Radiography education in 2022 and beyond - Writing the history of the present: A narrative review

Abstract

Objectives

The COVID-19 pandemic had a major effect on teaching and learning. This study aimed to describe a range of teaching, learning, and assessment strategies related to radiography education which have become more common due to the pandemic through a narrative literature review.

Key findings

Educational change in radiography was accelerated by the disruption caused by the pandemic. Changes included the site and mode of teaching and conducting of assessment. While some of the digital transformation trends were introduced before the pandemic, others were further amplified during this period of time. Alternative solutions such as virtual reality technology, gamification, and technology-enhanced learning were especially salient and have the potential to mitigate challenges brought about by the pandemic. The use of technology in the clinical setting, in assessment, and to facilitate feedback, are important tools for improving learners' clinical skills performance. Collectively, these digital technologies can maximise learning and support mastery of knowledge, skills and attitudes.

Conclusion

The pandemic has cast a new light on existing methodologies and pedagogies in education. This review suggests that digital technology is shaping teaching and learning within radiography education and also that educators cannot ignore this digital shift. With the digital trajectory, it would be highly useful to transform approaches to education within radiography to support learning as radiography education moves towards the new normal era.

Implications for practice

Digital technology in education can help improve the learning experience for learners but educators need to be equipped with the technological skills and be adaptable to these changes. Continual sharing of experiences and knowledge among radiography educators is essential. Safety nets need to be in place to ensure digital inclusiveness and that no learner gets left behind due to the digital divide in education.

Introduction

In June 2020, Professor Klaus Schwab, Founder and Executive Chairman, World Economic Forum, stated “The pandemic represents a rare but narrow window of opportunity to reflect, reimagine, and reset our world”.¹ While the pandemic has disrupted our normal lives, time has shown that it also presented a golden opportunity for many to seize something positive from this unprecedented crisis.

Following the declaration of the COVID-19 outbreak as a pandemic, the disease reached almost every country in the world.² With the prospects of an endemic, many radiography educators, and students, continue to ‘pick up the pieces’ of this pandemic on radiography education.³ The progression of COVID-19 over the past few years had a substantial impact on both the students and radiography educators, with profound impact at low resource/resource-constrained settings.4, 5, 6

The pandemic has intensified some of the existing education trends. Technology-enhanced learning and simulation were the epitome of education trends amplified by the crisis.⁷ Indeed, recent international studies, both pre- and during the pandemic, have highlighted the need for further exploration of the changing uses of simulation in radiography education.^{8 , 9} In addition, ‘timely change is needed to keep up with the times’ ¹⁰ which is always true of education.

A narrative review involves discussion of important topics from a theoretical point of view; taking a less formal approach than systematic reviews.¹¹ This narrative review will explore a range of teaching, learning, and assessment strategies which have become more common due to the pandemic and where the pedagogical value, when used appropriately, cannot now be ignored within radiography education.

Literature search

Literature searches were performed in February 2022 with PubMed and Google Scholar using specific keywords e.g. “Radiography”, “Education”, “COVID-19” and “Training”. Additionally, key radiography related journals e.g. Radiography, the Journal of Medical Imaging and Radiation Sciences, and the Journal of Medical Radiation Sciences were searched to retrieve relevant information. Publications had to draw on radiography or radiology education and training. Original research articles, reviews, editorials, commentaries, perspectives and short communications were reviewed. The first and second authors reviewed the articles for inclusion.

The new normal: online teaching and learning during the pandemic

For many, the pandemic accelerated the adoption of digital technologies and internet access is now considered an essential service, the fourth utility after electricity, gas, and water.¹² This is indeed no surprise as global education transited towards a new normal of virtual teaching and learning.

