Supporting radiography clinical placements in Ireland during the COVID-19 pandemic: The practice educators perspective

Introduction The COVID-19 pandemic has significantly impacted healthcare services and the clinical learning environment. Several studies have investigated radiography students' experiences of clinical placement during the pandemic; however, few have investigated the Clinical Practice Educator's (CPEs) perspective. CPEs play a pivotal role in supporting clinical education. Method A qualitative study was conducted using a purposeful sample of twenty-two CPEs, each working in a different Irish hospital. Four semi-structured focus groups were used to gather data. To maintain reasonable homogeneity, CPEs who were new to the role (n = 8) were assigned a separate focus group from experienced CPEs (n = 14). Inductive thematic analysis was applied. Results CPEs experienced role expansion, particularly in managerial and administrative aspects of the role. They described arranging COVID-19 vaccinations locally for radiography students and the complexities of student rostering during the pandemic. CPEs perceived the pandemic to have impacted students' emotional wellbeing with ‘high anxiety levels’ and ‘loneliness’ being reported. They also perceived issues with clinical readiness and the student transition to clinical practice. Many challenges were faced by CPEs including arranging clinical recovery time for numerous students when sites were already at full capacity, fewer learning opportunities due to decreased patient throughput and range of imaging examinations, social distancing constraints, resistance from staff to student placements, and a shortage of staff for student supervision. Flexibility, communication, and multi-level support helped CPEs to fulfil their role. Conclusion The results provide insight into how CPEs supported radiography clinical placements during the pandemic and into the challenges faced by CPEs in their role. CPEs supported student placement through multi-level communication, teamwork, flexibility, and student advocacy. Implications for practice This will aid understanding of the support mechanisms needed by CPEs to provide quality clinical placements.


Introduction
On the 30th of January 2020, the World Health Organisation declared the outbreak of coronavirus (COVID-19) a public health emergency of international concern (PHEIC). 1 This pandemic put healthcare services across the world under severe pressure. Community-based care, outpatient services and some inpatient services were temporarily suspended 2 with some healthcare workers redeployed to other areas 3 in order to cope with the outbreak of COVID-19. Hospital operations and procedures were altered to safeguard patients and staff and elective lists postponed. Increased infection control measures were introduced, additional personal protective equipment (PPE) procured, work patterns altered to extended team-based shifts and hospitals restructured to isolate COVID-19 positive patients from non-COVID patients. 4,5 Medical imaging plays an important role in supporting clinical decision making in the management and treatment of COVID-19 patients. 6 Although not required for diagnosis, chest imaging is essential for assessing and monitoring the severity and disease progression of COVID-19. 7 Chest computed tomography (CT) is the gold standard imaging modality for COVID-19 pneumonia; however, in some instances, chest radiography may be a suitable alternative e.g., mobile chest radiography of patients in intensive care units (ICU). 7 As such, radiographers are among the frontline healthcare professionals at risk of exposure to infectious patients. 4 The burden of the COVID-19 pandemic on radiology departments impacted radiography student clinical placement. 8e11 The lack of staff available for student supervision, PPE shortages, limited physical space for social distancing and the infection risk posed by students were some of the challenges faced with regards to clinical placement provision. 9,10 This resulted in postponement and in some cases cancellation of radiography student placements. 3,12,13 Whilst chest radiography and chest CT were frequently performed during the height of the COVID-19 pandemic, other imaging procedures were performed less frequently due to the curtailment of non-urgent healthcare services. 3 The decreased range of imaging examinations performed due to the altered patient throughput in departments posed further challenges in terms of radiography student skills development. 12 Although several researchers have investigated radiography student perspectives of clinical placements during the pandemic 11,12,14 and academic responses to adapting education delivery during this period, 12,15e17 very few have investigated the Clinical Practice Educators (CPE) perspective of supporting clinical placements during the pandemic. 8,9 Of those that have been published, one qualitative study carried out in the UK evaluated the experiences of a small number of CPEs (n ¼ 6) who supported final year radiography students recruited to work on the temporary HCPC register during the COVID-19 pandemic. This research study used semi-structured interviews and a focus group to collect data. 8 Subsequently, a questionnaire-based study of 58 clinical tutors (n ¼ 58) in the UK Devolved Nations (UKDN) and United Arab Emirates (UAE) was undertaken to gather clinical tutor's thoughts and experiences of supervising radiography clinical placements during the pandemic. 9 A commentary piece was also published regarding CPE experience providing Radiography placements during the pandemic in a Singaporean hospital. 10 Just two research studies have been conducted on placement provision from the CPE perspective, neither of which have been conducted in Ireland. Our research will investigate the CPE perspective of supporting clinical placements during the COVID-19 pandemic in Ireland using focusgroups. Focus groups are particularly useful to obtain rich, experiential feedback. 18 In Ireland, the CPE is a senior grade radiographer working in a hospital who is responsible for the day-to-day planning and implementation of an effective training programme for radiography students on clinical placement. The CPE works closely with the university to ensure learning outcomes associated with clinical placement are met and that clinical assessments are undertaken in line with university standards.

