Systemic disregard, demoralising occupational burnout, protective maturity: The ‘lived’ experience of nuclear medicine technologists and the impact of COVID-19

Abstract

Objective

It has been shown that stress in the workplace can contribute to the development or worsening of mental health conditions, as well as having a negative impact on personal relationships and life outside of work. Therefore, prolonged job stress can be damaging to an individual's mental health and wellbeing, potentially leading to burnout. There is limited research surrounding the wellbeing of nuclear medicine technologists practicing globally, and more specifically in Australia. This interpretative phenomenological study seeks the lived experience of nuclear medicine technologists within a large metropolitan city in Australia, how these experiences and COVID-19 has impacted their wellbeing.

Methods

Five participants were recruited who had greater than five years working experience as a nuclear medicine technologist. Data was collected using semi-structured interviews conducted online via Zoom to accommodate COVID-19 restrictions. The data was transcribed and analysed according to interpretative phenomenological analysis (IPA) protocols.

Results

One superordinate theme: systemic regard, demoralizing burnout, protective maturity, overarched four subordinate themes: staying physically and psychologically safe; risk of burnout; maturity as protective against burnout; and COVID-19 drain. Pressures both prior to and during COVID-19 leave the participants feeling undervalued, discredited, and at risk of burnout. However, maturity brings confidence to incorporate their strengths in a more holistic view of life. Glimmers of positivity come from choices to alter their career path and the unexpected opportunities to spend time with family through COVID-19 restrictions.

Discussion

Overall, the participants of this study expressed a lack of positivity about their own individual experiences within their career. Occupational stress, caused by workplace bullying, increased workload and understaffing increased their risk of burnout. Although as the participants matured, their ability to cope with occupational stressors improved. The recent COVID-19 pandemic exacerbated the participants’ risk of burnout.

Conclusion

Due to a number of contributing workplace factors, exacerbated by the unexpected COVID-19 pandemic, participants in this study appeared to have an increased risk of developing burnout. However, maturity and life experience has helped mitigate this risk.

Introduction

There is very little research into the wellbeing of nuclear medicine technologists globally and more specifically, in Australia where a variety of public and private health systems have the potential to impact wellbeing and longevity of career. Consequently, the coping mechanisms used by this professional group to maintain wellbeing despite the demands of caring for potentially very ill or dying patients, is unknown. Compounding this are the demands to keep abreast of technological advances. Previous research has highlighted the work environment of nuclear medicine technologists [1] and how this is related to work engagement and retention [2]. However, there was no data within these studies on the mental wellbeing of the technologist. Similarly, the impact of COVID-19 on this group, is unknown. This interpretative phenomenological study seeks the lived experience of nuclear medicine technologists within a large metropolitan city in Australia, how they manage the diverse systemic demands across private enterprise and public health, self-protect against occupational burnout, and manage longevity in their career, particularly during COVID-19.

Nuclear Medicine is integral to efficient health systems worldwide particularly, the management of various non-communicable disease such as oncological, cardiovascular, and neurodegenerative diseases. Out of 195 countries, 134 now have nuclear medicine facilities [3] placing it front and centre of accelerated health care and the reduction in healthcare costs globally. However, such exponential growth has impacted the working lives of nuclear medicine technologists. Within Australia, the working environment of nuclear medicine technologist's (NMT) can range from being part of a team in a hospital to being a sole practitioner in a small private practice in a metropolitan, regional, or remote setting [1]. They are responsible for the preparation and administration of radiopharmaceuticals, imaging of the patient, and the digital analysis of the images and data obtained for the diagnosis of injury and disease. They are also involved in the administration of radioactive isotopes for the treatment of cancer [4]. While these are the technical responsibilities of the technologist, the NMT also works very closely with the patient. NMTs require excellent skills in communication cross culturally and with patients across the life span, familiarity with radiation safety measures, and an ability to empathise with those needing various degrees of medical care. The interpersonal and intrapersonal challenges of such specialty caring can have psychological costs [5].

