Pandemic preparedness of diagnostic radiographers during COVID-19: A scoping review

Abstract

Introduction

As chest imaging is a tool for detecting coronavirus disease 2019 (COVID-19), diagnostic radiographers are a key component of the frontline workforce. Due to its unforeseen nature, COVID-19 has challenged radiographers' preparedness in combating its effects. Despite its importance, literature specifically investigating radiographers' readiness is limited. However, the documented experiences are prognostic of pandemic preparedness. Hence, this study aimed to map this literature by addressing the question: ‘what does the existing literature reveal about the pandemic preparedness of diagnostic radiographers during COVID-19?’.

Methods

Using Arksey and O'Malley's framework, this scoping review searched for empirical studies in MEDLINE, Embase, Scopus, and CINAHL. Consequently, 970 studies were yielded and underwent processes of deduplication, title and abstract screening, full-text screening, and backward citation searching. Forty-three articles were deemed eligible for data extraction and analysis.

Results

Four themes that reflected pandemic preparedness were extrapolated: infection control and prevention, knowledge and education, clinical workflow, and mental health. Notably, the findings highlighted pronounced trends in adaptation of infection protocols, adequate infection knowledge, and pandemic-related fears. However, inconsistencies in the provision of personal protective equipment, training, and psychological support were revealed.

Conclusion

Literature suggests that radiographers are equipped with infection knowledge, but the changing work arrangements and varied availability of training and protective equipment weakens their preparedness. The disparate access to resources facilitated uncertainty, affecting radiographers’ mental health.

Implications for practice

By reiterating the current strengths and weaknesses in pandemic preparedness, the findings can guide clinical practice and future research to correct inadequacies in infrastructure, education, and mental health support for radiographers in the current and future disease outbreaks.

Introduction

With over six million deaths,¹ the coronavirus disease 2019 (COVID-19) continues to be an unprecedented global emergency in the modern era. The International Health Regulations 2005 (IHR) and their Joint External Evaluation tool assess the preparedness of the World Health Organisation (WHO) and individual countries to manage public health crises.² However, several authors have demonstrated difficulty in defining preparedness in health emergencies.^{3 , 4} In current literature, pandemic preparedness has been characterised by several features, including adaptation of protocols and public-private collaborations.5, 6, 7, 8, 9, 10 Similar features are echoed by IHR and WHO. Adhering to these guidelines, governments mandated restrictions to safeguard the public by limiting COVID-19 transmission through social distancing, mask use, and quarantine.¹¹

The effect of these restrictions caused rapid changes to infection control and workload for healthcare workers (HCWs), forcing them to operate in unfamiliar ways. The ability to protect these HCWs was established as a favourable indicator within the theoretical interpretation of pandemic preparedness.12, 13, 14, 15 This was measured by the proper supply and usage of personal protective equipment (PPE), upskilling workers, and increased staff capacity.12, 13, 14, 15 Beyond physical safety, the importance of prioritising the mental health of HCWs was also enforced.^{12 , 13 , 15} Hence, pandemic preparedness is defined by the capacity to address the needs of the frontline health workforce.

Playing a vital role in the frontline, the needs of medical imaging professionals required particular attention, as thoracic imaging became a key diagnostic and management tool for COVID-19. The breadth of imaging professionals extends from general radiographers to radiologists and specialised medical imaging professionals, such as those working in computed tomography (CT). Although CT has a higher sensitivity to COVID-19, chest x-rays are used for patient triage, management of infectious patients, and post-recovery follow-ups, increasing the pressure on general radiographers.^{16 , 17} Since radiography requires close contact with suspected or confirmed patients, the existing literature demonstrated how the nature of x-ray imaging has induced fears of contracting COVID-19. Studies have implied that this fear is driven by infrastructural and educational factors including insufficient PPE, lack of staff testing, and limited pandemic training.17, 18, 19 These concerns have impacted the functioning of medical imaging departments and threatened the wellbeing of radiographers.¹⁸ This illustrates the importance of understanding preparedness in radiography practice.

