1 Behind the Images: A Study of the Relationship between Feedback and Impostor Syndrome Among Radiographers By Brittany Garcia Devin Horne A thesis submitted to the School of Radiologic Sciences in collaboration with a research agenda team In partial fulfillment of the requirements for the degree of MASTER OF SCIENCE IN RADIOLOGIC SCIENCES (MSRS) WEBER STATE UNIVERSITY Ogden, Utah December 13, 2024 2 THE WEBER STATE UNIVERSITY GRADUATE SCHOOL SUPERVISORY COMMITTEE APPROVAL of a thesis submitted by Brittany Garcia Devin Horne This thesis has been read by each member of the following supervisory committee and by majority vote found to be satisfactory. ______________________________ Dr. Tanya Nolan, EdD Chair, School of Radiologic Sciences ______________________________ Dr. Robert Walker, PhD Director of MSRS ______________________________ Dr. Laurie Coburn, EdD Director of MSRS RA 3 THE WEBER STATE UNIVERSITY GRADUATE SCHOOL RESEARCH AGENDA STUDENT APPROVAL of a thesis submitted by Brittany Garcia Devin Horne This thesis has been read by each member of the student research agenda committee and by majority vote found to be satisfactory. Date 12/12/2024 ______________________ ____________________________________ Brittany Garcia Date 12/12/2024 ______________________ ____________________________________ Devin Horne 4 Abstract This study explored the prevalence and impact of impostor syndrome among novice radiographers in diagnostic radiology, a field marked by high expectations and continuous feedback. Impostor syndrome, characterized by feelings of self-doubt and the belief that one’s success is due to luck or external factors, can have significant implications on professional development and well-being. The purpose of the study was to investigate the relationship between impostor syndrome and the nature of feedback provided to novice radiographers, with the goal of identifying strategies to foster professional confidence and mitigate selfdoubt. A qualitative approach was employed, utilizing structured interviews of novice radiographers from diverse clinical settings. . Thematic analysis was used to identify patterns and themes documented in the researchers’ code book related to impostor syndrome and feedback characteristics. Findings indicated a significant prevalence of impostor syndrome among participants, and feedback was a critical external factor influencing these feelings. Specific, timely and encouraging constructive feedback helped reduce self-doubt and reinforced participants’ confidence. Vague or overly critical feedback exacerbated impostor syndrome while constructive feedback reduced self-doubt and reinforced participants’ confidence. Researchers recommend structured feedback frameworks that emphasize balance and specificity, and appropriate delivery among supervisors, coaches, and peer relationships. Addressing impostor syndrome and refining feedback practices within radiology departments can foster a more confident and resilient workforce, ultimately improving professional wellbeing and patient care outcomes. 5 Acknowledgements I would like to express my heartfelt gratitude to my family for their unwavering love, encouragement and patience throughout the process of writing this thesis. Your belief in me has been my greatest source of strength and inspiration. I am deeply appreciative of Dr. Tanya Nolan for her invaluable guidance, expertise, and thoughtful feedback, which have profoundly shaped this work. A special thank you to Devin Horne and Mindy Edwards for your insightful contributions, encouragement and collaboration, all of which have been instrumental in bringing this thesis to fruition. This accomplishment would not have been possible without each of you. Brittany Garcia A special thanks to all those who have participated in the research of this study and their willingness to anonymously contribute their thoughts on this discussion topic. We are greatly appreciative of the professionalism, contributions and editing work by the faculty of Weber State University. Devin Horne 6 Table of Contents Chapter 1: Introduction ....................................................................................................... 7 Background ......................................................................................................................... 7 Statement of the Problem .................................................................................................... 9 Purpose of the Study.......................................................................................................... 10 Research Questions ........................................................................................................... 10 Nature of the Study............................................................................................................ 11 Significance of the Study .................................................................................................. 11 Definition of Key Terms ................................................................................................... 12 Summary ........................................................................................................................... 13 Chapter 2: Literature Review ............................................................................................ 14 Documentation .................................................................................................................. 15 Theme/Subtopic [repeat as needed] .................................................................................. 15 Summary ........................................................................................................................... 24 Chapter 3: Research Method ............................................................................................. 25 Research Methods and Design(s) ...................................................................................... 25 Population .......................................................................................................................... 26 Sample ............................................................................................................................... 27 Materials/Instruments ........................................................................................................ 27 Data Collection, Processing, and Analysis ........................................................................ 29 Assumptions ...................................................................................................................... 29 Limitations......................................................................................................................... 29 Ethical Assurances ............................................................................................................ 30 Summary ........................................................................................................................... 31 Chapter 4: Findings ........................................................................................................... 32 Results ............................................................................................................................... 32 Evaluation of Findings ...................................................................................................... 44 Summary ........................................................................................................................... 46 Chapter 5: Implications, Recommendations, and Conclusions ......................................... 47 Implications ....................................................................................................................... 47 Recommendations ............................................................................................................. 49 Conclusions ....................................................................................................................... 49 References ......................................................................................................................... 51 Appendices ........................................................................................................................ 52 Appendix A: Structured Interview Questions .................................................................. 52 Appendix B: Informed Consent Form ............................................................................... 54 Appendix C: Institutional Review Board (IRB) Approval Letter ..................................... 56 7 Chapter 1: Introduction Among most, if not all professions, impostor syndrome can be found. (Clance, Imes 1978) Impostor syndrome refers to internalized feelings of ineptitude despite personal and professional achievement. There is an abundance of evidence to support its presence among healthcare professionals. Research shows that impostor syndrome exists within the profession of radiology, and negatively impacts professional growth and well-being. A building block for growth and satisfaction within the workplace is feedback. Within the profession of radiology feedback plays an important role in many different ways. Feedback provides imaging professionals with opportunities to strengthen skill sets, and experience job satisfaction, as well as reduce risk of harm to patients. Despite how critical feedback is for professional growth and well-being, the feedback itself and how it is provided may produce or contribute to the impostor syndrome experienced by imaging professionals. Understanding the relationship between feedback characteristics and impostor syndrome could be an effective means for organizations and mentors to ensure a positive balance of professional acumen and individual well-being. Background It has been nearly fifty years since Clance and Imes began researching what we now know as impostor phenomenon. According to Clance and Imes (1978) impostor phenomenon refers to feelings of insecurity and ineptitude because of personal inability to internalize personal achievements and abilities. Now this phenomenon is coined as “impostor syndrome” and found among professions deemed as high-achieving. High achieving professions are commonly those that involve a greater level of pressure to produce or perform. Some professional examples include: engineering, law, technology, healthcare and academia. 8 Siqqiqui et al., found that 70% of professionals referred to as “high-achievers” identified with the symptoms of impostor syndrome including self-doubt, intellectual fraudulence, fear, and failure. Additionally, a survey performed by Haney, et. al, revealed that on average 59% of clinical nurse specialty students identified as having impostor syndrome. Thus, it is unsurprising that imaging professionals are not immune to this syndrome. In a study completed during a radiology conference, Deshmukh, et. al (2022), found that 83% of imaging professionals experienced feelings of impostor syndrome during the life of their career. Similarly, a survey done by Gibson and Lockwood (2023) among radiography students showed 77% of trainees experienced impostor syndrome during their education. Deshmukh et. al (2022) also found that healthcare workers acknowledged adverse connections between impostor syndrome and wellness. A meta-analysis of data among health professionals and students done by Ikidar, et. al (2023), noted continued dysphoric stress, anxiety, depression, and professional burn-out were persistent antagonizers, and Henning, et. al (1998) predicted elevated rates of expected suicide. Feedback plays an integral role in the health of any organization. The information it provides can help define an employee’s role and establish the type of performance that is expected within the organization. Feedback is needed for professional skill development and career advancement. Within the field of radiology, feedback is a key element in patient care, job satisfaction and employee safety. While feedback is a necessity, it can have both a positive and negative impact on the well-being of imaging professionals. According to a study by Choi, et. al (2018) the way in which we receive feedback directly influences our job performance, satisfaction and can be a