Nuclear medicine technologists have reported work related stress occurring 2–4 times per week [5]. Workplace stress occurs when the demand of work exceeds the ability of the worker and the resources and support available [6]. It can contribute to the development of a mental health condition or may cause an existing condition to worsen. Occupational stress can also have a negative effect on relationships and life outside of work as well as increasing a worker's risk of injury [7]. Therefore, prolonged job stress, particularly carer fatigue,[8] can be damaging to an individual's mental health and wellbeing. Poorly managed chronic workplace stress and carer fatigue can also be the source of burnout [7].

Burnout is characterised by three different factors; emotional exhaustion (feeling fatigued or emotionally drained), depersonalisation (feelings of cynicism or negativity towards an individuals’ workplace) and reduced professional accomplishment or efficiency (feelings of incompetence) [9,10]. Symptoms of burnout will vary, depending on the individual, but may include sleep disturbances, substance abuse, other physical illnesses and conflicts within personal and work relationships [11]. Occupational burnout in a health professional may negatively impact patient care, staff turnover and absenteeism [12], as well as negatively influence their professionalism and job performance [11]. Therefore, the maintenance of NMTs’ wellbeing is of high importance to the profession as a whole.

The aim of this study is to gather rich idiographic data from a group of nuclear medicine technologists working in the same region in order to explore both positive and negative interpretations of their working life and organisational care, and how this impacts on their wellbeing, self-care, coping strategies, and career longevity. As an iterative study, it will seek the ‘lived’ experience of this poorly explored phenomenon using interpretive phenomenological analysis (IPA).

Method

Participants

University Human Research Ethics Committee approval was obtained prior to the commencement of this study (H-2020-0085). Participants were recruited from nuclear medicine departments throughout a large metropolitan capital city of Australia. Selection criteria included full time equivalent of greater than five years working experience. It was felt that five years allowed time for participants to reflect on working practices, their own self-care and coping strategies, and organisational care. Of the five participants included in this study, 4 identified as female (pseudonyms used throughout). Other demographic information is displayed in Table 1 .

Table 1.

Participant demographics.

Participant	No. years working as a nuclear medicine technologist (NMT)	Current position	Age bracket	Gender
1	20	NMT	40–44	Female
2	26	Chief NMT	45–49	Male
3	40	NMT	60 and over	Female
4	30	NMT	50–54	Female
5	38	NMT	54–59	Female

Procedure

Following recruitment, a participant information statement, pre-consent form and demographic questionnaire were disseminated to participants. The completed pre-consent form was collected prior to semi-structured interview taking place. [13,14]. The semi-structured interview consisted of open-ended questions funnelling down to important aspects of their working life. To remain neutral, we asked participants to reflect on both positive and negative experiences of NMTs, for example “Tell me about your experiences as a technologist, both positive and negative, that have made an impact on you”.

The semi-structured interview schedule was emailed to participants the day before their interview, allowing for some pre-interview reflection by the participants [15]. The interviews were conducted by the first author (MS) online via Zoom, digitally recorded and held at a time suitable for the participant. This allowed for the verbal data to be anonymously transcribed at a later date and the non-verbal behaviour observed by the interviewer at the time of the interview and added to the transcription as a side note. Post interview consent was also obtained, recognising that phenomenological investigations are a participant's moment-in-time reflection and therefore eliminating the need to edit the transcribed data. Each interview lasted approximately 1 hour.

