key: cord-0931524-8hfl0tw8
authors: Naylor, Sarah; Booth, Sarah; Harvey-Lloyd, Jane; Strudwick, Ruth
title: Experiences of Diagnostic Radiographers through the Covid-19 pandemic
date: 2021-10-28
journal: Radiography (Lond)
DOI: 10.1016/j.radi.2021.10.016
sha: fd6a352f58cc58833d8925ec06900e1dab16cd19
doc_id: 931524
cord_uid: 8hfl0tw8

Introduction Diagnostic Radiography plays a major role in the diagnosis and management of patients with Covid-19. This has seen an increase in the demand for imaging services, putting pressure on the workforce. Diagnostic radiographers, as with many other healthcare professions, have been on the frontline, dealing with an unprecedented situation. This research aimed to explore the experience of diagnostic radiographers working clinically during the Covid-19 pandemic. Method Influenced by interpretative phenomenology, this study explored the experiences of diagnostic radiographers using virtual focus group interviews as a method of data collection. Results Data were analysed independently by four researchers and five themes emerged from the data. Adapting to new ways of working, feelings and emotions, support mechanisms, self-protection and resilience, and professional recognition. Conclusion The adaptability of radiographers came across strongly in this study. Anxieties attributed to the provision of personal protective equipment (PPE), fear of contracting the virus and spreading it to family members were evident. The resilience of radiographers working throughout this pandemic came across strongly throughout this study. A significant factor for coping has been peer support from colleagues within the workplace. The study highlighted the lack of understanding of the role of the radiographer and how the profession is perceived by other health care professionals. Implications for practice This study highlights the importance of interprofessional working and that further work is required in the promotion of the profession.

In December 2019 the World Health Organisation was notified regarding cases of pneumonia with unknown aetiology in Wuhan City (1) . A rapid global spread of the disease lead to the declaration of a pandemic known as Covid-19. On 13 th March 2020, the World Health Organisation declared that Europe was at the centre of a pandemic and as of 14 th October 2021, there have been 238,521,855 cases worldwide (of which 8,231,441 cases were in the United Kingdom (UK) and 4,863,818 deaths (of which 137,944 were in the UK) (1) . Due to the continuous discovery and resurgence of new variants, the pandemic continues to challenge even the most well-established healthcare systems (1) .

From the onset, it was quickly established that chest radiographs and computed tomography (CT) scans of the chest have played a significant role in the diagnosis and management of patients presenting with Covid-19 (2) (3) (4) . This has resulted in the demand for imaging services being increased, as the National Health Service (NHS) has faced increasing pressure to respond to the pandemic and the needs of the UK population (5) . Diagnostic radiographers across the UK have been on the frontline, dealing with an unprecedented situation in which there have been large volumes of very unwell patients who have needed repeated imaging to effectively manage their complex needs in an attempt to aid recovery.

There was much uncertainty around the nature and spread of the virus leading to concern about the impact on the health service. A multinational study exploring physical symptoms among healthcare workers during the Covid-19 outbreak found that headaches were the most commonly reported, suggesting this is associated with personal protective equipment (PPE) (6) . Migraines were also reported, possibly related to increased adverse psychological experiences which healthcare workers may need support for (6) . There were also reports of lethargy and fatigue. A UK-based study exploring the challenges faced by frontline workers in health and social care amid the pandemic using interviews as a method of data collection found a lack of preparedness for the pandemic with no clear strategic policy (7) . Participants expressed a severe shortage of PPE, feelings of anxiety and fear, challenges of enforcing social distancing, and social shielding responsibility for family members (7) . Hospital personnel may be stressed by the challenges of prolonged response to the pandemic (8) . This emphasises the importance of self-care, ensuring workers have adequate rest and can attend to personal needs such as the care of a family member (8) . It was also suggested that health workers dealing with the situation may experience moral injury or mental health problems (9) . Moral injury can occur when exposed to trauma that a person feels unprepared for, stressing the need for preparing and supporting staff for encountering moral dilemmas they may face during the pandemic. They also raise the issue of after-care once the crisis is over, and the need for supervision (9) . The Society of Radiographers (10) recognise the need to support the well-being, emotional and mental health of radiographers, recognising that with the increased demands on imaging services staff may J o u r n a l P r e -p r o o f experience significant stress and anxiety. Despite these challenges, an editorial in the Lancet identified that health care workers have shown an incredible commitment and have demonstrated compassion in these challenging and dangerous conditions (11) . This research aimed to explore the experience of diagnostic radiographers working clinically during the Covid-19 pandemic.

