Lived experiences of radiology caregivers during a health crisis: A COVID-19 case analysis

Background Health crises have been linked with the exacerbation of pre-existing difficulties and the emergence of unique challenges, as evidenced by the impact of coronavirus disease 2019 (COVID-19) on health caregivers worldwide. Baseline data allow for reflection and preparation for any future health emergencies therefore giving impetus to phenomenological enquiries among the experiencers. Aim This study aimed to explore the lived experiences of the eThekwini district frontline radiology caregivers during the COVID-19 pandemic. Setting The study was conducted in public and private radiology departments in the eThekwini district of KwaZulu-Natal, South Africa. Methods A qualitative, interpretative phenomenological analysis methodology was adopted in a multi-method data-collection context comprising semi-structured interviews and focus group discussions (FGDs) among 24 radiologists, radiographers, and radiology nurses obtained by non-probability sampling. Data were transcribed verbatim and analysed using an interpretative phenomenological approach. Results Three superordinate themes emerged, namely: (1) duties and roles during the COVID-19 pandemic, (2) work-related challenges, (3) personal challenges. Conclusion Frontline radiology caregivers experienced increased workload, staff shortages, salary cuts, personal protective equipment (PPE) shortages, non-recognition, poor managerial support, disrupted social relations, and poor work–life balance. This necessitates the need for the radiology departments to address staffing, infection prevention and control deficits, and invest in support interventions to assist frontline radiology caregivers during health crises. Contribution The findings comprise baseline information that can be used for reflection and guiding radiology departments in preparing for any future health crises.


Introduction
Frontline health caregivers are often exposed to nosocomial infections that can be potentially exacerbated by health crises, as reportedly healthcare workers constituted 20% and 10% of the population infected with Severe Acute Respiratory Syndrome Coronavirus (SARS) 1 epidemic and the novel coronavirus disease 2019 , respectively (Mossburg et al. 2019:1;Liu et al. 2012:15; World Health Organization [WHO] 2020).Spreading through air droplets and contaminated surfaces, the highly infectious novel coronavirus, SARS-CoV-2, was first reported in Wuhan, China in 2019 and hit South African shores on 05 March 2020.As of August 2020, over 27 000 healthcare workers had been infected with COVID-19 while 240 had succumbed to it, with the KwaZulu-Natal (KZN) province also suffering significant infection rates (Centres for Disease Control and Prevention [CDC] 2023; Ramphul, Mejias & Ramphul 2020:274;Singh 2020;South African Department of Health [NDoH] 2020:1).
In addition to infections and deaths, several consequences such as economic, educational disruptions, unemployment, and mental impacts were recorded worldwide (Sekyere et al. 2020).Shortage of hospital beds and Personal Protective Equipment (PPE) were among the difficulties faced by the South African healthcare industry and like any other frontline health workers, the radiology and radiography staff were also exposed to the highly infectious respiratory disease COVID-19 (Singh 2020;Zanardo et al. 2020:265;WHO 2020).Moreover, the increased use and indispensability of the chest radiograph (CXR) and the computed tomography (CT) scan in the Background: Health crises have been linked with the exacerbation of pre-existing difficulties and the emergence of unique challenges, as evidenced by the impact of coronavirus disease 2019 (COVID-19) on health caregivers worldwide.Baseline data allow for reflection and preparation for any future health emergencies therefore giving impetus to phenomenological enquiries among the experiencers.

