Towards describing the global impact of the COVID-19 pandemic on clinical radiography education: A systematic review

Introduction The sudden onset of the COVID-19 pandemic has brought significant and rapid changes to the traditional ways of providing radiography education, including adaptations to teaching and learning styles as well as disruptions to students’ clinical placement. This review explored the impact of the pandemic on clinical radiography education globally. Methods A systematic literature search was conducted on relevant databases, including PubMed, Science Direct, CINAHL (Cumulative Index of Nursing and Allied Health Literature, and SCOPUS. All relevant articles were critically appraised for quality and subjected to information extraction and results-based convergent synthesis. Results A total of 17 articles met the inclusion and exclusion criteria for this review. The key findings are themed around challenges and benefits with the introduction of new teaching and learning approaches and resilience exhibited by students during the pandemic to overcome: inadequate support and mentorship while transitioning to fully qualified professionals, challenges with PPE usage, and impact on personal and academic life. Conclusions Globally, radiography students experienced several challenges, especially during the initial acute phase of the pandemic. The pandemic-related challenges identified in this review could negatively influence the radiography student attrition rates, consequently worsening the existing radiography workforce shortage. Thus, urgent institutional level support systems and interventions would be necessary to mitigate the pandemic impact and improve the students' learning experience.


Introduction
The COVID-19 pandemic continues to disrupt key activities in virtually every sector of the global economy, including education. This has had serious implications for educational delivery and raises concerns, especially for healthcare training models with practical and clinical placement components [1][2][3][4][5] . The pandemic caused training institutions across the globe to suspend in-person campus activities in compliance with safe COVID-19 protocols to prevent the spread of the virus [6] . These safety measures required educators to rapidly adjust their teaching environment, educational strategies and delivery approaches with a subsequent, significant impact on both students' learning experience [7 , 8] and educators' workload and research output [3 , 9] .
Globally, traditional radiography training at the undergraduate degree level includes a combination of classroom teaching, clinical skills learning in a laboratory and placement in a hospital setting [4 , 5] . These key training components are designed to give students a variety of learning experiences, required knowledge, skills, and competencies to practise safely and effectively following graduation. Of note, studies by Mc-Nulty et al. [4] and Foley et al. [5] highlight the existence of a wide variation of pre-qualification student training hours and years in clinical practice globally between radiography programmes.
The sudden onset of the COVID-19 pandemic has brought significant and rapid changes to these traditional ways of providing radiography education, including adaptions to teaching and learning styles. According to Komlayut,[10] the higher education sectors have utilised various information and communication technologies (ICT) to promote effective and accessible learning, which has proved very valuable in the pandemic. Online tutorials and courses, discussion forums, virtual classrooms, digital communication channels and course websites are some of the common applications in the pandemic. Radiography education has a wide practical element that necessitates a great degree of clinical demonstrations using phantoms or through effective peer practical learning, student-teacher interaction and/or clinical placement contacts. Clinical placements are a vital part of undergraduate radiography programmes as they prepare students for registration with national regulatory authorities [11] . In some settings, [12][13][14] innovative strategies were devised (including simulations as reported by Hazell et al. [15] ) and coordinated preparation plans with university partners and hospitals for safe clinical teaching delivery following the resumption of student placements.
Earlier in the pandemic, Astirbadi and Lockwood [16] reviewed the literature (i.e., n = 4 original articles plus a commentary) to explore the impact of the pandemic solely focused on diagnostic radiography students and in most cases, with focussed discussions relating to the United Kingdom landscape. Similarly, Ng [17] reviewed some very early publications (i.e., original articles: n = 6, editorial: n = 1 and commentaries: n = 4) focused on adaptations implemented for radiography education and their effects on stakeholders. As the pandemic is quickly evolving and with consequent rapid changes to radiography education, a comprehensive review that broadly captures the impact of the pandemic on all radiography education stakeholders (i.e., both students and educators) is relevant as proposed by Ng [17] . This systematic review attempts to provide a comprehensive highlight from a global perspective (see Table 1 ) towards describing the impact of the COVID-19 pandemic on clinical radiography education, focusing on both students and educators from varied settings -low and high resource environments. Findings from this study may help in framework development for health education institutions to improve students learning and staff experience and to ensure appropriate skills are acquired for both students and academic staff in the post-COVID era.