The overarching approach to this research was influenced by interpretative phenomenology. It explored individual's lived experience and how they made sense of that experience (12) . The ideographic nature of the research meant that it involved a small number of participants focussing on each case in detail, aiming to gain understanding from that experience (12) . It is thought that by probing deeply into participant's accounts, general themes that are common to others can be illuminated or affirmed (13) . In keeping with this qualitative methodology, focus group interviews using a semi-structured interview schedule (Table 1) were used as the primary source of data collection (14) . Data were recorded, transcribed verbatim, and each researcher closely examined the data to identify patterns of meaning that came up repeatedly. The important factors considered when undertaking the analysis included double hermeneutics, reflexivity, immersion in the data, and the balance of emic and etic positions which was required as the researchers are all diagnostic radiographers. This was achieved through repeatedly reading the transcripts and becoming familiar with the content, followed by discussion between the researchers. The interpretive process is grounded in the participant's account of the experience in their own words (15) . Stages of analysis included an initial review to look for patterns, or themes. These emerging common issues were then discussed to interpret the data and explore meaning (16) . This reflective process aimed to reduce the influence of the researcher and maximise the validity of the findings. To establish the credibility of this study, different strategies were utilised, including member checking for respondent validation, peer-review J o u r n a l P r e -p r o o f between the researchers, reflexivity, a thoughtful self-awareness and by utilising the participants' accounts in the write-up (17) . Purposive sampling was utilised. Diagnostic radiographers were recruited via an invitation on social media. A poster containing information about the study and who to contact was shared via the professional networking platforms of Twitter and Linkedin. Anyone who responded to the advert who met the criteria of working as diagnostic radiographers throughout the pandemic irrespective of their speciality was invited to a focus group interview. An information letter and consent form were sent for their consideration. Four focus group interviews across a period of two months were held using a virtual platform with between two and five participants. There was no coercion and participants were provided with an information sheet electronically to inform their decision on whether to participate. Written consent was obtained via email before the data collection. Ethical approval for the study was granted from the researcher's universities of Derby, Suffolk, and Salford. Quotes have been anonymised and limited demographical information has been provided to preserve the anonymity of the participants ( Table 2) . 

The focus group interviews were conducted throughout March and April 2021 and as such participants were able to reflect on their experiences from both the first wave (March-May 2020) and the second wave (Dec 2020 -Feb 2021) of the Covid-19 pandemic. Participants included in this paper were working as diagnostic radiographers in the UK. Five themes emerged from the data. These can be seen in Figure 1 .

J o u r n a l P r e -p r o o f Figure 1 The experiences of the diagnostic radiographers emerging from the data Adapting to New Ways of Working

Participants described how departments had adopted new ways of working to help manage workload during the pandemic. In most cases in the first wave, clinics and elective cases were postponed and the radiographer's workload was predominantly Covid-19 related. However, during the second wave, there was an expectation for elective cases to continue and participants described increasing volumes of elective workload alongside rising Covid-19 cases. Participants whose roles included advanced practice reporting described a shift in their workload with a reduction in musculo-skeletal (MSK) workload and an increase in chest radiography reporting. Many described returning to work clinically or undertaking other roles to support departments. 

During the first wave, many participants described a rollercoaster of emotions including feeling nervous, scared, and anxious. In the early stages of the pandemic, some of this anxiety was attributed to a fear of contracting the virus or passing it on to family members and loved ones. During the second wave, many participants described their shock at the volume of patients affected, the age range of patients, and also the speed at which patients succumbed to the virus.

"I found that a little bit hard, thinking that, oh God, I X-rayed her or I CT'd her a while ago and now she's dead. I was more conscious of that in the second one than in the first one." DR3

"Especially during the second one I would say it became more prevalent, we were seeing younger and younger people which was much harder." DR1

Participants were asked about support mechanisms that they had utilised during the pandemic. Many acknowledged the wider Trust initiatives implemented to support staff including regular updates, well-being applications, links to counselling, support, and mental health first aiders. Participants were aware of such initiatives but uptake appeared to be low due to shift patterns or logistical reasons preventing individuals from engaging. 

The most significant response reported from participants was that support came from within the team itself. Particularly in the first wave of the pandemic, many spoke of high morale, team spirit, and colleagues looking after one another. "I think the team spirit in our working group has prevailed. We've got the various WhatsApp groups and we're quite sociable." DR11

In the early days of the pandemic particularly when PPE guidance was conflicting, many participants described making autonomous decisions around the use of PPE, often these decisions were contrary to departmental or Trust guidance. Participants felt this was necessary to protect themselves and others. "We became masters of our own defence against covid....So many different avenues of information, which one do you believe...basically the one that provided you with the most protection was the one we decided to follow ourselves." DR3

The resilience of the radiology workforce was apparent through all of the focus group interviews. Participants recognised when they were beginning to feel uneasy and many took their own action to address how they were feeling. 