Lived experiences of radiology caregivers during a health crisis: A COVID-19 case analysis
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management of COVID-19 patients for differential diagnosis and diagnosis of COVID-19 complications, coupled with reported shortages of infection prevention and control (IPC) equipment and protocols could potentially aggravate their risk of infection within the workplace (Murphy et al. 2022:388;Zanardo et al. 2020:265).
Studies on the COVID-19 experiences of healthcare workers and radiographers in various geographical locations including South Africa have commonly reported increased workload, shortage of PPE, and mental health repercussions (Akudjedu et al. 2021(Akudjedu et al. :1219;;Murphy et al. 2022:384;Lewis & Mulla 2020:346;Van de Venter et al. 2021:593;Watermeyer, Madonsela & Beukes 2023:2).The highlighted experiences have exposed lessons learned and areas of improvement within these specific locations.However, the unique lived experiences of radiologists, radiographers, and radiology nurses within the private and public radiology departments in the eThekwini district of KZN, South Africa, have not been explored, thereby preventing the reflective process, addressing areas in need of attention and planning for any further health crises.
Despite collectively being in the health sector, findings of lived experiences of a phenomenon cannot be generalised because of the diversity of the statistics and repercussions of COVID-19 in different geographical, social, and economic environments (Worldometer 2020).Nationally, the South African public healthcare system is decentralised at the provincial level; hence, provinces have different economic and operational statuses with records of non-operational or faulty radiology equipment and deteriorating healthcare services reported in KZN as well as unique occupational stressors among the KZN radiographers (Gam, Naidoo & Puckree 2015:18;Modisakeng et al. 2020:3).Therefore, the consequences and impact of COVID-19 could have been different with possible differing experiences of the frontline radiology caregivers, necessitating the need to capture their own phenomenological voice.This study therefore intended to explore the lived experiences of radiologists, radiographers, and radiology nurses working in private and public radiology departments within the eThekwini district of KwaZulu-Natal, South Africa during the COVID-19 pandemic to provide baseline information to necessitate reflective practice and preparation of radiology departments for any future health crises.

Research design
Taking a constructivist epistemological position and interpretivist theoretical stance, the qualitative, interpretative phenomenological analysis (IPA) approach was adopted to allow for a detailed exploration and sensemaking of each individual participant's lived experience during the COVID-19 pandemic (Smith, Flowers & Larkin 2022:1;Moon & Blackman 2014:3).

Setting
The study was conducted in the eThekwini district of KZN province, South Africa within both private and public radiology departments.The public radiology departments included in the study were from diverse health facilities comprising central, tertiary, regional, and district hospitals as well as community health centres allowing for a critical exploration of the lived experiences of the radiology caregivers in various radiology settings.

Study population and sampling strategy
The population comprised Health Professions Council of South Africa (HPCSA) registered radiologists and diagnostic radiographers as well as the South African Nursing Council (SANC) registered radiology nurses working in private and public eThekwini district radiology departments to ensure homogeneity of the sample (Pietkiewicz & Smith 2014:9).Eight public radiology departments and three private radiology practices with at least 11 branches within the eThekwini district were included in the study as they constituted the target population.The inclusion criteria comprised all frontline radiology caregivers with a minimum of 2 years' service at their respective hospitals to exclude the potential impact of lack of work experience on participants' lived experiences.Participants needed to be registered with HPCSA within either the independent, private, specialised or sub-specialised practice categories or SANC within either the enrolled or registered nurse categories.Community service nurses, radiology registrars, community service radiographers, student radiographers, and radiographers not working in facilities attending to COVID-19-related cases were excluded from the study as their lived experiences could have potentially been impacted by several other external factors not related to the radiology department.
The maximum variation purposive sampling method was adopted to allow for the capturing of a wider range of perspectives and representation of each professional category from each of the radiology settings (Johnson & Christensen 2014).The population was first categorised according to their working sectors (public and private), and then professional categories (radiologists, radiographers, and radiology nurses).In keeping with phenomenological studies that enable the researcher to generate and analyse data in detail with an utmost number of 15 participants, a minimum of four and a maximum of six participants from each professional category were interviewed (Pietkiewicz & Smith 2014:9).Consistent with Nyumba et al. (2018:23)'s recommendation that allows capturing of individual voices, a minimum of five and a maximum of eight participants were recruited for each of the two focus groups.The sample size was considered on a data saturation basis within the professional categories.

Data generation
After ethics and gatekeeper permissions were granted, the interview and FGD guides were pre-tested by the researcher among participants who did not take part in the final data generation.Because of COVID-19 regulations, data were generated virtually and telephonically between May and September 2021 using a multi-method approach comprising semi-structured one-on-one interviews with 13 participants in the first phase (n = 13) and two FGDs (n = 2) constituting five and six participants each in the second phase.This allowed for the simultaneous capture of individual perceptions of eThekwini-based frontline radiology caregivers' experiences as well as the ability to discuss work-related issues that individuals might fear to share in fear of victimisation (eds. Bauer & Gaskell 2000:48).Interview invitations were circulated among the population through their heads of departments (HODs).The invitations included information advising individuals to express their interest in participating in the study by either informing their HODs or emailing the researcher directly.The pre-tested interview and FGD guides comprised open-ended questions (Box 1), which were developed by interlinking the research study's aim and research questions to enable a comprehensive exploration of the frontline radiographers' experiences.