Methods
As done in our previous work, [18] a mixed-methods systematic review strategy was employed to integrate the available evidence to provide a global insight into the impact of the pandemic on the teaching and learning activities of key stakeholders of clinical radiography education. Thus, data were obtained from primary studies of varied methodological designs while following the Cochrane Collaboration guide [19] and the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement guidelines [20] . Due to the quickly evolving nature of the pandemic, the urgency, and the necessity of generating robust findings to inform innovative and safe radiography education strategies, we failed to register the review protocols a priori . Of note, ethical approvals are not requirements for literature reviews. To explore the experiences of students who were in the temporary register.
a. Working during the pandemic had some emotional impact on them, but they felt colleagues and managers supported them effectively, and it enabled them to recover. They felt appreciated and part of the team. b. They are more aware of their competence, which has helped improve their confidence as professionals. c. The constant use of PPE has been uncomfortable.   They also showed positive emotions as they were happy with their choice of career. b. The participants reported concern about the use of technology and coping with online learning. c. The participants stated that support from institutions, friends, and family helped alleviate their anxiety. High Legend: * = Australia, Austria, Belgium, Denmark, Ireland, Italy, Netherlands, Singapore, Slovenia, South Africa, United Kingdom and the United States of America. The QATSDD assessment tool was employed for quality assessment to reduce the risk of bias. This tool comprised 16 quality criteria, with 14 apply to qualitative studies, 14 to quantitative studies and all 16 to mixed methods papers. Each criterion scores from 0 to 3. Using the descriptions for each score, each included article is scored from 0 to 3 on each item within a scoring grid. In order to compare the quality of the included articles, an average of the quality score is calculated and converted into percentage quality scores for all studies of the same designs as a group. The studies were categorised as high quality if an aggregate score is above 70% is achieved, moderate quality for those scored between 50 and 70%, and low quality for those scored less than 50%, as done previously in Akudjedu et al. 17 . These aggregate quality scores were not a part of the article exclusion criteria.
The omission of studies with low aggregate scores could limit the review's global essence, since some findings relate specifically to certain geographical regions.

Eligibility criteria
Articles were included if they were published in English and explored the impact of the COVID-19 pandemic on clinical radiography education in relation to students and/or educators. Publications on the topic of the following formats were excluded: opinion reports, preprints, commentaries/editorials, literature reviews and primary studies with a focus outside of radiography education and/or those with a relatively small percentage of radiography students as part of a larger sample.

Data sources and search strategy
To minimize the risk of omitting relevant publications on the topic, a broad spectrum of key databases: PubMed, Science Direct, CINAHL (Cumulative Index of Nursing and Allied Health Literature, and SCOPUS were searched. In addition, the "COVID-19 article collection" of key radiography journals (including, Radiography, Journal of Medical Imaging & Radiation Sciences (JMIRS), Journal of Medical Radiation Sciences (JMRS) and Radiologic Technology) were manually searched for relevant publications. The reference list of relevant primary studies and review articles were also searched for other relevant publications which may have been missed. For each database, the search strategy included keyword terms, synonyms and Boolean operator qualifiers (OR, AND). The keywords included: ["Radiography" OR "Medical Radiation Science" OR "Radiologic Technology" OR "Radiotherapy" OR "Radiation Therapy" AND "education" OR "students" OR "educators" AND "COVID-19" OR "pandemic"] were employed for the search. To increase the sensitivity to the databases and minimize the risk of missing relevant studies, the search combinations were refined to include appropriate subject headings, abbreviations and/or truncated syntax in accordance with the specifications of each database as done previously by Akudjedu and colleagues [18] . Using this search strategy, two researchers (OL and TNA) carried out an independent electronic literature search to identify relevant articles from the 1st of July to the 21st of December 2021.