According to the Organisation for Economic Cooperation and Development,¹³ searches for terms such as online learning, e-learning and Massive Online Open Courses (MOOCs) increased up to fourfold between end-March and early April 2020. Education of allied health sciences undergraduates including radiographers,^{14 , 15} moved virtually with much of the teaching that was originally planned for face-to-face being delivered online. This is mirrored in radiology education where in-person teaching also moved online, teaching conferences transitioned to a fully virtual platform and digital learning resources were used as alternatives to in-person teaching.¹⁶

However, not everyone can embrace online teaching and learning. Individuals who thrive on human interaction may find virtual classes a challenging environment.¹⁷ Others who are accustomed to a planned fixed schedule may find themselves under pressure to keep up with the lessons following the transfer of “ownership” where asynchronous teaching is provided.¹⁸ Some may even disengage from their learning and risk falling behind their peers. Indeed, a systematic review by Astirbadi and Lockwood¹⁹ evaluating the impact of COVID-19 on diagnostic radiography students highlighted that the transition to online learning impacted the students significantly and posed challenges for them during the pandemic. In addition, the significant amount of screen time for online learning also resulted in screen fatigue for many.²⁰

Similarly, faculty and educators are also “victims” of the transition to online teaching or “emergency remote teaching”. The trajectory to virtual learning was remarkable but with the implementation under considerable time pressure, developing a well-structured, dedicated online teaching curriculum was a challenge.²¹ Moreover, some may feel ill-equipped to facilitate online teaching due to a lack of awareness of innovative teaching methods and effective online teaching pedagogies.²² Indeed, educators now also face the challenge of motivating learners with diverse abilities in a virtual setting.²⁰

Fortunately, literature also suggests that the rapid move to online learning resulted in a good learner experience that is conducive to sustained growth. A study²³ involving 3286 medical students from 12 different countries demonstrated the positive attitude of learners towards online learning. The authors further concluded that the COVID-19 pandemic might be the long-awaited catalyst for a new “online era” in the education of healthcare professionals.

Although it is impossible to predict when we will be able to put COVID-19 behind us, there is no doubt that it has had a lasting impact on education systems globally with future expansion of online teaching and learning options.

The virtual reality landscape: bridging the theory-practice-gap

Considering the limitation of online learning in the acquisition of clinical skills for student radiographers, educators may still leverage learning innovation and digitisation to support radiography education. In fact, as early as August 2007, Emeritus Professor Audrey Paterson, then Director of Professional Policy at the Society of Radiographers (UK),²⁴ said: “there is much discussion as to whether virtual training can replace clinical time. We don't know the answer to this question yet but what is clear from the evidence is that the time spent on clinical placement is very much enhanced by the confidence and skills built in the virtual environment.”

Fast-forward 15 years, some educators in this time of disruption are desperately sourcing for viable simulation-based solutions to support continual clinical education and assessment.²⁵ There were also others who were facing the challenge of transforming simulation-based activities into distance-learning.²⁶ With social distancing, curricula in medical schools were restructured under considerable time pressure to move towards online teaching.²⁷ This posed challenges to the conducting of practical courses or activities that require group interactions in nursing, medical and physiotherapy.^{28 , 29} Likewise, clinical placements had to be delayed or cancelled, especially at the onset of the pandemic.^{5 , 30 , 31} However, teaching must continue and alternatives to real-life simulation must be identified to support learning in the interim period.³²

Besides coping with the loss of training opportunities for students, educators also had to ensure that learning was sufficient for the current workforce. Learning had to be delivered “just-in-time” to upskill current healthcare professionals while supporting those returning to practice through refresher courses - thus ensuring sufficient and well-equipped workforce during the pandemic.³³ The focus of educators now lies on innovating in a new environment with novel technologies and adapting to flexible learning plans and outcomes. With today's immersive technology, these simulations can now happen in various realities such as augmented reality (AR), virtual reality (VR) or mixed reality (MR) while providing “omni-learning” - the ability to learn anywhere, anytime, with anyone.^{33 , 34} Though at the time of writing, there were no available AR-enabled simulation environments for training of radiographers, the prospects of AR simulation in healthcare education was positive.³⁵ Conversely, VR simulation for training of student radiographers has shown to yield improved patient positioning outcomes as compared to conventional laboratory practicum.³⁶ This was supported by a systematic review by Tang et al.,³⁷ where it was concluded that such immersive technologies can be widely adopted and used for medical practice and education to reduce drawbacks of traditional teaching formats and practical training.

