1 Introduction

Magnetic resonance imaging (MRI) scanner has the advantage of showing exquisite soft-tissue contrast with an excellent signal-to-noise ratio (SNR) for studying different anatomical areas in comparison to other tomographic imaging modalities. This is achieved by using a powerful static magnetic field combined with radiofrequency pulses and a time-varying magnetic field gradient (Stafford, 2020). However, MRI is not entirely safe; its features are accompanied by safety concerns and increased risks for untrained workers and patients present in the MRI environment (Stafford, 2020; Westbrook and Talbot, 2018). The MRI ranked eighth among the top ten health device hazards according to the annual report released in 2020 by the Emergency Care Research Institute (ECRI) (Brief, 2020).

Rapid switching gradients pose a theoretical risk of stimulating the peripheral nerves/muscle (PNS) and of inducing an electrical current in metallic implants and devices. Moreover, it may cause hearing loss due to a high acoustic noise especially in a rapid sequence that requires rapid switching gradients magnetic fields such as echo planner imaging (EPI) (Stafford, 2020; Westbrook and Talbot, 2018; Grainger, 2014; ACR manual on MR safety, 2020). Calculation of specific absorption rate (SAR) is an essential safety concern because the radiofrequency pulses are the main causes of tissue heating and burns in MRI (Stafford, 2020; Westbrook and Talbot, 2018; Grainger, 2014). In relation to these safety concerns, committees, and societies in MR safety, such as the American college of radiology (ACR), regularly provide updated recommendations and guidelines about different aspects in the field of MR safety (such as MRI personnel, screening, gowning, magnetic resonance safety officers (MRSO), who have the proper training for ensuring safety practices in MRI unit, etc.) to keep everyone in the MRI area safe (ACR manual on MR safety, 2020).

Owing to the possible hazards in the MRI environment, The Royal Australian and New Zealand College of Radiologists (RANZCR) specifically recommends that MR technologist who work out of hours should not be alone (RANZCR, 2017). The ACR strongly recommends that whenever the patients are in the MRI unit, a minimum of two MR technologists or one MR technologist (Level-2 MR personnel) in the presence of another person who has undergone training in MRI safety at least to a level that ensures his safety and the safety of others from dangers while in the MRI environment (level-1 MR personnel), they should be available in the MRI Zone II (patient preparation area) through Zone IV (MRI scanner room) at all times due to the high possibility of risk; the communication between the two MRI personnel must be direct and within earshot of each other at all times (ACR manual on MR safety, 2020). Therefore, working alone and away from sight, not being within earshot of the other person and without close or direct supervision in the MRI environment is associated with the increased likelihood of risks. These risks could affect the safety of workers and patients because it makes getting help during emergencies more difficult (Dewland et al., 2013; CCOHS, 2020). Some issues related to MR technologists working alone include but are not limited to: MR Technologists tiredness, missing some questions, forgetting patient weight registration leads to wrong calculation of gadolinium-based contrast agents (GBCAs) or (SAR) calculation, difficulty dealing with patient anxiety and aggressive behaviors, a missing object that increases the projectile risk, dealing with quenching, electrical hazard and any other emergency situations (Brief, 2020; Pyke, 2007; Liu et al., 2019).

This study focuses on the current situation of MR technologists working in southern regions of Saudi Arabia to assess the frequency of lone working and any related hazards through analyzing the data collected from the self-report questionnaire.

2 Materials and methods

A cross-sectional study uses an online questionnaire distributed to 92 MR technologists from February to March 2021. This study included all MR technologists of both genders with different qualifications levels, MR technologists working on different MRI field strengths and designs (open and close bore MRI), from public and private hospitals in Southern regions of Saudi Arabi, The study excludes MR technologists with experience of fewer than 6 months and hospitals that don’t have an MRI machine. The study covered 17 public and 6 private hospitals in Southern Saudi Arabia regions (Albaha, Asir, Jazan and Najran regions).

The questionnaire items were derived from previous studies and literature review (Dewland et al., 2013; Liu et al., 2019; Alsaleem et al., 2018), it consisted of 20 questions divided into six sections that vary between Yes/No, multiple-choice and 5-points Likert scale questions. It included items about participants demographic information, experience with lone working, department facilities, awareness about lone working regulations according to ACR, training in MRI safety, the efficiency of the MRI unit for lone MR technologists, the effect of this type of work on self-confidence, preference of working with other MR technologists, and experience with safety accidents/mistakes events. Exclusion criteria were the following: MR technologists with less than six months of experience, incomplete questionnaire, and participants that do not agree to participate in the study.

