Patients' Experience to MRI Examinations—A Systematic Qualitative Review With Meta‐Synthesis

Abstract

Background

Patients often mention distress, anxiety, or claustrophobia related to MRI, resulting in no‐shows, disturbances of the workflow, and lasting psychological effects. Patients' experience varies and is moderated by socio‐demographic aspects alongside the clinical condition. While qualitative studies help understand individuals' experiences, to date a systematic review and aggregation of MRI individuals' experience is lacking.

Purpose

To investigate how adult patients experience MRI, and the characterizing factors.

Study Type

Systematic review with meta‐aggregation and meta‐synthesis.

Population

220 patients' reported experience of adults undergoing clinical MRI and 144 quotes from eight qualitative studies.

Assessment

Systematic search in PubMed, Scopus, Web of Science, and PsycInfo databases according to the PRISMA guidelines. For quality appraisal, the Joanna Briggs Institute (JBI) tools were used. Convergent segregated approach was undertaken.

Data Analysis

Participant recruitment, setting of exploration, type of interview, and analysis extracted through Joana Briggs Qualitative Assessment and Review Instrument (JBI QARI) tool. Meta‐synthesis was supported by a concept map. For meta‐aggregation, direct patient quotes were extracted, findings grouped, themes and characterizing factors at each stage abstracted, and categories coded in two cycles. Frequency of statements was quantified. Interviews' raw data unavailability impeded computer‐aided analysis.

Results

Eight articles out of 12,755 initial studies, 220 patients, were included. Meta‐aggregation of 144 patient quotes answered: (1) experiences before, at the scanning table, during, and after an MRI, (2) differences based on clinical condition, and (3) characterizing factors, including coping strategies, look‐and‐feel of medical technology, interaction with professionals, and information. Seven publications lack participants' health literacy level, occupation, and eight studies lack developmental conditions, ethnicity, or country of origin. Six studies were conducted in university hospitals.

Data Conclusion

Aggregation of patients' quotes provide a foundational description of adult patients' MRI experience across the stages of an MRI process. Insufficient raw data of individual quotes and limited socio‐demographic diversity may constrain the understanding of individual experience and characterizing factors.

Level of Evidence

1

Technical Efficacy

Stage 5

At least one third of adult patients report distress, moderate anxiety, and discomfort related to MRI not only the time in the scanner but the experience all around the procedure. ¹ , ² , ³ , ⁴ , ⁵ A determinant factor that patients consider when choosing a healthcare provider is prior experience, and a lack of information and communication has been reported to cause dissatisfaction (36%). ⁶ The patient's experience is capable of positively or negatively influencing outcomes even long after the MRI examination, eg, enduring psychological distress, therefore healthcare professionals' careful consideration to this key element of the care process is needed. ⁷ , ⁸ Simultaneously, for healthcare teams facing a high volumes of patients, time constraints and demands for efficiency in scheduling, preparation for the examination, scanning, and reporting have made it more difficult to identify patients' MRI needs. ⁶ , ⁹ , ¹⁰ An analysis identifying patient needs and influencing factors in the specific stages of an MRI experience is lacking. Thus, clinical teams—referring physicians, scheduling staff, nurses, technicians, radiographers, and radiologists—are not able to avoid unanticipated events and offer a personalized approach. ¹¹

MRI is a globally used diagnostic tool, and patients' experience is often reported with feelings of moderate anxiety (ca. 25%–30%) ¹ , ² , ³ , ⁴ , ⁵ , ¹² and claustrophobia (1%–15%). ¹³ Patient perception of the experience, including distress and anxiety, varies per person and is influenced by gender, age, culture, socio‐economic status, literacy level, or prevailing developmental conditions like autism. ¹⁴ , ¹⁵ Disease presence, type, and stage can be influencing factors for an experience. ¹⁶ In addition, perception of experiences in healthcare can be exacerbated by asymmetry of information and assumed hierarchies between healthcare professionals and patients. ¹⁷ Some technological advancements in MRI have aimed to address the patient experience, eg, bore diameter, scanner look‐and‐feel, length of the scanner, protocols with reduced scanning time, quiet protocols. ¹⁸ , ¹⁹ , ²⁰

Qualitative research related to (potentially) stressful events, eg, an MRI examination should consider aspects including the way patients were recruited, the selection, the examination stage at which the participant is interviewed, and the setting of the interview. ²¹ , ²² , ²³ Addressing these aspects can avoid biased representation of the population, creating additional stress that impacts the reconsolidation of autobiographical memory, and influencing participants' perception. ²¹ , ²² , ²³ , ²⁴ Joanna Briggs Institute (JBI) considers qualitative and quantitative systematic reviews contribute evidence to a topic and together maximize informed recommendations to guide policymakers and practitioners. When collected, quantitative and qualitative evidence address different aspects of a phenomenon of interest, a convergent segregated approach is recommended, where qualitative evidence is reported separately to quantitative data. ²⁴ , ²⁵ A systematic review with meta‐synthesis and meta‐aggregation of qualitative studies was employed in the present analysis to gather participants' thoughts, feelings, experiences, and the diversity of perceptions and behaviors during an MRI examination. As quantification of stress provides a limited view on a patient's state, we consider the specific qualitative evidence to be essential.

The systematic review with qualitative meta‐synthesis aimed to address the questions: How do adult patients experience MRI examinations? Which factors influence their experience?