Usage of Microsoft HoloLens includes allowing medical students to learn by interacting with a holographic patient via VR and AR as part of telemedicine innovation^{38 , 39} and learning of new practical tasks such as catheter placement where MR technology is seen as a cost-effective method to facilitate practical medical education.⁴⁰ Examples that are more closely related to us are also illustrated by Uppot et al.⁴¹ where both VR and AR tools are used in radiology education for training communication and clinical care. This includes using AR to help learners conceptualise complex anatomy, experiencing a 3D conceptual model of a physical environment and interactive lectures. Such technologies have the potential for supplementing radiography training in anatomy and pathology and for procedural simulation.⁴¹

As opposed to textbooks or online learning modules, immersing the learner in a virtual world is associated with a higher level of active learner participation because of increased social, environmental, and personal presence within the learning activity.⁴² In addition, the use of such technology allows students to integrate lectures into practice sessions, where previously they would have to wait for lectures to refresh their understanding. In fact, holographic technology has recently been officially integrated into the curriculum for training medical and nursing students in Singapore.⁴³ Evidently, this is a shift in paradigm from our traditional mode of learning and such sight of students wearing headset will soon be much more common.

Especially in this COVID-19 pandemic, many had to challenge the status quo. In a recent commentary by Hayre and Kilgour,⁴⁴ the authors put forward the possibility of a paradigm shift within radiography education through use of technology including VR. The authors rounded up by concluding that VR does not offer a ‘one size fits all’ model but its current use and success for maintaining student progression should not be overlooked.

Application of VR in radiography education has been around for a while and models that have surfaced include Shaderware (Shaderware Ltd, Darlington, UK). The use of Shaderware for radiography training using 3D interactive simulation provides a cost-effective simulation training for radiographic equipment handling, receptor placement, collimation, side marker placement, exposure factor selection, control of scatter, and image quality assessment.⁴⁵ In fact, when available fully to learners, it facilitates asynchronous learning and acts as evidence of acquired competency prior to learners commencing their clinical placements.⁴⁶

In 2016, Monash University developed a VR simulation clinic to facilitate the training of medical radiation science students and reported improvement of student perception scores for clinical and technical skills.⁴⁷ Also in 2016, Shanahan⁴⁸ from the Royal Melbourne Institute of Technology investigated the students' perspective on using virtual radiography simulation. Her findings have been promising. Students feedback that the virtual radiography simulations have a valuable role to play in developing technical and cognitive skills. And this could be due to the strength of such a model where students can repeat activities and could quickly see images and understand if changes needed to be made without being burdened by the use of ionising radiation on actual patients. The value of VR simulation was also echoed in other studies which include Sapkaroski, Mundy and Dimmock's⁴⁹ study which illustrated the benefit of repetition afforded by the use of VR simulation. This has implications on radiography education as VR could potentially be used to augment practicum or laboratory session while having the benefits of being easily accessible and the ability to allow students to correct their mistakes at their own pace.⁴⁹

A similar picture was also painted in a recent study published by University College Dublin⁵⁰ on the use of 3D VR simulation in radiography education reported that the students “enjoyed” the VR simulation. Additionally, virtual immersion bolstered students’ confidence in a number of areas including beam collimation, anatomical marker placement, centering the X-ray tube, and selecting radiation exposure parameters. Their findings were in alignment with Gunn et al.⁵¹ who concluded that the integration of VR computed tomography simulation has the potential to increase both student confidence and preparation for the clinical environment.

For radiography educators, it is reassuring to know that students exposed to VR performed better than those in the traditional education group as suggested in a systematic review and meta-analysis published by Zhao et al.⁵² Additionally, in another meta-analysis by Chernikova et al., simulation-based learning offers a wide range of opportunities to practice complex skills and allows a variety of scaffolding to facilitate effective learning.⁵³ However, in a recent study conducted on radiologic technologists in Japan, the authors found that VR can be less effective than real-world training in radiographic techniques which often emphasises patient interaction and palpation skills.⁵⁴

Therefore, it is important to note that while such technology is scalable, reusable, and suitable for many students with limited patient access, the tasks should be meaningful and transferrable to the real world. Educators would also have to consider many factors including the ergonomic design and development of the applications; the financial and technological assistance in developing the VR environment and the requirement of a highly creative and educated workforce.⁵⁵ Nonetheless, these immersive technologies have enormous potential in medical practice and education.