Historically, issues in infection control and training in previous health emergencies have been documented as challenging radiographer preparedness, such as during 2003 Severe Acute Respiratory Syndrome (SARS)^{20 , 21} and Ebola virus outbreaks.^{22 , 23} Despite the diagnostic value of chest radiography in diseases like SARS^{20 , 24} and H1N1 influenza,^{25 , 26} the literature specific to radiography in past outbreaks is limited relative to other health professions. Likewise, the recent discourse on COVID-19 preparedness in healthcare primarily originated either from the perspectives of nurses27, 28, 29 and doctors30, 31, 32 or a generalised HCW experience.^{33 , 34}

At most, radiography-specific literature has established the adverse effects of COVID-19 on radiographers and demonstrated the measures implemented to mitigate its physical and mental consequences. Though this literature does not specifically assess pandemic preparedness, the elements covered can be prognostic. Since COVID-19 is an ongoing situation and preparedness involves different areas of clinical practice, the literature is scattered and difficult to locate. Hence, a scoping study was appropriate for collating evidence to understand the essence of preparedness in radiographers. In a preliminary search, there was only one literature review available, which focused on the impacts of COVID-19 and provided some recommendations for imaging professionals.³⁵ Our scoping review builds on and differs from this study by not just focusing on how radiographers were impacted, but also exploring what was implemented as mitigation. Given the importance of being equipped for crises, the purpose of this scoping review was to map the evidence and understand the pandemic preparedness of diagnostic radiographers during COVID-19.

Methods

Arksey and O'Malley's³⁶ framework, with enhancements by Levac et al.³⁷ and Peters et al.,³⁸ was used to conduct this scoping review. This study (1) identified the research question, (2) identified relevant studies, (3) underwent study selection, (4) charted the data, and (5) collated, summarised, and reported the results. The methodology was also registered as a review protocol with the Open Science Framework by the Centre for Open Science Inc., an online platform for research project management (https://osf.io/jw9dx).

Identifying the research question

This study aimed to explore the pandemic preparedness of radiographers and uncover associated factors using this question: ‘what does the existing literature reveal about the pandemic preparedness of diagnostic radiographers during COVID-19?’.

Identifying the relevant studies

Following the enhanced framework,³⁸ pilot searches were conducted through four common medical and health databases: MEDLINE, Embase, Scopus, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). This was performed to investigate the literature related to radiographers’ preparedness. With the assistance of an academic librarian, pilot searches identified relevant keywords that were used to refine the search. Using the final keywords (Table 1 ) and appropriate MeSH/CINAHL subject headings, formal searches were conducted through the four databases. The full electronic search strings can be accessed in Appendix A. The reference lists of included studies were then searched for additional articles.

Table 1.

Search terms, based on the PCC mnemonic, used to identify studies pertaining to the pandemic preparedness in radiographers during COVID-19.

Population terms:	(radiographer∗ OR “radiology tech∗” OR “medical imaging∗” OR “medical radiation∗”)
AND
Concept terms:	(prepar∗ OR respon∗ OR manag∗ OR support∗ OR readiness∗)
AND
Context terms:	(“SARS-CoV-2” OR covid∗ OR corona?virus∗ OR 2019-ncov)

To be included, studies needed to explore factors related to pandemic preparedness within general radiography practice. Studies that investigated diagnostic radiographers as the main subjects, part of the sample population, or data pertaining to general radiography were included. Only empirical articles published in the English language between 2019 and 2022 were included. However, studies were excluded if they only covered technical aspects of radiography. Similarly, studies that only focused on specialised imaging professionals outside of general radiography were excluded. Finally, if full texts could not be retrieved, they were also excluded.

Study selection

The final search was conducted on 21 November 2022. The formal searches from the four databases yielded 970 studies. These studies were collated in Endnote™ X9 and imported into Covidence, an online platform used to streamline the processing of literature reviews. Using automatic deduplication and manual review, 345 duplicates were removed. After title and abstract screening, 118 full texts were to be retrieved. Of these, 4 articles’ full texts were unavailable, and another 79 studies were excluded based on the eligibility criteria. This screening process was performed independently by three researchers (KK/WR/JR), to improve transparency and avoid uncertainty in study selection. Conflicts were discussed to reach a consensus. The remaining 35 studies were deemed eligible, and their reference lists were searched for additional studies. Finally, 43 studies were included in this scoping review. This selection process is illustrated in the PRISMA flow diagram in Fig. 1 .

Figure 1.

PRISMA flowchart of study selection and inclusion process.

Charting the data

A data charting form was created using Covidence, and pilot tested by three researchers (KK/WR/JR). Extracted data was collated into a data charting table (Appendix B), identifying study characteristics, such as design, population features, and key findings, and highlighting the relevance of each study.

