A cross-sectional student survey of the impact of the Covid-19 lockdowns on clinical placement in England

Introduction Clinical placement is an essential aspect of student radiographers' training. The Covid-19 pandemic proved challenging for diagnostic radiography students disrupting clinical placements. This study aims to explore the impact of Covid-19 on first and second year student diagnostic radiographers’ in clinical practice during the Covid-19 lockdown periods and Covid-19 waves in England. Method A cross-sectional online survey was used to attain quantitative attitudinal 5-point Likert and qualitative free-text response data. Descriptive and inferential statistics data analysis applied the Mann–Whitney U test and Kruskal–Wallis H test. The qualitative data were thematically coded and analysed for patterns of reoccurring themes. Results There were n = 85 responses from n = 9 different counties within England. Students reported missing between n = 1–14 weeks of placement. There was a lack of (41%; n = 35) or limited radiography staff (21%; n = 18) in the clinical departments and a lack of a range of X-ray examinations available (67%; n = 57) during the Covid-19 lockdowns, which affected completing practice assessments. Negative effects included stress, anxiety and worry (68%; n = 58); positive effects included team working (16.4%; n = 14), learning to work under pressure (12.9%; n = 11), and preparation for qualifying (8.2%; n = 7). Conclusions This study identified that students needed more support in this critical aspect of their training. There were both positive and negative responses; notably, the results highlight how the Covid-19 lockdowns have strained the National Health Service (NHS) and adversely affected radiography students. Implications for practice The findings underscore the need for university educators and student liaison radiographers within hospitals to have an awareness of the mental health and practical learning needs of the students they are instructing post-Covid-19 lockdown.


Introduction
For healthcare students, clinical placement is an essential aspect of their training. It enables them to understand the practical side of their chosen profession, giving an insight into what they will do in the future. 1 However, for many student diagnostic radiographers, 2 healthcare profession students, 2 and medical students 3,4 the coronavirus (Covid- 19) 5 pandemic affected this experience, particularly causing interruptions to clinical placement availability. 2 These changes occurred to mitigate the spread of Covid-19 6 but, in turn, have had consequences on educational learning, clinical experience and mental wellbeing. 7 Multiple United Kingdom (UK) [8][9][10] and global studies 11,12 have focused on clinical practice educators' perspectives on the challenges of balancing increasing workload and student supervision during the first Covid-19 wave. Raising similar concerns as student radiographers 5 about the impact of Covid-19 during the first wave. Cushen-Brewster, Strudwick, Doolan and Driscoll-Evans 9 had previously captured the feelings of third-year radiography students in clinical practice during the first English Covid-19 lockdown period, highlighting the positive and negative effects on mental health, learning and transition to qualification. The findings reflected comparable results to the multi-site study on student radiographers by Rainford et al. 13 with data from England and n=11 other countries during the first lockdown of Covid-19. The student's voice highlighted categories such as financial concerns, confidence when imaging Covid-19 patients, personal protective equipment (PPE), concerns about exposure to Covid-19, and missing clinical placement. Although it is recognised that the pandemic would have affected each country differently, similarities were noted in the student's responses and to comparable other international studies, [14][15][16] and UK studies. 17,18 These findings represent the student voice 19 raising common themes working through the first ovid-19 lockdown period and are significant enough for further research into clinical placements during the second and third lockdown periods in England. Therefore this study aims to explore the impact of Covid-19 on first and second year student diagnostic radiographers' in clinical practice during the Covid-19 lockdown periods (March -June 2020; October -December 2020; January -February 2021) 20 and Covid-19 waves (March 2020-June 2020; and September 2020-April 2021) 19 in England.

Method
This study used a cross-sectional survey to collect qualitative and quantitative data to capture the trends in responses and free-text descriptions of participants' feelings and experiences. 21  The survey requested information regarding the year of study, the county in England where they attend university, if there were a lack of radiographers or range in X-ray examinations during the lockdown, and how Covid-19 negatively and positively affected their placement. The survey tool used Microsoft Forms 22 to collect anonymised responses. Before completing the survey, participants received an information sheet on the nature of their participation, the purpose of the study, what information will be gathered, how the results will be disseminated, informed consent, and the right to withdraw. 23 A pilot version of the survey was tested for readability, order of questions and online returns of completed data. Ethical approval was gained from the University Ethics Committee (ETH2122-S19/RPR/09).

Sample
Purposive sampling methods were used to recruit current second and third year radiography students from universities across England who had experienced lockdown during their studies. The survey was sent electronically via email to all radiography courses in England for 'gatekeeper' permission to invite their diagnostic radiography students to participate. The survey ran between December 2021 to February 2022, with a reminder sent six weeks before the closing date.

Data analysis
The data collected were analysed against demographic variables of the year group and location data for patterns and trends of responses. The ordinal Likert responses were analysed using SPSS Statistics 24 and presented in descriptive statistics of the number of responses and percentages for each scale question. The year group comparisons (two independent groups) used non-parametric inferential statistics of the Mann-Whitney U test (Wilcoxon) for a difference (< p=0.05). The geographic location comparisons (three or more independent groups) used non-parametric inferential statistics of the Kruskal-Wallis H test (one-way ANOVA on ranks) for a difference (< p=0.05) and pairwise comparisons.
Open-ended questions were analysed using thematic analysis. Students' answers were examined for patterns of reoccurring themes, ideas and feelings 25

J o u r n a l P r e -p r o o f
There were n=85 responses from students across n=9 different counties in England; the percentage breakdown of the location of participants is shown in figure 1. The participant demographics consisted of n=41 second (48%) and n=44 third year students (51%;). The remaining questions are placed into subthemes, including placement attendance, disruption to clinical assessment, disruption to the normal range of examinations and consideration of stress, anxiety and worry.

