COVID-19 pandemic experience of diagnostic radiographers: A Singapore survey

Abstract

Introduction

Diagnostic Radiographers (DR) are the frontline responders during the COVID-19 outbreak, providing essential diagnostic imaging services for screening and monitoring of suspected and confirmed patients. Understanding the experience and perceptions of DR towards the COVID-19 outbreak enables radiography leaders to guide changes in the approach to managing response to future health outbreaks. This study aims to document the experiences of DR in Singapore during the COVID-19 pandemic.

Methods

All DR practising in Singapore institutions were invited to participate in an online survey, disseminated by the Singapore Society of Radiographers (SSR). The survey assessed the attitudes and perceptions of the respondents on the COVID-19 pandemic. The Holmes and Rahe Stress Scale was used to identify the respondents’ life events closely related to the pandemic. Data collection took place from 5 July 2020 to 5 September 2020.

Results

A total of 123 DR responded to the survey, where 89.4% of the respondents had been involved in the imaging of suspected or confirmed COVID-19 patients. Those performing General Radiography had the highest number of cases - 300 cases a month. The fear of transmitting COVID-19 to their family presented as the primary stressor (77.2%), followed by the lack of manpower (73.2%). The global themes that emerged from the study were (1) adapting to change and (2) quality of support.

Conclusion

Radiology departments in Singapore were able to cope with the high demands of the pandemic in terms of the provision of information, supplies, and physical equipment. However, they were less prepared to handle human factors such as mental health and staff morale. The safety and well-being of staff should not be compromised to reduce staff anxiety while performing their duties. Strategies to improve their ability to adapt to changes and provision of quality support are necessary measures in future pandemic situations.

Introduction

Singapore confirmed the first COVID-19 case on 23 January 2020. The same month, on 30 January 2020, the World Health Organisation (WHO) declared COVID-19 a global emergency [1]. Medical diagnostic imaging was in high demand for managing suspected and confirmed COVID-19 cases. Chest X-rays (CXR) and Computed Tomography (CT) scans were performed widely and readily to manage COVID-19 owing to the lack of test kits during the early pandemic period [2,3,4]. Other imaging modalities such as Ultrasound, Nuclear Medicine, and Magnetic Resonance imaging were necessary complementary diagnostic imaging for COVID-19 patients [5]. These modalities were easily available for diagnosing patients for suspected pneumonia, deep vein thrombosis, acute organ injury, and other secondary effects from COVID-19 for patient management decisions [6,7]. Diagnostic radiographers (DR) performing these imaging procedures were recognised as frontline workers during the pandemic [8]. Some diagnostic imaging procedures required long periods of exposure to suspected and confirmed COVID-19 cases.

Operationally, hospitals had to manage increased workloads, and there was a need to improve infection control practices. Radiographers experienced frequent practice and workflow changes following guidelines established by WHO and the local health ministry. They had to adopt strict infection control guidelines, team segregation, and limit staff interaction [9,10,11]. To address the rising numbers of COVID-19 patients in Singapore, additional treatment facilities were constructed to isolate and treat COVID-19-positive patients with mild disease. Radiographers were rotated to these facilities to provide radiography services in addition to their routine clinical workload [12].

During the severe acute respiratory syndrome (SARS) outbreak in 2007, stress and poor mental health were reported amongst healthcare workers [13,14,15,16,17]. Medical staff and nurses were said to be the most impacted [13,14,15,16,17]. In the literature, there were almost no studies that evaluated the SARS or COVID-19 pandemic's effects, specifically on Singapore's radiography community. We hypothesised that DR may potentially share similar stress and poor mental health concerns while working during a pandemic. Hence, this study aims to assess the radiography department's preparedness in responding to the COVID-19 pandemic as well as to understand the DR's attitudes and perceptions towards the pandemic in Singapore. The degree of stress that DR in Singapore may perceive during COVID-19 pandemic will also be assessed. It is hoped that the study would enable radiography leaders to guide changes in the approach to managing future pandemics.