The questionnaire was piloted on a small sample outside the study population to measure validity and reliability before the main distribution takes place. The questionnaire had a Cronbach's alpha of 0.803, thereby indicating an adequate level of inter-item reliability.

The numbers of MR technologists in each hospital were collected through phone calling the head unit in each hospital to quantify the research community in order to measure the response rate later.

The data were analyzed by using SPSS software Version 25.0 through descriptive (e.g. mean, standard deviation, frequencies) and inferential statistics ways (Fisher's exact test, Spearman's correlation, Kruskal Wallis and Mann-Whitney). A p-value ≤ 0.05 was considered statistically significant. Microsoft Excel 2010 was used in data visualization (graphs and figures).

Ethical approval was acquired from the regional committee for research ethics on Feb 4, 2021. It is numbered 2-2-2021, with registration number H-06-B-091 from the directorate of health affairs in the Asir region.

3 Results

A total of 79 MR technologists in the Southern regions out of 92 invited to participate in this study responded to this questionnaire; after applying exclusion criteria, only 73 MR technologists (71% male; 29% female) were involved in the study. Thus, the response rate was 79%.

Table 1 shows the descriptive analysis for participants’ demographic data and departments’ information. In terms of MRI experience, a majority of participants have an experience of 4 to 10 years (54.8%) in MRI; 84.9% work in the public hospital. The majority of the hospitals (61.6%) employ less than 5 MR technologists in the MR unit (with the minimum of two). On average, the MR technologists are handling between 10 and 16 patients daily. Most of the participants stated that the MRSO is unavailable in their departments (68.5%), but the policies for reporting safety incidents that occur in the MRI unit are available (83.6%). Regarding the safety training, 89% of MR technologists received training regarding first aids, while only 57.5% received training in MRI safety.

A question that measures the awareness about the ACR recommendations for the lone MRI workers shows that 50.7% do not know about this regulation. In addition, 20.5% are wrongly informed where they agree with the idea that working alone in the MRI unit is optional or depends on the person's desire to work alone. In comparison, only 28.8% are aware of the regulations that prevent the MRI technologist from working alone in the MRI unit.

Table 2 shows the degree of participants' awareness in relation to gender, qualification and experience. The level of awareness is statistically significant with qualification and the years of experience in MRI (p-value 0.000;0.024, respectively).

By applying the Mann-Whitney test to find the significant difference between each group, the awareness between diploma and master; and between bachelor and master are significant (p-value 0.001; 0.000, respectively). Furthermore, there is a significant difference in the level of awareness between those who have experience in MRI for 4–10 years vs. > 10 years (p-value 0.003); and those with 1–3 years vs. > 10 years (p-value 0.011). There is no significant difference between genders in level of MRI safety awareness. To sum up, Fig. 1, shows how MR technologists with higher education levels and years of experience tend to have a good awareness about the regulation governing the lone working, as it is associated with higher mean rank.

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Fig. 1

The awareness about the safety regulations for participants according to qualification level and years of experience using the mean rank values from the Kruskal Wallis test represented in the graph. MR technologists with higher education and experience years in MRI (master's degree and experience more than 10 years) tend to have a higher awareness about the safety regulation of lone working as they have higher mean ranks.

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The MR technologists in southern Saudi Arabia have an extensive experience with lone working (83.6%, 61/73). They displayed a positive reaction toward the efficiency of arrangements in their departments for getting an immediate assessment in case of emergencies and reporting any accident (mean 3 ± 0.9; 3.07 ± 0.8; respectively). On the other hand, working as an MR technologist in the presence of another medical staff (such as nurses) is also common between the participants (78%, 57/73).

The study uses 4-points Likert questions scaled from rarely to always to measure the rate of daily working for both types of MRI workers, the study found that (57.4%) of lone MR technologist and (57.9%) of MR technologist working with the presence of another medical staff is happening frequently for ''sometimes“ daily (Fig. 2).

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Fig. 2

The rates of daily working as alone or with the presence of another medical staff is happening daily for sometimes.

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The rate of lone working is statistically significant between workplaces (private and public) (p-value 0.044); the MR technologists in private hospitals tend to experience a higher daily rate of lone working where they have a higher mean rank than those working in the public hospital (mean rank 40.25; 29.19, respectively) (Table 3).