Analytic strategy

The aim of any IPA study is to explore how people are making sense of their experiences [15]. IPA utilises very small sample sizes from which detailed data is analysed providing thematic insights from a group for whom the research question is significant. IPA is philosophically underpinned by phenomenology (the study of experience [15]), hermeneutics (the theory of interpretation of given text, speech or symbolic expression) [15] and symbolic interactionism (the theory focusing on human interaction and how this influences their society [15]). It seeks essential components and uniqueness of a phenomenon from the individual perspective [16]

Analysis

The lived experience of a phenomenon is the emphasis of any IPA study [17]. The researcher is aiming to describe rather than explain the individual's response to the phenomenon under exploration [13]. In this study, IPA was used to analyse the comments from nuclear medicine technologists and how they interpret their working experiences and how these impact on their wellbeing. While IPA has guidelines [15] to analyse the data obtained from the interviews, they are flexible and adaptable to the specific aims of the research (Table 2 ). The first author (MS) transcribed the data and then both the first and third authors completed an in depth analysis of each case separately. Robust discussions ensued between the two researchers to determine, contrast and compare the themes arising from each case, followed by a reiterative write up of the resultant themes.

Table 2.

IPA Analytical process [13],[15].

Analytic Process
Step 1	Each interview is transcribed verbatim.
Step 2	Beginning with the first interview, researchers immerse themselves (independently) in listening to and reading the interview transcript. Initial thoughts and ideas are noted in one of the margins.
Step 3	In the other margin, the researcher expands their initial thoughts by recording more comprehensive notes identifying significant content, language and concepts that appear embedded in the transcript.
Step 4	Emerging themes are noted that concisely capture the essence of unique passages in the transcript. Quotes are highlighted that appear relevant to these themes. An extensive audit trail is now produced consisting of initial notes, more concise contextual notes, reflexive notes, emerging themes and relevant quotes for the first interview.
Step 5	The above steps are repeated for each of the interviews. At this stage any clusters of themes arising across the interviews (convergent themes) are noted. Any strong rich data with thematic representation that may exist in one data set only (divergent theme) is also noted
Step 6	Both researchers come together for robust discussions around each interview moving from first to last, comparing and contrasting themes and potential quotes. By engaging and focusing on the participant's words and experiences, any biases the researcher may have are put aside. Thematic inclusion in the results occurs when consensus is reached by both researchers accepting themes that are unique, rich, and substantiated by the data.
Step 7	Writing up of the results begins. At each draft of the results, auditing continues between researchers to ensure identifying themes are supported by the data. Superordinate and subordinate themes may emerge. The audit trail continues throughout the analysis and write-up of the results. Within the discussion, the relevant theory is linked to the identified themes.

Assessment of quality

Validity in IPA research is often assessed by examining the quality of the research performed. Yardley's four broad principles [18] for assessing the quality of an IPA study (sensitivity to context, commitment and rigour, transparency and coherence, and impact and importance) were followed in this study to ensure quality. Credibility was also achieved through audit trails and robust discussion concerning thematic findings [15].

Researcher's perspective

Researchers using IPA need to be aware of their own biases and presuppositions as possible obstacles to making sense of the participant's interpretation of their experiences. This is achieved by “bracketing” one's personal biases and preconceptions [15]. In an interpretative phenomenological study, the researcher temporarily sets aside their expectations and assumptions striving to reiteratively understand the participant's meaning making. However, it is important in any research to account for personal and professional experience. The first author (MS) was a nuclear medicine technologist with 25 years clinical experience, which gave her an insight into the participant's world and allowed her to empathetically engage in their experiences. The third author (LM) is a senior academic whose research focuses on the individual interpretation of experiences and sense making.

Results

One superordinate theme: Systemic disregard, demoralising burnout, protective maturity, overarches four subordinate themes: Staying physically and psychologically safe; Risk of burnout; Maturity as protective against burnout; and COVID-19 drain. Current work conditions leave the participants feeling at high risk of being compromised physically and psychologically within a system whose focus is not on staff wellbeing. Glimmers of positivity come from choices to change career and redefine their competencies, and the unexpected opportunities to spend time with family through COVID-19 restrictions. Table 3 gives a description of the subordinate themes.

Table 3.

Subordinate themes overarched by one superordinate theme - 'Systemic disregard, demoralising burnout, protective maturity'.