Following data charting, the included studies underwent critical appraisal (Appendix C). It was performed to provide readers with honest and transparent information on the quality of included studies. The Mixed Methods Appraisal Tool was used, which appraises empirical studies of different designs.³⁹ When studies were difficult to assess due to method ambiguity, they were discussed by the authors to reach consensus (KK/WR/JR). Overall, 31 studies were of quantitative descriptive designs,16, 17, 18, 19 ^, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66 primarily using convenience sampling. Due to non-random sampling, smaller sample sizes, and unclear non-response bias risks, the generalisability of these studies are limited, causing difficulty to draw causal relationships between different factors. While mixed methods studies67, 68, 69 were well-reported, the quality of one mixed methods study⁷⁰ was uncertain, due to unclear integration of data. The eight qualitative studies71, 72, 73, 74, 75, 76, 77, 78 were generally well-reported, with few variations related to their approaches to answer the research questions.

Collating, summarising, and reporting results

The extracted data was presented as a descriptive numerical summary of study characteristics within the charting table (Appendix B). The charting form in Covidence also facilitated a thematic analysis using inductive reasoning, where initial codes were generated based on the extracted data. These codes were organised into sub-concepts, and later into broader themes that encompassed aspects of pandemic preparedness. Any disagreements were resolved during arranged meetings between the authors (KK/WR/JR). A thematic overview was created to synthesise and visualise the distribution of themes across the included studies (Table 2 ).

Table 2.

A thematic overview of findings, with citations in chronological order (Agree:, Disagree:, Split findings:, Not reported: – [dash]).

First author, year (chronological)	Infection control and prevention					Knowledge and education				Clinical workflow				Radiographers' mental health and wellbeing
	Protective measures			Policy		Adequate knowledge of:		Training provided for:		Workload		Working arrangements		Mental health status			Stressors				Support
	Adequate PPE and resources supply	Staff testing available	Physical distancing enforced	Provision of infection guidance	Changed protocols for COVID-19	General infection control	COVID-19 specific management	Infection control (general)	COVID-19 specific	Changes to workload	Increased examination time	Changed shifts/work hours	Redeployment	Workplace stress	Anxiety	Burnout	Fear of contracting and spreading virus	Lack of resources, testing and training	Changed workload/protocols	Lack of professional recognition	Workplace-based
Huang, 2020a		–	–	–	–	–		–	–	–	–	–	–		–	–	–		–	–	–
Akpaniwo, 2020		–				–	–	–		–	–	–		–	–	–	–	–	–		–
Huang, 2020b		–	–	–	–	–		–	–	–	–	–	–	–		–			–	–	–
Elgyoum, 2020	–	–	–		–		–		–	–	–	–	–	–	–	–	–	–	–	–	–
Foley, 2020				–
Akudjedu, 2020			–	–	–			–				–			–	–				–
Kotian, 2020	–	–	–	–	–				–	–	–	–	–	–	–	–	–	–	–	–	–
Maizlin, 2020		–	–	–	–	–	–	–	–		–		–	–	–	–	–	–	–	–	–
Akyurt, 2021	–	–	–	–	–	–		–		–	–		–	–	–	–	–		–	–	–
Hasford, 2021	–	–	–	–	–				–	–	–	–	–	–	–	–	–	–	–	–	–
Almatari, 2021	–	–	–	–	–				–	–	–	–	–	–	–	–	–	–	–	–	–
Itani, 2021			–	–		–	–	–	–		–		–		–	–		–	–	–
Huang, 2021	–	–	–	–	–	–	–	–	–	–	–		–	–				–		–	–
Akudjedu, 2021		–	–	–				–			–	–			–	–			–	–
Elshami, 2021		–	–	–	–			–			–	–	–			–				–
Lewis, 2021						–	–				–		–			–			–		–
Ooi, 2021a	–	–	–	–	–	–	–	–	–		–		–	–	–	–	–	–	–	–	–
Ruiz, 2021	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–		–	–	–	–
Zervides, 2021			–	–		–	–	–		–			–		–	–	–	–	–	–	–
Ooi, 2021b	–		–						–	–	–	–	–	–	–	–		–	–	–	–
Shanahan, 2021		–		–				–	–				–			–		–	–
Garlisi, 2021	–	–	–	–	–	–	–	–	–		–	–	–	–	–	–	–	–	–	–	–
Pereira, 2021		–		–	–	–	–	–		–	–	–	–	–	–					–
Yasin, 2021		–	–	–		–	–	–	–		–	–	–		–	–				–
Aljondi, 2021	–	–	–	–	–					–	–	–	–	–	–	–	–	–	–	–	–
Jorge, 2021		–	–			–		–	–		–	–	–	–	–	–		–	–		–
van de Venter, 2021	–	–	–	–	–	–	–	–	–	–	–	–	–	–		–		–	–	–	–
Naylor, 2022		–	–			–	–	–	–		–			–		–
Marin, 2022	–	–	–	–	–	–	–	–		–	–	–		–	–	–	–	–	–	–
Broom, 2022	–	–	–	–		–	–	–	–	–	–	–	–	–	–	–					–
Martini, 2022		–	–	–				–	–	–	–	–	–	–	–	–	–	–	–	–	–
Brady, 2022	–	–	–	–	–	–	–	–	–	–	–	–	–		–	–			–	–	–
Salih, 2022		–	–	–	–	–	–	–	–		–			–	–	–	–	–	–	–	–
de Guzman, 2022	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–		–
Lock, 2022		–	–			–	–		–			–	–		–	–		–	–	–	–
Dann, 2022		–		–		–	–					–	–	–	–	–	–		–	–
Sheehan, 2022	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–		–	–	–	–	–
McFadden, 2022a		–	–		–	–	–		–		–	–		–	–	–	–	–	–	–	–
Flood, 2022	–	–	–			–	–	–	–	–	–		–	–	–	–	–	–		–
McFadden, 2022b	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–		–		–
Verma, 2022	–	–	–	–	–	–		–	–	–	–	–	–	–	–	–	–	–	–	–	–
Shubayr, 2022	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–		–	–		–
Booth, 2022	–	–	–	–	–	–	–	–	–	–	–			–	–	–	–	–	–	–	–