Methods

Ethics approval from the local centralised institutional review board was obtained, and consent was waived for this anonymous online survey.

A survey in the form of a questionnaire was developed to understand the experiences of DR during the pandemic, predominantly comprising structured questions. The survey platform, Form.SG (GovTech, SG), was used for gathering responses from the public sector and public healthcare clusters. Thirteen questions were included to assess the attitudes and perceptions of the respondents on the COVID-19 pandemic measured on a continuous 4-point Likert scale. The Holmes and Rahe Stress Scale was used to identify the life event (from a list of 43 life events) that the respondents closely relate to during the pandemic [18]. The rank ordering of each life event in the Holmes and Rahe Stress Scale was extremely consistent in health adults and patients (r > 0.90) [19]. Three open-ended questions at the end of the survey invited respondents to comment on their concerns, and support in their work environment as well as to document the notable changes since the COVID-19 pandemic (Appendix 1). The survey was refined by DR peers with varying radiography experiences between 1 and 16 years. Before circulation, the questionnaire was piloted on the Singapore Society of Radiographers (SSR) executive committee members, resulting in minor revisions.

In July 2020, an email was sent to all SSR members. The email invited all Allied Health Professional Council (AHPC) registered radiographers practising in Singapore, to participate in the online survey. The purpose of the study was made available on the survey landing page for the respondents. Reminder emails were sent out two weeks after the initial information to encourage participation in the study. Advertisements were placed on SSR's social media platform to improve the response rate further. The convenience sampling method was used to reach out to a specific target population that meets our criteria, such as easy accessibility, geographical proximity, or willingness to participate in the study [20].

Data analysis

Data analysis was performed by Statistical Package for Social Sciences SPSS Inc (Chicago, IL) version 25. Data screening was conducted to detect and remove errors and inconsistencies from the survey data to improve the data quality. Descriptive statistics were used to analyse the quantitative questions.

Thematic analysis was conducted manually using the following the systematic approach, by Braun and Clark [21]. Firstly, provisional codes were developed by one author from the dataset (i.e., responses to the open-ended questions). The provisional codes were then reviewed by another author and revised by both authors until a mutually satisfactory baseline analysis of the entire dataset was achieved. Both authors then generated initial themes by examining the codes and the collated data. Following this, a third author reviewed the interpretation of the data from the initial codification upward. Finally, all three authors then reviewed the total analysis independently and collectively completed an entire process of triangular consensus validation.

Results

Data was collected from 5 July 2020 to 5 September 2020, yielding 123 responses. The baseline characteristics of the survey respondents as shown in Table 1 .

Table 1.

Baseline characteristics of 123 survey respondents.

	Number of respondents (n = 123)
Gender
Male	47	38.2%
Female	76	61.8%
Allied Health Professional Council Registration Status
Full registration	107	87%
Conditional registration	16	13%
Institution
Tertiary hospital	97	78.9%
Private hospital	14	11.4%
Private clinic	6	4.9%
Polyclinics	6	4.9%
Engagement in Clinical Duties
100%	83	67.5%
75 - 99%	25	20.3%
50 - 74%	8	6.5%
< 50%	7	5.7%
Modality
General Radiography	95	77.2%
Computed Tomography	28	22.8%
Ultrasound	18	14.6%
Magnetic Resonance Imaging	16	13.0%
Fluoroscopy	15	12.2%
Mammography	14	11.4%
Interventional Radiography	10	8.1%
Others (Extracorporeal Shock Wave Lithotripsy, Bone Mineral Densitometry, Nuclear Medicine)	12	9.8%

Data was received from diagnostic imaging facilities in Singapore, with most (97/123, 78.9%) responses from those working in tertiary hospitals. The mean age of respondents was 34.8 (10.9; 22–85) years. The mean age of the male (36.9 ± 11.8 years) and the female (33.5 ± 10.3 years) respondents was not statistically significant (t = 1.680; p = 0.095). Most (107/123, 87%) of the respondents had full state registration. The rest of the radiographers (13/123, 13%) had conditional registration, which was defined as DRs with less than 1 year of professional practice experience in Singapore.