To measure MR technologists self-confident (ability to work in a proper, right and effective way) in both types of works, the study uses 5-points Likert questions scaled from “not confident at all” to “completely confident”, the result shows that the level of self-confidence among MR technologists is high either working alone (87.8%, n = 61/73) or working in the presence of another medical staff (such as nurses) (77%, n = 57/73); and 79% out of 73 participants preferred to work with another MR technologist (mean score 4.04 ± 1).

Regardless of the higher self-confidence, lone MR technologists express a greater amount of concerns and accidents/mistakes about different safety aspects (65.57%; 64.3%, respectively), (mean score 2.25 ± 0.9; 1.95 ± 0.6, respectively). However, comparing with the situation of working as an MR technologist in the presence of another medical staff; the concerns and accidents/mistakes are lower (59.65%;54.8%, respectively), with mean score (2.1 ± 0.9;1.8 ± 0.7, respectively) (Fig. 3).

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Fig. 3

Comparison between the level of concerns and accidents/mistakes experienced by MR technologists while working alone (A) and with another medical staff (B). Lone MR technologists have more concerns and accidents/mistakes than situation of working with other medical staff.

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More details are shown in Table 4. The rate of working alone is statistically significant added with concerns such as patient safety, presence of a person in MRI unit, any accident affecting the safety, and fear of being subjected to patient's and relative's aggressive behavior (p-value < 0.05). At the same time, there is no statistical significance about dealing with patients’ fears and fears from feeling isolated (p-value > 0.05). Additionally, there is no statistically significant difference between the rate of work as an MR technologist in the presence of another medical staff and concerns (p-value > 0.05).

Spearman's statistical result shows that there is a significant positive correlation between the rate of lone working and concern from patient's aggressive behavior (rho = 0.323; p-value 0.011).

Even though the lone MR technologists experience higher accidents/mistakes than the situation of working in the presence of another medical staff, the results show a statistical significance in both working situations with forgetting registration of patient weight, forgetting some questions in the safety questionnaire and feeling tired. This may affect safety (p-value < 0.05). Whereas, the experience with projectile danger is only statistically significant while working in the presence of another medical staff (such as nurses) (p-value 0.001) (Table 4).

4 Discussion

Magnetic resonance imaging (MRI) machines vary in design and in their range of magnetic field strengths to achieve higher performance with excellent SNR (Westbrook and Talbot, 2018). However, MRI is not entirely safe and if untrained workers or lone MR technologists are not provided with support and assistants in the MRI environment, it may lead to an increase in risks and affect the safety of workers and patients (Stafford, 2020; Westbrook and Talbot, 2018; Dewland et al., 2013).

To keep the MRI environment safe in light of these risks, the presence of MRSO is a good step that should be promoted in every department where the MRI technologist can be an MRSO and responsible for monitoring safety practices at all times. It is good to appoint an MRSO in duty (ACR manual on MR safety, 2020). The study results showed that most of the participants stated that MRSO was unavailable in their departments and that they received less training in MRI safety compared to first aid. This is possibly due to the Ministry of Health in Saudi Arabia requires health workers to obtain first-aid training and renew it every two years. At the same time, MRI safety training is not mandatory.

It is essential to have policies regarding safety in the MRI environment to document and report any risks in the unit, evaluate them, and prevent later occurrences. The policies for reporting safety incidents in the MRI unit were available in most facilities in our study. The participants stated the efficiency of the arrangements for providing reports about safety accidents and getting an immediate assessment in case of emergencies for lone MRI technologists. Still, the optimum presence of policies in the MRI departments was not always associated with good safety practices. This was obvious in a previous study, where most participants employed optimal policies regarding pre-MRI screening and the appropriate use of zoning systems. However, there were a relative lack of MRI-safe equipment and metal detection systems. So, it is most important to make sure practical implementation accompanies the existence of policies (Stogiannos and Westbrook, 2020).