predictor of future work behavior. A review of the study of varied feedback methods by 9 Tagliabue, et. al (2020) states, “ feedback delivery represents one of the most extensively used and researched practices.” Feedback can be classified as positive or negative and delivered in a constructive or destructive manner. Positive feedback refers to remarks that highlight good or wanted behaviors as a means of reinforcing that desired behavior, while negative feedback focuses on eliminating a specific behavior through criticism. Constructive feedback is based on commentary that is intended to promote positive change by recognizing areas of improvement and can encourage growth. Opposite of constructive feedback lies destructive feedback. Destructive feedback is commentary that focuses on incorrect action with the intent to tear the receiver down. Tagliabue, M., Sigurjonsdottir, S., & Sandaker, I. (2020). The effects of performance feedback on organizational citizenship behaviour: A systematic review and metaanalysis. European Journal of Work and Organizational Psychology, 29(1), 1–21. Statement of the Problem Diagnostic radiology plays a crucial role in clinical decision-making, yet within this demanding field, there exists a pervasive and underexplored phenomenon known as impostor syndrome. This syndrome is exhibited as persistent feelings of self-doubt and deficiency, despite evident competence and professional achievement. This phenomenon manifests among imaging professionals at indeterminate stages of their career, impacting diagnostic accuracy, professional satisfaction, and overall professional well-being. Arleo et al. 2021). Despite evidence and research suggesting its prevalence, the extent and implications of impostor syndrome specifically within the radiology community remain inadequately understood and under-represented. In the article “Tackling impostor syndrome: A multidisciplinary approach”, Arleo et. al. June 2021, expresses the importance of how impostor syndrome can negatively impact 10 how imaging professionals perceive their own value in their careers. This self-doubt can undermine the quality of care they deliver and harm the professional workforce. Therefore, it is important to recognize and address this issue to prevent such detrimental effects. Professionals experiencing impostor syndrome symptoms, with significant correlations to burnout and decreased job satisfaction very likely affect workforce environments and morale, imaging quality, and potentially patient outcomes. Additionally, in a qualitative analysis Deshmukh et. al. explored the lived experiences of radiologists and highlighted themes of self-doubt and fear of incompetence, suggestive of impostor syndrome’s profound influence on professional identity and performance. The analysis revealed that 83% of subjects studied reported feelings of impostor syndrome with a high correlation to burnout and decreased job satisfaction. Purpose of the Study The purpose of this qualitative study is to explore the experiences and perceptions of imaging professionals regarding impostor syndrome in diagnostic imaging, with a goal of understanding its prevalence, manifestations, and impact in relation to constructive feedback. Structured interviews were used to express emotion, depth, and genuine experience. Adult radiographers were invited to a structured research interview. Those who qualified to participate had been with the profession for 5 years or less as a licensed Radiographer through the American Registry of Radiologic Technologists (ARRT). All interviews were recorded and closed captioned via ZOOM. Resulting transcripts were reviewed and coded to identify feedback variables that may be affecting perceived levels of impostor syndrome. Coded outcomes and examples of narratives were provided as data for qualitative analysis. Research Questions Impostor syndrome appears in various professions; and the imaging field is no exception. Characterized by feelings of inadequacy and personal self-doubt, impostor 11 syndrome can hugely impact the well-being and performance of imaging medical professionals. The phenomenon can manifest in healthcare professionals at any stage of their careers, from the student stage to a seasoned imaging technologist or radiologist. The basis of this research is the query of whether feedback within an imaging department from peers, supervisors, and radiologists contribute to feelings of inadequacy, well-being, and self-doubt. Understanding the nuances of impostor syndrome within the imaging field and the impact of employee or student feedback are crucial in fostering environments of support and resilience among imaging healthcare professionals. The following research questions have guided the study’s design. Q1. What is the prevalence of impostor syndrome among novice radiographers? H10. There is no impostor syndrome among novice radiographers. H1a. There is a high level of impostor syndrome among novice radiographers. Q2. What correlations are found between feedback provided to novice radiographers and their perceived level of impostor syndrome? H10. There is no relationship between feedback and impostor syndrome. H1a. There is a negative relationship between constructive feedback and impostor syndrome. Nature and Significance of the Study The proposed quantitative survey design will demonstrate the impact of employee feedback on individual radiographers’ impostor syndrome. Feedback given to staff of imaging departments are no different than any other feedback given within business or organizational departments. (Moscu,Marina,et al 2023 p575) Appropriate feedback fosters professional development and boosts morale of the individual and department as a whole. Constructive feedback; both negative and positive will help professionals develop and enhance their job 12 performance and satisfaction. Addressing feelings of self-doubt and tackling impostor syndrome within an imaging department will enhance employee engagement and help imaging professionals reach their professional potential. (Arleo, Wagner-Schulman M,et al 2021 p170) Our research design will include a structured survey questionnaire relevant to our research goals. The questions will include demographic information and contextual statements to measure both impostor syndrome and its correlation to feedback. The questions were piloted for clarity and designed for imaging professionals new to the field. The sample size is sufficient to address our research questions in a qualitative manner. Structured interviews are designed to be completed within 45 minutes. Because of our method, our study will be limited in generalizability. Definition of Key Terms Impostor Phenomenon is a term used to designate an internal experience of intellectual phoniness. (Clance, P. R. and Imes, S. (1978). This psychological pattern exhibits doubt in an individual's accomplishments and talents and produces an internalized fear of being exposed as a fraud. Even with proven competence, a professional may attribute their achievements to luck or timing which in turn deceives their peers and leaders. This phenomenon is common among high achievers but can affect anyone, regardless of their education background or professional status. The impostor phenomenon in high achieving women: dynamics and therapeutic intervention. Psychotherapy: Theory, Research &Amp; Practice, 15(3), 241-247. https://doi.org/10.1037/h0086006). Feedback the transmission of evaluative or corrective information about an action, event, or process to the original or controlling source (Feedback. Retrieved April 20, 2024, from https://www.merriam-webster.com/dictionary/feedback). Constructive feedback is deemed by the learner as motivational, engaging, and relevant to their success and is evaluated by the 13 learner based on the delivered information and the characteristics of both the feedback giver and recipient (Fong, Schallert, Lin, & Altan, 2024) Summary The purpose of this qualitative study is to provide an investigative understanding of impostor syndrome among radiographers as indicated by the following research questions: 1. What is the prevalence and severity of impostor syndrome among radiographers/imaging professionals? 2. What are the correlations found between feedback provided to medical imaging professionals and their perceived level of impostor syndrome? The study will utilize a qualitative method and employ structured interviews of novice radiographers to discern common themes and variables that assist in understanding the prevalence of impostor syndrome among imaging professionals and its correlation with feedback. 14 Chapter 2: Literature Review Most professionals experience feelings of imposter syndrome as measured by varying levels of perceived competence and confidence. Professional growth and well-being require both an individual’s recognition of and determination for confidence and competence. These characteristics may only be gained through learning experiences led through feedback, coaching, and mentoring opportunities. Effectively, feedback is deemed both motivational and promotional which appears as treatment to imposter syndrome (Fong, Schallert, Lin, & Altan, 2024). Hence, recognizing the effects of feedback on imposter syndrome is critical to professional well-being and growth. The purpose of this literature review is to provide an understanding of the existing knowledge on imposter syndrome and feedback and identify gaps that the current research aims to address. Through this review, we seek to achieve several key objectives. First, we will explore the prevalence and characteristics of impostor syndrome within healthcare, specifically focusing on radiographers. We will highlight how impostor syndrome manifests in radiographers and the factors that contribute to its development, such as professional expectations, high-stakes environments and workplace dynamics. Last, we will investigate the role of feedback in professional development, particularly in the context of radiographers. We will examine how feedback, both positive and constructive, impacts professionals’ perceptions of their skills and competence. This will include an analysis of how feedback might mitigate or exacerbate feelings of impostorism. By synthesizing these two themes; impostor syndrome and the effects of feedback, we will establish a foundation of understanding and highlight any existing research gaps or established mechanisms by which feedback influences impostor syndrome. Ultimately, the 15 review will guide the research study in informing a hypothesis, framing research questions, and positioning the study within the broader context of scholarly discourse on impostor syndrome in radiographers. Documentation Our literature search strategy included peer reviewed content from articles and journals derived from the EBSCO library search engine. Abstracts and references were organized by use of a literature review matrix. Content related to both impostor syndrome and feedback were searched using strict filters; including only articles and journals written within the past 10 years tailored for the healthcare industry. A total of 25 journal articles were reviewed, 15 of which met the inclusion criteria. Ten articles were excluded because they either lacked the relevance to the imaging field or did not include reliable and credible research methods. The following key words were utilized in combination as Boolean phrases for our search: Education, Impostor Phenomenon, Imposter Syndrome, Radiography, Feedback, Burnout, and Healthcare Education Impostor Syndrome Impostor Syndrome, also known as the imposter phenomenon, was first identified in the 1970s by psychologists Pauline Clance and Suzanne Imes, is characterized by persistent feelings of self-doubt and fear of being exposed as a fraud, despite evident success. This phenomenon has since gained significant attention, particularly in high-achieving fields like radiology, where professionals often operate under intense scrutiny and pressure. Within the context of radiographers, impostor syndrome manifests as a pervasive sense of inadequacy, where individuals doubt their competence, feel unworthy of their accomplishments, and live in fear of making mistakes. People who experience impostor syndrome often attribute their 16 achievements to luck or external factors rather than their own abilities. They often feel that they do not deserve their success and that they are deceiving others into believing they are more capable than they perceive themselves to be. This phenomenon can lead to significant stress, anxiety, and self-doubt, impacting personal and professional life. Culturally, the healthcare environment has been a breeding ground for imposter syndrome. as it places high demands on knowledge, precision, and emotional resilience. Health professionals such as radiographers are often held to an impossibly high standard, expected to manage complex cases and make life-altering decisions with little margin of error. The hierarchical structure of healthcare systems, combined with the expectation of perfection, can exacerbate feelings of impostor syndrome. Feelings related to imposter syndrome are not confined to professionals early in their career, but they can persist even in experienced practitioners. The prevalence of impostor syndrome in health professionals is a growing concern due to its potential to contribute to burnout, reduced job satisfaction, and even compromised patient care outcomes. Gibson, C. et al (2023) reported up to 83% of clinical radiology staff experienced impostor phenomenon at some point in their careers significantly linked to burnout and increased stress. Subani et al (2019) described radiology staff as having experienced notably higher levels of frequent or intense impostor syndrome traits when compared with other healthcare professionals. Students and residents, in the early stages of their careers, were particularly at risk (Gibson, C. et al 2023 p.62). Understanding the roots and impact of impostor syndrome within radiology is crucial for developing strategies to support the mental well-being and professional confidence of radiographers. 