Results

Eligible research has been published in a wide range of countries from Asia (n = 16), Europe (n = 16), Africa (n = 7), Australia (n = 3), and North America (n = 2). Adding the number of articles may be incorrectly interpreted as 44 individual studies instead of 43. This slight discrepancy is caused by one study⁴⁵ covering countries in Asia and Africa. The majority used quantitative descriptive surveys, while eight studies were of qualitative design and four used mixed methods. The sample sizes ranged from one to 1638, primarily with radiographers as main subjects or a portion of the sample.

Key findings that emerged from the included studies were categorised into four main themes: infection control and prevention (IPC), knowledge and education, clinical workflow, and mental health. The distribution of these themes is seen in Table 2.

Infection control and prevention

A total of 26 studies reported on the changes to IPC resources and protocols available to radiographers.16, 17, 18, 19 ^{, 40 , 41 , 43 , 46 , 48 , 52 , 53 ,} 55, 56, 57, 58, 59 ^{, 61 , 66 , 67 , 69 ,} 72, 73, 74, 75, 76 ^{, 78} Most studies investigated outcomes using cross-sectional surveys, while four studies used interview methods to explore this concept.^{67 , 74 , 75 , 78}

The most reported and divergent factor of IPC was PPE access. Eleven studies validated overall adequacy in PPE for radiographers.^{16 , 18 , 19 , 41 , 46 , 48 , 55 , 56 , 66 , 67 , 69} However, two studies^{57 , 75} reported PPE shortages, with Jorge & Fridell's⁷⁵ interview responses indicating daily changes to IPC protocols as a result. This discrepancy was reflected in the mixed responses regarding PPE supply of the remaining studies.^{17 , 40 , 52 , 53 , 59 , 61 , 76 , 78} Similarly, while most studies^{16 , 18 , 19 , 40 , 41 , 46 , 55 , 57 , 58 , 66 , 69 , 72 ,} 74, 75, 76 ^{, 78} reported that IPC protocols were adapted to COVID-19, guidance for radiographers varied across eight studies.^{25 , 40 , 58 , 67 , 72 , 73 , 75 , 76 , 78} Three of these studies^{58 , 73 , 78} reported provision of IPC guidance, while Akpaniwo et al.⁴⁰ indicated limited availability of guidelines to reduce transmission. This difficulty was reflected within the remaining studies,^{67 , 72 , 75 , 76} where IPC guidance was criticised for frequently changing what was considered best practice for infection control. These studies' participants stated this as a cause of confusion and uncertainty. McFadden et al.⁶⁷ also highlighted that PPE decisions were made without radiographers.

