinical assessments in a timely manner due to limited case availability.

Unlike the clinical placements, the learning and teaching activities, and the assessments for the academic component of the MRS courses could continue in most cases even during the lockdown but with the online formats. 2,4-6,11,12 Learning management system (Blackboard Regarding the delivery of practical classes which was more challenging when compared to non-practical ones such as lectures, workshops and tutorials, the CBS software was used by some survey participants (USA MRS academics) of Webster and Clark. 12 However, their participants also indicated synchronous virtual tours of clinical facilities via the online conferencing platforms such as Zoom could be used to cover some practical activities. Currie et al. 5 used a similar approach in Australia to demonstrate practical skills to their students through asynchronous practical videos but requiring their students to complete intensive faceto-face laboratory sessions after the lockdown. Nevertheless, when there was no creative way to provide the online practical classes, these classes might be removed from the MRS courses. For example, the practical classes were removed entirely from the SIT's MRS course, negatively affecting its students' learning experience. 11 In spite of the aforementioned positive findings reported by Webster and Clark, 12 50% of their participants (USA MRS academics) expressed a concern about online learning quality.

Teo et al. 11 indicated that the students' suboptimal online learning experience in Singapore was due to a lack of appropriate home-based learning environments and immediate feedback provided by their lecturers, and different students' study paces affecting subsequent group J o u r n a l P r e -p r o o f discussions. However, these negative students' experiences seemed contradictory to findings of the online collaborative enquiry-based learning study by Higgins et al. in UK. 6 The online collaborative enquiry-based learning was a pedagogy emphasising online collaboration between peers to learn practice related concepts through research. To enhance the collaboration, the Microsoft Teams instead of the Blackboard Learn was used for sharing documents, asynchronous and synchronous discussions between the students, and academic staff to provide real-time support and feedback online. These instructional strategies for the online learning were carefully designed to address the common issues of the online learning such as a lack of student-student and student-tutor interactions, leading to the positive students' learning experiences. For example, the majority (68%-91%) of their students indicated strong agreements on both task value and self-efficacy for learning and performance within this online experimental research module despite that their students' academic results of this module were not evaluated specifically. 6 Hence, this demonstrated the importance of having the MRS academics to work with their institutional instructional designers for adapting the content delivery mode to achieve the quality online learning. 12 However, for the delivery of research module online, just changing the instructional strategies was not adequate because data collection might be prohibited during the lockdown. For Higgins et al., 6 they provided experimental data to their students for completing the research module. Currie et al. 5 indicated that some of their honours research project students were required to change research directions to non-human contact-based studies as a remedy. Also, there is a lack of standard approaches for the adaptations which can be due to a great variation of circumstances (e.g. frequencies and durations of the lockdown, COVID-19 restriction types, resource availabilities, etc.) in different countries / regions / institutions. [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] Similar findings are also noted in the literature reviews about the adaptations of learning and J o u r n a l P r e -p r o o f teaching approaches for the undergraduate radiology and nursing educations during the COVID-19. 16, 17 Although the simulated learning is commonly reported as the replacement for some clinical placements and practical classes, the simulations in the physical MRS laboratories and use of immersive three-dimensional (3D) virtual reality (VR) simulation tools such as VR software by Virtual Medical Coaching Ltd (Christchurch, New Zealand) and VERT (Vertual Ltd., East Yorkshire, UK) may not be feasible during the lockdown. 5, 9, 13, 29 The CBS programs such as Shaderware Virtual Radiography (Darlington, UK), MRI Simulator (The Institute for Advanced Clinical Imaging, Georgia, USA) and Netrad (administered by University of Sydney, Cumberland, Australia) which are more readily applicable to the home-based learning environment are more COVID-19 compliant. 5,24 However, with preparations in advance, it is feasible for the students to utilise some immersive 3D VR simulation tools at home. For example, the VR software by Virtual Medical Coaching Ltd only requires generally available equipment such as HTC Vive Pro headsets and hand controllers (Taoyuan, Taiwan) for using it in the home-based learning environment. 29 With the high fidelity simulation tools, this might allow international MRS students to continue studying online for an extended period due to COVID-19 travel restrictions. 13, 30 Nevertheless, findings of a survey study with 205 Australian academic, clinical and accrediting stakeholders published in 2011 shows that even for a well designed simulated learning program, it could only replace about 10-20% of clinical hours of a MRS course. 31 Also, according to recent literature reviews, 13,24 effectiveness of the simulated learning including the CBS has only been evaluated based on perceptions of the students and MRS academics rather than the students' actual competencies. Given the less predictable, intermittent nature of the lockdown and the recent advancements of the high fidelity simulation tools, 29,32,33 management of academic institutions should at least consider making an investment in these high fidelity simulation products for minimising the potential cancellation / extended delay of the clinical placements and the practical classes in the future. 12, 13 Apparently, among the stakeholders, the MRS academics have been least affected by the adaptations and their students have been most affected. [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] Nevertheless, the challenges faced by the MRS academics cannot be underestimated. For example, it is difficult to work from home for changing and delivering the MRS curriculum when optimal work environments such as free from distractions, reliable internet and adequate bandwidth are not available. The adaptations also create uncertainties and cause extra workload to the academics and hence increasing their stress together with the general COVID-19 impacts such as worries about getting infected and potential redundancies, and feeling isolated despite that peer support through informal online meetings regularly may help to address some of these. 5 Besides, the institutional instructional designers would be good resource people to support the academics in adapting the curriculum for achieving good student learning outcomes and hence relieving some of their stress potentially. 12 For the impacts of the MRS curriculum adaptations on the stakeholders reported in all included articles except Ng's study, they are only based on the perceptions of the stakeholders. [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] Similar issues are also noted in the literature review about the adaptations of learning and teaching approaches for the undergraduate nursing education during the COVID-19. 17 Hence, future studies should be conducted to objectively assess these impacts.