Subordinate Theme	Description
Staying physically and psychologically safe	Safety risks to technologists’ mental health as they strive to give more, care more and carry responsibilities.
Risk of burnout	Working pressures leave the technologists feeling undervalued, discredited, disregarded, and at risk of burnout.
Maturity as protective against burnout	Maturity brings confidence to incorporate their strengths in a more holistic view of life.
Covid-19 drain	Unrelenting work schedules

Theme 1: staying physically and psychologically safe

Participants sense disregard of their wellbeing as they navigate value differences in corporate versus public working environments. For example, after spending some time working in a more corporate private facility, Shyla feels depersonalised:

“I think maybe it was the culture because it was just this corporate culture, you're just a number … it didn't appeal to me at all” (Shyla).

Corporatisation of nuclear medicine leaves Katia wary of management:

“The bit I'm most cynical about is that those that are put into positions of power … might know business but don't know nuclear medicine” (Katia).

As such, participants struggle to navigate what they describe as a toxic work environment, where self-worth is minimised through a sense of invalidation:

“Afraid because I didn't want to go and ask a question, ask to check something because you'd feel like an idiot” (Solomon).

Sensing a slow eroding of her value as a professional, Katia makes the decision to resign:

“I went on to work for people that respected me … they valued my work, they valued my input as a tech” (Katia).

Each participant speaks of how senior roles which invariably include Human Resources duties, distance them from their nuclear medicine passion - “that's what loses your interest”. In fact, rising through the ranks leaves Solomon feeling overwhelmed with the workload having to “do it before or after work, cause you just can't do it in time”. Managerial duties begin to impede his personal life:

“It puts a strain on the relationship … when you're working constantly long hours” (Solomon).

Importantly, for those who stay at the coalface, participants recognise that the forced increase in workload and shortage in technologists increases occupational radiation exposure risk and the potential implications on technologist retention:

“Because there's not a lot of technologists around … you're not being rotated out of PET as much … consequently your doses are higher … I know for some people it would be the reason why they leave the field … because if you can't reduce your exposure and you're … trying to have a child … that's a major concern for you” (Shyla).

Theme 2: risk of burnout

There is tension for staying safe physically and psychologically as a nuclear medicine technologist that risks occupational burnout. Additionally, as much as nuclear medicine “has shaped a large part of who” Shyla is, she admits that there are limited career paths for some technologists “it's such a small field and your skills are so specialised”. Recognising these cumulative risks to wellbeing and feeling stuck - “I can't do anything else” - Shyla is prompted to change career:

“I think if I hadn't did what I did, I would be bitter and twisted, I think I would be quite unpleasant to work with” (Shyla).

Re-training and having other options creates a sense of freedom and decisiveness for Shyla “as opposed to sort of just rambling along”. Similarly for Katia who doesn't “know how to do anything else”, nuclear medicine as a “niche” career, creates anxiety. Retraining offers a reprieve from boredom and future uncertainty:

“Once you've been doing it for a long time it becomes … very boring after a while … I went and did another career” (Shyla).

Burnout is very real for each of these participants who talk of adopting self-protective behaviour such as internalising feelings:

“When I come home and you've just had a rotten day, don't want to talk about it, and I just want to sit down, say nothing” (Solomon).

Similarly, cynicism underpins a lack of trust:

“I need to be careful of who I trust all of my information to, because that could be spun around and used against me as I've had happen to me in the past” (Solomon).

Over time, Shyla acknowledges her risk of burnout revealing that she has become “more cynical because I don't trust people … (they) won't tell you the truth or go off on a tangent”. This is exacerbated by their sensed invisibility as real people by patients:

“They don't seem to acknowledge the fact that you're people with family and feelings … pressures outside of work … that you too could become unwell” (Shyla).

