A qualitative analysis of radiography students' reflective essays regarding their experience of clinical placement during the COVID-19 pandemic

Background The COVID-19 pandemic significantly impacted healthcare services and clinical placement for healthcare students. There is a paucity of qualitative research into radiography students’ experiences of clinical placement during the pandemic. Method Students in stages three and four of a 4-year BSc Radiography degree in Ireland wrote reflective essays regarding their experience of clinical placement during the COVID-19 healthcare crisis. Permission was granted by 108 radiography students and recent graduates for their reflections to be analysed as part of this study. A thematic approach to data analysis was used, allowing themes to emerge from the reflective essays. Two researchers independently coded each reflective essay using the Braun and Clarke model. Results Four themes were highlighted; 1) Challenges associated with undertaking clinical placement during the pandemic, such as reduced patient throughput and PPE-related communication barriers; 2) Benefits of clinical placement during the pandemic, in terms of personal and professional development and completing degree requirements to graduate without delay; 3) Emotional impact and 4) Supporting students in clinical practice. Students recognised their resilience and felt proud of their contribution during this healthcare crisis but feared transmitting COVID-19 to family. Educational and emotional support provided by tutors, clinical staff and the university was deemed essential by students during this placement. Conclusions Despite the pressure hospitals were under during the pandemic, students had positive clinical placement experiences and perceived these experiences to have contributed to their professional and personal growth. Implications for practice This study supports the argument for clinical placements to continue throughout healthcare crisis periods, albeit with additional learning and emotional support in place. Clinical placement experiences during the pandemic prompted a deep sense of pride amongst radiography students in their profession and contributed to the development of professional identity.


Introduction
In March 2020, the World Health Organisation (WHO) declared the novel coronavirus (COVID-19) outbreak a global pandemic. Several infection control measures were implemented to reduce the spread of this highly contagious virus such as travel restrictions, mandatory mask-wearing, self-isolation and contact tracing. Widespread school and university closures were mandated by Governments as part of public health efforts to contain the spread of COVID-19. 1 Education providers were instructed to facilitate distance learning where possible to ensure the continuity of education. 1e3 The issue of clinical placements came to the forefront for healthcare education providers. 4e6 Clinical practice is a cornerstone in the development of competent healthcare professionals. 2 Radiography students in Ireland must complete 1200 placement hours prior to graduation, a requirement of the state regulatory body CORU. 7 Practical experience and realeworld interactions with patients and healthcare professionals in the clinical setting cannot be replaced with online education. 6 Many clinical placements were cancelled or postponed early in the pandemic. 4,8e11 Alterations to work patterns (e.g., team working based on shift patterns), coupled with a greater number of staff isolating with COVID-19 symptoms, resulted in fewer staff available for student supervision. Furthermore, social distancing was difficult in clinical areas due to limited physical space. 9,10 Healthcare workers experienced heightened anxiety levels and fatigue due to the pandemic 12e14 and were concerned about the additional infection risk posed by students. 4 Forty percent of radiographers in Ireland reported burnout symptoms related to the COVID-19 crisis. 13 Radiography plays an important role in the management of patients with COVID-19. 15 Although not required for diagnosis, imaging (typically chest X-ray/CT) is essential for assessing the severity and disease progression of COVID-19. 16 Whilst mobile chest radiography and chest CT were frequently performed during the height of the COVID-19 pandemic, other imaging procedures frequencies declined due to the curtailment of non-urgent healthcare services. 17 Reduced exposure to various imaging examinations posed challenges in terms of radiography student skill development. 4 Clinical placement for students in their final year radiography students was prioritised in order to graduate healthcare professionals to join the depleted workforce.
Radiography clinical assessments were amended such that high-stakes summative clinical assessments were removed and replaced with lower stakes clinical assessments. This was deemed necessary to reduce the burden on students and practice educators, who roster students and conduct assessments in the clinical settings. 2 Considering all these changes, it stands to reason that radiography students' experiences would differ substantially compared to pre-pandemic times.
Several studies have investigated radiography students' experiences of clinical placements during the pandemic, 4,5,11,18e21 only one of which included Irish radiography students. 4 Most of these studies employed online surveys to gather predominantly quantitative data. 4,5,18e20 Findings suggest that students were primarily concerned about accommodation and cohabiting risks, isolation from family, and transmitting the virus to family members. 4,5 Feelings of anxiety and isolation were common amongst students. 18,19 Furthermore, many experienced financial hardships due to job losses during the pandemic. 18,19 Students reported that extended periods without clinical placement negatively impacted their skill development. 20 Only two of these studies were qualitative in nature, using semi-structured interviews of a small sample of students from the United Kingdom (UK) (n ¼ 9) 21 and UK new graduates (n ¼ 5). 11 The Health and Care Professions Council (HCPC) and Department of Health implemented an emergency measure for final-year radiography students, which enabled students in the UK who had completed all practical elements of their training, but had yet to graduate, the opportunity to join the workforce on the temporary HCPC register. 11,21 This was unique to the UK.
The COVID-19 pandemic represents an unprecedented global health crisis with profound economic and social repercussions. The pandemic was experienced in a varied way depending on the different socioeconomic, age, ethnic, and gender groups. 22 It has provided an opportunity for deep reflection, particularly for healthcare students who experienced significant changes to their clinical education. Reflection promotes experiential learning, whereby students interpret and integrate experience into existing knowledge to produce new knowledge. 23 It contributes to self-discovery, self-regulation, and professional development. 24 Evaluations of student reflections are useful to inform curricula and support learning. 24,25 Whilst previous literature provides some insight into the student experiences of clinical placement during the pandemic, 4,5,11,18e21 further insight could be gained through qualitative research. In this study, reflective essays written by third-and fourth-year radiography students in Ireland related to their experience of clinical placement during this healthcare crisis will be thematically analysed.