Many participants described professional challenges during the pandemic, particularly around the role of the radiographer and how it is perceived by fellow professionals. Initially, diagnostic radiographers were not considered as frontline workers particularly concerning the provision and use of PPE.

"Across the hospital it didn't seem to be we were acknowledged as frontline workers initially." DR12 

The adaptability of radiographers came across strongly in this study as recognised by others (19) .The management of departments suspending services and reducing non-Covid-19 workload during the first wave is evident as in previous studies (20) (21) (22) . There is little published research on the impact of the second wave. However, the reported increase of Covid-19 patients is supported by data released by the Office of National Statistics UK (23) who reported an 81% increase in hospitalisations from the first wave (18,974) to the second wave (34, 336) . In response to this increased workload, the introduction of new ways of working in departments such as adjusting staffing levels out of hours appears to have been adopted by many departments (22, 24) . Changes in workplace organisation such as segregation of departments to minimise cross-infection are also noted as common practice (24) .

Anxieties attributed to the provision of PPE, fear of contracting the virus, and spreading it to family members was a common concern for healthcare workers during this pandemic (7, (25) (26) (27) . Reports of PPE provision varied across organisations with some participants reporting a lack of PPE, particularly in the first wave of the pandemic. Fluctuating guidance around the use of PPE is supported by other UK-based research (20, 28) . Anxiety around PPE subsided as confidence in its supply and use grew. However, other emotions such as shock and exhaustion increased during the second wave. The emotional toll of witnessing the impact of the disease on patients is highlighted in the work of Bennet et al. (28) through the personal stories of 54 healthcare workers. Those stories also elicited a response of shock and upset at the effect of the virus and the age range of patients who were affected.

As found elsewhere, the resilience of radiographers working throughout this pandemic is evident (27) . A significant factor for coping has been peer support from colleagues within the workplace. Reports of improved teamwork and camaraderie are evident in other bodies of work (28, 29) . The use of WhatsApp for peer support along with dissemination of information has also been adopted by radiographers in other studies (29) . This study highlighted that radiographers had not been offered any form of debriefing by management teams over the duration of the pandemic, and this was also reported by Foley et al. (22) who examined the experience of radiographers in Ireland. The role of psychological debriefing is debated with some advocating its use (30, 31) while others support the use of alternative interventions (32) . Examining the value of debriefing for radiographers would be worthy of further research.

The study has highlighted the lack of understanding of the role of the radiographer and how the profession is perceived by other health care professionals (27) . Although vital to modern health care, diagnostic radiographers enter a profession that is poorly understood by both the public and other health care professionals (33, 34) . Evans' vision identifies the key role radiographers have in service delivery (35) . However, this does not appear to be understood by the wider health care workers and the promotion of radiography as a profession needs to continue. Lack of professional recognition leads to misunderstanding and conflict. The fight for professional recognition is hampered by feelings of subordination and the 'just the radiographer' syndrome which incites low self-esteem, inferiority complex, and apathy (36, 37) . There also appears to be a self-blame culture in diagnostic radiography where, out of concern for their reputation, radiographers take the blame for errors or poor service, such as keeping patients waiting (38) . Professional recognition is hampered by many factors including hierarchy, culture, and lack of professional dialogue (39) . Nursing literature recognises the need for a good working relationship between health professionals involved in mobile radiography which played a major role during the pandemic (40) . This highlights the importance of interprofessional education and working as a professional identity is influenced by respect from patients and colleagues (41) .

This study explored the experiences of diagnostic radiographers through the Covid-19 pandemic. During this time chest radiographs and CT scans of the chest played a significant role in the diagnosis and management of patients. Through four focus group interviews, it was revealed that diagnostic radiographers needed to adapt quickly to constantly changing new ways of working including changes to shift patterns and organisation of the workload. The pandemic elicited a rollercoaster of strong emotions which changed throughout the first two waves. There was anxiety and conflict over the accessibility and use of PPE and shock at the sheer volume and condition of patients. Support was largely sought from peers facilitated in part by technology. Trust initiatives were appreciated but not often accessed. There appeared to be a lack of targeted support, particularly in the form of debriefing. The radiographers taking part in the study demonstrated their resilience and self-protection, becoming 'masters of their own defence'. The long-recognised issue of a lack of professional recognition and understanding of the role of the radiographer came across strongly in this study and further work is required in the promotion of the profession.

The purpose of this study was to explore experiences in depth and how the participant's perceived their experiences. The findings are thus intrinsically linked to this particular context and limit the transferability of the findings. However, the experiences discussed might resonate across the profession.

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This project has been funded in part by the College of Radiographers Industrial partnership Scheme.

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