Materials and Methods

This systematic review followed JBI methodology considering a convergent segregated approach. ²⁶ JBI is based on Hong et al and Sandelowski et al, recommending meta‐aggregation to synthesize qualitative evidence. ²⁷ , ²⁸ Methods and scope of this review were preregistered at the International Prospective Register of Systematic Reviews (PROSPERO CRD42021225489). ²⁹ Included studies had appropriate written informed consent and ethics approval.

Search Strategy

We systematically searched Pubmed, PsycInfo, Web of Science, and Scopus databases according to the PRISMA guidelines to identify studies reporting patient responses to MRI. ³⁰ The search strings encompassed the four categories “MRI,” “subjective patient‐centered outcomes,” “physiological patient‐centered outcomes,” and “behavioral outcomes.” The terms for “subjective patient‐centered outcomes” were acceptability, anxiety, anxiety concerning the results, claustrophobia, change of claustrophobia, comfort of contrast injection, complaint, confidence, depression, discomfort, distress, experience, panic, preferences, recovery, relaxation, satisfaction in general, satisfaction with information, scan burden, tolerance, willingness to undergo further MRI examinations, and worry about the apparatus. For “physiological outcomes” the terms were blood‐pressure, heart rate, and heart rate variability. Terms searched for “behavioral outcomes” were costs associated with unexpected‐patient related events, delays, failed scans, hourly scan rate, interruptions, image quality, motion artifacts, no‐shows, patient volume, refusal to undergo MRI, rescheduling rate, scan duration, scan repetitions, sedation or general anesthesia, and unexpected patient‐related events.

Additionally, the references of all studies eligible for the review were searched for studies unidentified by the database search. The main search was conducted up to December 17, 2020, updated by May 31, 2023. Search strategies are reported in Table S1 in the Supplemental Material. The search strategy addressed quantitative and qualitative studies. However, following a convergent segregated approach, the present article focuses on the qualitative studies. ²⁵

Inclusion/Exclusion Criteria

Primary studies with a study population aged ≥18 years old receiving MRI as standard of care were included, as were randomized control trials, economic evaluations, cross‐sectional, cohort studies, prevalence studies, qualitative research, quasi‐experimental studies, case control studies, and economic evaluations were included. Criteria for exclusion were studies conducted in healthy volunteers, methods other than “standard MRI” (eg, PET‐MRI), editorials, letters, case reports, conference proceedings, review articles, and articles written in languages other than English, German, Spanish, or French.

Titles and abstracts of all identified records were screened by independent reviewers (JM, IN/SN), and full‐texts were retrieved when deemed eligible, or eligibility could not be determined based on title and abstract only. Eligibility of studies was assessed versus inclusion criteria. Although other tools are used in qualitative systematic reviews, JBI requires the inclusion of PICo (population, phenomena of interest, context) specifications in the protocol and the use of the JBI critical appraisal tools for the assessment of a study's risk of bias in its conduct, analysis, and interpretation of data completed by two independent reviewers for all studies (JM, IN). ²⁴ , ²⁵ , ³¹ Qualitative studies were excluded if at least two criteria or critical criteria were not fulfilled, reported in Table S2 in the Supplemental Material. We applied a segregated approach for synthesis and qualitative studies underwent extraction. ²⁵

Data Extraction and Quality Assessment

The data of qualitative primary studies was extracted (IN) via the JBI QARI extraction tool for qualitative research into a spreadsheet table (reported in Tables 1 and 2, and Table S3 in the Supplemental Material), reviewed by an independent reviewer (JM). ⁴⁰ A third reviewer (LB) independently assessed eligibility and methodological quality when there was disagreement, consensus was reached through discussion.

TABLE 1.