17 The impact of impostor syndrome not only affects an individual directly, but it also affects many others indirectly, including close relations, colleagues, and patients. Individuals performing under unrealistic perfectionism and fear of failure or making mistakes are overworked because they continually attempt to “prove” themselves and their ability to perform skills and responsibilities. This pressure potentially influences staff members to choose to steer clear of added responsibility or seek promotion. Additionally, patient outcomes are diminished due to a lack, delay, or inconsistency of care. Imaging professionals who second-guess themselves, their training, and their proficiency are prone to inactivity and errors. Their hesitation, derived from impostor syndrome, can lead to misdiagnosis, longer hospital stays, and increased patient costs. (Gibson, C. et al 2023 p.63) Being overly cautious, when caution is not warranted, reduces the quality of services offered to patients and the safety in which they are performed. Additionally, stress is imposed on imaging professionals due to rapidly developing healthcare entities, protocols, and policies. Imaging professions are constantly adapting to advanced technological equipment, software, and artificial intelligence. This rapid evolution often leaves professionals feeling as if they are behind and unqualified. Patients and organizations are now skilled at finding medical information, potentially inaccurate and unreliable, at the stroke of a button. Thus, matters of liability and finger-pointing are sorely tied to raised anxiety and atelophobia. Feedback Feedback is essential in professional development as it serves as a cornerstone for continuous improvement and growth. It provides individuals with valuable insights into their performance, highlighting both strengths to build upon and areas of weakness. Constructive 18 feedback highlights specific areas where skills can be enhanced, offering guidance on how to refine techniques, adopt new strategies, or acquire further knowledge. It helps professionals align their efforts with organizational goals, ensuring that their work is focused on the priorities that matter in their professional objectives (Zahra et al., 2021). Feedback also fosters a culture of continuous learning by encouraging professionals to think critically about their actions and consider new perspectives. It motivates individuals by acknowledging their accomplishments, boosting morale, and reinforcing positive behavior. Likewise, it can identify challenges and provide opportunities for problem-solving and innovation. Engaging in feedback conversations enhances communication skills, encourages open dialogue, and promotes mutual understanding. Ultimately, by acting on feedback, individuals can accelerate their career development, improve their confidence and make more meaningful contributions to their organization. In this way, feedback is an indispensable tool for professional growth and success. In radiology, feedback can come in both formal and informal ways, depending on the purpose and situation of the feedback. Informal feedback allows for continuous, in-themoment learning, while formal feedback is crucial for long-term development and accountability in the field. For example, feedback from a Radiologist towards a technologist in passing in which they may comment on how excellent the technologist’s positioning was on the last examination would constitute informal feedback. As expected, informal feedback within the imaging field may vary widely. However, it has powerful potential to cling either positively or negatively to the recipient. Quality Assurance programs, wherein radiologists or senior staff evaluate, audit, and discuss exams in comparison to defined standards with the performing technologist are good examples of formal feedback. Again, there are various written or verbal structured formal 19 evaluations or reviews of performance. Clinical education and training of imaging staff and students utilize feedback as a necessary means for learning. Burns, Chetlen, et al (2022) expressed that, “feedback is a critical part of the learning process and is a valuable tool to empower adult learners [because] modern feedback styles place the student at the center of the feedback scenarios.”(p. 113) Barriers to effective feedback may be overcome when attention is given to the feedback content and delivery with the learner center to its design. Importantly, both the giving and receiving of feedback are not innate abilities and skills must be developed and practiced. Constructive, direct, and specific feedback assists individuals suffering from impostor syndrome because this communication clearly guides the learner toward self-efficacy. Moscu (2023) found that positive reinforcement and targeted suggestions for improvement strengthened professionals’ belief in their abilities and reduced self-doubt. Feedback is a scaffolded framework that step-by-step helps the learner achieve feasible goals that build confidence necessary to support professional competence. As a result, validation serves as a critical component in the process of overcoming impostor syndrome because an individual is affirmed in their capability to meet the demands of the professional role and are recognized for their progress and accomplishment. This recognition helps professionals internalize their successes and helps them gradually shift from attributing their achievement from external factors, such as luck or impostorism, to recognizing their own skills and effort. Feedback and validation reduce feelings of inadequacy and promote job satisfaction. Feedback can become destructive and have negative effects if not delivered thoughtfully. Moscu (2023) found that poorly timed or overly critical feedback exacerbated feelings of inadequacy and self-doubt. For individuals with impostor syndrome, negative feedback reinforced their belief that they were not truly competent, and led them to focus 20 disproportionately on their perceived failures rather than their successes. Furthermore, when feedback was vague or lacked specific guidance for improvement, it left individuals feeling uncertain about their abilities and unsure of how they could meet expectations. This uncertainty amplified the self-doubt, associated with impostor syndrome, and made it harder for these individuals to feel confident in their skills and contributions. Therefore, feedback must be delivered with care to avoid unintentional reinforcement of negative thought patterns that characterize impostor syndrome. (Moscu, 2023). Most individuals experiencing impostor syndrome struggle with perceived discrepancies between the feedback they receive and their self-perception. Arleo et. al. (2023) found individuals with impostor syndrome found it difficult to reconcile positive feedback with their internal beliefs about who they were and what they could accomplish. Despite praise or recognition received for their work, these individuals felt the feedback was undeserved and attributed their success to luck or external factors. Positive feedback was easily dismissed as flattery or assumptions that the giver of feedback was unaware of their “true” capabilities. This persistent disbelief in personal competence resulted in an ongoing cycle of self-doubt that prevented them from internalizing their successes and impeded them from developing a strong sense of self-efficacy. As a result, even when persons are objectively successful, they may continue to feel like frauds, negatively impacting their overall job satisfaction and mental well-being. The relationship between feedback and impostor syndrome is significantly influenced by various moderating factors. Moderating factors alter how feedback is perceived and consequently, impacts feelings of impostorism. For example, a person’s self-esteem and experience play a crucial role in determining how feedback will be internalized. Zahra et al. (2021) found that Individuals with lower self-esteem and/or a history of academic struggles 21 were far more susceptible to interpreting feedback negatively, thereby exacerbating their feelings of being an impostor. Another critical moderating factor is the type of feedback given and received. Positive and constructive feedback are far more likely to reinforce a technologist's sense of competence and may potentially mitigate impostor feelings. Conversely, negative, evaluative, and/or overly critical feedback often reinforces existing insecurities and heightens symptoms of impostor syndrome, particularly among persons predisposed to the phenomena. As a result, the context and delivery of feedback significantly influences its impact on the recipient, wherein the message is either internalized or acted upon (Zahra et al., 2021). Finally, the overall culture and environment in which feedback is given moderates the relationship between feedback and imposter syndrome. Graduate students in highly competitive or high-pressure programs often experience intense impostor feelings, particularly if they perceive the feedback as part of an unforgiving academic culture. In contrast, a supportive and inclusive environment can help buffer against the negative effects of feedback, reducing the likelihood of impostor syndrome taking root. Understanding the moderating factors between feedback and imposter syndrome is essential for developing interventions to support professionals who struggle with impostorism (Zahra et al., 2021). Feedback Best Practices To be effective, feedback should be timely, specific, and focused on particular behaviors rather than vague generalities. This approach enables immediate reflection and targeted improvement essential to fast-paced healthcare environments. Feedback is best balanced. A combination of positive reinforcement with constructive criticism helps create a 22 safe learning atmosphere. Professionals need opportunities to celebrate their successes while simultaneously setting goals to address weaknesses. This approach promotes continuous professional development. Another key to effective reception is interactive feedback. Engaging in a two-way dialogue allows radiographers to reflect on their performance, ask questions, and set goals for future improvement. This collaborative approach fosters a deeper understanding of the feedback and strengthens the commitment to making necessary changes. Feedback needs to be actionable, clear, and practical. The steps to improvement should be organized and logical with several