Gamification: driving engagement through game-based learning (GBL)

Another technique that can promote student learning is in the form of gamification which is increasingly being adopted by educators to optimise students' learning outcomes. In a systematic review by van Gaalen et al.,⁵⁶ it was suggested that gamification, when used appropriately, improves learning behaviors and attitudes towards learning in health professions education. A similar picture was also painted in another systematic review by Gentry et al.,⁵⁷ where they further concluded that gamification or serious gaming is more effective for improving knowledge, skills, and satisfaction in health professions education. In alignment with the systematic reviews, Arruzza and Chau⁵⁸ in their scoping review of randomised controlled trials concluded that gamification may be advantageous for health science undergraduates. In addition, they also suggest educators supplement conventional teaching methods with gamification rather than replace them and to also consider group-based gamification, employed at irregular intervals.

Gamification can also be used in tandem with VR for teaching and learning. For example, gamification and VR have been used for teaching mobile radiographic imaging. Leveraging on the benefits of both simulation-based learning and gamification, it provides learners with a user-friendly and sufficiently realistic training tool with a high educational value for mobile imaging.⁵⁹ In radiology, the incorporation of gamification is able to improve learners' diagnostic confidence, reducing errors rates in training for pneumothorax detection and offering the element of fun in the learning process.⁵⁴ The fun factor of the learning tool encourages continuous utilisation of such learning aids and helps keep the learners motivated.⁶⁰

GBL in virtual worlds such as Second Life™ is also widely published in literature. Second Life™ has been used for health professional learning where learners from various health profession disciplines, including medical radiation sciences, to develop their communication and history taking skills in a fun and safe learning environment of Second Life™ - enhancing learning outcomes.⁶¹ In fact, the radiology profession has been using Second Life™ to teach medical students undergraduate radiology^{62 , 63} including core radiological anatomy and radiological signs content. Furthermore, experiences from the use of Second Life™ by radiology⁶⁴ further supported Arruzza and Chau's⁵⁸ findings of group-based gamification where competing in teams has the advantages of promoting collaborative learning and responsibility in collective work.

Despite GBL gaining momentum in education, there are also critics. It has been suggested that GBL tends to address lower-level learning goals rather than higher-level goals.⁵⁸ Additionally, Sánchez-Mena and Martí-Parreño⁶⁵ further highlighted the lack of resources, classroom dynamics and students’ apathy towards GBL as barriers to widespread adoption in education. Cultural differences may also affect the effective use of gamification as a teaching and learning methodology.⁶⁵ Educators will have to consider and address these elements before implementing this as a new teaching methodology in their course.

Technology-enhanced learning (TEL): innovating teaching and learning practices

TEL is now commonplace and widely accepted in teaching and learning in health professions education following the influx of new technology in education.⁶⁶ Some of the TEL tools include the use of digital learning objects such as videos, mobile, and learning management systems (LMS). While such tools delivered online learning adequately, many learners experienced superficial learning.⁶⁷ Thus, it is imperative to adopt an innovative pedagogy approach in tandem with digital learning objects to deliver quality and inclusive education in online environments.⁶⁷ TEL tools facilitate flipped classroom models which yields many advantages such as: allowing learners to learn at their own pace, frees up contact time for more effective, creative and active learning activities and facilitating learners' control, focus and responsibility for their own learning.^{68 , 69} Such a combination of technology and teaching approach can also increase learners’ motivation and engagement.⁷⁰