Measures of trustworthiness
Trustworthiness of the study was adopted throughout the study by incorporating the trustworthiness framework by Guba and Lincoln (Johnson & Christensen 2014).To ensure credibility of the study, the researcher developed an interview schedule and conducted a pilot study to sharpen their interviewing and group discussion facilitating skills.Peer validation and cross-checking of interview or FGD notes with audio recordings was conducted by the researcher and verified by the research supervisors (Johnson & Christensen 2014).As a form of an audit trail, a Microsoft OneNote research journal comprising interview and FGD schedules, notes, audio recordings, and reflective log was kept throughout the research process to establish dependability of the research study and outcomes.To ensure confirmability of the study's findings, investigator triangulation was adopted by incorporating an independent data analyst and implementation of reflective journaling through use of the developed reflective log.Transferability of the study findings was established by adopting the maximum variation purposive sampling technique and provision of direct quotations from the participants within the results section (Creswell 2014;Denzin 2013:15;Johnson & Christensen 2014).

Data analysis
The interview and FGDs, which were audio recorded upon the participants' approval, were transcribed into text data by an independent professional transcriber and then cleaned and verified by the researcher.After this the data were coded and categorised into themes through the use of the IPA; therefore, allowing the researcher to engross in the data.In line with double hermeneutics, this enabled the researcher to simultaneously capture the frontline radiology caregivers' sense-making of their experiences and make sense of the shared accounts (Pietkiewicz & Smith 2014:11).The steps in Figure 1 were incorporated to allow a detailed case-by-case analysis of the interviews, FGDs, and capturing of individual voices and experiences during steps one to five; therefore, enabling the idiographic focus of IPA (Smith, Flowers & Larkin 2022:125).During the first five steps, the interview and FGD transcripts were individually read and re-read for better understanding (Smith & Osborn 2007:67).Any arising thoughts and outcomes of the exploratory analysis of semantic and language use in the transcripts were documented using a reflective log.During step four, common themes were checked for connections and grouped according to abstraction, subsumption, polarisation, contextualisation, numeration, and function (Smith, Flowers & Larkin 2022:130-137).A master table of themes for the sample was developed by second-order analysis, which entails a search across individual cases (Smith & Osborn 2007:75) (Step seven).To confirm the themes, an independent data analyst perused the transcripts and data analysis process.

Ethical considerations
Prior to data collection, ethical approval (IREC 177/20) was obtained from the Durban University of Technology Institutional Research Ethics Committee and gatekeeper permissions obtained from the KZN department of health, eThekwini Health district, hospital and radiology departments' management.Participants were provided with a letter of information and requested to provide written informed consent by completing the issued consent form prior to the interview or focus group discussion (FGD).The letter of information informed participants of the objectives, voluntary nature of the study, non-involvement of financial benefits, and their right to withdraw from the study at any time they felt uncomfortable with participating in the study.It also emphasised the prioritisation of confidentiality and anonymity during the study.In keeping with this, a separate demographics questionnaire was completed prior to data generation and each participant was allocated an anonymous code.Furthermore, no personal details were included on the interview or FGD transcripts.Participants were also provided with a form to indicate their preferred data-generation method (interview or FGD) and preferred platform (online or telephonic) without coercion.To address the challenge of bringing together participants for FGDs because of differences in work shifts and preferred data-collection times, an online poll site was used to reach a common time slot.During data generation, the researcher regularly observed participants for any signs of distress, and allowed the participants to take a break, stop the interview, or withdraw from the FGD if a need arose.

Demographic characteristics
Most of the participants were working in public radiology departments, identified as female, and were in the age range 18 years -49 years (Table 1).Grade 1-3 radiographers made up most of the sample, which also comprised four chief radiographers, two radiography managers, two radiology nurses, and four radiologists.The majority of the participants had 6 years -10 years' work experience within their roles, with the most experienced participants having more than 20 years.Many of the participants attended to COVID-19 patients with some attending to more than twenty COVID-19 patients per week.