Methodologies for Interviewing Patients and Type of Data Analysis Across Studies

Authors	Methodology of the Study	Participant Recruitment and Selection	Setting of the Interview and Length	Type of Interview	Question Type	Raw Data and Analysis (Computer‐Aided)	Raw Data for Meta‐analysis
Brand et al 32	Qualitative thematic analysis	From hospital records Date: November 2012	After MRI	Semistandardized interviews	Open ended questions	Raw data audio recorded. Thematic analysis: guided by the thematic framework analysis	Not available
Evans et al 33	Qualitative thematic analysis Part of larger randomized clinical trial.	From diagnosed patients in the hospital, contacted after imaging was done (mean 15 days) Dates: March 2013–July 2014	Face to face or per telephone Length: 12–86 minutes Interviewer: Psychologist with expert cancer training	Semistructured interviews	Open ended questions (oral) based on topic guide	Raw data recorded digitally and transcribed verbatim. Thematic analysis: computer‐aided (Nvivo V.10) for coding, matrix of themes, and report	Data sharing not possible. No patient permission in data sharing agreement.
Funk et al 34	Qualitative thematic analysis	From radiology site patients were contacted via letter, four patients agreed before arrival, 24 on‐site Dates: Autumn 2010–Spring 2011	Immediately after MRI or in radiology department room Length: 5–30 minutes	Semistructured interviews	Open ended questions (oral) based on interview guide	Raw data recorded and transcribed by a secretary verbatim. Thematic analysis: themes, meaning units, smaller units for descriptive categories. Calculated distribution.	Not available
Laidlaw and Henwood 35	Qualitative thematic analysis	From MS Society meeting, volunteers who underwent MRI in the last 10 years Date: 2003	At home Length: 50–90 minutes	Unstructured interviews	Open ended questions (oral) based on topic guide	Raw data tape‐recorded and entirely transcribed. Thematic analysis: open thematic coding in line‐by‐line analysis.	Not possible to contact author
Leithner et al 36	Qualitative data analysis Part of larger randomized clinical trial	From 62 consecutive patients referred from different fetal medicine units, semiassessed in the trial Dates: February–July 2006	Immediately before and after MRI	Semistructured interviews	Interviews were performed pre‐ and post‐MRI with five open ended questions and one closed question	Raw data tape‐recorded and transcribed. Thematic analysis: analysis with 11 main categories, coding with independent raters, assessment of interrater correspondence.	Not available
Lie et al 37	Qualitative narrative and thematic analysis Part of larger clinical trial	From 41 patients and 3 partners in the trial, recruited after iuMRI and counseling. Selection: pregnancy outcome, clinical and socio‐demographic, satisfaction, perceived utility. Date: September 2012–December 2013	At home Length: 60–120 minutes Interviewer: researcher	Narrative approach	Open ended questions (oral) based on topic guide	Raw data digital voice‐recorded and transcribed. Thematic analysis: with ATLAS.ti software for indexing and retrieval. Thematic generative analysis and inductive‐abductive strategy to interrogate data with positivism, emotionalism and constructionism.	Data sharing not possible. Not part of ethics approval process
Törnqvist et al 38	Qualitative inductive design and hermeneutic phenomenological	From patients who underwent MRI, invited immediately after MRI. Date: 2003	Choice from patients: a room immediately after MRI Length: 30–90 minutes	Unstructured interviews Emanated from the patients' own narratives	Start question and spontaneous questions for specificatione	Raw data tape‐recorded and transcribed verbatim. Thematic analysis: hermeneutic‐patient lived experience, units of meaning, themes and categories.	Not possible to contact author
Tugwell‐Allsup and Pritchard 39	Qualitative grounded theory Part of larger randomized clinical trial	From 74 patients, six selected per trial arm and invited to interview Date: 2017	Per telephone Interviewer: Research radiographer with experience interviewing	Semistructured interviews	Interview with topic guide on key questions and conversation points	Raw data recorded and transcript reviewed thrice. Thematic analysis: data condensing, coding, categorization. High inter‐coding reliability. Generated a concept map.	Not available. Data destroyed (>5 years old)

TABLE 2.

Patients' Socio‐demographic Context Across Studies

Authors	Total Sample	Participants' Age and Gender	Geographical Context	Socio‐Cultural Characteristics	Clinical Setting
Brand et al 32	5	Age: not reported Gender: all females	Germany	German speaking participants	Outpatient University Medical Center Hamburg Eppendorf
Evans et al 33	51	Age: 65 years + −11 (Lung cancer), 64 years + −9 (Colon cancer) Gender: 17 females, 34 males	UK, London East and South East	English speaking, 2 patients not native—a relative translated. Index of multiple deprivation: social deprivation varied based on postcode Lung: 1 quintile =1 13 pts, 2 = 8 pts, 3–5 = −2 4 pts. Colorectal: 1 = 8 pts, 2 = 6 pts, 3–5 = 12 pts.	55 patients from 10 hospitals in London East and South East
Funk et al 34	28	Age: Median 55 years (women), 49 years (men) Gender: 21 females, 7 males	Sweden	Swedish speaking participants	Radiology department of university hospital
Laidlaw and Henwood 35	8	Age: Not reported Gender: 6 females, 2 males	UK	UK Volunteers	From the MS Society
Leithner et al 36	62	Age: mean 30.2 ± 4.8 years Gender: 62 females	Austria	German speaking	Referred from different fetal medicine units in Vienna to Vienna Medical University Radiology department
Lie et al 37	41	Age: 31.3 years + −6.0 Gender: 41 females	UK	English speaking.	Five centers: iuMRI locally (1), iuMRI central where patients travel (2), hybrid model local‐regional (3), and smaller FMU‐for secondary level provision (4).
Törnqvist et al 38	19	Age: range 22–73 years Gender: 12 females, 7 males	Sweden	Swedish speaking participants	Lund Sweden University Hospital, Radiology basement
Tugwell‐Allsup and Pritchard 39	6	Age: 51.1 years + −12.4 Gender: 4 females, 2 males	UK, Wales	Four English speaking and two Welsch speaking	Radiology Department, Ysbyty Gwynedd

iuMRI = in utero magnetic resonance imaging, FMU = fetal medicine unit.

Data Synthesis

The approach used for the study was meta‐synthesis and meta‐aggregation. Data were evaluated for similarities and differences and discussed in the group. Meta‐synthesis was supported by a concept map (Figures 2 and 3). For meta‐aggregation, direct patient quotes were extracted from the studies (IN), similar findings grouped, themes abstracted, and categories coded in two cycles by two researchers independently (IN/JM), and consensus was reached through group discussion. A quote was assigned for all categories and themes that applied when the content covered more than one. Where a quote expressed specific influence factors they were also coded. In case of disagreement, a third reviewer (LB) independently assessed categories and themes. Consensus was reached through discussion. To avoid de‐contextualization of the original research, maintaining a person‐centered perspective, this review describes the participants' socio‐demographic background, study context and methodologies used to collect the patients' experience of MRI. Members of the research group discussed and negotiated using a “thinkaloud” strategy for understanding quotes, category definition, coding and decisions. To ensure a person‐centered approach and reduce researchers' bias, categories and themes were reviewed by three patients experienced with MRI (at least two MRI examinations in the past year), an experienced MRI radiographer (20 years of experience) and an interventional radiologist researcher (20 years of experience) specialized on distress management. Strategies are summarized in Table S4 in the Supplemental Material.