Context
A qualitative study using reflective essays was used to explore the experiences and perceptions of radiography students who undertook clinical placement in Ireland during the pandemic. Students in stages three and four of a 4-year BSc Radiography degree were required to submit a reflective essay regarding their experience of clinical placement during the COVID-19 pandemic healthcare crisis as part of their reflective clinical portfolio. Reflections were structured on Gibb's cycle of reflection (Fig. 1). 26 Reflective writing and the Gibb's cycle was taught in year-one of the programme and used by students for reflective essays throughout their degree. There was no minimum or maximum word count. The average length of reflective essays was 1053 words (SD ¼ 518; range 439e1831 words).

Sample
Purposive sampling was used to select radiography students who undertook clinical placement during the pandemic and had completed a reflective essay related to their clinical experience as part of their coursework. Radiography students and recent graduates who undertook their stage 3 or stage 4 radiography clinical placement after March 2020 met these criteria. An email was sent to students to request permission for their reflective essays entitled 'Undertaking clinical placement during the COVID-19 pandemic healthcare crisis' to be included in this study. The email contained a participant information leaflet and a link to an online consent form. A total of 108 out of 320 students (33.8%) gave consent for their reflective essays to be included in this study. Participant demographics are outlined below including the number of participants per year group and the duration of their clinical placement which occurred during the pandemic.

Data collection & ethical considerations
Ethical exemption was granted from the host institution on the basis that the study was low-risk for participants (LS-C-22-177-OConnor). With informed consent from individual students, their reflective essays were exported from the electronic clinical portfolio into word documents and de-identified to ensure that neither participants nor clinical sites could be identified. Protecting student anonymity was important to ensure no harm to student's emotional wellbeing. This could occur if identifiable personal reflections were shared. Students had the opportunity to withdraw their consent prior to de-identification of data.

Data analysis
A thematic approach to data analysis was used, allowing themes to emerge from the reflective essays. 27 Each step of the process was transparent, aligned with established methodologies and clearly documented to ensure trustworthiness. 28,29 The overall dataset was coded by four researchers, using the Braun and Clarke model. 27 Investigator triangulation using several researchers provided multiple observations and conclusions reflecting different perspectives. 28,29 Researchers began by reading and rereading the reflective essays to become familiar with the content. Prolonged engagement during the data familiarisation stage strengthens credibility. Each reflective essay was independently coded by two researchers based on the content of the reflective essays. Codes were revised, agreed by consensus, and refined by all researchers. Finally, common themes were extracted, discussed by all four researchers, and agreed by consensus.