To moderate her cynicism the change of career has “definitely made my eyes wider and just more accepting of different cultures and different beliefs”. Grace is aware of her reactions to patients and knows that if “I mentally think that's really annoying” that it is time she took a break from work. However, trust is nurtured by a team environment “just being able to ask for help is a big thing … being able to trust and rely on people”. For Sally, her inability to cope outside the team is personally insightful “if you're on your own you kind of flounder a little bit”.

Theme 3: maturity as protective against burnout

Katia's patient care and compassion has been at the forefront throughout her career, but when she was newly trained she “didn't know why I was doing it”. She reflects on how being “more aware of why” due to her life experiences and having ageing parents, brings maturity:

“I think as I've got older, I've become a little bit more empathetic … but that comes with age, that comes with experience, that comes with life lessons” (Katia).

The empathy that has emerged throughout Sally's working life also shines in her personal life, helping her to “be the best you can”. She self-edits as a form of emotional regulation:

“If someone says something just take a step back and think about it, process it, then reply. Don't take it so personally” (Sally).

Shyla has a “more holistic approach” to her nuclear medicine work since retraining in another health-related career. Sensing other technologists “are very much focused on getting that scan done and getting them out”, she recognises that she now has more job satisfaction and can mentor her colleagues through a wider lens:

“That's been really good to be able to, I guess educate, and that's just added to my satisfaction in working as a tech” (Shyla).

The sheer volume of exposure to sick patients brings a constant re-evaluation of life choices:

“You see them from a point as a new diagnosis and then you follow them through the progression of their disease, and I think it makes you question your values … it makes you appreciate what you've got” (Shyla).

Long careers, maturity and the reality of retirement brings a sense of “accomplished” and humility in having “made an impact on a variety of people”. Katia feels fortunate to have such a long and enjoyable career “I still love being a tech … I loved everything about it and I still do” and that she is able to choose to retire “I want to go out on a high, I don't want to be pushed”. In retirement, Grace still wants to serve the community “I still want to be out there helping people” without losing a wise pragmatism around her experiences in health care:

“Life is too short to worry about things you cannot fix or have control over” (Grace).

Theme 4: COVID-19 drain

COVID-19 brings an exhaustion unknown before from constant use of PPE, supply issues and staff shortages:

“I'd be happy to crawl up in a ball and cry. We are so understaffed, the workload doesn't stop, but we've got no staff” (Katia).

Furthermore, there is no reprieve from understaffing and the stress of navigating constantly changing rules surrounding COVID-19 restrictions, leading Katia to extreme thoughts “I almost want to have it (COVID-19) so I can have some time off”. The relentless snowballing impact of the pandemic precipitates a sense of collective deteriorating mental health:

“Failure to communicate these changes in a timely manner contributed to confusion and misinformation” (Shyla).

A sense of being overwhelmed, “undervalued … by hospital administration and patients” is cumulative upon the struggle to persuade patients to adhere to PPE requirements.

There are moments of unexpected positives during COVID-19 - “my immediate family has spent more time together in lockdown”, but as health workers, it is also the catalyst for the breakdown of some relationships due to “their blatant disrespect for medical advice”. “Lonely at times”, from the loss of physical connections with friends, both Sally and Katia nonetheless feel “lucky” they were able to leave their homes “go to work, a few laughs” during COVID-19 lockdowns. Conversely, the workload brings challenges - “very work dominant” and being “confined to your local area” leaving Shyla unable to relax on days off. In fact, the COVID-19 load leads Shyla to “re-evaluate what's important” and reconsider her career:

“I have no desire to stay in an environment where patient safety and job satisfaction are compromised” (Shyla).

Discussion

This study aimed to explore the lived experiences of a group of nuclear medicine technologists from a metropolitan area of Australia and how work practices and organisational support, particularly during the COVID-19 pandemic, impacted wellbeing, risk of burnout, and longevity of career. Overall, the participants of this study expressed a lack of positivity about their own individual experiences within their career.