The average working experience of the respondents was 9.9 (10.3; 1–59) years. A total of 89.4% (110/123) of the respondents had been involved in the imaging of suspected or confirmed COVID-19 patients. The mean suspected or confirmed COVID-19 cases the respondents saw in one month was 19.6 ± 43.7. At 300 cases a month, the highest number of cases was from those performing General Radiography modality.

The responses to the personal statements of the respondents are shown in Table 2 .

Table 2.

Personal Statements by respondents during the COVID-19 pandemic.

Question	Not at all	Not really	Somewhat	Very much	Mean	SD
I felt that the information circulated on COVID-19 has been prompt by my institution.	1 (0.8%)	7 (5.7%)	38 (30.9%)	77 (62.6%)	3.55	0.64
I found the infection control protocols within the institution are simple to follow.	0 (0%)	11 (8.9%)	55 (44.7%)	57 (46.3%)	3.37	0.65
I felt that there are enough preventive measures in the department workflow to prevent community spread of COVID-19 such as self-recording of temperature of staffs, patient screening, split team operation, setting up isolation areas for suspected COVID-19	3 (2.4%)	12 (9.8%)	49 (39.8%)	59 (48.0%)	3.33	0.75
I felt that my department/institution has adequately prepared me for my duties during COVID-19 outbreak.	4 (3.3%)	13 (10.6%)	50 (40.7%)	56 (45.5%)	3.28	0.78
I found my institution to have sufficient personal protective equipment (PPE).	2 (1.6%)	6 (4.9%)	30 (24.4%)	85 (69.1%)	3.61	0.66
I found the support system at work to be strong.	2 (1.6%)	14 (11.4%)	54 (43.9%)	53 (43.1%)	3.28	0.73
I am confident in my ability to manage COVID-19 patients.	1 (0.8%)	6 (4.9%)	41 (33.3%)	75 (61.0%)	3.54	0.63
I tended to over-react to situations.	18 (14.6%)	73 (59.3%)	27 (22.0%)	5 (4.1%)	2.15	0.71
I find it difficult to manage stress during this period.	21 (17.1%)	57 (46.3%)	37 (30.1%)	8 (6.5%)	2.26	0.82
I felt that I am valued by the community for the role I play as a radiographer.	10 (8.1%)	31 (25.2%)	54 (43.9%)	28 (22.8%)	2.81	0.88
My family is concerned about my health during COVID-19.	4 (3.3%)	21 (17.1%)	42 (34.1%)	56 (45.5%)	3.22	0.85
I fear that I might pass COVID-19 to my family members.	9 (7.3%)	30 (24.4%)	50 (40.7%)	34 (27.6%)	2.89	0.90

Two global themes emerged from the analysis of the open-ended questions that explored the general concerns, support, and changes since the pandemic: (1) Adapting to changes; (2) Quality of support.

Adapting to change - Communication

A large proportion of respondents (115/ 123, 93.5%) felt that the information circulated on COVID-19, such as workflow changes and safety briefs by their institutions, have been timely. Many were comforted by the frequent instructions and found these to be helpful, whilst others found these to be confusing.

“Constantly being reminded if there's a change in workflow. If there are patients who are suspected, the team will work together to give a heads-up to the radiographer”

[Respondent ID: 102]

“Frequent huddle sessions at work”

[Respondent ID: 122]

“Poor dissemination of instructions from higher-ups (management etc.). Poor communication between departments.”