Study design
A qualitative study using a phenomenological approach was conducted to better understand the shared experience of CPEs in Ireland while supporting clinical placements during the COVID-19 pandemic. 19 Husserl's transcendental phenomenological style of thought was employed by researchers in this study who bracketed their preconceptions in order to obtain an unbiased description of the raw data. Focus groups were employed to gather data and promote self-disclosure among participants. Communication in a group setting can stimulate participants to generate further questions, clarify their views and develop their own analysis of the shared experience views. 20 Open-ended questions were used to explore participants' feelings, perceptions, and thoughts. Inductive content analysis was used to understand the specific context, and to reach nuanced descriptions surrounding different qualitative aspects of the CPEs' experiences supporting radiography students during the pandemic.

Participants and data collection
Ethical approval was granted from the Human Research Ethics Committee (LS-LR-22-155-OConnor). Radiography CPEs were invited to participate in this study. Twenty-two CPEs (n ¼ 10 males, n ¼ 12 females), ranging in age from their mid-twenties to midfifties, volunteered to participate. All participants were working in Irish radiography departments. To maintain reasonable homogeneity across focus groups, CPEs who were new to the role were separated from experienced CPEs. Fourteen experienced CPEs (n ¼ 6 males, n ¼ 8 females) were assigned across three focus groups (mean 3.8years experience, range:10monthse10.5years). The fourth focus group consisted of eight newly appointed CPEs (n ¼ 4 males, n ¼ 4 females) who had supervised student radiographers during the pandemic in their role as radiographers (prior to being appointed CPEs).
The focus group questions in Table 1 were adapted from a published study. 8 Audio-recorded focus groups were transcribed verbatim, de-identified using 'CPE' for experienced CPEs and 'RAD' for newly appointed CPEs, and coded. Data was stored in a coded, anonymised format. The data was of a non-sensitive nature and was stored on the university cloud platform. It was backed up regularly on two BitLocker encrypted storage devices in accordance with the research data management guidelines '3-2-1' rule. 21

Data analysis
A thematic approach to data analysis outlined by Braun and Clarke (2021) was used. 22 Researchers began by familiarising themselves with the transcribed dataset and then undertook a rigorous and systematic coding process. Three researchers independently coded each focus group transcription. Codes were then revised, agreed by consensus, and refined by all researchers. Researchers then explored, developed, reviewed, and refined themes.

Results
Following data analysis, four main themes emerged: (i) Clinical Practice Educator role expansion during the COVID-19 pandemic (ii) Emotional impact of the pandemic on radiography students (iii) Perceived challenges associated with radiography clinical placements during the pandemic and (iv) CPE approaches to supporting Radiography clinical placements during the pandemic. Each of these themes were further deconstructed under emergent subheadings.