Other IPC measures that had difficult outcomes were staff testing and physical distancing but were less frequently reported. Studies indicated little to no staff testing in radiography practices.^{16 , 18 , 58 , 76} Similarly, physical distancing was deemed as difficult to maintain.^{18 , 19 , 40 , 46 , 76}

Knowledge and education

Twenty-five studies reported on radiographers' knowledge and access to training.17, 18, 19 ^, 40, 41, 42, 43, 44 ^{, 46 , 48 , 50 ,} 52, 53, 54, 55 ^, 57, 58, 59 ^, 65, 66, 67 ^{, 73 ,} 75, 76, 77 These studies utilised online surveys and mostly obtained self-reported data, alongside three interview-based studies.^{67 , 75 , 77} Notably, 12 studies reported sufficient understanding of general infection measures.17, 18, 19 ^{, 41 , 44 , 48 , 50 , 54 , 57 , 58 , 73 , 75} A similar trend was seen in radiographers' COVID-19 knowledge, indicating adequate understanding of symptoms and transmission.^{18 , 19 ,} 41, 42, 43, 44 ^{, 48 , 50 ,} 52, 53, 54 ^{, 58 , 65} Despite studies suggesting adequate infection and COVID-19 knowledge, Akudjedu et al.¹⁷ found that radiographers’ confidence in using this knowledge to manage COVID-19 was limited.

In regard to education, there was evident provision of basic infection training for radiographers.^{18 , 43 , 44 , 46 , 50 , 55 , 58 , 67 , 73 , 76} This training was focused on reinforcing hand hygiene^{44 , 73} and PPE use.^{46 , 50 , 58} Conversely, only some studies^{18 , 42 , 43 , 76} reported the implementation of COVID-19 specific training. However, the remaining studies demonstrated inconsistent pandemic education. For instance, Akpaniwo et al.⁴⁰ reported that only 15% had pandemic training.

Clinical workflow

Twenty-four studies reported on aspects of clinical workflow, including workload and working arrangements.16, 17, 18, 19 ^, 40, 41, 42 ^{, 46 , 48 , 49 , 51 , 55 , 56 , 61 , 66 , 67 ,} 69, 70, 71 ^, 74, 75, 76, 77, 78 Again, online surveys were utilised, alongside a qualitative questionnaire⁷⁶ and six interview-based studies.^{67 , 74 , 75 , 77 , 78} Two other mixed methods studies^{69 , 70} also used statistical data to explore workflow.

A majority reported changes in radiographers' workload during the pandemic.16, 17, 18 ^{, 41 , 46 , 48 , 49 , 55 , 56 , 61 , 67 , 69 , 70 , 75 , 76 , 78} However, whether workload increased or decreased varied across these studies. Many studies demonstrated increased workload for radiographers.^{16 , 55 , 61 , 67 , 69 , 75 , 78} Reflecting this, Yasin et al.’s⁶⁹ mixed-methods study indicated 176.4% and 237.9% increases in mobile and emergency department x-ray examinations, respectively. Conversely, three studies^{49 , 56 , 70} reported decreased workload, while Shanahan and Akudjedu¹⁹ indicated no change. This discrepancy is featured within individual studies as mixed responses.^{17 , 18 , 41 , 46 , 48 , 76} For instance, Akudjedu et al.⁴¹ correlated regions of high COVID-19 cases with increased imaging workload. Similarly, Foley et al.¹⁸ highlighted how the temporal context influenced an overall increase in workload over time, due to resumption of non-essential imaging. Studies^{19 , 46 , 56 , 76} also reflected the difference in workload between public and private sectors, with increased procedural volume in public hospitals and reduction in private practices, causing them to shutdown.⁵⁶

To accommodate for the workload changes, working arrangements for radiographers were modified. While participants in the private sector saw reduced hours and pay cuts,⁷⁶ hospitals implemented altered shift rosters to manage the increased workload.16, 17, 18 ^{, 42 , 51 , 61 , 70 , 72 , 74 , 76 , 78} Specifically, 12-h shifts were implemented for radiographers to meet the imaging demands of COVID-19.^{17 , 42 , 70 , 75 , 76} However, it was noted that the longer shifts left radiographers feeling exhausted.^{70 , 76 , 78} Staff redeployment was also used to accommodate the workload but was reported less frequently.^{17 , 18 , 40 , 61 , 67 , 71 , 77 , 78} These studies indicated that radiographers worked in interprofessional treatment units and specialised imaging professionals were deployed to perform x-ray imaging. However, Akudjedu et al.¹⁷ highlighted that deployed staff felt they were unskilled working in general radiography, inducing stress.