Superordinate theme 1: Duties and roles during the coronavirus disease 2019 pandemic
Duties and roles during the COVID-19 pandemic comprised four subordinate themes, namely: (1) use of radiology modalities in the management of COVID-19 patients, (2) role of radiologists, (3) role of radiographers, (4) role of radiology nurses.Participants outlined that there was an increased  Step 1: TranscripƟon of interview audio-recordings Step 2: Reading and re-reading of the transcript Step 3: IniƟal noƟng Step 4: Developing emergent themes Step 5: Searching for connecƟons across emergent themes Step 6: Moving to the next case Step 7: Second order analysis (developing a Master table of themes) Despite this, participants tried their best to adhere to the recommended IPC protocols although at times they slackened because of fatigue: '[B]ut as far as possible, we are trying to be as cautious; hand hygiene, keeping our mask on all the time.We are trying our best.'(Radiographer, Female, Participant 3) '[I] think everybody is at the stage where they are sort of fed up a little bit, and you maybe tend to let your guard down when you should not.' (Radiographer, Female, Participant 9) Radiology health caregivers found the process of donning and doffing PPE to be cumbersome, time consuming, and uncomfortable when they had to wear it for longer periods.
Together with the cleaning of equipment between patients and after visiting the COVID-19 ward for mobile radiographic examinations, this increased workload and was perceived as overwhelming because of associated staff shortages: ' To accommodate the increase in demand for medical imaging and safety of staff and patients, CT scans were booked for the late afternoon after other patients had been attended to, unless it was urgent: 'If it is a really urgent scan, sometimes we will try and squeeze it in where we have got a gap, but generally we do try and sort of wait a little bit later in the day … so that it does not create a huge impact on our list … because you have got to wait for the patient to come down, scan the patient and do a full clean of the room …' (Radiographer, Female, Participant 9) Changes in protocols, staff shortages, COVID-19 infection among staff, and sick leave severely impacted duties and shift rotation; therefore, radiography managers got more involved with clinical duties to relieve the pressure where possible: '[P]ublic hospitals are facing a shortage of staff … and also because we now started to see a lot of patients … then as managers we had to help with Bedside Unit [BSU]s and CT scans … so that we can ease the load on radiographers …' (Radiographer, Female, Participant 4) Social distancing protocols disrupted peer-to-peer interactions and brought social events to an end as only a limited number of people were allowed in a closed space at a time: 'Our social events in the department, these are the things that keep us together as a team, were limited and there was change in the nature of those.' (Radiologist, Female, Participant 6) Early into the pandemic, there was scarcity of information on the nature, spread, and prevention of the virus.Also noted was a significant number of incomplete radiology request forms from referring clinicians, as they did not share adequate COVID-19-related information that was In as much as respondents were scared of contracting the virus themselves, they were even more worried that they were going to carry the disease home and pose a danger to their immediate families as they felt they had a social shielding responsibility for family members.In the process, interactions with family members were strained:

Discussion
Most of the participants did not feel safe while working within their departments during the COVID-19 pandemic because of the perceived unpreparedness of radiology departments in the form of PPE shortages, structural deficiencies limiting proper implementation of IPC protocols, and scarcity of COVID-19-related information; therefore, aligning with studies in other radiology departments (Akudjedu et al. 2021(Akudjedu et al. :1219;;Murphy et al. 2022:384;Yu et al. 2020:616).Shortage of PPE was attributed to perceived unfair distribution of PPE as radiology and radiography staff were not recognised as frontline workers, echoing the perceived long-standing global issue of non-recognition of radiographers' well-being and professional contribution to the patient's healthcare journey (Chevalier et al. 2022:649;Gqweta 2012:24).Together with non-recognition, lack of managerial support presented as perceived barriers to the frontline radiology caregivers' ability to acquire PPE and the vaccine to protect themselves from COVID-19 as they went about with their duties, which was unique to this study.
Changes to systems and protocols during the pandemic aimed to protect the staff and patients from the virus and aligned with national and international protocols and resonated with experiences in other institutions (Lewis & Mulla 2020:348;Murphy et al. 2022:388) (Birman 2023:24;Leung et al. 2020Leung et al. :2190)).Use of cassettes for mobile x-rays presented back pain and demonstrates the continued use of computed radiography in some parts of the globe because of its reduced costs of migration from film-screen based radiography in comparison to digital radiography (Bhvita & Cooke 2022).
Considering that the sample comprised participants who are possibly breadwinners, the financial impact of the salary reductions and COVID-19-related medical costs on their families are imaginable.These findings correlate with other studies globally (Itani et al. 2021:5,7;Lewis & Mulla 2020:348;Murphy et al. 2022:388).Family relations were impacted as frontline radiology caregivers avoided interaction with vulnerable family members.They felt they had a social shielding responsibility for protecting their families from possible virus transmission from their workplace; therefore, echoing Murphy et al. (2022:393)'s findings.The administration of contrast media by private radiographers confirms the longstanding challenge of breach of HPCSA scope of practice (Gqweta 2012:24;HPCSA 2020:4).Arguably, extending this role to radiographers as practised in other geographical locations such as the UK could alleviate radiologist shortages that impact service delivery (Bwanga, Kayembe & Sichone 2022:632-633;Koch, Swindon & Pillay 2018:60); however, as far as current policies are concerned, the HPCSA is adamant on the responsibility of cannulation and contrast media administration lying with the radiologists because of potential adverse reactions (HPCSA 2020:4;Koch et al. 2018:34).