checkpoints. Encouraging self-assessment empowers health professionals to confidently identify their own areas for growth, proving a culture of self-awareness and lifelong learning within healthcare settings. (Burns et al. 2022). One effective intervention for imposter syndrome is the development of peer support groups. These groups provide a safe space for professionals to share their experiences and realize that they are not alone in their feelings of inadequacy. By normalizing these experiences, radiologic technologists can begin to reduce feelings of isolation and self-doubt. Mentorship programs are invaluable feedback relationships. Pairing less experienced professionals with seasoned mentors and peers offers individuals a life-line for guidance, encouragement, and validation. Mentors can help mentees navigate challenges, provide perspective on their achievements, and reinforce their competence. Fostering a culture of open communication within imaging departments helps mitigate impostor syndrome. Encouraging discussions about mental health and professional challenges, without fear of judgment, creates supportive environments wherein technologists feel valued 23 and understood. This cultural shift may significantly reduce the prevalence of impostor syndrome and promote well-being among radiologic technologists. Training Programs for Educators and Supervisors Educational workshops focused on impostor syndrome should be aimed to increase awareness of the condition, teach coping strategies, and promote resilience. By equipping professionals with the knowledge and tools to recognize and manage impostor syndrome, individuals are empowered to maintain their confidence and professional identity. For example, imaging professionals equipped with the skills to deliver constructive feedback discover confidence in their ability to create real and relevant change. Receivers of constructive feedback trust the message and allow themselves opportunities to grow and increase in their job performance, satisfaction, and competence. Indeed, both educators and supervisors must be adept at navigating difficult conversations, managing conflicts, and understanding the emotional and psychological needs of their trainees. Embracing a growth mindset, necessary for resilience, does not negate the presence of conflict. Rather, individuals with a growth mindset use conflict as an opportunity to develop new perspectives, attitudes, and behaviors that strengthen the team and patient care. Thus, all training programs begin by learning about and trusting one another. Each program should emphasize the importance of cultural competence. Radiology is increasingly diverse, and educators need to be prepared to address the unique needs of trainees from various cultural backgrounds. This includes understanding different communication styles, learning preferences, and addressing biases that might affect the learning process. Cultural competence training ensures that all trainees receive fair and equitable education and support. Diversity training also accounts for a variety of learning preferences among adult learners that 24 require varied teaching strategies, such as problem-based learning, simulation, and experiential learning. These strategies help to actively engage learners and facilitate the application of knowledge and real-world scenarios. Conclusively, training programs should provide ongoing professional development for educators and supervisors. Radiology is a rapidly evolving field, and professionals need to stay current with the latest practices, technologies, and educational methods. Continuous professional development ensures that educators can provide the highest quality training to their students, ultimately leading to better outcomes in patient care and professional satisfaction. Summary Impostor syndrome is characterized by persistent self-doubt about one’s ability. Imposter syndrome is prevalent in high-stress fields like radiology, where professionals face high expectations and operate in high-stakes environments (Gibson et al, 2023; Subani et al., 2019). Impostor syndrome can lead to stress, anxiety, burnout, reduced job satisfaction, and compromised patient care (Gibson et al. 2023). Feedback is essential for professionals to align their actions with organizational goals, improve professional skills, and boost personal confidence. Effective feedback reduces imposter syndrome when it is constructive, specific, and balanced (Burns, Chetlen Et al., 2022). Strategies to enhance organizational feedback are mediated through peer support groups, mentorships, and education focused on deliberate, interactive, diverse, and culturally competent means (Burns et al., 2022). Understanding the nuanced relationship between feedback and impostor syndrome can lead to more tailored and supportive feedback practices, reducing the negative impact of impostor syndrome on radiographers and patient care. 25 Chapter 3: Research Method The literature review demonstrates that impostor syndrome exists within the profession of radiology, and negatively impacts professional growth and well-being. Feedback provides imaging professionals with opportunities to strengthen skill sets, and experience job satisfaction, as well as reduce risk of harm to patients. Despite how critical feedback is for professional growth and well-being, the feedback itself and how it is provided may produce or contribute to the impostor syndrome experienced by imaging professionals. Understanding the relationship between feedback characteristics and impostor syndrome could be an effective means for organizations and mentors to ensure a positive balance of professional acumen and individual well-being. The purpose of this mixed method design is to determine the prevalence of imposter syndrome among novice radiographers and determine relationships between levels of imposter syndrome and feedback provided. Research Methods and Design(s) A qualitative research method was utilized to gain pertinent insights about the complex human experience defined by impostor syndrome. This method is flexible and allows for an open-ended approach that adapts as the study progresses. By designing structured interviews for the participants, interviewers collected non-numerical data and completed an analysis and synthesis of text-based data to define and code variables highlighted from the participants’ perspectives on the impostor phenomenon and feedback as a Radiographer. A structured interview can be a very successful qualitative research method. The structured interview provides consistent and reliable text driven data. With the same set of questions being asked to each participant, researchers ensure comparability of the responses and identify themes among them. Interviewers also control the direction of each interview engaging participants to cover all pertinent topics. Because no participant has a personal or working 26 relationship to the interviewer, researchers have reduced bias, enhancing honest responses pertinent for valid results and analysis. A matrix, or code book, of participant responses was compiled to include critical parts of the study’s design including verification of signed consent from each participant. Each structured interview was done 1:1 with each participant via zoom with recorded transcripts. This design allowed for flexibility for the interviewer and each participant involved. Data was collected in response to 14 questions and themes were triangulated among the research team. Population The population for this study consists of seven ARRT registered radiographers working within various healthcare institutions. Radiographers are medical imaging professionals responsible for operating x-ray diagnostic imaging equipment, to assist in diagnosing and treating patients. This group has been identified as particularly susceptible to experiencing impostor syndrome due to the high-pressure, fast-paced, and technically demanding nature of their work environment. This population encompasses professionals at an entry-level with less than 5 years of experience. According to the Bureau of Labor Statistics, as of 2023, there are 271, 200 radiologic technologists employed in the United States. This population is appropriate for the study because the characteristics of the professional environment (e.g., high expectations, rapid technological changes, and the need for precise accuracy) closely align with known triggers of impostor syndrome. Studying this group will help uncover insights into how impostor syndrome manifests and affects professional performance and well-being in high-stakes medical fields. Furthermore, the study will examine how feedback mechanisms can either exacerbate or alleviate impostor syndrome, making the findings directly relevant to the daily work experience of radiographers. 27 By focusing on this population, this study aims to explore how professional experiences, feedback and workplace dynamics contribute to the prevalence and management of impostor syndrome among radiographers. Understanding these dynamics within this group will provide valuable insights into potential interventions, training programs, and feedback strategies that can improve professional confidence and reduce the effects of impostor syndrome. Sampling This study will utilize a qualitative research approach with a purposive convenience sampling strategy to explore the experiences of impostor syndrome and the role of feedback among radiographers. Purposive sampling will be used to identify individuals who can provide detailed, insightful accounts of their experiences, focusing on those who have dealt with impostor syndrome and have varying levels of exposure to feedback mechanisms in professional settings. This method ensures that participants are selected based on their ability to contribute valuable, in-depth information that aligns with the study’s research objectives. The study will include a sample of seven radiographers. While relatively small, this sample size is appropriate for qualitative research, where the focus is on obtaining in-depth, detailed insights rather than achieving statistical generalizability. The chosen sample size allows for a thorough exploration of participants’ experiences with impostor syndrome and feedback, aiming to reach data saturation - a point in which recurring themes emerge, and no new significant information is uncovered. This ensures a comprehensive understanding of the phenomena being studied within the context of the radiography profession. Materials/Instruments This study employed structured interview questions inspired by the Clance Impostor Phenomenon Scale (CIPS). The CIPS is a well-established tool used to measure impostor 28 syndrome, and its key constructs were used to design the interview questions. A sample of questions include: • Have you ever felt like a fake or a phony in your job? • Do you feel your success is mostly due to luck? Why or why not? • Who provides you with the most feedback in a typical week working as a Radiographer? • Are you able to easily accept praise or compliments regarding your work? Why or Why not? • In your opinion, what changes could be made to help you feel motivated to improve your skills and support your feelings of competence? To explore how feedback influenced perceptions of competence and confidence among radiographers, a unique and customized questionnaire was developed by the researchers. Questions were both closed and open-ended to capture data on feedback frequency, types and quality, as well as qualitative insights into participants’ experiences. The development process involved reviewing existing literature on feedback mechanisms in healthcare and consulting with experts in radiology to ensure content validity. A standardized protocol for the semi-structured interviews was utilized, and each interview was recorded and transcribed over ZOOM.. The questions focused on the participants' experiences with impostor syndrome, how it affects their professional life, and the role of feedback in influencing these feelings. The semi-structured format allowed participants to elaborate on their experiences while ensuring that core topics were consistently covered. Interview questions were crafted to align with qualitative research principles, ensuring they were open-ended, clear, and non-leading. The protocol was reviewed and refined to ensure its appropriateness for gathering rich, detailed data. A complete list of interview questions is included in Appendix A: Structured Interview Questions. 