FIGURE 2.

Resulting concept map of socio‐demographic and clinical context factors influencing the patients' experience of MRI. COPD = chronic obstructive pulmonary disease.

FIGURE 3.

Resulting concept map of situational factors characterizing the patients' experience of MRI.

Difference between Protocol and Review

A convergent segregated strategy was undertaken, meta‐synthesis and meta‐aggregation for the qualitative evidence, according to JBI methodology. The quantitative analysis is reported in a separate publication. ²⁹

The statistical analysis included quantification of extracted quotes, and calculated percentage per phase of the MRI examination.

Results

Included Studies

The search strategy revealed 12,755 unique entries in all databases; 12,439 records were excluded during initial screening and 316 reports were sought for retrieval. Full texts were retrieved for 294 studies and assessed for eligibility, leaving 104 studies for quality assessment. Methodological quality was sufficient for 56 studies. Eight studies reported qualitative evidence and were included in this review (N = 220 patients, 144 quotes extracted) (Figure 1). Qualitative studies were excluded if at least two criteria or critical criteria were not fulfilled, reported in Table S2 in the Supplemental Material. Disagreement on assessed eligibility and methodological quality for 12 articles was resolved by consensus through discussion. Two studies were excluded for this reasoning.

FIGURE 1.

Flowchart of the study from initial retrieval to final study cohort. ³⁰

Characteristics of Socio‐Demographic and Clinical Context of Studies

Few, one out of eight studies fully report participants' age, gender, ethnicity, country of origin, socio‐cultural background, health literacy, socio‐economic background, or occupation (see Table 2). Prevailing developmental conditions were not reported in any study. There were 220 patients, most were female (76.3%). Age ranged from 22 to 76 years; two studies ³² , ³⁵ did not report average age or age range. All studies were conducted in Europe (1996–2020): four in UK, ³³ , ³⁵ , ³⁷ , ³⁹ two in Sweden, ³⁴ , ³⁸ one in Germany, ³² one in Austria. ³⁶

Only one study reported the participants' socio‐economical context via the Index of multiple deprivation, and ensured participants with varied financial backgrounds were part of the study. ³³ No study reported whether patients' MRI was covered by healthcare insurance or paid out‐of‐pocket. Most, six out of eight, studies were conducted in a University Hospital setting. ³² , ³³ , ³⁴ , ³⁶ , ³⁸ , ³⁹ Data on the experience of patients attending a community hospital or diagnostic center was not available.

Experience was reported from 1) patients with multiple sclerosis in two studies, ³² , ³⁵ 2) patients facing suspected cancer and metastasis, ³³ , ³⁴ 3) pregnant women with fetal brain abnormalities, ³⁶ , ³⁷ and 4) patients undergoing MRl for a wrist, spine, abdomen, head, or heart diagnosis ³⁸ , ³⁹ (see Table 3). Conditions for the examination and the articles reporting the number of novice MRI patients (about 24 patients) ³⁴ , ³⁵ , ³⁶ , ³⁹ are reported in Table 3.

TABLE 3.

Patients' Clinical Condition

Authors	Total Sample	Clinical Condition	Conditions of Examination
Brand et al 32	5	Patients with Multiple Sclerosis. Stage: Patients with an average disease duration of 4 years. Including long‐term disease (>10 years) and short‐term disease (<5 years since diagnosis) included.	Previous MRI examination: All patients had at least one previous experience with MRI. Examination: Head inside MRI with head coil (inferred not described in article).
Evans et al 33	51	Patients highly suspected or known colorectal or lung cancer.	Examination: 45–90 minutes Whole‐body MRI staging scan with all body coils covering vs. Current staging scans, eg, CT (duration: seconds). Contrast medium injected.
Funk et al 34	28	75% Referred due to suspected malignancy and metastasis of the liver.	Previous MRI examination: About 50% had previous experience with MRI. Precondition: Empty stomach. Examination: 2 hours, with standard breath‐hold and additionally two alternative breath‐hold techniques.
Laidlaw and Henwood 35	8	Patients with Multiple Sclerosis who had undergone MRI part of the Multiple Sclerosis Society. Last scan: 2 years (2), 10 years (2), 18 months (2), 1 year, and 6 years ago	Previous MRI examination: Six and two patients had undergone two and one previous MRI scan respectively. Examination: Head inside MRI with head coil (inferred not described in article).
Leithner et al 36	62	Women who had undergone fetal MRI	Previous MRI examination: A realistic description of the cthese of the examination was given by 23 (37.1%) women, 35 (56.5%) women gave partly realistic descriptions, and four (6.5%) women had no idea. Examination: supine, inferred head‐first.
Lie et al 37	41	Fetal brain abnormality, search for pathologies that coexist and can change or evolve over gestation. Patient pathway: Anomaly suspected, referred to second sonographer, further referral to in‐house fetal medicine expert or FMUnit, further blood, and uiMRI testing.	Precondition: Highly sensitive patient, fetus at risk of brain anomaly. Fetus high activity during scan could delay iuMRI. Examination: 20–40 minutes (inferred with head and abdomen inside MRI) Postexamination: In the academic radiological site women view images directly after scan and discuss with academic radiologist.
Törnqvist et al 38	19	Diagnose wrist, spine, abdomen, head with MRI and head inside tunnel.	Previous MRI examination: Four patients did not complete the scan due to strong worries, six patients pronounced worries before the scan but completes the scan, and 10 patients did not show worries before and did complete the scan. Examination: varied between 30 and 90 minutes (MRl with head inside tunnel)
Tugwell‐Allsup and Pritchard 39	6	Diagnose head, lumbar spine or heart with MRI. Patient pathway: Outpatient	Previous MRI examination: All patients were MRI novices. Precondition: No benzodiazepines prior to the scan. Examination: MRl with head inside tunnel (inferred not described). No contrast medium injected.