Data extraction and synthesis
Microsoft Excel 2019 and the RefWorks (ProQuest) referencing software were used together to manage the screening process and search outputs, including removing duplicates. Two reviewers double screened the remaining studies independently using the titles and abstracts against the eligibility criteria. Any disagreements were debated over by the two reviewers (OL and DO) until a consensus was reached. A third reviewer (TNA) double-checks the process to ensure the search strategy was adhered to. The included papers were then screened for full-text inclusion against the eligibility criteria by the same reviewers. These results were again compared, and any disagreements were discussed, with the third reviewer having the final decision on their eligibility. Each excluded full text was accompanied by a justification as to its exclusion.
To reduce the risk of bias and ensure a consistent appraisal of the included studies, the Quality Assessment Tool for Studies with Diverse Designs (QATSDD) tool was employed to evaluate the studies as suggested by Sirriyeh and colleagues [21] . See Table 1 Legend for a detailed explanation of the use and application of the QATSDD tool to this study. Similarly, any differences in quality assessment scores were discussed among the research team. All the included studies were subjected to a data extraction process that included the completion of a template with fields to capture the study methods, aims and key findings. The data extraction was completed by one of the authors and reviewed by all research team members.
A results-based convergent synthesis approach was employed for the synthesis of the findings. Briefly, the findings from the different methodological studies identified in our search are presented in a tabular format and analysed separately. The extracted qualitative data was analysed thematically while employing textual narrative synthesis for the extracted quantitative data. After qualifying the quantitative data, both results were integrated and synthesised [22][23][24] into themes to highlight the findings further.

Search results
A total of 3782 articles from databases -[PubMed: ( n = 157), Science Direct: ( n = 1546), CINAHL: ( n = 43), and SCOPUS: ( n = 2036)] with others obtained from additional sources ( n = 83) from our initial search. Furthermore, a total of 3803 articles remained after the removal of duplicates, and these were screened by titles and abstracts. As detailed in Fig. 1 , 69 full-text articles were assessed for eligibility and 29 were included for a discussion in a consensus meeting. A total of 17 articles fulfilled the search criteria and were included in this review.

Study characteristics
The quality of the articles reviewed was assessed against the QATSDD criteria. The quality assessment exercise ranked the included articles from moderate to high. Six articles were conducted in Europe, four were in Africa, three in Asia, two in North America, one in Oceania, and one multinational study. The studies included six qualitative, nine quantitative, and two mixed-methods designs. A common limitation noted with all the included studies that employed a closed-ended questionnaire approach was the lack of the involvement of participants in developing the data collection tools [2 , 3 , 12] . However, they all had open-ended questions at the end of their questionnaires, which allowed participants to provide comments on issues that were not covered in the questionnaire. Thus, this limitation has less impact on the findings, as the participants had an opportunity to comment on issues that had not been addressed in the survey instruments [25] . The participants of the various included studies were current students, newly qualified radiographers, academics and practice educators. Eleven of the studies focused on diagnostic radiography students, two focused on therapeutic radiography students, and four featured both groups of students, with some having educators as part of the sample (see Table 1 ).

Summary of the key findings
The findings of the articles were classified into two main themes; the introduction of new teaching and learning approaches and the challenges and resilience of students in the pandemic. A few benefits were associated with teaching and learning via the online platform, such as reduced cost and flex-ibility. At the same time, the challenges include the struggle to use the platform effectively, increased stress levels and inadequate resources (in some settings).
Most of the papers showed that radiography students were willing to support the service delivery activities of the clinical departments where they were placed during the peak of the pandemic. However, the students were anxious due to the unprecedented nature of the pandemic, and they struggled to cope with the constant use of personal protective equipment whilst they were at the hospitals. These topics are discussed in greater depth in the subsequent section.

Discussion
In this systematic review that explores the impact of the pandemic on clinical radiography education globally, the key findings are themed around challenges and benefits with the introduction of new teaching and learning approaches and resilience exhibited by students during the pandemic to overcome: insufficient support and mentorship while transitioning to fully qualified professionals, challenges with PPE usage and the impact on personal and academic life.