Limitations
Notwithstanding its benefits, the chosen interview-focus group hybrid data-collection method was time consuming as the researchers had to engross themselves in the large amounts of data.To avoid interference with the quality of the study findings, investigator triangulation was adopted as well as repetition of the data analysis steps for each case.Furthermore, incorporating Guba and Lincoln's Trustworthiness Framework from earlier in the study facilitated trustworthiness of the study findings through reflective journaling and bracketing (Johnson & Christensen 2014).

Study's implications
The study has provided baseline information that can be used as part of reflective practice, addressing post-event consequences of COVID-19 among radiology and radiography staff and departments, as well as planning for any future health crises.This includes development programmes to equip managers with skills and knowledge on how to support staff through challenges, continued support of staff suffering from COVID-19 consequences, and development of ways of information sharing among staff and institutions through online means to enable easier coping during future health emergencies.Moreover, the skill and knowledge gaps identified in the study can motivate for further staff developmental training.Among others, this would include educating referring departments on radiology protocols and adequate completion of radiology request forms.The findings have also exposed the poor ventilation and infrastructure within some public radiology departments that requires attention to ensure staff and patient safety.

Conclusion
Frontline radiology caregivers in the eThekwini district of KZN, South Africa experienced personal and work-related challenges which impacted them physically, financially, and socially.Lack of support from management exacerbated the experiences.It is imperative that solutions, support, and coping mechanisms be developed to assist frontline radiology caregivers and ensure continuity of radiology service delivery during any future health crises.

BOX 1 :
Interview and focus group discussion questions.Please describe how it has been working in your current job during the COVID-19 crisis.(Interpersonal relationships, safety in the workplace, support from peers and support from management).Please describe your feelings around your safety (risk of infection) in the workplace.What factors (within the department or work environment) are influencing these feelings?How have your professional duties been impacted by working during the COVID-19 crisis?What factors are influencing this impact?Who do you think is responsible for each mentioned factor?COVID-19, coronavirus disease 2019.
[W]e cannot do as many patients as we would like to, because of cleaning time.It does increase the workload … If we had more staff, I do not think we would have been in the situation we were in … my call was coming around so quickly …' (Radiographer, Female, Participant 10) '[W]earing masks all the time is exhausting.It is also stressful because some of us are reacting to these masks …' (Radiology nurse, Female, Participant 18)

TABLE 2 :
Master table of superordinate and subordinate themes.
COVID-19, coronavirus disease 2019; CT, computed tomography; IPC, infection prevention and control; HPCSA, health professions council of South Africa; PPE, personal protective equipment; BSU, bedside unit; PUI, Person under Investigation.'[I]t has been very stressful because of the lack of PPE specifically … they were telling us that it is the people who physically deal with the patients … but we do come in direct contact [with patients] …' (Radiographer, Female, Participant 3) '[T]hey are saying we do not need most of these things -gloves, gowns, aprons.' (Radiology nurse, Female, Participant 18) 'When I showed symptoms and took COVID-19 leave, I was not at work for a good two weeks, and there was no one carrying on the work in the department, because I am the only one … the department was closed so, unfortunately, the x-ray patients had to go to x-ray departments in other hospitals …' (Radiographer,