Theme 1: Clinical Practice Educator role expansion during the COVID-19 pandemic
This theme explores CPE role expansion during the pandemic as perceived by radiography CPEs in Ireland.

Managerial and administrative role expansion
CPEs described new responsibilities related to managing COVID-19 student vaccinations in their hospitals. They also discussed counselling students who had vaccine-related concerns.
'Arranging vaccinations for students was new to us and was a lot of work. Additionally, I had to deal with a particular student who did not want to take the COVID-19 vaccination, which was very difficult' (CPE12) Most CPEs felt they became 'more efficient at managing the extra work surrounding rosters and vaccines' over time. The administrative complexities of tailoring clinical placement rosters to align with learning outcomes and social distancing constraints were discussed. Many students missed clinical time due to contracting COVID-19 or being a close contact; CPEs found themselves arranging more clinical recovery time than ever before. This task was deemed 'complex' and 'time-consuming.' According to many participants, rosters were updated daily and were relied upon for local contact tracing.
'There was a lot more administrative support required as lots of students were off sick with COVID and we needed to arrange time for students to make up this missed clinical time.' (CPE11)

Protector role and advocacy
Some participants felt the need to protect students from COVID-19 and did so by prohibiting students from imaging COVID-19 positive patients. Examples were given of radiography students being excluded from the 'COVID positive areas' and 'portable rounds' to reduce their risk of infection.
'We were sheltering students. We didn't send them on portables to avoid contact with known COVID cases.' (CPE14) This sentiment was reiterated by radiographers recently appointed CPE posts, who considered it unfair to expose students to unnecessary risk.
'Once COVID hit, we no longer sent them on portables because we didn't want to expose them to COVID. We just didn't think it was fair to them. They're not employed staff.' (RAD20) CPEs advocated for students when faced with resistance from colleagues to student placements. CPEs reported that students were perceived to be a 'burden' on radiology departments by clinical staff, who felt students 'should be removed from clinical placement' as they were 'an unnecessary source of infection'.
'Getting the staff to accept the students as part of the team was key. We had to demonstrate to other staff that students were aware of infection control measures and could be trusted.' (CPE10) Theme 2: emotional impact of the pandemic on radiography students This theme encompasses CPE's perceptions of the emotional toll of the pandemic on radiography students. Anxiety and loneliness were at the forefront of discussions.

Heightened anxiety levels
Participants described heightened anxiety levels amongst radiography students during the pandemic. Various stressors were identified such fear of contracting COVID-19, fear of transmitting COVID-19 to family members, limited opportunities for making up missed clinical time, and dealing with critically ill patients.
'Students told me they were afraid of passing COVID to their family at home' (CPE11) 'Students were stressed about making up missed clinical time.' (CPE13) 'I remember how scared they (student radiographers) were. They were scared looking at patients that were really sick with COVID.' (RAD6)

Sense of isolation
CPEs observed less camaraderie amongst students who had experienced predominantly online rather than campus-based learning. These students seemed 'lonelier' and 'less connected' to their classmates than in pre-pandemic times.
'They hadn't met each other until they actually walked into placement. They didn't have that camaraderie that they get from being in the university together.' (CPE4) Theme 3: challenges faced by CPEs during the COVID-19 pandemic CPEs faced several challenges during the pandemic in relation to arranging clinical recovery time for students who missed placement, curtailment of imaging services, social distancing constraints, staff resistance to student placements, staff shortages, and the clinical readiness of students.

Clinical recovery time
CPEs spoke about the challenges of reorganising clinical time for numerous students who were absent due to COVID-19/close contact self-isolation when clinical sites were at full capacity. 'We had an outbreak in the department, so students were sent home for two full weeks. It was difficult to find alternative time for them considering how full the clinical calendar is.' (CPE13) CPEs described creating additional capacity through securing out-of-hours clinical placements. Some departments altered work patterns to team working based on shift patterns which further reduced capacity and complicated student rostering.