Mental health

A total of 31 studies reported on the impacts on radiographers’ mental health, highlighting stressors and support mechanisms that were utilised.16, 17, 18, 19 ^, 40, 41, 42 ^, 45, 46, 47, 48 ^, 51, 52, 53 ^{, 55 ,} 58, 59, 60 ^, 62, 63, 64 ^{, 66 ,} 68, 69, 70 ^{, 72 ,} 74, 75, 76, 77, 78 Mental health was investigated using online cross-sectional surveys, alongside one qualitative survey⁷⁶ and six interview-based studies.^{68 , 72 , 74 , 75 , 77 , 78}

Most studies emphasised the fear of contracting and spreading COVID-19 as a major stressor for radiographers.16, 17, 18, 19 ^{, 45 , 48 , 52 , 53 , 55 , 59 , 60 , 63 , 64 , 68 , 69 , 72 , 75 , 76 , 78} Though few studies highlighted a division in participants’ pandemic fears,^{41 , 58 , 68} spreading COVID-19 was a perceived threat to family, with correlation between concern of COVID-19 transmission and being a parent.⁶⁰ Corroborating this, Pereira et al.⁵⁹ indicated an association between fear of infecting family members and emotional exhaustion in radiographers. Hence, radiographers took additional personal measures, such as showering immediately after work and isolating from family.^{18 , 19} Furthermore, Elshami et al.⁴⁸ found that this pandemic-related fear was statistically linked to limited training.

The insufficient training paired with inadequacies in IPC and workload changes were also deemed as stressors.^{17 , 18 , 41 , 46 , 48 ,} 51, 52, 53 ^{, 59 , 68 , 69 , 72 , 74 , 76 , 78} For instance, Pereira et al.⁵⁹ observed higher risks of burnout in departments that had poorly perceived quantity and quality of PPE. Furthermore, Naylor et al.’s⁷⁸ and Yasin et al.⁶⁹ highlighted that PPE recommendations frequently changed and emphasised how the uncertainty in protocols induced confusion and stress in radiographers. Moreover, the limited resources was reportedly influenced by minimal professional recognition.^{72 , 76 , 78} The perceived lack of recognition also caused radiographers to feel “forgotten”,^{18 , 19 , 78} “obstructive”,⁷⁸ “unappreciated”,¹⁸ and experience discriminatory jokes.⁴⁷ Hence, failing to be acknowledged as part of the frontline workforce was another stressor in radiographers.^{18 , 19 , 40 , 47 , 63 , 72 , 76 , 78}

The effects of these stressors were linked to mental health conditions in radiographers. Workplace stress was the most frequently reported condition.16, 17, 18, 19 ^{, 41 , 45 , 48 , 52 , 66 , 69 , 72 , 76} An overwhelming majority16, 17, 18, 19 ^{, 41 , 45 , 48 , 69 , 72 , 76} reported workplace stress in most participants, indicating the pandemic's detriment to radiographers' wellbeing. Furthermore, Brady et al.⁴⁵ highlights moderate-to-severe post-traumatic stress disorder symptoms in 73% of radiographers, exceeding the nurses and doctors included in their study. While Zervides et al.⁶⁶ agreed with elevated stress in hospitals, they indicated lower levels of stress in private centres, correlating with their limited COVID-19 workload.

Unlike workplace stress, anxiety in radiographers had greater variance in results.^{18 , 19 , 42 , 48 , 51 , 53 , 59 , 60 , 64 , 76 , 78} Though there were reports of increased anxiety in radiographers,^{18 , 19 , 76 , 78} several studies used validated scales and indicated minimal accounts of anxiety.^{48 , 51 , 53} This contradiction is inversely depicted by van de Venter et al.’s⁶⁴ study. Most of their participants believed they had not experienced anxiety behaviours, but their scores on the Coronavirus Anxiety Scale indicated possibilities of dysfunctional coronavirus-related anxiety. They also highlighted a statistically significant difference between females and males, deeming females to be more likely to experience anxiety.⁶⁴ This greater mental health impact on females is corroborated by three other studies.^{42 , 59 , 60}

Burnout also varied across studies but was less frequently reported.^{18 , 51 , 59 , 62} Foley et al.¹⁸ and Huang et al.⁵¹ used self-reported data to assess burnout in radiographers and found low burnout scores in most of their participants. Sheehan et al.’s⁶² established instrument validated this, showing that no radiographers experienced burnout in their sample. However, only three radiographers were included in their study. Conversely, Pereira et al.⁵⁹ used a validated survey to measure three burnout dimensions in 386 radiographers. They found that most participants had at least one elevated dimension, indicating greater risk of burnout in radiographers.