The pandemic mandated social distancing, thus reducing interactions between people and avoiding physical gathering including academic institutions. The use of digital learning objects has helped to “overcome the distance”, while facilitating remote learning and education. LMS were leveraged at the onset of the pandemic to facilitate knowledge transfer across the globe. A LMS can be defined as an all-in-one organisation software that automates the administration, tracking, reporting, and delivers accessible contents rapidly.⁷¹ The dissemination of mobile radiography knowledge through a global collaboration was an exemplar of LMS usage during a pandemic.⁷² A narrative review by Konstantinidis et al.⁷³ concluded that e-learning is an attractive training method, equally or occasionally more effective than the conventional educational methods for the lifelong training of healthcare professionals in the field of medical imaging and radiation therapy. In alignment, a systematic review by Naciri et al.⁷⁴ concluded that health professions students demonstrated a positive response to e-learning in domains such as perceptions, acceptance, motivation and engagement. Furthermore, such asynchronous e-learning has shown to be effective in improving knowledge acquisition in radiology (chest radiology suggestive of COVID-19) while being a flexible tool to adapt to complex situations caused by the pandemic.⁷⁵ This may be of value for training of radiographers in image interpretation or preliminary clinical evaluation delivered through asynchronous online learning/distance learning.

Other examples of innovations in TEL is the curation of 10 min video lectures called voice annotated presentations (VAPs) by Duke-National University of Singapore. The curated digital library consists of various Learning in 10 videos from radiology and radiography.⁷⁶ Such approaches allow greater accessibility to medical information by learners globally which ultimately contribute to a better health system for all. Like many TEL tools, video lectures can also be used with flipped classrooms. Vavasseur et al.⁷⁷ illustrated blended learning using video-based lectures. In fact, they also suggest that low achievers take the best advantages from this approach, with overall higher student engagement. This can be attributed to the empowerment of these low achievers in terms of gaining more opportunities to reflect and learn at their own pace rather than being afflicted by the more challenging and fast-paced traditional lectures.⁶⁹

Educators could also use dynamic eLearning authoring tools to create responsive, learner-focused structured courses for any device. It is no surprise that radiology adopted this new method for teaching medical imaging since radiology itself consists of highly visual content.^{78 , 79} Experiences from the University of Southampton,⁸⁰ has suggested that a well-designed and integrated TEL solution can be an efficient approach for facilitating the application, integration, and contextualisation of anatomy and radiography - one that radiography can take a leaf from.

The emergence and increased deployment of mobile learning is well suited for our learners, many of whom are technologically digital natives. Mobile technology has become an intrinsic part of everyday life and the use of mobile learning as an educational method would facilitate delivery of educational content which is readily accessible, up to date, and technology enriched.⁸¹ Moreover, it is also a good source of information for “just-in-time” learning.

In fact, the role of mobile electronic devices in radiographer education has been explored for some time. In 2010, Applegate⁸² illustrated in a literature review the potential use of mobile electronic devices in radiography education and concluded that such mobile electronic devices are valuable as an information delivery tool. Another more recent 2019 systematic review and meta-analysis by the Digital Health Education Collaboration⁸³ suggested that mobile learning is as effective or even better than traditional learning. Makary et al.⁸⁴ further supported the use of mobile electronic devices and concluded that such devices have the potential to remarkably transform content delivery in the education of residents. In alignment with radiology, radiography has also adopted mobile learning in the training of radiographers. Alsharif et al.⁸⁵ validated the educational effectiveness of a mobile learning app in improving radiographer knowledge about magnetic resonance image quality optimisation and artefact reduction. Their findings were positive and underpin the potential of mobile applications as an effective educational tool.

While the benefits of mobile learning are undeniable, it also exposed the digital poverty position. Beyond any doubt, learning in a digital environment is not compatible with digital poverty. Substantial investment is required while developments need to be well-calibrated to address the specific needs of the most deprived; mitigating the digital exclusion while supporting technology-enhanced learning into the future.⁸⁶

Digital assessment and feedback

Prior to the pandemic, digital assessment was gaining traction and popularity in medical education with the trajectory of digital transformation and digitalisation.⁸⁷ During the pandemic, with the transition to online teaching, assessment of the learners also moved online. One example is the MammographyOnline,⁸⁸ where high quality academic components are delivered with assessment embedded at the end of each module. Almeida et al.⁸⁹ further spotlighted Modular Object-Oriented Dynamic Learning Environment (Moodle) utilisation as an LMS to assess learning, collect, assess and provide feedback in medical imaging education and training. While many medical schools have implemented such platforms for their learners prior to the pandemic, medical schools in low and middle-income countries experienced obstacles in the development and adoption.⁹⁰ However, the current pandemic has forced many to adopt it for education; institutions that were previously resistant had to now accept the new transformation or be excluded.^{22 , 90 , 91}