Lack of exposure to radiological examinations
Participants reflected on the reduction in volume and range of radiological examinations being performed, except for COVIDrelated chest imaging, which impacted learning opportunities for students.
'Many outpatient lists were cancelled which meant students weren't seeing many X-ray examinations other than chest x-rays. There were very few patients…we weren't doing much advanced technique X-rays' Table 1 Focus group questions.

Schedule of Questions for Focus Groups
1. Did the support you provided to students change during the pandemic? If so, how did it change? 2. Did you notice any differences in the students on placement during the pandemic compared to pre-pandemic times? 3. On reflection, what were the greatest barriers or challenges you faced in providing student placements during the pandemic? 4. Did the attitudes of clinical staff change towards having students on placement during the pandemic? 5. What lessons have you learnt from supporting students during this time? 6. What else would you like to share about your experience?
They described students 'fighting over X-rays' due to the reduced patient throughput and 'struggling to apply theoretical knowledge' to their practice. CPEs delivered 'a lot more tutorials' to make up for the lack of radiological examinations.

Social distancing constraints
Social distancing constraints proved a major challenge for CPEs in terms of rostering students. CPEs gave examples of students being asked to leave 'operating theatres' and 'imaging modalities' they were rostered to by staff who considered them 'supernumerary' and 'unnecessary'.
'You could have two radiographers in A&E, the assistant, the porter and a student. There just wasn't enough space and staff were very uncomfortable not being able to socially distance so often the student was the one asked to leave because they could be moved' (CPE12) Physical space limitations often meant that student cohorts had to be split into smaller groups for tutorials and the same tutorial delivered multiple times.
'We delivered the same tutorials several times due to lack of space and not being allowed more than a certain number of people in a room'' (CPE3)

Staff shortages & CPE redeployment
CPEs described staff shortages which impacted student supervision. Furthermore, CPEs were redeployed to other clinical areas which were short-staffed; this meant CPEs did not have enough time for their educational and assessment responsibilities.
'As tutors we weren't given any time to do our job because we were needed in other areas.' (CPE6)

Resistance of radiographers to student placements
Many participants recounted strong resistance from their colleagues to student placements early in the pandemic. They talked about colleagues' fear of contracting COVID-19 from students and the assumption that students were 'socialising more than the rest of us'.
'Staff were terrified of students because they were another source of infection. They were constantly asking students if they had taken an antigen test recently and made statements such as 'o maybe he/ she caught covid-19 from students.' (CPE12) 'Some staff just didn't want the extra bodies there …. They were sending them (students) to the library.' (CPE4) There was distrust noted amongst participants in relation to students' honesty in declaring their COVID-19 status, their competence in PPE use and their reliability to follow infection control guidelines.
'When it comes to students saying they have COVID, how do you trust them? Aren't they going to push boundaries and come back from late from their J1 (American visa) holidays using COVID as an excuse?' (CPE 14) 'You'd just be apprehensive wondering if they are following all the precautions. Would they be out partying, meeting people.' (RAD3)

Clinical readiness of students
First-year radiography students who began clinical placement during the pandemic were perceived to have inferior technical proficiency than previous cohorts, with some CPEs attributing this to fewer pre-clinical practical labs.
'I noticed a lot of weak students that potentially would have had a lot more practice previously. They struggled with technique and practical aspects of the job.' (CPE3) When asked about differences in student radiographers during the pandemic compared to pre-pandemic cohorts, participants reflected on the professional socialisation of student radiographers and their transition to the clinical environment.
'With first years, you could really tell how inexperienced they were. It was really a shock for them figuring out what radiography was and what placement was all about. Initially it was just about getting them used to being in a hospital, not even radiography.' (RAD2) 'They were like rabbits in headlights. They hadn't even met each other really.' (RAD7) Theme 4: CPE approaches to supporting radiography clinical placements during the pandemic