[Respondent ID: 87]

“…unclear and rapidly changing instructions, very difficult to schedule (inpatient and outpatient) cases because have to isolate the rooms, prep the room, and information downstream is largely inaccurate hence very hard to schedule…”

[Respondent ID: 46]

Adapting to change – pandemic preparedness

On COVID-19 preparedness, 86.2% (106/123) of the respondents felt that their institution had adequately prepared them for their duties during the pandemic; 91.9% (113/123) of the respondents commented that they had received some form of training to prepare for the pandemic. Most (108/123, 87.8%) felt that there were enough preventive measures in the department workflow to minimise the community spread of COVID-19, such as self-recording of staff temperature, patient screening, split team operation and setting up isolation areas for suspected COVID-19. A total of 93.5% (115/123) of respondents also believed their institution had sufficient personal protective equipment (PPE). One respondent highlighted that the facility was not equipped to perform X-rays other than a chest X-ray for COVID-19 patients using a portable X-ray unit.

“Lack of proper imaging facility for imaging of suspected/confirmed COVID-19 patient for procedures other than CXR. e.g., performing pelvis, hip, shoulder using a portable unit in a ward-like setting”

[Respondent: 122]

Quality of support – peers and institutions

Regarding the support received within their institution, 87% (107/123) of the respondents found the support system at work to be strong. A total of 63.4% (78/123) of the respondents reported having no difficulty managing stress during the pandemic. There was no correlation between stress management and respondents’ experience, r (121) = −0.020, p = 0.826. The support received was described to be in terms of collegial support, adequate resources, and welfare. At times, these featured everyone putting in their best effort. Some highlighted personal stigma related to contracting COVID-19, while others were discontented with the quality of support provided.

“Team members always keep a look out for each other, make sure each of us have enough rest”

[Respondent ID: 24]

“Segregation was difficult but support was still evident by providing care packs. Not enough places to have meals due to limited seat availability from social distancing, but management supported with additional locations to rest”

[Respondent ID: 29]

“The morale is low at work. The supervisor is good at enforcing rules from MOH and hospital. They threaten to take punitive punishment against simple thing like providing two daily temperatures. If you are sick, mean you are not doing your hand hygiene properly.”

[Respondent ID: 28]

“Not very good. Being ostracised by some colleagues who branded me as 'secondary contact' when another staff whom I worked with contacted COVID-19.”

[Respondent ID: 54]

“Meaningless words. Songs and dance and claps that are not substantial.”

[Respondent ID: 92]

Most of the respondents (95/123, 77.2%) indicated that the safety of their family or the fear of transmitting COVID-19 to their family members was their main stressor (Fig. 1 ). This finding was consistent with the 65.9% (n = 81/123) respondents who earlier indicated that they were somewhat or very much fearful that they might pass COVID-19 to their family members (t = 35.641; p < 0.01). Lack of manpower was the second highest source of stress (90/123, 73.2%).

“I worry that I might pass the virus to my family members if I got it from work. I worry that I am not able to take care of my parents if they ever fall sick and I can't be there.”

[Respondent ID: 20]

“The fear of contracting the virus and passing on to my young son”

[Respondent ID: 118]

“Workload seemed heavy as we have to clear backlog from circuit breaker period. Staff segregation reduced our movement between centres and made it difficult to roster manpower and cover each other when one centre is busy, hence reduced flexibility.”

[Respondent ID: 39]

Fig. 1.

Diagnostic radiographer sources of stressors during COVID-19 period.

On the Holmes and Rahe Scale, most of the respondents (20/123, 16.3%) described COVID-19 as a life event that resulted in a “Change in work hours or conditions” (Fig. 2 ).

Fig. 2.

Life event that closely associates current experience during the COVID-19.

Discussion

The survey demonstrated that radiology departments in Singapore could cope with the high demands of the pandemic in terms of the provision of information, supplies, and physical equipment but were less prepared to handle human factors such as mental health and staff morale.

It showed that Singapore institutions have sufficient PPE and that COVID-19 information was circulated promptly. Radiographers could manage their workflow undisrupted by the fear of undersupply of PPE [22]. In contrast to the UK, 24% of radiographers felt that they had inadequate PPE [23]. The virus infected a significant number to health care workers (HCWs) due to an inadequate supply of PPE during the early phases of the pandemic [24]. The adequate provision of medical supplies, PPE, and COVID-19 information was crucial to ensure the limited spread of the virus within the healthcare facility.