29 Data Collection, Processing, and Analysis This qualitative method involved the use of a structured interview with a systematic and standardized approach involving recorded transcripts from the responses of participants. The data collected responses were structured and standardized to ensure consistency across the interviews. The sample of participants were selected based on our objectives and criteria, that participants must be working as a full licensed Radiographer for 5 years or less. Data processing was done at the conclusion of all interviews wherein participants answered all questions fully. All transcribed data was transferred into an organized spreadsheet, cleaned, and coded. Data was reviewed for missing, incomplete, or corrected responses. Introductions and closing remarks were excluded. The data collected from the interviews were coded based on structured themes and categorized by color and/or number. All codes were reviewed by at least three reviewers for appropriate triangulation. The data spreadsheet was analyzed pending the nature of the data and themes collected. Frequencies, means and percentages were calculated. A graph is used to provide a visual representation of our qualitative findings in demonstrating the key themes and conclusions discussed in Chapter 5. Assumptions It is expected that participants would be honest and open about their experiences and that they would answer all questions in their entirety without an agenda. It is also assumed that each interview was conducted similarly in a standardized format. Limitations Limitations of the study included the small sample size, which, while appropriate for qualitative research, may limit the generalizability of the findings. Additionally, potential biases in participant self-reporting were acknowledged, and measures were taken to reduce bias, such as using consistent interview protocols. 30 Ethical Assurances The study adheres to ethical standards for conducting research as appropriate for qualitative research design. Compliance with these standards is essential to ensure protection of participants’ rights, the integrity of the research process, and the validity of the findings. Prior to participating in the study, all participants received an informed consent explaining the purpose of the study, the nature of their participation, potential risks, and benefits, as well as their rights as participants. This form also outlined how their data would be used and required that all participation was entirely voluntary. Participants were given the opportunity to ask any clarifying questions, and each participant signed the informed consent. The informed consent is in Appendix B. Confidentiality is a top priority of this study. Participant names and any identifying information has been anonymized, and each participant has been assigned a unique code to ensure their data is not linked to their identity. Only the research team has access to the key that matches participant codes with their identities. All data, including interview recordings, transcripts, and questionnaire responses, are securely stored on a password-protected computer. Access to these data files will be restricted to authorized research personnel only. After the study is complete, data will be retained for two years and then deleted and/or destroyed. In reporting results, pseudonyms are used, and any potentially identifying information has been removed to preserve confidentiality. Measures have been taken to ensure that any quotes or excerpts from the interviews included in the final report do not inadvertently reveal participants' identities. Prior to any data collection, Institutional Review Board (IRB) approval has been obtained. The IRB application included details about the study’s purpose, methodology, informed consent procedures, and confidentiality measures, ensuring that the study meets all 31 ethical requirements for the protection of human subjects. A copy of the IRB approval letter is included in Appendix C: Institutional Review Board (IRB) Approval Letter. Summary The qualitative research design utilized structured interviews, and purposive sampling of ARRT certified novice radiographers to examine impostor syndrome and the role of feedback among radiographers. The careful design of interview questions, systematic data analysis, and ethical considerations ensured that the study was conducted with rigor and integrity. These methods allowed the researchers to gain deep insight into how professional experiences and workplace dynamics contributed to impostor syndrome, offering valuable guidance for future interventions and feedback strategies within the radiography profession. Data was collected from ZOOM transcripts, analyzed for themes and coded through deductive triangulation as a research team. Limitations of the study included the small sample size and potential bias. Ethical compliance was followed through strict adherence to IRB protocols, informed consent procedures, and appropriate confidentiality practices. 32 Chapter 4: Findings The purpose of this research study was to explore the prevalence of impostor syndrome among novice radiographers and examine the impact that feedback has on their professional experiences. Impostor syndrome, characterized by feelings of inadequacy and fear of being exposed as a fraud, can adversely affect professional growth and well-being. This study aimed to gain insights into how feedback mechanisms within the workplace contribute to or alleviate these feelings. By understanding the relationship between feedback characteristics and impostor syndrome, the study intends to inform organizational strategies that enhance professional development and individual well-being in radiology. Results Demographics gathered from participants included age, months of employment, employment setting, and part/full time work experience. The average age in years is 22.42 years, the average months of employment are 6, and most participants worked in a clinic part-time (See Table 1) Table 1 Demographic Information Participants Age Yrs Months Employed Clinic (C) Lab (L) Hospital (H) PT/FT P1 22 6 C PT P2 22 6 L PT P3 24 6 C PT P4 23 17 C PT P5 22 3 H FT P6 22 1 C PT P7 22 3 C PT 33 The first 7 questions of the structured interview were designed to explore and answer the first research question regarding the prevalence of imposter syndrome among novice radiographers. Coded responses to the structured interview questions can be reviewed in Figure 1. Themes explored include role responsibilities, confidence, growth mindset, teamwork, and competency. Figure 1 Structured Interview Coded Themes for Research Question 1 RQ1. What is the prevalence of imposter syndrome among novice radiographers? Structured Interview Q1. What is your current title and position and what are your responsibilities? Participant Response Coded Themes P1 So taking care of patients while taking Patient Care (1) • patients back to where they need to be. HIPAA/Protocols/Policies All, while. Patient Safety (1) • Communication (Questions) • Staying within HIPAA Images are provided to • And making sure patients are safe. physicians (2) • Their questions are answered. • And then always making sure, like their images, are going over to PACS • That gets the doctors P2 Education • Licensed in X-ray • Works as a Lab Aid in the X-ray program • Aids in teaching students P3 X-Ray Technologist (3) • X-ray Technologist Patient Care (1) • Provide Patient care Radiation protection, and aid in the Radiation Protection • diagnosis for the patient. • Problem solving P4 X-Ray Technologist (3) • X-Ray Technologist Take images, and providing patient care Patient Care (1) • Take Images (2) P5 full-tech x-ray technician/radiographer X-ray technologist • Patient care (1) • good patient care, take good quality images, quality diagnostics • • proper body mechanics, • cleaning the rooms after every patient, P6 X-Ray Technologist (3) • radiologic technologist patient safety (1) • Radiation safety patient care (1) • patient safety 34 radiation safety • patient education • quality patient care P7 X-Ray Technologist (3) • Certified Radiologic Technologist patient safety (1) • verify orders patient safety imaging protocol (2) • teamwork • imaging protocol team work • Structured Interview Q2: Which responsibilities do you do well, and which responsibilities do you struggle to accomplish? Participant Response P1 • I make really fast and easy connections with the patients. I love people so I can make conversation really easy. I think that I do a good job of keeping the patients comfortable. P2 • Does well connecting with students • Does well instructing & helping students understand P3 • Coded Themes Do well -Connecting and conversing with patient (Interpersonal Skills Patient Care (1) Peer connections.(Interpersonal Skills) Educates others well. Patient Care (1) Empathy Radiation protection Communication Provides excellent patient care, loves working with people. • Good at being empathetic • Good communication • Understanding patient dose P4 • Good with time management patient care (1) • Good with patient empathy and patient language barriers communication P5 patient care (1), OR/C-arm, • does well with the x-rays- OR/C-arm teamwork • patient care • works well with team P6 patient care (1) • Interacting with patients P7 Patient care (1) • patient care. Structured Interview Q2: Which responsibilities do you do well, and which responsibilities do you struggle to accomplish? P1 • Struggles with image interpretation and Struggles with people technical and procedural factors. asking her technical/procedural (1)/ QA questions P2 Struggles with confidence in the lab Lacks confidence (2) • • Even though she has taken the board exam herself, she lacks the experience to teach it. P3 Image repeats (1) • Struggles with just going through the struggles with routine motions. • Feels like she repeats images unnecessarily 35 P4 • • Struggles with exam protocols Struggles with protocol (3) Forgets protocol variations from site to site. P5 • struggles with specific patient situations; patient care ie spanish speaking P6 protocols (3) • Protocols and doctor preferences P7 lacks confidence (2) • struggles with confidence Structured Interview Q3: Do you feel capable of learning new things and successfully pivoting when things aren’t going as expected? Why or why not? P1 Yes (1) – adaptable (2) & • Yes, I feel. Like. I am a pretty flexible flexible. Open to learning person, and always am always wanting to learn. • And so if I'm doing something. Wrong or different, or it could be changed for the better. • I'm always willing to kind of mold into doing that. P2 • Yes, feels like she was a good student to Yes (1)- adaptable (2) and open to change change and adapt. That there are many ways to accomplish goals. • Has the ability to be flexible in learning and teaching. P3 Yes (1)- likes the critical • Yes, definitely. Loves that about the thinking and adaptability (2) field of imaging. Critical thinking and needed.