iuMRI = in utero magnetic resonance imaging, FMU = fetal medicine unit.

Quality Appraisal and Characteristics of Methodologies of Studies

Participant recruitment, setting of exploration, type of interview questions, and type of data analysis varied across studies (See Table 1 and Table S3 in the Supplemental Material for author's themes). Recruitment methodology varied distinctly across studies: from hospital records, ³² from societies, ³⁵ before, ³⁴ , ³⁶ or after ³³ , ³⁷ , ³⁸ , ³⁹ MRI. Only one study ³⁷ implemented a strategic patient recruitment. Four studies ³³ , ³⁶ , ³⁷ , ³⁹ were situated within larger clinical trial studies. All qualitative studies except one, ³⁸ recruited patients based on a particular disease. One narrative ³⁷ and three interview studies took place at home ³³ , ³⁵ , ³⁹ or through the phone. Three study interviews were done immediately after the examination, ³⁴ , ³⁶ , ³⁸ while one study did not report interview location. ³²

Data acquisition methodology ranged from unstructured ³⁵ , ³⁸ to highly structured interviews. ³² , ³³ , ³⁴ , ³⁶ , ³⁹ One study used a narrative approach, ³⁷ and data for one study emanated from patients' own narratives. ³⁸ Thematic analysis was the most common analysis methodology (n = 5, 62.5%). Six studies ³² , ³³ , ³⁴ , ³⁵ , ³⁶ , ³⁹ used themes, categories, and units of meaning. One study ³⁷ used positivism, emotion, and constructionism, and one study ³⁸ used hermeneutic‐patient lived experience. Only one study quantified frequency of statements. ³⁶ The question “What is the benefit of this MRI scan vs. the (distressful) experience of going through it?” was approached by only one study. ³⁷

In total, 144 patient quotes were extracted for meta‐synthesis from the articles: Brand et al ³² (10%), Evans et al ³³ (44%), Lie et al ³⁷ (8%), Funk et al ³⁴ (4%), Laidlaw and Henwood ³⁵ (6%), Törnqvist et al ³⁸ (13.19%), Tugwell‐Allsup and Pritchard ³⁹ (14%). For the meta‐aggregation, two extracted quotes were excluded (Table S5 in the Supplemental Material). For nine quotes there was disagreement during classification of theme and factors, a third reviewer (LB) independently assessed categories and themes and consensus was reached. One study ³⁶ did not report direct quotes. Raw data for further investigation was unavailable for this meta‐synthesis: patients were not asked for consent for data sharing, ³² , ³³ sharing not covered by approval of ethics commission, ³⁷ recordings of interviews were not archived, ³² data were destroyed under the retention policy of research material, ³⁹ contact author was not available or contactable. ³⁶ , ³⁸

Meta‐Synthesis: What Do Patients Experience Before, Entering the Scan Room, during, and after MRI Examinations?

A resulting concept map of factors related to the patients' experience of MRI examination are presented in Figures 2 and 3.

All studies extracted psychological and behavioral responses to MRI; physiological responses, eg, shortness of breath, is only mentioned in two studies. ³³ , ³⁷ On the experience of MRI, common expressions across studies are fear or relief of results, a loss of control, enclosed space, and physical discomfort. ³² , ³⁴ Törnqvist et al, 2006 analyzed the specific triggers per examination stage: at home, waiting before the MRI, and after the MRI, grouping the perceived experience as: no threat, small threat, or big threat. ³⁸

Specific Factors per Clinical Condition

Patients referred to an MRI scan for the diagnosis of multiple sclerosis more often reported negative experiences of loudness, doubt on the benefit of MRI for staging of the disease, and they mentioned being aware of room for error in the diagnosis. Patients referred for the diagnosis of cancer, reported more often perceived experiences as being “inside a coffin,” and they mentioned being aware of the importance of MRI for disease staging and therapy planning. ³³ , ³⁹ Patients with lung cancer mentioned back, chest, and breath‐holding difficulty. ³³ Patients who were pregnant reported a need to be informed before the MRI of how it affects the fetus; they were particularly worried about the effects on the baby, the (questionable) benefit of the diagnosis vs. the (distressful) experience, and their belly fitting in the MRI scanner.