Placement attendance
Students were asked whether Covid-19 had caused any interruptions to their clinical placement, with a significant difference (p=0.001) in the responses from the second years compared to the third years. Notably, 80% of third year students missed out on allocated placement time, whereas only 17% of second year students reported missing placement (Table 1a). The amount of placement missed ranged from 1-14 weeks across both years. This calculated an average of 2 weeks missed by second year students and 6 weeks missed by third year students during the three lockdown periods

Disruption to clinical assessments
Using the Likert attitudinal responses students agreed (n=35; 41%) that there were a lack of radiographers in the department to assist with assessments and learning experiences ( J o u r n a l P r e -p r o o f Table 2b. Subgroup analysis at location level for lack of radiographers in the department to complete clinical assessments during the lockdown. The free text qualitative responses identified through thematic analysis commented upon either a lack of (41%; n=35) or limited radiography staff (21%; n=18) on clinical practice during the lockdowns to assist with signing off paperwork, with some moving paperwork online but clinical radiographers either didn't have access to login to the university systems to sign off competencies or hadn't had time to complete the specific university training to gain a computer account due to the Covid-19 workload. Other common and reoccurring trends included the inability to complete practical assessments resulting in stress, anxiety, and pressure levels.   The free-text responses demonstrated that 67% (n=57) of students agreed that there were not the usual range of X-ray examinations during the lockdown. Extremities (37.6%; n=32) and spines (30.5%; n=26) were the examinations that were missed the most by students ( figure 2). Additionally, 87% (n=74) were not allowed to do mobile chest X-rays due to Covid-19 infection control restrictions on their permitted scope of practice during the lockdown.

Figure 2:
The number of X-ray examinations stated as lacking by students

Consideration of stress, anxiety and worry
There was a consensus among the students (68%; n=58), particularly the second year students (73%, n=30/41), that they felt stress, anxiety or worry, which affected their concentration during practice assessments (

Concerns about returning to practice
The overall findings from the previous questions reflect the student responses on amount of radiographers available in the departments, the lack of range of X-ray examinations during the

Discussion
The survey provided a picture of how the Covid-19 pandemic impacted student radiographers in critical aspects of their training. Notably, the results highlight how the Covid-19 lockdowns have strained the National Health Service (NHS) and adversely affected radiography training. The findings identified several important factors. Firstly, students missed a significant number of placement weeks, with some losing out on as many as 14 weeks. This result alone is critical as placement hours are a major contributing factor to the training of student radiographers. A lack of radiographers in the department and a lack of the normal range of X-ray examinations resulted in some students' delays in completing assessments, which impacted their ability to get paperwork signed off. In addition, students experienced stress, anxiety and worry due to fears of contracting the virus, which affected their concentration during practice assessments. However, the study also identified positive experiences during the pandemic, including teamwork, preparation for qualification and working under pressure.

J o u r n a l P r e -p r o o f
The concerning matter of the significant number of placement weeks missed means that students will be going into the following year or employment lacking the same amount of experience as previous cohorts. There is also a clear difference between the second year students compared to the third year students (table 1a), suggesting possible implications for employers recruiting newly qualified radiographers, as further support will need to be offered. Tay are the profession's basic skills. 16 Some students expressed stress and pressure when they could not complete their practice assessments in a timely manner, resulting from a scarcity of extremity X-ray examinations ( figure 2). Furthermore, students merely attending clinical placement do not automatically lead to learning. Students require an immersive and hands-on clinical learning environment where they will receive support from their supervisors. If staff are "unwilling to teach" [YR2 RAD15], as stated by one participant, students' learning will be hindered. 30 This supports the findings from the first wave of Covid-19 lockdown of Tay, Wei, Aw and Lai; 28 Tay, Cai, Chow and Lai; 31 and Akudjedu et al., 10 where students reported problems completing specific assessments for lack of non-urgent examinations.
Students also reported experiencing stress, anxiety and worry during their second year (73%; n=30/41) and third year (64%; n=28/44; table 4a), which affected their concentration during practice assessments and are comparable to previous studies. 9,12,[15][16][17][18] The staff on placement need to be conscious of the impact stressful environments can have on students, especially during assessments.
The NHS People Plan 32 suggests a coordinated approach regarding improving the clinical experience and being attentive to individuals' health and wellbeing.
Lastly, while students are on clinical placement, their risk of contracting the virus greatly increases. It is easily spread within households 6 and poses a risk to those with underlying health conditions. 33,34 This was one of the top concerns for many of the students surveyed, as some feared spreading it to family members; one student expressed their concerns by saying, "Getting Covid- 19 ]. These findings correlate to international student radiographer studies, [13][14][15][16][17] and literature reviews 12,19 highlighting similar concerns from the first wave of the Covid-19 lockdown.
Potential limitations of the study findings included the low response rate, and not all universities in England with a diagnostic radiography programme responded, limiting broader inferences of the data.

Conclusion
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