(adapting to patient adapting. size) • adapting to different patient sizes and abilities. P4 Yes (1)• Yes, very capable and adaptable. • Decent at change, good training as made Capable, adaptable (2) Good Training her able to adapt and pivot directions P5 Yes (1) - Good at learning • I feel like I'm good at learning new things new things and willing to change adaptable (2) P6 I think I do like new changes. Yes (1) - likes new • challenges, and new • I like when there's new advancements, technology when there's new technology that's Adaptable (2) rising. P7 Yes (1), but prefers hands • I would say yes,I learn from doing things not just seeing or being told on instruction Structured Interview Q4: Do your co-workers and physicians count on you to do a job well done? Why or why not? P1 100% (1) - her work is tied • 100% I feel like if we don't do or take images effectively and efficiently, and if to the patient outcomes (2) they don't look good, then the providers and her relationship with her coworkers (3) 36 • P2 • • P3 • • P4 • P5 • P1 • can't help those patients. And if I'm not pulling my weight. With my coworkers. They're going to get annoyed or mad at me. And I think relationships will kind of be rocky And stuff like that. Yes- believes everyone in their unique positions is expected to do a good job. Tries hard to make sure she has the facts right when teaching a topic. Yes- believes she pulls her weight and works as hard as those around her. co-workers count on her to help in the exam. Yes- being dependable is important Yes (1)- believes she is matching the expectation Educating the correct concepts Yes (1)-Works hard, and is a team player (3) Yes (1) Dependable Yes (1), aids in diagnosis (2) Yes. So we kind of like the eyes of healthcare. We can help see what's going on with patients and they use our images for diagnosing or placement, all kinds of things that are important. P6 • Oh, they do. Yeah. So they have a lot of Yes (1), patient safety (2) high expectations and standards. P7 aids in diagnosis (2) • It depends because what I'm doing changes the patient's diagnosis and how they're treated. Structured Interview Q5: Have you ever felt like a phony at your job? • P2 • P3 • • • • Yes, as a student, and technologist. With Lack of knowledge even being licensed still feels like a fake. When asked questions by peers she feels unsure of the answer. In OR situations, feels unsure of herself. When the Surgeon wants the C-arm moved quickly to positions, and has many eyes on her as the tech. Yes, for sure. Mostly due to her age she feels like a fake. Feels others look at her as inexperienced When she started the career YES, now not as much. Felt like she was never going to reach the status of others around her. Called her boss a lot for help. Felt under qualified to start her career. Yes (1). Questions competency. Lacking knowledge. (2) In the OR (3) with Surgeons. Yes (1), due to her young age and inexperience (2). Yes (1), More at the beginning of her career (2). Lacked status compared to others. underqualified. 37 P4 P5 P6 • • • • • Yes, when starting out for sure. Stressful to go from a slower pace clinical learning environment to a fast pace workplace. Working in the OR. Doctors are impatient. Yes (1), Stressful at fast pace The OR (3) lacks confidence (4) Um, kind of. struggles with confidence lacks confidence (4) I think, yeah, there's been various points to stressful situations situations where I have felt that, and power differentials (3) especially as a student. especially as student / lack • I think a big part of that was just kind of experience (2) like, especially for me, it was like, I knew they were doing like something wrong, but I felt like me telling them that like would make them kind of get offended. And so it's like that power between like a tech and actual student, that was like the most challenging part, especially like advocating. And like, I think that was a big part of it. P7 lacks confidence (4) • I think since I just graduated, I was lacks experience (2) always having my clinical instructor or tech, whoever I was with, check my images or if I had to retake an image, it would be on them to decide • whether or not we retake an image. And so I think I often feel the need to have someone hold my hand when I'm sending off images, and sometimes I'm just slightly unsure, and so I'll ask for help with that, and it makes me feel, I guess, inferior in that way. Structured Interview Q6: Are you comfortable with praise or compliments regarding your work? Why or why not? P1 Yes/No/Unsure (3) • Yes, and No. Doesn’t believe in the Lack of security in positive compliments - Maybe those feedback. providing the positive feedback are just being kind. P2 No (2), feels undeserving of • No, very uncomfortable with praise. praise. • Feels undeserving in a way. P3 No (2), feels uncomfortable. • No - makes her feel uncomfortable. • Blames how she was raised, to not have Doesn’t want to come across as a know it all. or an a big head and be braggy. individual with a big head. • Makes her feel eerie to be given praise. 38 P4 • • P5 • Yes, appreciates the compliments. It is a helpful part of feedback to her. Yes (1). Compliments help her be successful. Yes (1), compliments help to feel more confident Um, yes, I feel like it makes me feel better about how I'm doing. Um, and I like to do that for others and let them know that they're doing a good job. P6 Yes (1), provides • I think I am. I think that is something reassurance that I actually enjoy when I get those certain comments, because it makes me or kind of like reassures me that I'm like, on the right page that I'm doing everything well. And so like, being appreciated for the work I'm doing, I think is something that really does help me a lot for sure. P7 Yes (1), provides positive • I would say for the most part, yes. feedback • I think at this point, I've worked hard enough to start, I guess, earning back some compliments if I'm doing well. Structured Interview Q7: Do you feel your success is mostly due to luck? Why or why not? P1 • Yes, but not to the point of luck carrying Yes (1) -Belief in Luck combined with dedication & her through life. Luck mixed with hard Hard Work work and dedication. P2 Yes (1). Feels like others • Yes, even getting into the X-ray got her where she is, not program feels like was lucky. herself. • Feels it wasn’t due to her interview skills or GPA. • Feels the letters of recommendation got her to where she is. P3 Yes (1), got into the X-ray • Yes, in some ways. X-ray as a career program on the 1st try. was never the plan. until just a couple • P4 • • months before applying. Knew how hard it is to get in, and felt it a miracle when she got in her 1st try. Yes, sometimes. With certain sized patients. Almost shooting the X-ray in the dark hoping for the best. And get lucky on positioning. Miracles got her in. Yes (1). Difficult patient sizes lead to luck. 39 P5 • P6 • • P7 • Um, not really. I feel like I put in the work to do well. Um, like I've learned how to position and what to look for. And I know how to fix things when they're not right. I think I deserve it. And so like, I just kept working, studying, But then there's also this side of me where it's like, do I really belong here? I should be doing something else. And so like, there's a lot of self doubt. And it's just that it was just a lot of self doubt. No (2), feels accomplished due to hard work I would say no. At this point, I've tried to really learn how to succeed in my field and how I can be better. No (2), feels accomplished due to hard work No (2) but self doubt and feeling disconnected The next 4 questions were included in the structured interview to assist in responding to the second research question. This question inquired whether there were any correlations between the feedback provided to novice radiographers in comparison with their level of imposter syndrome. Responses were coded to determine influential supervisors/instructors, their feedback delivery, and the effectiveness of the feedback given in reducing imposter syndrome. The responses to structured interview questions are provided in Figure 2. Figure 2. Structured Interview Coded Themes for Research Question 1 RQ2. What correlations are found between feedback provided to novice radiographers and their perceived level of imposter syndrome? Structured Interview Q8. Who provides you with the most feedback in a typical week working as a radiographer? P1 Feedback from both • Most of the time she gets feedback from other techs (1) and her other staff and peers, but also from her imaging manager (2) manager. About equal amounts from both. 40 P2 • P3 • • P4 • P5 • • P6 • • • One of the schools professors give her the most feedback Her manager and providers share the most feedback evenly Asks providers for their opinion on what to improve upon. Her manager now, but as a student was her CI. Um, I would say the radiologists, you know, um, they're good at telling us what they like and what they don't. Same with the doctors we do exams for. They tell us what views they want and, you know, how they just special views that they want from us. So I feel like a lot of time, the doctors are the ones giving us the most feedback. I think a big part of it were the techs. I mean, there were certain techs that were amazing, like, honestly, like, they helped me a lot. They gave me a lot of, they were just like, really, I think a big part of it was them being patient, especially since I was still a student. And so like them taking the time to teach me even during like downtime, where there wasn't like anything going on, I think that really benefited me a lot. I would also say my, Devin. So Devin actually used to be my old clinical instructor, and honestly, like, like, thanks to like, thank you to like Devin for everything, like, you know, like, he like helped me like, he would do like simulations where like, like, I would practice like with other students just to ensure that I was on the right page. And it was kind of like designated time where you can just kind of explain Feedback by a professor (3) Manager (2) & Providers (4) Manager (2) the Radiologist, doctors (4) Techs (1), CI 41 everything. So my clinical instructor played a big part in that too. P7 Techs (1); constructive • At my site, typically the other feedback. Doctors (4) radiographers that I work with have helped give me the most • feedback and then from that point, if it's not them, typically the doctors that I'm working directly with. I would probably say like 70% of the time it's the radiographers or maybe 80% of the time and then 20% the doctors. Structured Interview Q9. How well do you feel this person delivers feedback to you? P1 Well delivered (1) • She feels that all involved provide Positive feedback (2) feedback well. and her positive work Constructive (3) environment aids in that and incircles Criticism more positive feedback being a positive work environment. P2 Well delivered (1) • She feels the feedback given is pretty Fair and polite (2) good. delivered fair and not rude P3 Well delivered (1) • Delivered really well. Not harsh (2) • The environment is really good. Helps her be capable of • advice never given harshly. delivered in learning and growing a way that makes her believe she is (3) capable of achieving the goal. P4 Well delivered (1) • Great at delivering Positive & Negative Feedback P5 lacks detail and • it kind of depends on which doctors, relevance (4) cause some doctors are no, no, for sure what they want and what we're looking for. While others will take any kind of image, not really knowing what • exactly it is P6 constructive and helpful • feedback is constructive and very (3) helpful P7 Constructive feedback • I would say pretty well for the most part. (3) I would say more constructive feedback. Structured Interview Q10. Do you trust this individual and feel important and validated when you receive feedback? Why or why not? P1 Yes (1) Validated & • Yes, Some feedback from individuals must be taken with a grain of salt. But from those she trusts, she appreciates and respects the feedback and finds it beneficial. Important from Feedback 42 P2 • P3 • • P4 • • P5 • • P6 • P7 • Yes, For sure. Feels with him being a previous professor of hers has the background and knowledge to trust what he says. Yes from her manager, but not as trusting of the providers. The providers never seem to know what they want, just ask for whatever is going to give them the most views. Yes, her manager is kind, and wants to give feedback for the whole purpose of making her better. Very respectful and understanding. Her manager is approachable feedback is delivered in a constructive way and it makes me feel like I’m doing better Yes, my CI was patient and would help me a lot. Yes (1), Trustworthy background Trust her manager (1) Lacks trust in the providers (2) Yes (1), Trustworthy & Kind Approachable Yes (1), feels like I am doing a good job. Yes (1), trustworthy and patient Yes (1), has trust in other Yes, I think they all have a decent radiographers amount of experience and have seen a lot, done a lot, so I feel like their experiences allowed me to trust them more Structured Interview Q11. Is their message clear, understandable, and useful to you? Why or why not? P1 Yes, Clear & • Yes, for the most part all messages and Understandable feedback feedback are clear, understandable and Useful feedback (1) useful. Those I respect the most I feel the feedback