Theme 1: introduction of new teaching and learning approaches: benefits and challenges
Most countries around the world introduced lockdowns to lower the spread of COVID-19 within their population. In order to continue learning while movement was restricted, higher institutions transitioned from face-to-face delivery to an online delivery format. The benefits identified by students include flexibility and reduced cost of transportation and living, as some students could study from home while living with family rather than renting accommodation closer to university [26 , 27] . Ng [28] showed that despite these flexibilities, standards of radiography education were maintained as online open-book assessments presented no issues relating to academic integrity. However, other studies show that learning via the online delivery method increased students' stress levels and anxiety [26 , 29-31] .
The factors associated with the increased stress level are the inability to interact effectively with tutors, poor computer skills, and inadequate resources that prevailed critically in some settings. Notwithstanding, two studies [8 , 12] showed the effectiveness of the implementation of the online approach in the delivery of specific modules, as demonstrated by the students' good feedback. Of note, Abuzaid and colleagues [12] highlighted the need for improvement in communication infrastructure, at least in the United Arab Emirates for a good student and staff experience with online learning. It might be useful for institutions to train staff and students to improve their information technology (IT) skills and equip their institutions with high-quality communication equipment. The students believe that the support provided by their lecturers in this period helped them with the transition to online delivery methods. [29 , 32] This review recommends that improved communication infrastructure, staff and student training on how to use the online platforms, and availability of online facilities might enhance students' learning experience.
The only study conducted with postgraduate radiography students showed that even with the increased workload in their clinical roles, these professionals were concerned about their postgraduate studies and were not satisfied that there was no provision for studies to be transferred to the online format while there was lockdown [33] . They believed the delay in completing their programmes increased their expenses and could lead to missed career progression opportunities.
In place of clinical placement and practical laboratory practice, most clinical radiography training institutions employed simulation sessions to augment students learning and make up for the required clinical hours for professional registration [13 , 34] . In a recent meta-synthesis [15] that explored the clinical readiness of students (including radiography students), the findings indicate that readiness was enhanced with increased use of simulation training. Thus, these findings strongly support the transition of learning and training to online formats during the pandemic to prepare students for clinical practice. Many students have had reduced clinical time during the pandemic, and these hours will need to be undertaken prior to graduation. This in itself is causing stress and concern for students in radiography education programmes in most parts of the world.

Theme 2: challenges and resilience of students in the pandemic: clinical placement and personal life
In the COVID-19 pandemic, most radiography departments experienced staff shortages (as a result of illnesses, selfisolation and ongoing shortage issues) and increased patient influx [35 , 36] . Most studies [30 , 32 , 37 , 38] that explored the experience of radiography students on clinical placements during the pandemic showed that they were willing to support their clinical departments. This is highly commendable as it showed that they were genuinely interested in caring for others (patients). Also, the students believed that their contributions were valued by radiographers, managers, the government and members of the public [30 , 32 , 37 , 38] . This is consistent with findings from other studies among nursing [39] and medical students [40 , 41] in the United Kingdom during the pandemic. Consequently, the evidence, thus far, indicates that students could contribute to potentially reducing the workload burden on clinical radiography departments moving forward.

Subtheme 2a: student support challenges and the temporary register
In some countries, for instance, in the United Kingdom and Australia, a temporary register was introduced for the registration of final year students with the respective professional regulatory bodies [42] . The students who were added to the temporary register found the transition challenging as they did not have as much support from staff or mentors as they would have had pre-pandemic due to the pressure on clinical departments [43] . However, they felt the experience helped improve their confidence in caring as well as supporting patients and competence in performing key radiological examinations. Mentorship support is important in helping newly qualified staff to develop their skills and understand how departments work [44] . Regular reflection activities could be used to complement the support the mentees might be getting from their mentors in order for them to develop as professionals effectively. In addition, this will help them cultivate a habit of independently identifying areas of their practice that are up to standard and aspects that needs improvement. Therefore, it is recommended that departments use the mentoring support approach combined with individual regular reflections on practice to support the staff new to their departments.

Subtheme 2b: use of personal protective equipment (PPE)
The use of full PPE became mandatory in hospitals as an effort to reduce the spread of coronavirus from staff to patients or amongst colleagues [45 , 46] . Prior to the COVID-19 pandemic, staff only had to use the full PPE when they had a barrier nursed patient [47] . Students found the regular use of PPE uncomfortable, and it was a barrier to effectively communicating with patients [38 , 43 , 48] . This is similar to the findings of studies that assessed the opinion of other health professional trainees, as they also stated that communicating with patients and other colleagues was challenging in full PPE [49] . Thus, the need for an increased patient allocated time for clinical care examination and regular staff breaks are encouraged to manage staff and students' stress levels.