Meta‐Aggregation of Quotes

The meta‐aggregation of the quotes resulted in four categories based on stages in the MRI process and five to eight themes per category (Table S5 in the Supplemental Material and Figure 4). Influence factors were noted if distinctly mentioned in the quote. To clarify, the theme “Anxiety or distress” was demarcated as related only to the experience of the scans, and “fear of the results” was considered a separate theme. The theme “Information (varying degrees/needs)” encompasses, eg, phone call from MR scanning site, written, pictorial, digital, comments from other people, as well as medical report. Social media was not directly mentioned in the patient quotes.

FIGURE 4.

Meta‐aggregation of the patient quotes, themes, and influence factors across the stages of the MRI process, including: 1. experience outside the scanner (previous), 2. experience on the table before scanning (preparation), 3. experience during the scan (during), and 4. experience outside the scanner (post‐MRI).

CATEGORY: EXPERIENCE OUTSIDE THE MRI SCANNER (35/163 QUOTES, 21%)

Themes and influence factors were Information (varying degrees/needs) (18 quotes, 51% within the category) was the most mentioned theme before MRI, specifically: how the MRI works, side effects, and one quote highlighted not being informed of having to undress. One patient mentioned reading information before the exam adds distress: “I had enough to think about without the added pressure of having to read and understand information just prior to the scan.” ³⁵ Patients mentioned the need for visual information, pictures and a phone call as preferred. Coping strategies/external support (6 quotes, 17%) included information in written format, per phone call, and from relatives, as factors for coping before the MRI and at home. Fear of results (4 quotes, 11% was already present before the MRI; a specific factor mentioned was fear cancer spread. Anxiety/distress (3 quotes, 9%) included fear of metal in the body, distress due to information from relatives, and simply “feeling terrified.” ³⁸ Waiting (3 quotes, 9%) by which patients referred to waiting on the waiting list with an unknown diagnosis, waiting in the waiting room with unpleasant thoughts arising, and waiting undressed alone as influencing their experience of MRI. Information (lack of understanding) (1 quote, 3%) referring to the fear of not understanding the implications of the MRI result.

CATEGORY: EXPERIENCE ON THE TABLE BEFORE SCANNING (18/163 QUOTES, 11%)

Themes and influence factors for this category were Anxiety/distress (12 quotes, 67%) was the most mentioned theme, relating to the look‐and‐feel of the MRI machine, enclosed space, and constrainment from placing of coils. One patient mentioned distress from an unfriendly technologist. Coping strategies/external support (2 quotes, 11%) included self‐talk; pregnant patients mentally reinforced the importance of the diagnosis for the baby to cope with the enclosed space. Easy laid‐back experience (2 quotes, 11%) including proactively addressing physical discomfort on the table, and habituation to shock and discomfort. Information (varying degrees/needs) (1 quote, 6%): a patient who is a healthcare professional mentioned: “you get that feeling of vulnerability, especially when you realize you don't know much about the procedure.” ³³ Physical discomfort (1 quote, 6%) specifying arthritis.

CATEGORY: EXPERIENCE DURING THE SCAN (88/163 QUOTES, 54%)

This category had the most patient quotes, mentioning: Anxiety/distress (33 quotes, 38%) due to noise, unable to see outside, enclosed space, anxiety “from the unknown,” vibrations in the body, having to remain still or hold the breath appropriately. Distress was expressed for not being able to inform the relative waiting outside, and for the unfriendly attitude from staff “I don't know whether the people doing the scan knew I had lung cancer, I didn't feel any empathy or any sort of friendly attitude. I walked out of there feeling quite upset actually.” ³³ Coping strategies/external support (18 quotes, 20%) mentioning self‐initiated coping mechanisms such as deep breathing, reminder of the importance of diagnosis, concentration to relax, noise as a distracting factor: “I would say, What's coming next? What's the next noise? So, I enjoyed that.” ³³ External support factors included: holding the buzzer, music, companion inside the MRI room, technician speaking. Easy laid‐back experience (13 quotes, 15%): “very simple,” ³³ “wasn't so unpleasant,” ³³ “it's actually quite comfortable in there. ³³ A patient working in pipes found the MRI experience similar to his professional activities and reported “it [MRI] doesn't bother me.” ³³ Clinical process (10 quotes, 11%) referring to their MRI process, mentioning difficulty of the full‐body scan, need to follow breathhold commands, louder noise, and time in the MRI when compared with other diagnostic processes: “PET scan isn't noisy” ³³ and “the CT scan is very quick … you're in and out. Whereas the MRI scan was very long,” ³³ and “if you took the PET scan, and take the waiting time [for radioactive glucose to circulate], and deduct that, timewise, they're much the same.” ³³ Physical discomfort (7 quotes, 8%) mentioning discomfort from chest, back, belly, or neck. “My back was uncomfortable. My, the back of my neck was uncomfortable … my brain was saying, ‘You can't go much longer …’.” ³³ “Fear of results (3 quotes, 3%)” although mentioned more often after the scan, three quotes mention fear finding cancer spread. Information (varying degrees/needs) (2 quotes, 2%) during the scan was mentioned less, mainly for not knowing the process: “I'd like to know what's going to happen, after all it is my body. I need to know more so as to take control.” ³² Neutral experience (2 quotes, 2%) “It wasn't unpleasant or pleasant. It was just a different experience for the first time ….” ³⁷