To mitigate these impacts on radiographers’ wellbeing, 13 studies reported on workplace mental health support.16, 17, 18, 19 ^{, 41 , 46 , 48 , 59 , 68 , 69 , 74 , 77 , 78} Yasin et al.⁶⁹ indicated the presence of support and highlighted that radiographers favoured department-specific support services, as opposed to hospital-wide initiatives. Two studies also indicated the positive effects of team huddles and increased communication on their wellbeing.^{74 , 77} However, five studies^{17 , 41 , 46 , 59 , 68} reflected limited access to any psychological support, with only few respondents agreeing that workplace support existed.^{17 , 41} Four studies^{16 , 19 , 48 , 78} amplified this discrepancy with varied responses regarding the adequacy of such services. Even with the presence of mental health support, some studies indicated a lower uptake by radiographers due to logistical issues.^{18 , 78} Despite this, radiographers felt they would still need psychological help to cope with the pandemic.^{16 , 41 , 48} Despite the discrepancies, the pandemic had less detriment on those who accessed support services,⁶⁹ suggesting the benefit of workplace mental health support.

Discussion

This scoping review suggests that four key factors outline the pandemic preparedness of diagnostic radiographers during COVID-19, although to varying extents. The 43 studies revealed that IPC, knowledge and education, clinical workflow, and mental health were defining features of pandemic preparedness. Though there were some pronounced trends, the findings reveal high variability in COVID-19 impacts and subsequent implementation of protective measures, particularly in PPE availability, pandemic training, and mental health support.

While IPC measures were based on recommendations, certain protocols may be contingent on PPE availability⁷⁵ and possibly made without radiography perspectives.⁶⁷ Even studies that reported adequate PPE access demonstrated concerns surrounding the future availability of such equipment.^{18 , 70} This unreliable supply presents a source of uncertainty. Interestingly, this uncertainty is also embedded in the knowledge and education of radiographers. Despite being equipped with sufficient understanding of COVID-19,18, 19 ^, 41, 42, 43, 44 ^{, 48 , 50 ,} 52, 53, 54 ^{, 58 , 65} radiographers had limited confidence of using that knowledge to manage the pandemic.¹⁷ This contradiction between knowledge and confidence is possibly due to most studies using self-reported data, as opposed to testing radiographers' knowledge in infection control and COVID-19. This leads to potential false reporting of adequate understanding. The limited confidence may also imply a gap in training. In the wider discourse, staff training is considered a key component of pandemic preparedness.^{12 , 14 , 15} Corroborating with Akudjedu et al.’s³⁵ review, our scoping review found that the provision of COVID-19 training was inconsistent. This suggests that limited access to pandemic-specific training hinders the confidence of radiographers working in a crisis. Similarly, to manage the pandemic workload, longer working hours and staff redeployment were implemented.³⁵ However, it increased exhaustion and stress among radiographers, suggesting use of suboptimal strategies.

These inconsistencies in IPC, training, and workflow strategies exacerbate the uncertainty of COVID-19, negatively impacting radiographers' mental health. These uncertainties are embodied as stressors, including pandemic-related fears and limited resources. Surprisingly, this review also highlights a perceived lack of professional recognition, exhibiting as a stressor in radiographers.^{18 , 19 , 40 , 47 , 63 , 72 , 76 , 78} This negatively affected radiographers' access to resources,^{72 , 76 , 78} suggesting that their need for protection may be downplayed by other HCWs. Despite the value of chest imaging for COVID-19, this limited acknowledgement is potentially due to poor understanding of a radiographer's role in a pandemic. It is suggested that this can be alleviated by increased radiographer involvement in interprofessional teams.⁷¹ Collectively, these stressors induced a decline in radiographers' wellbeing. Though workplace stress is pronounced, discrepancies in anxiety and burnout also highlighted the difference between self-reported data and validated scales. Though self-reported data showed minimal effect on wellbeing,^{18 , 51 , 56} studies using validated scales revealed greater risks to radiographers' mental health.^{59 , 64} This indicates that the pandemic's impact on wellbeing was possibly underestimated by self-reported data, suggesting limited self-awareness of mental health indicators among radiographers. As mitigation, the broader literature emphasised protecting HCWs' mental health as a priority in pandemic preparedness.^{12 , 13 , 15} However, the findings suggest that the mental health support for radiographers was generally insufficient.