Results
Four main themes emerged in relation to the impact of COVID-19 on students' clinical placement experience: (i) Challenges of undertaking clinical placement during the pandemic, (ii) Perceived benefits of undertaking clinical placement during the pandemic, (iii) Emotional impact of the pandemic on students, and (iv) Supporting students during clinical practice. Each of these themes were further deconstructed under emergent subheadings.

Theme 1: challenges of undertaking clinical placement during the pandemic
This theme explores the challenges identified by radiography students who undertook clinical placement during the pandemic

Personal protective equipment (PPE)
Whilst students appreciated the importance of PPE, they found it uncomfortable to wear over long periods, describing 'difficulty breathing', 'claustrophobia' and issues with 'glasses fogging'. They also struggled to recognise staff as 'masks obscured their faces'. Several students discussed difficulties they encountered when interacting with patients, particularly patients with hearing difficulties and paediatric patients. They recalled attempts to speak more audibly and clearly to enhance communication and became more aware of their body language, especially when providing reassurance to anxious patients.
'I have become aware of my spoken and body language. My smile can't be seen underneath my mask and therefore, I have had to adjust my body language to compensate.' (SR84) 'It depersonalises the situation when you cannot see somebody's face.' (SR105) 'Masks were sometimes intimidating to paediatric patients as they were unable to see our faces and our smile. For deaf patients that rely on lip reading, they are deprived of a primary method of communication.' (SR88)

Reduced exposure to trauma imaging
Students viewed the scarcity of radiological examinations requiring adaptive technique as detrimental to their skill development, leaving some apprehensive about how whether they would be competent to undertake trauma imaging as graduates. They described spending most of their time taking chest radiographs.
'The majority of the workload was chest imaging. As a final year student, we require more trauma and acute presentations to challenge our advanced skills.' (SR38) 'I did not gain as much experience in areas such as trauma radiography as I would have liked. I would have liked more practice in modification of technique. Such experience was limited as fewer patients presented to A&E post-trauma.' (SR96)

Financial burden
Some students moved out of home for the placement block to avoid the risk of transmitting COVID-19 to vulnerable family members. The cost of this accommodation was perceived to be 'very expensive' and an 'additional financial burden' to students who were 'already struggling financially'.
Theme 2: perceived benefits of undertaking clinical placement during the pandemic Most students perceived clinical placement during the pandemic to have been a challenging yet rewarding experience that enriched their personal lives and aided their professional development.
Opportunity to graduate without delay and join the depleted workforce Radiography students expressed gratitude at being afforded the opportunity to resume clinical placements during this healthcare crisis. Many final-year students recounted their eagerness to complete clinical placement and so that they could graduate and join the short-staffed workforce.
'Watching the news and seeing the HSE call for help, I longed to be able to help out during the crisis. Once news came that we were to return to placement, I was relieved.' (SR103) 'I was very thankful for the opportunity to be on placement during this pandemic and I felt the experience was very rewarding, helping people who need it most during such difficult times.' (SR90) A small number of students could not resume clinical placement immediately due to their health conditions and felt disheartened by this.
'Finding out that I wouldn't be allowed return to placement under medical consultant's advice, I was disappointed because I knew I wouldn't be graduating with my friends, and even more so because I wouldn't be able to play a part in helping on the frontline which is what I had trained for over the past 4 years. I felt guilty that I wasn't out there with the others helping.' (SR95)

Clinical readiness
There was widespread consensus amongst students that undertaking clinical placement during the pandemic helped prepare them to work as graduate radiographers. One student described the decision by clinical sites and universities to resume clinical placement as 'the right decision'.
'I feel my time on placement was worthwhile as I learnt a lot and I am more competent now than I was at the start.' (SR101) 'This placement has stood to us and prepared us for the new system we will soon be working within.' (SR100) 'I concluded this placement with a wealth of clinical experience, enhanced by the provocations of the global health crisis and I am enthused by the prospect of commencing my career as a radiographer in the coming months.' (SR41) Students felt that their skills in relation to 'problem-solving', 'communication', 'decision-making', 'time management' and 'infection control practice' were enhanced through this clinical placement. Their confidence in efficacy of hospital-based infection control measures grew through the placement with one student stating she felt 'safer in the hospital' than in public spaces.
'As final year students, we were expected to act as the "dirty" radiographer for various exams which allowed for my confidence to grow as we could take responsibility over these highly infectious group of patients'. (SR90)

Adaptability
These reflective essays gave an insight into the many ways in which students adapted their personal and professional lives during this pandemic. Examples were given of adapting to new work practices in clinical, increased infection control measures and altered working hours. Students recalled their conscious efforts to minimise social contact outside of the clinical environment to reduce the risk of contracting COVID-19 and bringing it into the hospital.
'Placement during the pandemic gave me a different perspective. It highlighted the importance of being able to adapt quickly to new policies, protocols, and work patterns' (SR96) 'I have learned how there cannot be a one size fits all response to a crisis, and each hospital must respond to the crisis in their own way, depending on the equipment, resources and staffing they have. Being flexible is very important during a crisis. As a radiographer you must be prepared to work different hours, depending on the needs of your department.' (SR105) 'In hindsight, I think it is good to introduce the shift work to students while on placement to prepare them for the reality of the working world where weekend and night shifts are part of the flexibility required of a qualified radiographer.' (SR94)

Teamwork
Students reiterated that they felt part of the healthcare team and felt valued by healthcare workers. They recognised the importance of the teamwork to cope with the healthcare crisis.
'There was a sense of unity and as though I was not alone in this new environment'. (SR78) 'Staff shortages allowed me as a student to perform more tasks and feel part of the team.' (SR84) 'The teamwork displayed by radiographers, nurses and doctors was excellent. The importance of the multi-disciplinary team aspect of our profession was highlighted.' (SR85) 'Our teamwork and communications skills were needed more than ever to get through this stressful period. We figured out solutions together …. It was good to be part of a team who discussed issues and problem solved together.' (SR 42)

Professional identity
The development of professional identity was evident in student radiographer reflections, where students' attitudes and values aligned with those expected of radiographers. They demonstrated critical awareness of the role of radiographers within the healthcare team and described a deep sense of pride in the profession they are soon to graduate into.
'I feel proud that I will soon be a radiographer and part of a profession pivotal in the delivery of healthcare.' (SR94) 'This crisis has highlighted the passion healthcare staff have for their profession and how committed they are to keeping their patients safe. I witnessed radiographers carry out their duties with such professionalism. This is very refreshing for a soon-to-be graduate as it shows the respect the radiographers have for their colleagues, patients, family and healthcare system as a whole.' (SR88) Theme 3: emotional impact of the pandemic on radiography students undertaking clinical placement Positive emotional impact Students described feeling 'proud' of their contribution to the healthcare crisis and acknowledged their 'resilience' during this difficult time. They described their 'respect' for healthcare workers and the 'camaraderie' they experienced with peers and the wider healthcare team. 'Compassion' for patients and an appreciation for one's own health was discussed.
'Being able to work and grow both professionally and personally through such a phase of adversity is something I feel proud of' (SR78) 'This experience has also shown me how resilient I can be and that I can get through tough situations if I put my mind to it.' (SR83) 'Seeing unlikely patients being admitted to ICU really humbles you and makes you think about life from a different perspective. I think this is a positive of the crisis as it allows you to reflect upon what is important to you and to appreciate your health.' (SR89)

Negative emotional impact
Students described their initial apprehension about commencing clinical placement, which was compounded by 'frightening COVID-19 news reports'.
'An overwhelming sense of both foreboding and anxiety was palpable prior to commencing this block of placement.' (SR55) 'I was worried as the media was blowing up with stories and disasters happening in other hospitals around the world. The hospital itself had an uncertain atmosphere about it.' (SR97) Students were afraid of transmitting the virus to family members and in efforts to reduce this, felt 'isolated' from family members. One student described feeling 'ostracised' by family members who didn't want to be near them as they were seen as a potential source of infection.
I was worried that by working in the hospital I was at a higher risk of contracting the virus and I would be putting my family at home at risk. (SR104) 'I found the fear of COVID quite paralyzing at times and found it quite difficult at times to balance this with the need to learn and focus on the patient.' (SR52) Feelings of 'powerlessness' and 'sadness' were described in relation to witnessing critically ill patients.
Many students were anxious about completing enough clinical hours to graduate on time.