CATEGORY: EXPERIENCE OUTSIDE THE SCANNER (22/163 QUOTES, 13%)

Themes and influence factors for this category were Information (lack of understanding) (9 quotes, 41%) mentioning: incomprehension of the images and diagnosis, interest in obtaining further information to clarify the person‐specific diagnosis, and clinician uncertainty, eg, “When we went to the MRI scanner … they found the cysts and they still didn't know what they meant,” ³⁷ and “information what happens after the scan, e.g., results.” ³² Fear of results (7 quotes, 32%) mainly focused on the fear of the diagnosis. Relief from results (3 quotes, 14%) “[…] I feel a lot better now having the MRI scan, knowing that they've picked up on all of it [cancer] without that, they would … I would just be having the chemo and not the full treatment that I need” ³³ or “my biggest fear, I know I've got the cancer in the bowels. I've seen it myself on the colonoscopy. And I was worried that they might, it might just disguise I've got other cancers. So when he said straight away, there was nothing else and I feel relieved.” ³⁹ Anxiety/distress (9%) was mentioned twice only, eg, “I had a CT scan before so was expecting it to be similar, so after my MRI scan I was very anxious and shook up.” ³⁹ Coping strategies/external support (5%) mentioned once “now I have got through one scan, I know what to expect.” ³⁵

Discussion

This systematic review of eight qualitative studies details adults' experience of MRI examinations, influence factors and their relevance along the examination based on patients' direct quotes. The number of studies initially screened was large. Therefore, the present investigation focuses on the qualitative meta‐synthesis. The low number of qualitative articles resulting from the selection process points to the fact that research until now has mainly focused on quantitative rather than qualitative studies.

The study informs patients' experience is associated with the clinical condition of the patient and described in categories: before the scan, at the scanning table, during, and after the MRI scan. Amending previous research, ³² , ³⁵ , ³⁶ , ³⁷ , ³⁸ , ³⁹ where anxiety, coping strategies, and information need were generalized, the meta‐synthesis specified the influencing factors to address at each stage of an MRI examination.

Before the examination, priority themes were information need and format, followed by coping strategies and fear of results. These findings confirm the asymmetry of information mentioned by Baker et al present in the MRI setting. ¹⁷ Moreover, the findings can inform patient organizations and healthcare professionals of the need to provide preparation material (eg, information and distress management) with patient‐friendly formats. ³⁶

At the table of the scanner, priority themes were anxiety and distress related to look‐and‐feel of the MRI, enclosed space, and placing of the coils. Identification of neck pain and arthritis needs technicians and nurses' attention. ²¹ The review enhances Törnqvist et al, findings, i.e., anxiety management techniques for enclosed spaces are specifically needed at this point of the process. ³⁸

During the MRI scan, priority themes were anxiety and distress related to noise, body vibrations, inability to see outside or communicate with waiting companion, self‐initiated or supported coping strategies, and an easy laid‐back experience. Physical discomfort remains an issue for the patient after lying a few minutes inside the scanner. Additionally, the cohort in this meta‐synthesis excludes advanced examinations with high physical discomfort, eg, MRI‐guided breast biopsy. ⁴¹ For clinicians, findings highlight the potential distress and discomfort increase the longer a patient lies in the bore. Moreover, clinicians' education and future medical equipment should integrate coping strategies during scanning. ⁷ , ⁴² Only three studies included questions and themes of patient coping strategies, indicating a lack of research on how patients calm themselves. ³³ , ³⁴ , ³⁸ The findings inform clinicians that personal coping mechanisms, self‐initiated or externally supported, are needed for efficient distress management, and potentially influence compliance with future screening. Clinicians should be aware of coping approaches to positively influence the experience and plan scans personalized to the patients' capacity. ⁷

After the MRI scan, themes were: lack of understanding of the process, fear of results and relief. Meta‐aggregation highlights a lack of information and understanding, confirming the need for a solution, eg, patient‐friendly reporting as mentioned by Kemp et al. ⁴³ Surprisingly, anxiety and distress is mentioned to increase when leaving the MRI scanner, thus clinicians would do well to support patients even after the scan ended.

In contrast to disease‐specific research, the review aggregates evidence for distress factors and highlights differences per clinical conditions. ²³ , ²⁵ , ²⁷ , ²⁸ , ²⁹ , ³¹ While a possible limitation is that patient groups varied across the included studies, this review provides a broader, more diversified insight on how the population perceives MRI. Should MRI professionals adapt their communication and preparation approach per clinical diagnosis? Studies highlighted similar aspects per clinical diagnosis, eg, loudness for patients with multiple sclerosis, small bore for pregnancy, and enclosed space for patients with cancer. ³² , ³³ , ³⁴ , ³⁵ , ³⁶ , ³⁷ While the alignment of experience and clinical diagnosis is intriguing, there are different possible explanations including how the researchers phrased their questions, the positioning of the body coils which enhance perceived confinement, the psychological preconception of mortality, the scanner model (eg, 60 cm vs. 70 cm bore diameter with open design), and the scanning time. ³³ , ³⁴ This investigation does not aim to claim that patients' experience is due to a particular factor, rather that patients with a particular condition who undergo MRI examinations will be more sensitive to the specific experience. To this end, this review highlights an area for further investigation of the alignment between experience and clinical diagnosis.