In confirmation of the above, and despite what participants were shown in terms of availability of policies and efficiency of regulations, this work revealed that more than two-thirds of the participants had insufficient awareness about ACR regulations related to working alone in the MRI unit. At the same time, a lower qualification level and a lesser number of years of experience in the MRI unit were significantly related to lower awareness. That was understandable since we know that a diploma provides a basic theoretical background with little to no hands-on practical experience for radiographers, resulting in inadequate awareness and skills on MRI safety issues. These results were contrary to a study that were opposite to a study that concluded that there is no relationship between MRI safety awareness, performance, and experience (Hossen et al., 2020). A previous Saudi study that included a convenience sample of nurses from government hospitals and multiple primary health centers proved that adherence to safe practices was strongly associated with their level of awareness (Alghamdi et al., 2021). Although awareness was limited among our study participants, they felt “high” to “complete” confidence while working alone or with other medical staff. In contrast, our result was different from a previous study that indicated that departments, such as diagnostics and laboratories, have the lowest perception of demographic confidence compared to other departments (Owens and Keller, 2018).

The defect in safety practices was not limited to a lack of awareness about the recommendations for lone workers, but it was also reflected in their work. Approximately more than four-fifth of the MR technologists in Southern Saudi Arabia had experience working alone in the MRI unit, as the results showed, contrary to the ACR and RANZCR recommendations. The daily rate of working as a lone MRI technologist was statistically significant between workplaces, with a higher rate in the private sector than in the public sector, which might be attributed to financial reasons, as indicated by a previous study (Dewland et al., 2013).

Many safety aspects are affected by working alone compared to working with other medical staff. As the results indicated, it was clear that the concerns of lone workers were higher than situation of working in the presence of another staff member. This observation was similar to a previous study that reported a decrease in concerns among MR technologists when working in the presence of other healthcare professionals (Dewland et al., 2013). The concerns about patient safety, accidents affecting safety, and fears of being subjected to aggressive behavior from the patients and their relatives were statistically significant while working alone, but not in the presence of another medical staff. Regarding technologists' concerns about aggressive patient behaviors, a previous study in Abha city, which is one of the cities covered in our study, reported a high rate of workplace violence that comes mainly from patients' relatives, with more than half of healthcare workers reporting encounters of violence at the workplace (Tohidnia et al., 2019; Alsaleem et al., 2018).

On the other hand, lone workers did not just experience more concerns, but their encounters with accidents/mistakes while working alone in an MRI environment were also higher in general than situation of working with another medical staff member, as shown by our results. The safety accidents/mistakes, such as forgetting some questionnaire questions or the registration of the patients' weight and tiredness that may affect the safety, were statistically significant for both lone workers and technologists working in the presence of other medical staff. In contrast, the danger of projectile objects was only significant when technologists worked in the presence of other medical staff (such as nurses) in the MRI unit. Previous studies observed that higher tiredness could adversely impact mental health and increase anxiety (Dewland et al., 2013; Sun et al., 2012). In addition, forgetting patients’ weight registration may affect patients' safety because it is required to keep the SAR levels within the normal range to avoid chances of overheating and burning and to calculate contrast media dosage (Stafford, 2020; Liu et al., 2019). The hazard related to projectile objects could be attributed to the limited awareness of medical staff about safety regulations in an MRI environment (Alghamdi et al., 2021).

The situation of MR technologists working alone is accompanied by an increase in concerns and accidents/mistakes. Additionally, it seems that MR technologists did not prefer to work alone, and they are usually looking for regulations to avoid lone working due to uncomfortable work experiences and fear of increased risks (CCOHS, 2020).

The main limitation of this study is data collection, which relies on a self-administered questionnaire, not on the collection of events/accidents. This is due to some restrictions of the hospitals or institutions' regulations and policies that need more agreements to collect these kind of data.

5 Conclusions

MRI is a useful and safe diagnostic modality with no ionizing radiation hazards and it is providing high image quality for different body areas. Screening patient prior study, availability of multiple MR technologists per scanner also regular training of MR technologists and medical staff on MR safety is essential to keep higher performance and avoid any possible risks. MR technologists from Southern Saudi Arabia had high experience with lone working without presence of anybody with them. Most of the MR technologists have insufficient awareness about lone working regulations and encountered an increase in concerns and accidents/mistakes, affecting the safety of patients and medical staff. There is a need for training in MRI safety and adequate practical experience to raise the awareness of departments and MR technologists about MRI safety regulations related to lone working.

6 Declaration of Helsinki

The research was completed in accordance with the Helsinki Declaration.

7 Disclosure of funding

Authors extend their appreciation to the College of Applied Medical Sciences Research Center and Deanship of Scientific Research at King Saud University for funding this project.

8 Disclosure of any conflict of interest

None.