is most useful from. P2 Yes, Clear and • Yes, very clear and useful. • Tells her corrections in a straightforward straightforward communication (1). manner. P3 • Yes, Clear on how to improve from her Yes from Manager (1), No from providers. manager. Providers (2) • Providers feedback not as useful, because they are usually wrong or lacking the knowledge of what they want. P4 Yes, Clear from her • Very Clear on feedback, and uses manager examples to validate the point. Clear Examples (1) • Clear direction on feedback to make it useful P5 Yes, clear from other • Yes, clear and uses examples, learns radiographers (1) from hands on experience 43 P6 • P7 • Yes, feedback was clear and constructive and super helpful Yes. Yes, clear and very helpful (1) Yes (1) The final research question was asked as an opportunity to explore future research, policy change, and or behaviors that would promote and support participants competency and motivation. The participants’ answers are provided in Figure 3. Figure 3. Structured Interview Conclusive Statements Structured Interview Q12. In your opinion, what changes could be made to help you feel motivated to improve your skills and support your feelings of competence? P1 • P2 • P3 • • P4 • • P5 • • P6 • Feels an increase in positive feedback in many formats, text, words, acknowledgements would be a positive change. Techs are often in their own bubble and are not noticed as much as other departments maybe. The amount of patience staff and others have with students and new techs could change. Feels the X-ray program attended should grow in structure. Too much information thrown all at once rather than growing. Being thrown in and asking to do so much so fast affected her confidence. Keeping repetitive nature so ensure competency The more she did of the same exam- the more competent she felt Increase Positive Feedback. Increased Acknowledgement. Increased amount of Patience. Add slow building structure to X-ray programs. Don’t flood information at students. Continue to add repetition into training and exams to build confidence. I think all of just more positive feedback from more people. Um, cause I know some other places we don't really get, um, much information back from other like radiologists or doctors. So I feel like it's helpful to hear those things from the people who are looking at these images. more positive feedback from the docs I think honestly, a big part of it, in order for me to feel even more confident, I feel like it's just continuing to get training, continuing to get or just having like a more support and check ins. 44 • P7 • support system where they're, they're willing to have like, check ins, I think, is really beneficial for me because that allows me to kind of check in and let them know like, hey, I'm struggling with this. And like, they can like help me like, improve in that aspect. I think hearing more feedback because a lot of the times I don't hear back, which means I'm technically doing good, but sometimes I need to hear that I'm doing good to allow things to sink in. I think it would be more validating coming from probably top as radiologist and then the doctors or providers that I'm working with more consistent feedback from docs. Evaluation of Findings Evaluation of the interview responses indicate that many participants lack a complete understanding of their job descriptions as radiographers and attribute much of their success to luck rather than their abilities, diligence or hard work. While they feel they are adaptable to change and value feedback in the workplace, they commonly struggle with confidence and have a shared distrust in many sources of feedback and show a strong belief that the manner in which it is delivered significantly impacts their self-competence. Participants consistently expressed feelings of inadequate knowledge and experience, coupled with stress and uncertainty about whether they truly deserve compliments or praise. Although they acknowledge that support and recognition have contributed to their careers, they do not feel deserving of such acknowledgement, suggesting a strong prevalence of imposter syndrome among these novice radiographers. These findings align closely with the literature on impostor syndrome, also known as impostor phenomenon. As outlined by Gibson et al. (2023) and Subani et al. (2019), this phenomenon is notably prevalent in radiology and other high-achieving fields, where 45 professionals operate under intense scrutiny and pressure. As evident in the data, radiographers experiencing impostor syndrome often attribute their achievements to external factors like luck rather than their skills or efforts. Healthcare environments, particularly radiology, are fertile grounds for impostor syndrome due to high expectations of knowledge, precision, and emotional resilience. As Gibson et al.(2023) highlighted, up to 83% of clinical radiology staff report experiencing impostor syndrome traits at some point in their career, with students and residents in early career stages being most at risk. These findings resonate with the participants’ feedback, reflecting their doubts about their competencies and feelings of distrust regarding praise and recognition. The connection between impostor syndrome and feedback delivery is evident in this context. Research by Moscu (2023) and Zahra et al(2021) emphasizes that constructive, clear, and timely feedback can help alleviate impostor syndrome by reinforcing professionals’ belief in their abilities. Conversely, poorly delivered or vague feedback exacerbates self-doubt and reinforces impostor feelings, as seen in this study’s participants. Participants’ report of distrust in feedback sources and its impact on their self-competence underscores the need for thoughtful feedback mechanisms to foster their professional growth and mitigate impostor syndromes effects. The rapid evolution of healthcare technology, increasing accountability pressures, and heightened patient expectations contribute to stress and feelings of inadequacy among radiographers. These environmental factors amplify impostor syndrome and hinder individuals from internalized success, aligning with Gibson et al.’s (2023) findings regarding the broader implications of impostor syndrome in radiology. 46 Summary The findings reveal that impostor syndrome is prevalent among novice radiographers, with many participants experiencing persistent self-doubt and feelings of inadequacy. Constructive feedback, characterized by specificity, timeliness and balance, was shown to help alleviate feelings of impostor syndrome by strengthening the radiographers' sense of competence and self-efficacy. Conversely, feedback that is overly critical, vague, or delivered negatively was found to intensity feelings associated with impostor syndrome, suggesting that the way feedback is delivered plays a crucial role in shaping radiographers’ self-perceptions. 47 Chapter 5: Implications, Recommendations, and Conclusions A comprehensive analysis of the study’s findings is presented here, integrating the results with the initial problem statement, purpose and research questions. The study aimed to understand the prevalence and impact of impostor syndrome among novice radiographers, focusing on its relationship with feedback characteristics. Through structured interviews, the research sought to reveal how feedback may either contribute to or alleviate feelings of inadequacy and self-doubt among participants. Implications The findings for the first research question indicated a significant prevalence of impostor syndrome among novice radiographers. Many participants reported persistent feelings of self-doubt. This often attributes their success to external factors rather than their abilities. This aligns with the literature showing that impostor syndrome is pervasive in highstakes environments where professionals are expected to perform consistently under pressure. The implication of these findings is twofold; first, they validate the need for healthcare institutions to recognize and address impostor syndrome as a significant factor affecting the mental well-being of radiographers. Second, the findings underscore the importance of creating support systems within radiology to reduce feelings of inadequacy, including mentorship programs, peer support, and mental health resources. Recognizing impostor syndrome’s impact on radiographers can guide the development of tailored interventions that support professional growth and mitigate burnout. The results from the second research question demonstrated a correlation between feedback characteristics and impostor syndrome levels. Constructive feedback, which was specific, timely, and positive, generally helped participants internalize their achievements and reduce self-doubt. However, feedback perceived as overlay critical or vague tends to exacerbate impostor syndrome. These findings suggest that while feedback is essential for 48 professional growth, the manner in which it is delivered can either support or hinder a radiographer’s self-perception and confidence. The overall implications of this study are that healthcare institutions need to adopt structured feedback frameworks that emphasize constructive, balanced feedback. Supervisors and senior radiographers could benefit from training on effective feedback delivery, focusing on specificity, timeliness, and an encouraging tone. This training could improve radiographer’s receptiveness to feedback and reduce their susceptibility to impostor syndrome, enhancing their job satisfaction and overall quality of care to patients. In practical terms, the findings of this study highlight the potential for applying feedback models and processes that support radiographers in recognizing their achievements and developing confidence. The adoption of supportive feedback delivery and the introduction of peer support systems could enhance radiology departments, improving the work environment and patient outcomes. In summary, this study underscores the critical need for healthcare institutions to address impostor syndrome and refine feedback practices within radiology. The study’s results highlight that constructive feedback can play a pivotal role in reducing feelings of impostorism and enhancing radiographers’ confidence and job satisfaction. By recognizing impostor syndrome and creating a supportive feedback structure, healthcare institutions can foster a more resilient and confident workforce, ultimately contributing to improved quality of care in patients and a healthier work environment. The study’s insights pave the way for future research on impostor syndrome within radiology, offering a foundation for developing interventions that promote professional well-being and growth. 49 Recommendations The insights gained from this study will support the development of targeted interventions to help imaging professionals manage impostor syndrome. This research will inform best practices in feedback delivery, ensuring that it contributes positively to professional development rather than exacerbating self-doubt. Moving forward, this study lays the groundwork for larger-scale investigations and the implementation of training programs designed to improve the mental well-being and performance of radiographers. Conclusions The relationship between feedback and the impostor phenomenon is strongly prevalent among novice radiographers in the field of healthcare. Radiology involves complex diagnostic decision-making and continuous exposure to peer and mentor evaluations, often contributing to feelings of inadequacy. Results from this qualitative study point towards a strong prevalence of impostor syndrome among novice radiographers. Many questions directed at the participants included self-evaluations of their job description and duties as a radiographer. Answers on this matter all pointed to a lack of full understanding of their roles in their positions, contributing to elevated feelings of self-doubt and lack of confidence within themselves. Feedback within the field of Radiology is very prevalent. An evaluation of the participants' responses shares, that the delivery of the feedback shows a moderate impact on their feelings of competence and performance. Other evaluations of responses show that the manner in which the feedback is delivered and by whom, does indeed matter greatly in the development of the technologist. Behind the images, are caregiving technologists struggling to find their confidence within a forever adapting and changing field of radiology. Providing structured, constructive and regular feedback by the appropriate sources can aid the mitigation of these feelings by 50 affirming competence and highlighting areas of genuine improvement. Incorporating a positive learning environment, reinforces self-efficacy and promotes professional growth, ultimately helping radiographers overcome the feelings of impostor syndrome and perform their duties with confidence. 