Similar systematic reviews in other fields have analyzed gender differences. ⁷ In the present review, we found insufficient data in the patient quotes to analyze gender differences. Policy makers and clinicians need to foster further patient experience research with diverse populations, and in community diagnostic centers to get to generalizable recommendations.

Medical technology design was added to the concept map based on indirect factors mentioned by patients. However, patients' quotes did not reflect specific MRI design improvements. There have been continuous technological advancements of MRI systems in the past five decades with feet‐first positioning and noise reduction techniques introduced in 2004, quiet protocols, developments in scanner design, eg, scanner length of >150 cm and bore diameter up to 70 cm introduced in 2007, which have had an impact in MRI scanning. ¹⁸ , ¹⁹ , ²⁰ Apart from two articles in 2005 and 2006, ³⁵ , ³⁸ all the research included in the review was published after 2007. ³² , ³³ , ³⁴ , ³⁶ , ³⁷ , ³⁹ Thus, we consider the studies to be sufficiently recent to reflect currently used technology. The results indicate a need to evaluate technological advancements and patients' perceived experience. Patients continue to mention noise, physical discomfort, inability to see outside the scanner, feeling enclosed inside the scanner, or from the local coils placed on them. Further research on patient experience will be needed as further advancements are introduced, eg, a new 80 cm bore MRI introduced in November 2021. ⁴⁴

As patients did not report technological advancements or varying examination protocols, it is probable that they have not been attending different MRI scanning sites. Articles included patients without and with prior MRI experience. Prior experience of MRI scan, prior knowledge of disease, prevalence of the disease, and need of repeated follow‐ups are known to have an impact on experience and the memory of the experience these aspects should be considered in future research. ²¹ , ²³ , ⁴⁵ Nonetheless, aggregated patient quotes were more explicit in the preparation phase before MRI scanning, which is confirmed by Madl et al who suggested anticipation effects might be most relevant for the patients' experience. ⁴⁶

Methodological Considerations

The findings may be critically analyzed in the light of the methodological (variable) approaches across the included studies, eg, participant recruitment, type of interview, and questions used. Quotes from studies using semistandard questions did not reveal influence factors, in contrast the phenomenological study themes were broader and unexpected aspects surfaced. ³² , ³⁶ , ³⁸ , ³⁹ We agree with research on stress, the moment of interview influences the participant's perception. ²¹ , ²² , ²³ When interviewed at home, patients reflected more on the information and analyzed the situation with emotional distance, contrary to studies with interviews done immediately after the MRI scan. ³⁴ , ³⁵ , ³⁶ , ³⁷ , ³⁸ Benefit of diagnostic procedure from the patient's perspective was rarely asked for, Lie et al reflects patients' opinion on the benefit of the procedure vs. the stress. ³⁷ Healthcare professionals, when planning clinical trials, should consider qualitative research of the patients' perceived benefit versus the stress of the exam.

Studies in this review, many with small samples, have a limited representation of experiences, from, eg, diverse socio‐demographic backgrounds. ³² , ³⁵ , ³⁸ , ³⁹ We are aware that data categorization and theme identification can be labor‐intensive with samples larger than 20 participants. In this study, unavailability of the raw anonymized interviews impeded meta‐aggregation with computer‐aided solutions or machine‐learning techniques, eg, using natural language processing or other textual emotion detection. ⁴⁷ , ⁴⁸ Thus, clinicians and researchers should consider the concept map as a model combined with computer‐aided solutions or artificial intelligence to collect, analyze, classify, and consolidate larger amounts of interview data, to strengthen a (meta) analysis, reduce interpretation bias and provide comprehensive guidance. ⁴⁹

Limitations

This systematic inclusion method and excluding studies based on methodological quality may have influenced the quality of the meta‐synthesis. Researchers' background may have introduced biases during interpretation and synthesis.

Conclusion

This systematic review and meta‐aggregation of patients' experience in MRI revealed characterizing themes and factors across the stages of an MRI process, including before, at the table, during, and after MRI examination. The findings provide guidance for practitioners to understand patients' anxiety, information need, fear of results, as well as coping strategies. Thus, this review provides a foundation for further research, eg, on the physical and psychological experience, on the patient's clinical condition, the socio‐demographic diversity, and on collecting data from larger participant cohorts. The research results inform the radiology, psychology, medical technology, and physician communities, through the patient's voice about the experience and characterizing factors for guidance of future efforts addressing patient needs in MRI examinations.

Funding Information

This research did not receive any specific grant from funding agencies in the public, commercial, or not‐for‐profit sectors.

Ethical Statement

Institutional Review Board approval was not required because this systematic review and meta‐synthesis is no original research.

Supporting information

Supplementary Table 1. Search strategy applied to different databases.

Supplementary Table 2. Studies included and excluded with reasons and JBI critical appraisal criteria for Qualitative research.

Supplementary Table 3. Complementary information from the JBI QUARI Extraction tool for Qualitative Research across studies.

Supplementary Table 4. Strategies implemented to enhance the trustworthiness and the rigor of the meta‐synthesis and meta‐aggregation.

Supplementary Table 5. Summary table of coding and detailed extracted quotes.

Data Availability Statement

Data and material is available on reasonable request.