For example, clinical performance of newly registered MRPs who have experienced the J o u r n a l P r e -p r o o f adapted curriculum should be evaluated to ensure that they are fit for purpose. 15, 17 Longitudinal studies about the academic performances of the students who have experienced the online learning during the pandemic should also be conducted. 2 Besides, only one person was involved in the article selection and quality assessment processes leading to potential bias. Nonetheless, it is expected that the use of PRISMA guidelines and QATSDD for these processes can address the bias issue to some extent. 26, 34 Conclusion This literature review reveals the pre-registration MRS curriculum adaptations implemented in response to the COVID-19 pandemic in 12 countries of five continents. Through changing the content delivery and assessment modes from face-to-face to online, the non-practical classes and the academic assessments could continue without the significant interruptions.

However, the cancellation / postponement of the practical classes and the clinical placements J o u r n a l P r e -p r o o f was common during the COVID-19 lockdown. The simulated learning was used by some institutions to replace some practical classes and placements.

Among the stakeholders of the MRS education, the students were most affected. The main impacts on them were the negative psychological effects and learning experiences. For the academics, they had the common concerns about the online learning quality and the assessment integrity. It is suggested that the provision of wellbeing support, the good planning of online content delivery based on the sound pedagogical approaches, the implementation of CBS tools suitable for the home-based learning environment and the use of authentic online assessments should be able to address these issues to some extent.

However, all but one of the included articles have not objectively assessed these impacts.

Also, their long-term consequences have not been explored yet. Further research is warranted for determining the sustainable strategies for the 'new normal'. 

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I wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome.I confirm that the manuscript has been read and approved by the named author and that there are no other persons who satisfied the criteria for authorship but are not listed. I further confirm that the order of author listed in the manuscript has been approved by myself.I confirm that I have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication, including the timing of publication, with respect to intellectual property. In so doing I confirm that I have followed the regulations of my institution concerning intellectual property. I further confirm that any aspect of the work covered in this manuscript that has involved either experimental animals or human patients has been conducted with the ethical approval of all relevant bodies and that such approvals are acknowledged within the manuscript.