Subtheme 2c: anxiety as a result of the unprecedented pandemic
Most of the studies (see Table 1 ) showed that students were anxious as they did not know what to expect from the government with regards to guidelines and the universities. The radiography students were concerned about the rapidly changing landscape around guidelines, supporting family and friends affected by COVID-19 and the impact of working alongside COVID-19 patients. However, it is worth mentioning that they felt that the support they had from their tutors, family, and friends helped alleviate this anxiety. There were reports that tutors provided one-on-one pastoral care sessions with students to help ease their anxieties [3] .
Rainford and colleagues [2] reported that students were concerned about financial issues as well as accommodation and childcare. This is similar to the report by the Health Education England [50] that assessed the impact of COVID-19 on nursing and allied health students. Cushen-Brewster and colleagues [38] did not report this issue among the cohort of radiography students recruited in their study; however, this cohort was concerned about caring for patients with COVID-19. This might have been due to the financial support received by these students from the UK government at the time of that study. Radiology departments within the United Kingdom offered employment to most third-year students while still training as temporary staff during the pandemic. Thus, there is a need for financial support from various governments and educational institutions and/or clinical departments for students to lessen their burden and improve the student learning experience.

Limitations
Despite the systematic nature of our literature search, it is possible that some studies might have been missed. The COVID-19 pandemic was still ongoing while this paper was written; thus, studies published since the search ended are not included. Therefore, an update might be required to include future studies. To lower the chances of missing relevant articles on the topic, an additional search was conducted in four principal radiography journals, but articles published in nonradiography related journals might be difficult to find. We employed a robust synthesis methodology that allowed us to integrate findings of studies of varied designs. While this adds to the strength of this article, we acknowledge the associated limitation of this synthesis approach relating to the possibility of introducing changes to the interpretation/meaning of the data.

Conclusions
This systematic review set out to explore the impact of the pandemic clinical radiography education globally. The COVID-19 pandemic has impacted radiography students' personal, clinical, and academic experiences. This was particularly around the rapid move to online learning and the impact of workload and staffing issues within the clinical settings, leading to inadequate placement opportunities. Students also experienced difficulties wearing PPE, which impacted communication, comfort, and increased their workload on placement. Of note, students exhibited resilience and rose above the pandemic-related challenges, and were willing to support their clinical placements and made valuable contributions to the care of patients.
In some cases, students joined temporary registration systems to enable them to work alongside their qualified colleagues. However, this early transition did cause some anxiety around the lack of support and mentorship, which are necessary for a smoother transition. Some students used this as an opportunity to improve upon their clinical confidence in practice before joining the workforce as fully qualified radiographers.
An ongoing concern is the impact on these students' mental health and well-being as they continue through the program and on to employment. The long-term impact on the mental health of health care students may take months to be fully recognised.
On a positive note, this global pandemic provided opportunities to upgrade educational modes of delivery and develop knowledge and competence in emerging technologies. It also resulted in the University staff re-evaluating delivery methods, curriculum content and placement opportunities. Globally, radiography students experienced several challenges, especially during the initial acute phase of the pandemic. The pandemic-related challenges identified in this review could negatively influence the radiography student attrition rates, consequently worsening the existing radiography workforce shortage. Thus, urgent institutional level support systems and interventions would be necessary to mitigate the pandemic impact and improve the student learning experience.

Recommendations
Further research will be required to explore the long-term impact on the education of radiography students following the COVID-19 pandemic and the impact on postgraduate education.
Universities should further evaluate the requirements in relation to the impact of flexible education models in clinical/healthcare education, including radiography education. This would include evaluation of online learning platforms, online assessment methods and preparation of students for hybrid learning in higher education.
In addition, there will be a need for the government and universities to evaluate the impact of pastoral and mental health needs of students working through the pandemic and the development of health interventions that support the students in preparation for their ongoing academic progress and future careers. These interventions need to be culturally aware and timesensitive.