51 References Arleo EK, Wagner-Schulman M, McGinty G, Salazar G, Mayr NA. Tackling impostor syndrome: A multidisciplinary approach. Clin Imaging. 2021 Jun;74:170-172. Burns, Judah, Alison Chetlen, Desiree E. Morgan, Tara M. Catanzano, Theresa C. McLoud, Priscilla J. Slanetz, Ann K. Jay, "Affecting Change: Enhancing Feedback Interactions with Radiology Trainees," Academic Radiology, Volume 29, Supplement 5, 2022, Pages S111-S117, https://doi.org/10.1016/j.acra.2021.05.018. Choi, E., Johnson, D. A., Moon, K., & Oah, S. (2018). Effects of positive and negative feedback sequence on work performance and emotional responses. Journal of Organizational Behavior Management, 38(2–3), 97–115. Clance, P. R., & Imes, S. A. (1978). The impostor phenomenon in high achieving women: Dynamics and therapeutic intervention. Psychotherapy: Theory, Research & Practice, 15(3), 241– 247. Chandra, Subani, Candace A. Huebert, Erin Crowley, Aneesa M. Das, "Impostor Syndrome: Could It Be Holding You or Your Mentees Back?" Chest, Volume 156, Issue 1, 2019, Pages 2632, https://doi.org/10.1016/j.chest.2019.02.325. Deshmukh, S., Shmelev, K., Vassiliades, L., Kurumety, S., Agarwal, G., & Horowitz, J. M. (2022). impostor phenomenon in radiology: Incidence, intervention, and impact on Wellness. Clinical Imaging, 82, 94–99. https://doi.org/10.1016/j.clinimag.2021.11.009 Fong, C. Schallert, D., Lin, S., & Altan, S. (2024). How constructive is that feedback? Associations with undergraduates’ future time perspectives moderated by student characteristics. Studies in Educational Evaluation. 81, 1-9. Gibson, C., & Lockwood, P. (2024). Impostor phenomenon traits in radiography students: Findings from a UK pilot survey. Radiography, 30(1), 61–65. https://doi.org/https://doi.org/10.1016/j.radi.2023.10.005 Haney, T. S., Birkholz, L., & Rutledge, C. (2018). A workshop for addressing the impact of the impostor syndrome on Clinical Nurse Specialists. Clinical Nurse Specialist, 32(4), 189–194. https://doi.org/10.1097/nur.0000000000000386 Moscu CA, Marina V, Anghele AD. (2023). "The Impact of Work-Related Problems on Burnout Syndrome and Job Satisfaction Levels among Emergency Department Staff." Behav Sci (Basel). 2023 Jul 11;13(7):575. Tagliabue, M., Sigurjonsdottir, S. S., & Sandaker, I. (2020). The effects of performance feedback on organizational citizenship behaviour: a systematic review and meta-analysis. European Journal of Work and Organizational Psychology, 29(6), 841–861. https://doi.org/10.1080/1359432X.2020.1796647 52 Appendix A: Structured Interview Questions In Person Structure Interview Questions Imposter Syndrome- Feedback Demographics: Please answer the following. 1. What is your age in years? 2. How many years/months have you been employed as a Radiographer? 3. Do you work in a hospital or clinic setting? 4. Are you working full time/part time/ other? RQ1. What is the prevalence of imposter syndrome among radiographers? Let’s begin by exploring how you would rate your competency. Competency refers to the ability and skills one has to do a job effectively and accurately. The following questions relate to how you perceive your competency. 1. What is your current title and position and what are your responsibilities? 2. Which responsibilities do you do well, and which responsibilities do you struggle to accomplish? 3. Do you feel capable of learning new things and successfully pivoting when things aren’t going as expected? Why or why not? 4. not? Do your co-workers and physicians count on you to do a job well done? Why or why Imposter syndrome is the psychological experience of feeling like a fake or a phony despite any genuine success that you have achieved. 1. Have you ever felt like a fake or a phony in your job? a. If yes, can you describe common situations in which you felt like this? b. 2. not? If no, how have you avoided the feeling this way or learned to cope with it? Are you comfortable with praise or compliments regarding your work? Why or why 3. Do you feel your success is mostly due to luck? Why or why not? 53 RQ2. What correlations are found between feedback provided to medical imaging professionals and their perceived level of imposter syndrome? All radiographers have experienced feedback from various persons in the form of advice, critique, and/or coaching to assist us in improving our performance. 1. Who provides you with the most feedback in a typical week working as a radiographer? 2. How well do you feel this person delivers feedback to you? a. Do you trust this individual and feel important and validated when you receive feedback? Why or Why not? b. Is their message clear, understandable, and useful to you? Why or Why not? 3. Are you able to easily accept praise or compliments regarding your work? Why or Why not? Wrap Up Question In your opinion, what changes could be made to help you feel motivated to improve your skills and support your feelings of competence? 54 Appendix B: Informed Consent Form IRB STUDY # IRB-AY24-25-85 WEBER STATE UNIVERSITY INFORMED CONSENT Behind the Images: A Study of the Relationship between Feedback and Impostor Syndrome Among Radiographers You are invited to participate in a research study about imposter syndrome and feedback among radiographers. You were selected as a possible subject because you are an employed radiographer who has 5 years or less of experience. We ask that you read this form and ask any questions you may have before agreeing to be in the study. The study is being conducted by Tanya Nolan, Devin Horne, and Brittany Garcia as part of the MSRS program. STUDY PURPOSE The purpose of this qualitative study is to explore the experiences and perceptions of radiographers regarding impostor syndrome in diagnostic imaging, with a goal of understanding its prevalence, manifestations, and impact in relationship to constructive feedback. NUMBER OF PEOPLE TAKING PART IN THE STUDY: 7 If you agree to participate, you will be one of 8-10 subjects who will be participating in this research. PROCEDURES FOR THE STUDY: If you agree to be in the study, you will do the following things: you will participate in a ZOOM structured interview wherein you will answer questions regarding competence, imposter syndrome, and feedback for approximately 30-45 minutes. RISKS OF TAKING PART IN THE STUDY: The risks to the study would include a possible breach of confidentiality and/or discomfort in asking personal questions regarding your professional practice and learning. BENEFITS OF TAKING PART IN THE STUDY You will not) receive payment for taking part in this study. ALTERNATIVES TO TAKING PART IN THE STUDY: There are no alternatives to help or participate in the study in a way different than explained above. COSTS/ COMPENSATION FOR INJURY In the event of physical injury resulting from your participation in this research, necessary medical treatment will be provided to you and billed as part of your medical expenses. Costs not covered by your 55 health care insurer will be your responsibility. Also, it is your responsibility to determine the extent of your health care coverage. There is no program in place for other monetary compensation for such injuries. However, you are not giving up any legal rights or benefits to which you are otherwise entitled. If you are participating in research which is not conducted at a medical facility, you will be responsible for seeking medical care and for the expenses associated with any care received. CONFIDENTIALITY Efforts will be made to keep your personal information confidential. We cannot guarantee absolute confidentiality. Your personal information may be disclosed if required by law. Your identity will be held in confidence in reports and databases in which results may be stored to aid in publication. Interviews will be recorded and maintained by password only to be viewed and reviewed by the research team for education purposes. All information will be destroyed within 2 years. Organizations that may inspect and/or copy your research records for quality assurance and data analysis include groups such as the study investigator and his/her research associates, the Weber State University Institutional Review Board or its designees, the study sponsor, and (as allowed by law) state or federal agencies, specifically the Office for Human Research Protections (OHRP) and the Food and Drug Administration (FDA) [for FDA-regulated research and research involving positron-emission scanning], the National Cancer Institute (NCI) [for research funded or supported by NCI], the National Institutes of Health (NIH) [for research funded or supported by NIH], etc., who may need to access your medical and/or research records. CONTACTS FOR QUESTIONS OR PROBLEMS For questions about the study, contact the researcher Tanya Nolan at 801-626-8172. For questions about your rights as a research participant or to discuss problems, complaints or concerns about a research study, or to obtain information, or offer input, contact the Chair of the IRB Committee IRB@weber.edu. VOLUNTARY NATURE OF STUDY Taking part in this study is voluntary. You may choose not to take part or may leave the study at any time. Leaving the study will not result in any penalty or loss of benefits to which you are entitled. Your decision whether or not to participate in this study will not affect your current or future relations with Weber State University Radiologic Sciences. SUBJECT’S CONSENT In consideration of all of the above, I give my consent to participate in this research study. I will be given a copy of this informed consent document to keep for my records. I agree to take part in this study. Subject’s Printed Name: Subject’s Signature: (must be dated by the subject) Date: 56 Appendix C: Institutional Review Board (IRB) Approval Letter September 17, 2024 Tanya Nolan School of Radiologic Sciences Re: Exempt - Initial - IRB-AY24-25-85 Behind the Images: A Study of the Relationship between Feedback and Impostor Syndrome Among Radiographers Dear Tanya Nolan: The Weber State University Institutional Review Board has rendered the decision below for Behind the Images: A Study of the Relationship between Feedback and Impostor Syndrome Among Radiographers. Decision: Exempt Approval: September 17, 2024 Selected Category: Category 2.(i). Research that only includes interactions involving educational tests (cognitive, diagnostic, aptitude, achievement), survey procedures, interview procedures, or observation of public behavior (including visual or auditory recording) if at least one of the following criteria is met: The information obtained is recorded by the investigator in such a manner that the identity of the human subjects cannot readily be ascertained, directly or through identifiers linked to the subjects; Findings: Research Notes: Subjects are considered adults, signatures/consent are required, and they may choose not to participate. Anonymity and confidentiality are addressed appropriately, and the type of information gathered could not "reasonably place the subjects at risk of criminal or civil liability or be damaging to the subjects' financial standing, employability, or reputation" (Code of Federal Regulations 45 CFR 46, Subpart D). You may proceed at this time; you have one year to complete the study. Please remember that any anticipated changes to the project and approved procedures must be submitted to the IRB prior to implementation. Any unanticipated problems that arise during any stage of the project require a written report to the IRB and possible suspension of the project. If you have any question please contact your review committee chair or irb@weber.edu. Sincerely, Matthew Nicholaou, DrPH, MT(ASCP) Chair, DCHP IRB Sub-committee Weber State Institutional Review Board