Staying physically and psychologically safe became a priority for the participants, following workplace bullying in the form of verbal intimidation and sabotage of their work. Ultimately, resignation became an option as they struggled to maintain their mental wellbeing. In 2021, Youngblood [19]. found that nearly 50% of American NMTs and nuclear medicine students had been subjected to some form of workplace bullying in the previous six months. The implications of workplace bullying included decreased job satisfaction, retention issues and mental health issues (including burnout) for the victims, as well as a decrease in patient care [19].

Participants also expressed a perceived increase in overall workload throughout their career, which included an increase in patient load, as well as added responsibilities. The increase in patient workload is supported by Australian Medicare statistics, with a 39% increase in billable nuclear medicine studies between 2011/12 and 2021/22 and a 214% increase in billable PET studies between 2017/18 and 2021/22 [20]. The stress that an increased workload caused American nuclear medicine technologists was documented in 1990 [21], ranking sixth on the list of stressors in nuclear medicine technology. Indian nuclear medicine technologists also listed workload as a cause of occupational stress [22]. The observed increase in workload by participants could also be attributed to understaffing, especially during the COVID-19 restrictions. Adequate staffing levels is one of the most expensive elements of any nuclear medicine department, putting pressure on the budgets of healthcare corporations [23]. However, the introduction of new technologies, the increase in occupational radiation dose in PET departments, as well as added administrative responsibilities necessitates an increase in staffing levels to ensure patient and personnel safety [23].

The occupational stress caused by workplace bullying, increased workload and understaffing, manifests into an increased risk of burnout in the participants. Exhaustion from increased workload causes distance from their work and the development of feelings of mistrust (or cynicism) towards both patients and colleagues. Even though participants showed a passion for nuclear medicine, this, at times, had dwindled. There were concerns of being in a profession that had a limited career path with a specialised skill set that led to monotony and feeling of reduced effectiveness. The corporatisation of nuclear medicine left some participants feeling a lack of self-confidence and not in line with their work ethic. This can be seen as a contradiction to a study performed in 2010, which found that NMTs working in the Australian private sector had greater levels of job satisfaction and work engagement compares to those working in public hospitals [2].

As the participants matured, experienced life, and settled into their careers, their ability to cope with occupational stressors improved. Participants were proactive in retraining to stimulate their work engagement, they showed confidence and assertiveness in their ability and were able to reflect on their experiences to help facilitate decisions. By developing their personal resources, participants were able to protect themselves from the risks of burnout [24].

The COVID-19 pandemic exacerbated the participants’ risk of burnout. Their physical and emotional exhaustion levels skyrocketed, they felt undervalued by both management and patients, and they were unable to relax and enjoy downtime away from work pressures due to lockdown restrictions. There were, however, glimmers of joy for some, with more time with immediate family due to lockdown restrictions.

Limitations

As this study is qualitative in nature, it is not feasible to generalise the results, nor can there be any cause-and-effect outcomes generated. Results are specific to the participants and cannot be used to make generalised statements about the wider population [14,17,25] However, the results provide rare observations for future nomothetic research. As idiopathic research, this study could have been impacted by the researcher's bias and preconceptions, however the IPA technique that was followed, including robust discussion and audit trails, ensured the data spoke for itself.

Conclusion

The participants in this study were asked to discuss and interpret their lived experiences as a nuclear medicine technologist living and working in a large metropolitan city in Australia. As individuals, they speak of being marginalised through an unforgiving workload and differing demands of private verse public health that leaves them feeling disrespected and depersonalised. The lack of concern for staff wellbeing by management, who are potentially driven by profit margins in some centres, has led to an increased risk of burnout for the participants. This risk is also exacerbated by the lack of career options and trust in colleagues and patients. This increased risk of burnout in the participants may also have implications on staffing levels in Australia.

The findings of this study have highlighted the need for future research to evaluate the job satisfaction and risk of burnout of the wider community of NMTs working in Australia.