Flexibility and communication
CPEs suggested that flexibility was key to supporting clinical placements during the pandemic. They described flexibility in terms of adapting to their expanded role, constantly adjusting student rosters, and working outside normal working hours to support student placements. Communication with all stakeholders was deemed 'crucial' to facilitating 'safe' clinical placements 'You needed to constantly keep updated with guidance and communicate with students. If a student developed symptoms, it was time-sensitive to counsel that student on what to do in line with the latest hospital guidance. Your job wasn't 9-5.' (CPE2) 'The hospital was going in different directions each week with changes to hospital protocols and workflow, so you had to constantly update the students on what was going on. That communication piece really was key.' (CPE12) According to CPEs, student flexibility was also essential in terms of adapting to the ever-changing clinical environment. CPEs described students as having a 'good attitude' towards clinical practice and noted feedback from students that they 'enjoyed clinical placement', 'appreciated their clinical education' and felt it 'gave them a purpose' during this challenging time 'Students were much more flexible than previous cohorts. Some of them had to work different hours etc and they all got on with it. They learnt to be flexible and adapt to the environment.' (CPE10) 'There was a real sense of gratitude from the students who were returning to clinical placement and seeing human faces. Work was the only place you could go at that time.' (CPE14) Insight into students' experiences through reflective portfolios Some participants got an excellent insight into the student experience through reading reflective portfolios and felt students were more honest and detailed about their clinical experience in their written reflective portfolios that in face-to-face meetings.
'It surprised me really reading reflections in the clinical portfolios to see how students were struggling with mental health. Whenever I would ask them face-to-face how they were doing, they would always say they were fine.' (CPE14)

Teamwork
CPEs described greater success in their roles when working closely with universities, hospital management, occupational health departments and clinical staff to deliver clinical placement. Multi-level support was appreciated by CPEs.
'Our management was very helpful. And I think it was important for the students to feel supported. We all checked in with students so that they would feel supported.' (CPE11)

Inclusion of students in COVID-19 imaging examinations
Many participants stated that they regretted preventing students from being involved in COVID-19 imaging at the beginning of the pandemic. They discussed the 'valuable learning opportunities that were lost' through exclusion from these examinations. Those that involved students in COVID-19 imaging found them very helpful.
'In hindsight, we relied a lot on the students because we didn't have so many hands. Staff would take a student with them on portable rounds instead of a second radiographer. They were a great help.' (CPE5)