Despite the conflicting outcomes, the identified measures align with those featured in the broader literature, where the pandemic needs of radiographers are addressed to varying extents. Interestingly, the wider discourse underlined a predominant element of pandemic preparedness that was not featured in the included studies: public-private collaboration.^{5 , 6 , 9 , 10} Despite the private sector having reduced workloads,^{19 , 46 , 56 , 76} the included studies did not mention the deployment of radiographers from private practices into hospitals. This proposes a possible missed opportunity to boost manpower and relieve pressure on hospital radiographers. Alongside the absence of public-private collaboration, the inconsistencies across studies stipulate a universal need for improving radiographers’ capacity to mitigate pandemic consequences.

Limitations

The inconsistencies may highlight the heterogeneity of the included studies. This is a potential limitation of this scoping review. The variations across these studies can be explained by the diversity of geographical and temporal contexts. Due to this, their individual findings reflect the specific stages of COVID-19. Of the 43 studies, only two papers were from North America and no studies came from South America. Considering the global nature that defines pandemics, it is limiting that minimal empirical evidence of pandemic preparedness were found in these continents. Despite the systematic approach to literature searching and selection, it is possible that studies from these global regions were missed, due to only including empirical studies with available full texts.

The differences in the studies' methods may have also contributed to the inconsistencies in data. Though most studies were quantitative descriptive, quality of methodologies and clarity in approach differed. As stated in ‘Charting the data’, critical appraisal challenged the generalisability of the included studies. This may limit the use of this scoping review to draw strong correlations, hindering its ability to provide definitive guidance for clinical and policy decision-making.

Implications for future clinical practice and research

Despite its potential limitations, this scoping review consolidated what is known about the pandemic preparedness of diagnostic radiographers, proposing implications for clinical practice and research. Uncertainty is inherent to pandemics and other disease outbreaks. Therefore, policymakers and medical imaging departments should not escalate this uncertainty, and instead provide assurance to radiographers. This alludes to the importance of correcting the inadequacies in infrastructure and education within medical imaging sites. Specifically, departments should boost the confidence of radiographers through timely pandemic-specific training. It would be beneficial to go beyond reinforcing hand hygiene and PPE, and provide active strategies for patient care, self-protection, and working in crises. Policymakers should also foster public-private collaborations to effectively deploy radiographers from private practices into hospitals, increasing manpower as preparation for future outbreaks. Similarly, implementing interprofessional learning can increase the understanding of different roles within pandemic teams, facilitating recognition of radiographers and other HCWs.

Furthermore, our findings emphasise the pandemic's toll on radiographers' mental health and suggest that support structures are limited. This pinpoints the need for clinical and research efforts to mentally prepare and build psychological resilience in radiographers for future outbreaks. Specifically, policymakers and imaging departments should invest in support structures to regularly evaluate their staff's wellbeing. Implementation of stress management and resilience training should also be considered as preparedness tools for radiographers. Furthermore, researchers should consider exploring the utility of different workplace mental health interventions and personal coping skills of radiographers. This would further guide policymakers, departments, and radiographers in utilising mental health support and resilience strategies. These implications can be extended to guide other frontline HCWs in future outbreaks.

Conclusion

Overall, this scoping review gives insight into the lessons learned from COVID-19, by uncovering four key characteristics that underlie radiographers’ pandemic preparedness: infection control and prevention, knowledge and education, clinical workflow, and mental health. In these four domains, pandemic measures were implemented in radiography practice in preparation for COVID-19, albeit to varying degrees. The inconsistencies within empirical evidence illustrate an overarching narrative where inefficiencies in IPC, training, and workflow, intensify the uncertainty intrinsic to pandemics. This ultimately harms the mental health of radiographers, for which they may not adequately supported. Hence, this scoping review reveals that diagnostic radiographers should be better supported with preparedness tools for future outbreaks. Prioritising the physical and mental needs of radiographers is fundamental to any preparedness plan designed to build their capacity to mitigate the consequences of future pandemics.

Conflict of interest

None.

Supplementary data

The following are the Supplementary data to this article: