“It has been the most difficult time in my career”: A qualitative exploration of UK obstetric sonographers’ experiences during the COVID-19 pandemic

Introduction Substantial changes were made to the provision of pregnancy ultrasound services during the COVID-19 pandemic with the intention of minimising virus transmission and maintaining service continuity. Published literature describing the impact of the pandemic on obstetric sonographers is predominantly quantitative in nature, however statistics cannot fully convey sonographers’ voices. This study aimed to gain a deeper understanding of the lived experiences of UK obstetric sonographers performing pregnancy ultrasound scans during the pandemic. Methods A UK-wide, online, anonymous cross-sectional survey on Qualtrics XM™ was open to responses between 9th March and 6th May 2021. Whilst this survey contained some quantitative elements, open questions were included to capture additional qualitative detail from respondents about their perceptions and experiences of scanning during the pandemic. Key themes were generated from free text responses using thematic analysis. Results : Written responses were received from 111/138 sonographers participating in the survey. Five themes were generated, depicting the impact of the pandemic on obstetric sonographers: 1) continuity in a crisis; 2) decisions about me, without me; 3) battle scars – the lasting damage of COVID-19; 4) what people think I do vs. what I really do; and 5) the human touch. A cross-cutting theme was sonographers’ feelings of disconnection from senior figures and expectant parents which created a sense of abandonment and distrust. Conclusion Survey respondents’ self-reported experiences of ineffective leadership and management, and perceived lack of understanding of the complexity of the sonographer role are potential contributory factors in the high levels of moral injury and occupational burnout reported within the workforce during the pandemic.


Introduction
During the COVID-19 pandemic, healthcare services made substantial changes to balance continuity of care with safety of service users, members of the public and staff. 1 Recommended changes to the provision of obstetric ultrasound included reprioritisation of fetal scans because of reduced departmental capacity, 2 risk assessments, 3 and temporary restrictions on additional people attending scans. 4,5 Early published literature exploring the experiences of healthcare professionals reported immediate considerations for services, including the supply (or lack) of personal protective equipment (PPE), 6 telehealth in place of in-person appointments, 7 and screening initiatives to reduce virus transmission in hospitals. 8 However, as staff adapted to new working practices, research foci shifted to explore the longer-term psychological impact of the pandemic on workers. 9

Moral injury and burnout in COVID-19
The negative psychological impact of the COVID-19 pandemic on healthcare professionals is well documented. 10 This has been described in relation to occupational burnout, and attributed to factors such as fear of contracting or transmitting the virus, being redeployed to unfamiliar clinical areas, and increased workloads because of staff shortages. 11 However, it has been suggested that research exploring occupational burnout in healthcare professionals often fails to give appropriate recognition to the prevalence and influence of moral injury as a precursor to burnout. 12 Moral injury is often described in the military context, whereby individuals experience guilt or shame as a result of their own actions (or lack of), which conflict with their moral values. 13 However, it is also experienced through the recurrent violation of normative expectations, or betrayal of trust, by a person in authority. 14 Normative expectations are broadly defined as "beliefs about what people should do combined with predictions about what they will do". 15 When they are felt to be breached, individuals may experience a strong affective response including feelings of cynicism, disengagement resentment, and withdrawal of trust 16 causing a moral injury. 17 It is important to make the distinction between occupational burnout and moral injury, as without full appreciation of the underlying cause of an individual's psychological distress, appropriate support and initiatives for recovery cannot be actioned. 18

The impact of COVID-19 on sonographers
There is a growing body of literature reporting the impact of the COVID-19 pandemic on obstetric sonographers working in the UK, 19e21 Australasia 22e24 and other countries. 25 As with other healthcare professionals, the lack of adequate and available PPE for sonographers was a common finding, 19,21,23 with concerns raised by 71.9% of sonographers across 124 countries. 25 Substantial modifications to scanning practices were noted; including reducing the number of scans 22 and length of appointments, 23 restricting the number of people permitted to attend, 21,23 and making changes to public waiting areas following risk assessments, 20 although these varied between countries. Additionally, increased workloads from rigorous cleaning and infection control procedures, 23,24 rapidly changing guidance perceived as ambiguous 21 and unhelpful, 20 and concerns over personal safety because of aggressive and abusive behaviour towards sonographers from expectant parents and the public are also reported. 21 Although studies reporting the psychological impact of the pandemic on sonographers are fewer, fear of contracting or transmitting the virus is highlighted as a contributing negative factor on sonographers' well-being, 21,24 exacerbated by the inability to physically distance whilst scanning. 21 In UK obstetric sonographers, high levels of occupational burnout were reported, with over 90% of respondents meeting thresholds for emotional exhaustion and disengagment. 19 In addition, 73.9% of respondents were considering leaving the profession completely, or changing their area of clinical practice within the next five years, 19 which would have a significant impact on the already stretched UK sonographic workforce. 26 With one exception, 21 published literature regarding sonographers' experiences of scanning during the COVID-19 pandemic is largely based on numerical data and statistics which cannot fully capture individual voices and reflections. The aim of this paper, therefore, was to qualitatively explore UK obstetric sonographers experiences of performing pregnancy ultrasound scans during the COVID-19 pandemic, and to provide additional, psychosocial context to previously reported quantitative findings 19,20 which may be used to underpin workforce recovery strategies in the aftermath of the pandemic.

Methods
Reporting of the study is guided by the Journal Article Reporting Standards for All Qualitative Research Designs (JARS-Qual). 27 An online, anonymous questionnaire was developed using the Qual-tricsXM™ platform, 28 and the weblink was shared within the UK sonographic community using a snowball sampling technique via social media and professional networking channels (e.g. Twitter, Facebook, LinkedIn). Departmental managers were also approached by the research team to share the weblink with staff who were not active on social media. This approach was used to facilitate rapid collection of a large dataset for the quantitative components of the survey during a period of national lockdown, 29 and to adhere to additional restrictions on conducting research activity which were in place during the COVID-19 pandemic. 30 The survey was reviewed by volunteers from the Society of Radiographers' Ultrasound Advisory Group who gave feedback on readability of questions and usability of the QualtricsXM™ platform, resulting in minor changes to the wording of questions for improved clarity. No data was collected during this review phase, and volunteers could still take part in the main study if they wished to. The questionnaire was composed of four sections: 1) sonographer experiences of performing obstetric ultrasound examinations during the COVID-19 pandemic (Supplementary Appendix 1); 2) Oldenburg burnout inventory 31 to evaluate self-reported levels of occupational burnout; 3) CORE-10 tool 32 to assess psychological distress in respondents; and 4) participant demographics. Section one featured multiple choice questions and provided the option for respondents to share further insight into their experiences through free text responses. Further details about the study design and the quantitative results for sections 1-3 have been previously published. 19,20 This paper presents the qualitative analysis of sonographers' free text survey responses from section one.

Eligibility and informed consent
Sonographers could participate if they were 21 years old or over and had performed obstetric ultrasound examinations during the COVID-19 pandemic (i.e., since March 2020). Exclusion criteria were trainee and non-obstetric sonographers to keep alignment with the research focus. Prior to accessing the questionnaire, respondents were required to read the accompanying information sheet, confirm their eligibility to participate, and complete an electronic declaration of informed consent. Participants were prompted to answer all questions, although they were free to leave blank responses if they wished.

Qualitative analysis
Data were downloaded into Microsoft Excel (version 2008) 33 from the QualtricsXM™ platform 28 after the questionnaire was closed to responses on 6th May 2021. Qualitative data were extracted and imported into NVivo (version 12) 34 for thematic analysis. This method was chosen for its flexibility to facilitate a thorough analysis of the large and heterogeneous qualitative dataset acquired through the online questionnaire. 35 An inductive approach was taken following the 6-step framework described by Braun and Clarke. 36,37 Following familiarisation with the dataset, the free-text responses for individual questions were coded. Codes were reviewed collectively for further exploration of patterns of meaning across the dataset. During this process, similar codes were combined, and new codes were generated to represent the groups. The groups were reviewed against the full dataset, and overarching themes were developed and subsequently refined to reflect the individual codes. Finally, core themes were reviewed during the writing up process, and illustrative quotations were selected from the dataset to provide supportive examples. Prior to submission, a near-final version of the manuscript was reviewed by two sonographers who volunteered to provide feedback on the findings. 38 This was an important process to validate the findings. These volunteers had not completed the survey themselves, but confirmed the developed themes were reflective of their clinical experiences, therefore no changes were made to the reporting.

Ethical considerations
This study was reviewed and granted ethical approval by the School of Health and Psychological Sciences at City, University of London (reference: ETH2021-1240, date of approval 09 March 2021). Due to the sensitive nature of the research topic and timing of data collection, there was a possibility that sonographers' participation may have led to psychological distress in recalling and relaying their experiences. Therefore, contact details for UK-based mental health organisations were provided to all respondents on completion of the questionnaire.

Results
In total, 138 sonographers actively participated in the questionnaire with a completion rate of 81.0%. Free-text responses were provided by 111 sonographers across 15 questions. Most participants were female (96.6%), of white ethnicity (86.5%) and working in full-time clinical roles within the NHS during the COVID-19 pandemic (49.4%) ( Table 1). Despite the potential risk of distress, many sonographers expressed gratitude through their responses at the opportunity to take part in this study and share their perspectives.

Findings
Five themes were generated: 1) continuity in a crisis; 2) decisions about me, without me; 3) battle scars e the lasting damage of COVID-19; 4) what people think I do vs. what I really do; and 5) the human touch (Table 2). Themes and illustrative quotations are provided below.

Continuity in a crisis
Continuity of obstetric ultrasound services during the pandemic was primarily facilitated by sonographers' immense professional pride and duty of care to expectant parents. Despite concerns around contracting the virus because of working in physical closeness to parents, they did not let this stand in the way of them providing high-quality care.
"I am professional and will care for women and their partners as usual." (Full-time sonographer, aged 51e60) Efforts required to keep the screening service going were also driven by feelings of satisfaction and accomplishment in the role, particularly when drawing on specialist knowledge to contribute to care management pathways. In contrast, risk mitigation strategies and new guidance issued by professional organisations to assist the safe running of imaging services were not highly regarded, because of their perceived lack of direct benefit to sonographers and ambiguity leading to variation in implementation.
"I feel that the guidelines have been as a result of public pressure as opposed to being actually supportive of sonographers." (Full-time sonographer, aged 21e30) The focus from leadership and management personnel on preservation of the parental experience during scans above the well-being of sonographers, led to solidarity in their shared sense of abandonment from senior figures, and sonographers seeking compassion from other members of the immediate ultrasound team to keep them going. Decisions about me, without me Sonographers felt excluded from discussions at both local and national levels, about their own working practices, creating a sense of isolation.
"We as sonographers feel as if we were forgotten during the pandemic." (Part-time sonographer, aged 31e40) They described indignation at how decisions to reintroduce partners and support persons to scans, as national lockdown restrictions lifted, had been made by non-sonographer colleagues, whilst restrictions and/or virtual appointments remained for other antenatal care consultations. This evoked a feeling of distrust, which was further exacerbated by contradictory risk assessments and mitigation strategies which failed to reassure them of the safety of their working environments.
"The risk assessments were initially done on a generic basis and were found to be lacking. They have since been redone and there is some disagreement between the staff actually working in the environments and what the health and safety advisor and management assessments state …" (Employment status not shared, aged 31e40) In addition, sonographers were frequently made to feel like troublemakers for raising concerns over their safety, particularly after the restrictions around partner attendance at scans were lifted around the end of 2020, and described encounters where they had been berated by senior management for speaking out. These events served to reinforce a shared belief that sonographers were expendable workers whose safety needs could be compromised to avoid confrontation and facilitate "business as usual".
"Obstetric ultrasound was the sacrifice given to protect other staff providing antenatal care. The scan was promoted by the Trust as a gift to pregnant women and partners so they wouldn't complain about the reduced antenatal checks without partners." (Part-time sonographer, aged 51e60) Battle scars e the lasting damage of COVID-19 Most sonographers described how the pandemic had a considerable, and long-standing negative impact on their psychological and mental health. In the early stages, they experienced significant distress at being "sat cuddled up to patients" for extended periods of time whilst scanning, or felt upset after giving unexpected news to pregnant mothers and people who had been scanned without a support person. Later, increasing numbers of parental complaints and episodes of aggression prompted sonographers to withdraw because of emotional exhaustion and burnout. Complaints received were often not considered valid ("you have ruined my gender reveal scan"), and sonographers felt personally attacked for encouraging mask-wearing and physical distancing in scan rooms. They were also deeply distressed by abuse received from parents via unmoderated social media platforms, some of which was individually targeted. A heightened perception of public disrespect for sonographers was further reinforced by the stark contrast of praise and recognition given to other healthcare services.
"I felt the population clapped for the NHS but sonographers were abused verbally at work and on social media." (Full-time sonographer, aged 51e60) Lack of support from senior staff who failed to respond adequately to online comments further increased anxiety levels in sonographers. This caused sonographers to question their trust in their employers, as well as their future careers, with many actively seeking to leave obstetric ultrasound or sonography as a result.

What people think I do vs. what I really do
This theme captures the perceived disconnect between the way sonographers understand their role, and how they considered others to. They expressed disappointment and frustration with the portrayal of scans as entertainment for expectant parents, their families, and friends.
"Feel as though the medical element of ultrasound is no longer important and that patients are obsessed with ultrasound as an entertainment scan and gender scan." In these scenarios, sonographers felt their clinical expertise was being undermined. An inferred emphasis on the parent experience placed them in an uncomfortable position where they felt the pressure of balancing the potential risk of failing to detect an unexpected fetal condition with that of receiving criticism from parents.
"Constant worry about missing pathology because you are too busy trying to make experience nice for patient […] because you are worried about getting a complaint." (Full-time sonographer, aged 41e50) Some sonographers described how parents' use of private ultrasound clinics (both prior and during the pandemic) contributed to the disparity between medical and social elements of scans by setting unrealistic expectations for parents and conflating ultrasound screening and diagnosis with the promise of a fun, family experience. Respondents called for initiatives to improve public and professional understanding of the role following the pandemic.
"It is imperative we are not seen as entertaining clowns but an essential part for the medical profession." The human touch Despite its challenges, the pandemic presented an opportunity for some sonographers to return to their core professional values in providing high quality parent-centred care. They were emotionally responsive to expectant parents' needs and desires to share the scan with a fellow human, and whilst attendance restrictions were in place, they extended their roles to act as default companions, offering temporary social support during the scan appointment. This working relationship was gratifying for sonographers who described feeling more engaged and appreciated in their role through the enhanced connection.
"Many [mothers] interacted with me in a way that they wouldn't if their partner was there." (Full-time sonographer, aged 51e60) Without additional attendees, sonographers felt better able to focus their attention on the individual they were scanning. They described how this facilitated a richer, more personal scan experience that was more aligned to the purpose of the scan and created a safe and trusting environment in the scan room. As a result, many observed increased disclosure of additional issues such as domestic violence. These positive interactions helped sonographers to feel valued and satisfied in their roles, despite the challenges of working during the pandemic.

Discussion
The themes generated depict UK obstetric sonographers' experiences of facilitating the continuity of obstetric ultrasound services during the COVID-19 pandemic. Sonographers relied on their strong professional values and sense of duty to overcome challenges in the interpretation and implementation of new guidance and avoid disruption to antenatal care provision. However, their efforts were not felt to be fully appreciated or supported, resulting in reduced trust and increased disengagement from leadership and management figures. The themes reflect the occurrence of moral injury amongst sonographers, who, despite this, continued to engage with their role, finding satisfaction in team-working, deeper connections with pregnant women and people, and the application of their specialist ultrasound knowledge and skills.

Occupational moral injury
In addition to concerns around the risk of contracting COVID-19 and personal safety within the scan room, disconnect from senior professional colleagues was identified in this analysis as a longerterm influence on the psychological well-being of obstetric sonographers. Feelings of disappointment were consistent across all but one of the themes generated ("the human touch"), and were evoked in response to sonographers' perception that their normative expectations of senior management, professional organisations, and the general public had been violated. Sonographers felt let down by senior management and professional organisations because of the perceived inadequacy and lack of visible leadership, which may have been interpreted as contradictory to recommendations emphasising the importance of authoritative figures being present during a time of crisis for staff support. 39 Sonographers also felt dismissed when concerns shared over safety in the scan room were not taken seriously. This finding was not unique to this analysis, with failures in PPE provision reported as a major cause of distress in UK healthcare professionals. 40 A study of Australasian workers also reported feeling shamed and victimised when asking for higher-grade PPE. 41 Dismissal of concerns by senior managers can be perceived as a lack of care, and causes staff to question their position as a valued team member or dispensable object, 42 in this case, merely an extension of the ultrasound machine.

Occupational moral injury and parent-centred care
Occupational moral injury in healthcare professionals has been dubbed as the "hidden pandemic" of COVID-19, 41 however it was not just ineffective leadership that was identified as morally injurious in this study. Obstetric sonographers also felt let down by expectant parents and the public who displayed threatening behaviour and directed abuse towards them, most often regarding the restrictions around partner attendance. As sonographers identified themselves as the victims in this situation, expectant parents also experienced feelings of disappointment; that these restrictions were not in their best interests, 43 resulting in a mutual withdrawal of trust.
Trust is integral to parent-centred care, as it underpins the relationship between the sonographer and the expectant parent. 44 Trust in healthcare professionals develops from both an understanding and appreciation of clinical skills, as well as demonstration of "humaneness" through compassion and care. 45 The parentsonographer relationship is acknowledged as complex, 46 and development of trust can be challenging in the obstetric setting. As highlighted in this analysis, it was hindered by the COVID-19 pandemic. Survey responses suggested that lack of public recognition and awareness for obstetric sonographers' clinical role could be explained by the absence of statutory regulation for the workforce. This failure to acknowledge sonography as a distinct occupation creates ambiguity around the role, and as such lowers the public profile of sonographers and recognition of specialist clinical skills. 47 This can be further confused by the rise in popularity of private scanning clinics which promote more social aspects of obstetric ultrasound. 48 In addition, it may be considered that guidance recommending shorter scan times and the restriction of partners and supporting persons at scans during the pandemic 4 were not conducive to developing the trusting parent-sonographer relationship and the subsequent perception of high-quality care. 49 However, obstetric sonographers did not consider these as significantly impactful on their communication with expectant parents during scans. 19 Instead, efforts to enhance interactions with parents during the peak of the pandemic restrictions, as described in the final theme, suggest incidences of psychological growth in response to the situational trauma, 50 whereby sonographers made positive changes to their practice to ensure the provision of parent-centred care.

Moral repair and recovery
Recovery following moral injury is essential to prevent progression to burnout 12 and the development of deeper psychological trauma. 14 The context-driven nature of moral injury and burnout suggests that initiatives at the individual level (e.g. practising mindfulness, resiliency training) are likely to be ineffective in the longer term. 51,52 Therefore, structural reform is urgently required to support post-pandemic recovery of the workforce. However, unlike mitigation for occupational burnout which may attempt to reduce job demands and increase resources for workers, 53 moral repair requires that the "moral equilibrium" between the perpetrator and the victim is re-established, such that trust can be restored. 54 Shale describes a 7-point framework for moral repair that places the notion of acknowledgement firmly at the centre of trust restoration. 15 This includes acknowledgement that moral injury has occurred, acknowledgement of responsibility for causing harm, acknowledging the feelings of those who have been injured, and acknowledging what is required to rectify the wrong. These are fundamental components of an apology, which is used as the first step to facilitate resolution between two parties after a moral violation. 55 Apologies are moral acts, integral to the practice of ethical leadership, as they provide an opportunity for individuals to publicise their values and present themselves as figures of integrity who are worthy of trust and respect. 56 In the first instance, the findings of this analysis call for effective and ethical leadership in the aftermath of the COVID-19 pandemic, whereby individuals are seen to demonstrate and promote normatively appropriate conduct to their followers. 57 This leadership approach has been associated with increased job satisfaction and staff morale, and reduces burnout by encouraging positive working environments 58 because of its focus on two-way communication, reinforcement of common moral values, and practice of shared decision-making. 55 Interprofessional teamwork in collaboration with Maternity Voices Partnerships is also needed to rebuild trust between sonographers, parents and professional groups, as highlighted in recent reports reviewing maternity services in England 59,60 and Wales. 61

Strengths and limitations
The study findings provide qualitative context which help to explain previously reported high levels of occupational burnout in obstetric sonographers. 19 Although limitations inherent in the sampling strategy are acknowledged, 62 survey responses were received from sonographers who were working across all regions of the UK during the COVID-19 pandemic, which has enabled good geographical representation of obstetric ultrasound departments. The sample size was comparable with another recent study involving UK sonographers. 63 Respondents were predominantly female and white, which is reflective of the current workforce, 64 and advantageous from the qualitative perspective because the sample is relatively homogeneous. 65 However, it must be recognised that the experiences of male or ethnic minority sonographers may be different. Due to the cross-sectional nature of the survey, self-selecting population and timing of data collection, findings may not be transferable outside of the study setting, 66 and follow-up research may be beneficial. The theoretical principles of thematic analysis preclude the use of established quality practices (e.g. member checking) to determine credibility of the findings. 67 An alternative practice (member reflection) was utilised, 38 whereby sonographers reviewed a near-final draft of this manuscript to confirm the developed themes were consistent with their experiences.

Conclusion
This analysis provides qualitative context to previous research findings of occupational burnout within the workforce, highlighting sonographers' moral injury through perceptions of ineffective and invisible leadership and management during the pandemic as a key contributing factor. Failure to urgently acknowledge and appropriately repair the harm experienced by obstetric sonographers is likely to exacerbate occupational burnout at the detriment of staff well-being and high-quality parent-centred care. Senior figures must work in collaboration with sonographers to rebuild trust and recreate supportive working environments. Additionally, whilst positive interactions with expectant parents in the scan room were identified as integral to role satisfaction, this is often undermined by a lack of understanding of the clinical aspect of pregnancy ultrasound, and future efforts should be made to raise awareness of the sonographer's role amongst service users and the public.

Declaration of competing interest
GH is the Professional Officer for Ultrasound at the Society and College of Radiographers.

Author contributions
ES and CM conceptualised the study. All authors developed the study design. ES analysed the data and drafted the paper. All authors revised the paper for publication.

Ethical approval
This study was granted approval from the School of Health and Psychological Sciences Research Ethics Committee at City, University of London (reference: ETH2021-1240, approval date: 09 March 2021). All participants gave their informed consent prior to accessing the online survey, which included giving their permission to use anonymised quotations for research presentation and publication.

Funding
This work was funded by the College of Radiographers' Doctoral Fellowship Award (DF017) and the School of Health and Psychological Sciences at City, University of London. Funding from the City Radiography Research Fund has been instrumental for the dissemination of this research. The funders were not involved in the study design, analysis, interpretation or writing of this manuscript.

Data availability
Due to the nature of this research, participants of this study did not agree for their data to be shared publicly, so supporting data is not available for distribution.