Discussion
Radiography students reflected on the impact of the pandemic on their clinical experience and on their perspectives of Radiography as a profession. Despite the challenges faced during this period, students focused primarily on the positive aspects of clinical practice such the camaraderie with peers and healthcare professionals, their personal growth and professional development. Radiography students, similar to medical students who undertook placement over this period, felt a sense of pride in their profession. 18,21,30 The positive mindset portrayed in these reflective essays reflect students' resilience, especially considering many clinical staff were struggling with heightened anxiety levels and occupational burnout. 13 Radiography students in the U.K and United Arab Emirates demonstrated similar resilience. 19 Students focussed on the benefit of frequently imaging infectious patients and working out-of-hours in preparing them for 'the reality of the working world', enhancing their infection control practice and overcoming PPErelated communication challenges. PPE is known to impact students' communication with patients and peers, 11,19 which is integral to patient-centred care. 31 Whilst students were afraid of transmitting COVID-19 to family members, echoing previous studies, 4,5,11 they were appreciative of the opportunity to undertake clinical placement. Students embodied the values and attitudes expected of graduate radiographers in their reflections. They depicted integrity, respect and altruistic behaviour with their primary concern being the patient's welfare. 32 There was evidence of thoughtful consideration of patient's needs and values, which aligns with the professional code of conduct. 33 Students expressed respect for healthcare professionals and acknowledged the importance of multi-disciplinary teamwork. They were proud of how they coped emotionally, their adaptability to the changed clinical environment and their clinical competence. Students felt proud of their contribution to the healthcare services during this crisis, a sentiment also captured in a UK-based study of radiography student placement experiences during the pandemic. 18 The insight into professional practice and critical thought processes illustrated in these reflective essays suggest that clinical placement during the pandemic positively contributed to clinical readiness, the development of professional identity and reflective practice amongst radiography students. Reflective practice plays a critical role in advancing and improving skills, knowledge and practice amongst healthcare professionals 34 and is mandated by the professional regulatory body. 7 In line with previous studies, radiography students expressed concerns about the impact of the COVID-19 pandemic on their skill development. 4,9 Students had limited opportunities to practice adaptive technique due to the lack of trauma imaging. Despite this obstacle, there was widespread consensus amongst students that clinical placement was beneficial to overall skill development. They commended radiographers and practice educators for positively contributing to their clinical education. Practice educators have a significant positive influence on the development of students in clinical practice, 35 perhaps even more so during a healthcare crisis. Students relied more heavily on simulationbased learning in tutorials during placement to develop their trauma imaging skills, which is an important consideration for curriculum design. Innovative technology, such as virtual reality, may assist in training radiography students when exposure to certain imaging is reduced in clinical practice. 36e38 Furthermore, radiographers who graduate during the pandemic may need additional support in transitioning into workforce in the form of mentorship and training. 11 Students indicated that they felt more worried about COVID-19 prior to commencing clinical placement, particularly after watching the news. Consumption of distressing news media, which substantially increased during the COVID-19 pandemic, has demonstrable negative effects on mental health. 39 However, it should be noted that students' perspectives changed throughout the clinical placement block and were reframed after interactions with supportive clinical staff. This is consistent with previous studies that have reported dissipation of pandemic-related anxiety upon commencing clinical practice 21 and students feeling safer in the hospital due to the stringent infection control measures in place than in public spaces. 11 The sense of camaraderie and support from clinical staff described in these reflections likely contributed to students' positive clinical learning experience despite the challenging clinical environment.

Limitations
Potential limitations of this study include recruitment of student radiographers from a single University, although these students were undertaking clinical placement in twenty different clinical sites across Ireland. Information regarding whether students contracted COVID-19 during this placement or whether they had dependants living with them was not gathered, which may have influenced their clinical experience.

Conclusions
The COVID-19 pandemic had a profound effect on radiography clinical placements. While students reported some negative experiences, such as lack of exposure to trauma imaging and PPE-related communication challenges, they focussed primarily on the benefits of clinical practice in preparing them to join the radiography workforce. The development of professional identity and sense of pride in their profession was evident. This study highlights the benefit of continuing radiography placements during a pandemic, albeit with additional learning and emotional support in place for students.