Discussion
This study provides an insight into Clinical Practice Educators (CPEs) experiences of supporting radiography student placements in Ireland during the COVID-19 pandemic. Clinical placements are critical components of Radiography education as they offer experiential learning opportunities which are core to developing practical skills, clinical decision-making, and professional identify formation. 23,24 CPEs play a pivotal role in creating a positive clinical learning experience for healthcare students. 25,26 Findings from this study demonstrate a wide range of challenges faced by CPEs in providing quality clinical placements during the pandemic. The radiology department was impacted by staff shortages which meant there were less radiographers available to supervise students. This issue was not unique to Irish radiography departments. 27 A study by McFadden et al. reported that staff shortages during the COVID-19 pandemic negatively impacted the level of clinical supervision and feedback received by students. 27 Feedback on clinical performance from supervising clinical staff is critical for the development of the competent practitioner. 28 Furthermore, it emerged that there was strong resistance from clinical staff to student placements during this period, with many 'terrified' of contracting COVID-19 from students. Several examples were given of students being asked to leave clinical areas by radiographers as there were too many staff present to socially distance themselves. One CPE recalled a scenario whereby students had been sent to the library during clinical practice. This hinders learning opportunities and may make students feel unwelcome. CPEs described advocating strongly for the students and attempting to persuade colleagues to 'accept the students as part of the team'. They described their efforts to demonstrate students' competence in PPE use and awareness of infection control protocols to staff.
In addition to students frequently being asked to leave their rostered clinical area, there was a reduced range and volume of non-COVID radiological examinations, which further limited students' opportunity to practice. 3,9,12 CPEs observed first-year students struggling with 'practical, hands-on work'. McFadden et al., found that radiography students themselves perceived that their practical skills development was hindered by the reduced number of radiological examinations. 27 According to the theory of experiential learning, students actively construct knowledge and meaning from real-life experiences. 29 It is important that learners believe they are accepted as a legitimate part of the workplace, supported to make sense of their experiences, and given meaningful forms of participation in the workplace. 29 The reduction in radiology services and resistance from radiographers likely impacted experiential learning opportunities. CPEs suspected that a lack of pre-clinical practical labs negatively affected skill development and clinical readiness. Simulation-based learning is proven to prepare students for clinical practice by enhancing knowledge, decision-making and practical skills. 17,30,31 Pre-clinical practical labs were replaced with online learning during the COVID-19 travel restrictions. CPEs responded to students' needs by delivering more 'hands-on tutorials' to students whilst in clinical placement.
Consistent with previous research, 8,12,32 CPEs observed heightened anxiety levels amongst radiography students during the pandemic. Students were in a pressured clinical environment, surrounded by clinical staff who were experiencing higher levels of anxiety 3 and occupational burnout. 3,33 Stress and anxiety can impede learning and retention of new information. 34 Loneliness was another unfortunate consequence of the pandemic. CPEs sensed 'loneliness' and a 'lack of camaraderie' between radiography students who hadn't had much in-person peer-interaction and described a difficult transition to clinical practice. Many COVID-19 infection control measures were detrimental to the social cohesion of the student cohort. The replacement of campus-based learning activities with online learning meant students lost opportunities to spend time together on campus. Within the clinical setting, CPEs described separating student cohorts into smaller groups for tutorials and sending students on lunchbreaks at different times to avoid the spread of COVID-19 amongst students. There is ample evidence on the benefits of comradeship and peerlearning in clinical education; improved transition into clinical practice, 35,36 decreased student anxiety, 36 improved communication skills and teamwork, 35,37 improved confidence, 35 and greater reflective practice. 38 CPEs gained valuable insights into students' emotional wellbeing and clinical placement experience from reading students' reflective portfolios. Some felt that students were more forthcoming in written reflections than in face-to-face interactions.
The importance of flexibility, communication and multi-level support came into focus for CPEs during the pandemic. CPEs who felt supported by their managers, colleagues and occupational health department felt they were in a better position to fulfill their duties. Those who were redeployed and not allocated 'enough time' to work with students felt unsupported. The transfer of knowledge from CPE to student is dependent on CPEs having the time to support student learning. 39 Flexibility was required by CPEs in terms of working hours, role expansion, changing work practices, and student rostering. CPEs also felt flexibility from students was pivotal to delivering clinical placement during the pandemic and commended students on their flexibility. CPEs described role expansion in managerial and administrative aspects of their job; Vaccination management was a new CPE responsibility 25 which involved liaising with students and occupational health. Administrative duties in terms of student rostering were complicated by the curtailment of non-urgent imaging services, team-based shift patterns, social distancing constraints, and lack of physical space in clinical areas. Rosters were continually updated to reflect departmental changes, COVID-related absences, and clinical recovery time. The state regulator requires radiographers to have undertaken 1200 h of clinical training and did not amend this during the pandemic. 40 Overall CPEs described frequent written and verbal communication with stakeholders to ensure information from students was consistent, clear and evidence-based to create a supportive learning environment. Robust communication processes should be in place to support clinical placements, particularly during the pandemic. 8

Limitations
The focus groups were facilitated by academics who work directly with CPEs in coordinating the clinical program so there was a risk of bias and CPEs not feeling comfortable enough to be completely open and honest. Facilitators encouraged participants to be honest and used semi-structured focus group questions.

Conclusions
This study explored the experiences of CPEs who supported student placements during the COVID-19 pandemic. CPEs encountered challenges in relation to the acceptance of students in the department, student rostering and clinical recovery time, managing vaccinations, range and volume of radiological examinations, clinical readiness and bridging the theory-to-practice gap. CPEs observed heightened student anxiety levels and loneliness. Approaches used by CPEs to support student placements were identified.