Another transformation to assessment could be the use of screencasts for assessment. Jones and Wisniewski⁹² used screencast video assignments to replace multiple-choice quizzes and such an approach was proven to be an innovative way to assess pharmacy students’ knowledge and to provide feedback on their assignments. Indeed, screencasts can also be used to provide feedback to learners.⁹³ A qualitative literature review by Killingback et al.⁹⁴ concluded that alternative feedback modes, including screencast, aids learners to achieve a greater level of comprehension of feedback through more personalised feedback.

Objective structured clinical examinations (OSCEs) are another important component in the summative assessment of medical students.⁹⁵ Indeed, OSCEs are recognised by radiography as a valuable form of assessment in evaluating clinical competence of student radiographers since it targets the ‘Shows How’ level of Miller's pyramid of assessment.⁹⁶ Due to the COVID-19 pandemic, many face-to-face OSCEs were converted to an online or hybrid format.97, 98, 99, 100, 101 Experiences from Nurse Practitioner students¹⁰² were positive and it highlighted that the interactive Virtual OSCE was deemed an extremely effective tool for virtual evaluation of various clinical competencies. Similar positive findings were also echoed by Farrell et al.¹⁰³ where students rated telehealth OSCE positively while adequately assessing the students' foundational clinical skills performance. It is no surprise that practical tips from various authors' experience¹⁰⁴ are gradually emerging and contributing to the small but developing body of literature on VOSCE - one where radiography educators could potentially contribute.

The role of technology in clinical settings

Experiences of student diagnostic radiographers transiting into the workforce during the pandemic¹⁰⁵ spotlighted the concern regarding training for competencies during their induction period. The lack of formal training compounded with the inadequate support from mentors due to increased workload and manpower shortage have implications for their early career as a radiographer. Though it remains to be seen, video conference technology may be a solution to the current challenge posed. Rawle et al.¹⁰⁶ illustrated a teleradiography pilot project which presented positive results - improvement of image quality of radiographers through the introduction of video conference supervision. Similarly, Cameron et al.‘s qualitative study also supported the use of remote supervision through video conference where trainees are provided with readily available guidance and well supported in their delivery of care to patients.¹⁰⁷

In a commentary by Singh,¹⁰⁸ various examples and features of emerging technologies that were deemed beneficial to radiography education were highlighted. It was suggested that technology advancement could be a game changer in the way tracking of clinical competency for both students and newly graduated staff under supervision is done. Alismail et al.¹⁰⁹ illustrated a clinical education tracking system that overcomes the challenge of tracking student competency while supporting the provision of immediate student feedback on their progress, thus improving student outcomes. Another model could be the use of electronic clinical tracking systems. Bakers and Dubose¹¹⁰ in 2009 published electronic systems for medical sonography student clinical records where the electronic systems enabled rapid collection and analysis of clinical education data while eliminating problems associated with paper forms - a common scene in radiography education. In a similar vein, an integrative review by Branstetter et al.¹¹¹ concluded that electronic clinical tracking systems are increasingly being utilised in advanced practice registered nurse education.

In radiography education, Monash University is an exemplar of introducing technology in all aspects of clinical placement. In fact, being the first undergraduate radiography course in Australia to implement such technology, their experiences were a timely reminder for us to enculturate positive attitudes towards technology and associated pedagogical change.¹¹² Clearly, such models could be studied further by the radiography educators on its feasibility and appropriateness for radiography education.

Conclusion

While advances had been made in technology-enhanced radiography teaching and learning prior to the COVID-19 pandemic, the significant disruption to learning due to the pandemic accelerated the transformation of digital teaching and learning in radiography education around the world. Most importantly, it provided a unique window for fundamentally transforming approaches to teaching and learning within radiography as radiography education “recovers” and moves on from the pandemic. To achieve a better outcome for learners, radiography educators must act jointly and swiftly to revamp various aspects of radiography education. This will enhance radiography education and strengthen the future of the profession.

Conflict of interest statement

None.