Radiographers feared possibly acquiring the virus and spreading it to their families. Lock et al. found that many staff performing mobile radiography in pandemic and isolation wards within their institution in Singapore feared getting infected due to prolonged exposure time with COVID-19 positive patients [25]. They also mentioned that their staff perceived a higher workload and higher fatigue [25]. This is similar to what we found in the present study, where the lack of manpower was another primary stressor. Another qualitative study in Iran indicated challenges in increased staff workload, fatigue, and burnout during the COVID-19 pandemic [26]. Due to the general demand and high workload, HCWs have shown intention to quit the profession, which was directly related to the pandemic [27].

It was also found that the perceived stress level for our radiography community was relatively low, akin to a “change in work hours or conditions”. This could be due to excellent internal institutional support for staff, such as care packs and increased eating spaces. Most staff may be able to work insouciantly. One respondent, however, indicated experiencing stress levels at the most significant scale. A study by Chong et al. during the severe acute respiratory syndrome (SARS) pandemic showed feelings of vulnerability, uncertainty, and threat to life, with somatic and cognitive symptoms of anxiety amongst HCWs in Taiwan [13]. Some studies also found that HCWs in high-risk areas of SARS had greater distress [15,16,17]. Tan et al. found burnout evidence within HCWs during the COVID-19 pandemic, which may be higher amongst those redeployed to high-risk facilities compared to those at familiar facilities [28]. Jagiasi et al. found that the prevalence of clinically significant anxiety and depression was high, owing to the lack of social or emotional support for HCWs [29]. In Singapore, Teo et al. reported stress and burnout associated with longer working hours. However, having good teamwork and being appreciated at work were associated with lower odds of stress, anxiety, and burnout [30].

Possible strategies are suggested to mitigate and prevent mental illnesses such as depression, stress, anxiety, and burnout in the DR community. Firstly, institution must be enablers to support the transition of their staffs in adapting to the new changes. Good communication of workflow updates through electronic or physical means and team huddles sessions are seen to be integral in allowing the appropriate adoption of new practices. Colleagues can work together to provide emotional and intellectual support. There was increased use of virtual continuing professional development during the pandemic, where older staff were required to adopt and adapt to new learning environments [31]. Their adaptability can be eased with institutional and team support.

Another strategy is providing quality support by addressing the pain points of the service delivery team, such as adequate staff support. The safety and well-being of staff should not be compromised to reduce the possibility of fear while performing their duties. This can provide good emotional support and develop enthusiasm and self-efficiency [30]. Interventions and organisational measures should be placed within institutions for HCWs to support their mental well-being [32]. Mental health programmes can provide some catharsis to empower the staff to improve their psychological well-being in the long term.

Limitations

We calculated our sample size of an estimated amount of 317 respondents would be necessary, based on the finite population of 1800 registered DRs in Singapore, at a 95% confidence interval and 5% error. However, we only obtained 123 respondents for the survey. Hence our margin of error was 8.53% compared to what was previously predicted. A larger sample size would be recommended for future studies.

Finally, as this was the first exploratory survey study of the COVID-19 pandemic experience amongst DR community, the survey was designed to elicit breadth and not depth of the impact, within a certain period. We recommend further prospective mixed methods cohort study, to understand the reason behind the emotions felt attributing to personal stress and if there are temporal changes to the conditions over time.

Conclusion

COVID-19 has had a radical impact on radiographers’ practice. It is essential to understand the extent and spectrum of the effects brought to the radiography community to address ways to reduce exposure to stress within the workplace and manage positive change. The survey allowed us to recognise the variable experiences brought on by the COVID-19 pandemic in the DR community. This may allow potential new strategies to ensure the psychological well-being of radiographers in future pandemic situations.