The Role of Medical Imaging Leaders in Employee Satisfaction By Ryan Anderson Erica Brown Dulce Carter A. Leah Johnson Kirk McKinlay Tabatha Moore Abbey Pitt Lexie Thompson 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 August 4, 2023 THE WEBER STATE UNIVERSITY GRADUATE SCHOOL SUPERVISORY COMMITTEE APPROVAL of a thesis submitted by Ryan Anderson Erica Brown Dulce Carter A. Leah Johnson Kirk McKinlay Tabatha Moore Abbey Pitt Lexie Thompson This thesis has been read by each member of the following supervisory committee and by majority vote found to be satisfactory. ______________________________ Dr. Robert Walker, PhD Chair, School of Radiologic Sciences ______________________________ Dr. Tanya Nolan, EdD Director of MSRS Innovation & Improvement THE WEBER STATE UNIVERSITY GRADUATE SCHOOL RESEARCH AGENDA STUDENT APPROVAL of a thesis submitted by Ryan Anderson Erica Brown Dulce Carter A. Leah Johnson Kirk McKinlay Tabatha Moore Abbey Pitt Lexie Thompson This thesis has been read by each member of the student research agenda committee and by majority vote found to be satisfactory. Date Student Signature August 4, 2023 Ryan Anderson August 4, 2023 Erica Brown August 4, 2023 Dulce Carter August 4, 2023 A. Leah Johnson August 4, 2023 Kirk McKinlay August 4, 2023 Tabatha Moore August 4, 2023 Abbey Pitt August 4, 2023 Lexie Thompson Abstract Background: Employees in medical imaging have felt significant burnout post-pandemic. These feelings may be related to the leadership of the imaging team. This mixed-method study investigated whether leadership behaviors and attitudes influenced employee satisfaction thus informing best practice. Materials and Methods: A total of 189 quantitative surveys were completed and analyzed. Each survey included Likert-scale statements designed to measure how participant’s perceived their leaders’ ability to Model, Inspire, Challenge, Enable, and Encourage employees. Participants were also asked to respond to their current levels of employee satisfaction based on performance, engagement, and well-being. Six semi-structured interviews were conducted and coded for common themes to provide depth and detail to the quantitative measures. Results: Most participants were female and located in Utah, Oregon, or Idaho. No statistical significance was identified between the technologist’s modality, education, experience or income. Quantitative analysis had a moderate positive correlation between leadership and satisfaction. Most participants considered their leader as a ‘Chief Technologist’ or ‘Administrator/Manager.’ There was a moderate positive correlation of 0.520 (p <0.001) between leadership and job satisfaction. Encourage and Inspire had the strongest relationship to job satisfaction with correlations of 0.535 and 0.503 (p <0.001). Challenge had a correlation of 0.473 (p<0.001), and Model had a correlation of 0.361 (p<0.001). Enable did not reach statistical significance with a correlation of 0.109. Coded interviews identified increased communication, feedback frequency, monetary compensation, increased personal responsibility, implementation of employee suggestions, and workplace activities as valuable in improving employee satisfaction. Acknowledgements We would like to give special thanks to everyone who contributed to our research and those who supported us during the process. Thank you specifically to Tanya Nolan for being a superb mentor and Heather Chapman for graciously teaching us how to clean our data and reminding us to keep it simple. We would also like to acknowledge those technologists who gave their valuable insights, whether it be from the survey or through our interview process. Finally, we would like to thank caffeine’s consistent supportive role in the production of this work. Table of Contents Chapter 1: Introduction 1 Background Statement of the Problem Purpose of the Study Research Questions Nature of the Study Significance of the Study Definition of Key Terms Summary 1 3 3 4 5 6 6 7 Chapter 2: Literature Review 9 What is a Leader Leader Performance Leadership Behaviors & Attitudes: Model Leadership Behaviors & Attitudes: Challenge Leadership Behaviors & Attitudes: Inspire Leadership Behaviors & Attitudes: Enable Leadership Behaviors & Attitudes: Encourage Leadership Behaviors & Attitudes: Engagement Leadership Behaviors & Attitudes: Performance Employee Satisfaction: Well-Being Summary 10 12 13 16 18 20 22 24 26 27 29 Chapter 3: Research Method 31 Population Sample Materials/Instruments Operational Definition of Variables Data Collection, Processing, and Analysis Assumptions Limitations Delimitations Ethical Assurances Summary 32 32 33 36 37 39 39 41 43 43 Chapter 4: Findings 46 Results Evaluation of Findings Summary 47 67 78 Chapter 5: Implications, Recommendations, and Conclusions 80 Implications 80 Recommendations Conclusions 82 85 References 88 Appendices 98 Appendix A: Quantitative Survey Instrument 98 Appendix B: Quantitative Informed Consent 103 Appendix C: Qualitative Survey Instrument 106 Appendix D: Qualitative Informed Consent 108 Appendix E: Code Book - Themes & Frequencies 111 Appendix F: Code Book 116 List of Tables Table 1. Participants by Clinical Setting………………………………………………………………49 Table 2. Leadership and Job Satisfaction Sub Variable Results……………………………………54 Table 3. Job Satisfaction to Leadership Qualities……………………………………………………56 Table 4. Positive Model Themes ………………………………………………………………………57 Table 5. Negative Model Themes…… …………………………………………………………………58 Table 6. Leader’s Communication and Impact on Satisfaction ……………………………………59 Table 7. Future Behaviors That Would Increase Satisfaction………………………………………60 Table 8. Do Leaders Inspire Employees……………………………………………………………….61 Table 9. How Leaders Can Communicate Goals in the Future to Increase Satisfaction ………61 Table 10. What Ways Leaders Make Changes to the Department to Improve Satisfaction ……62 Table 11. Leadership Allowing Staff to Challenge the Status Quo ………………………………63 Table 12. Desire for Employees to be Challenged …………………………………………………64 Table 13. Obstacles in the Workplace…………………………………………………………………65 Table 14. Future Resources to Improve Satisfaction ………………………………………………66 Table 15. What Recognition is Given to Employees and Its Effects ……………………………66 Table 16. How Leadership Can Encourage Employees ……………………………………………67 List of Figures Figure 1. Participants of Respondents vs Percent of Industry by Modality …..…………………48 Figure 2. Participants by Clinical Setting ………………………………………………………49 Figure 3. Participants by Level of Education ……………………………………………………50 Figure 4. Participants by Years of Experience Figure 5. Participants by Income …………………………………………………50 …………………………………………………………………51 Figure 6. Participants by Age ………………………………………………………………………52 Figure 7. Title of Leader With Most Influence Over Daily Work ………………………………53 Figure 8. Two-Tailed Pearson Correlation Between Leadership and Job Satisfaction ………55 Chapter 1: Introduction Medical imaging leaders have a responsibility to serve, provide positive support, and respond to department uncertainties. According to Martinussen & Davidsen (2021), leaders need to maintain professional standards and quality in patient care, ensure professional collaboration across different departments, and provide motivation for technologists. Additional responsibilities include establishing and utilizing new routines, solving interpersonal problems, and maintaining costs within a set budget. Expectations of an emerging generation of technologists differ from those of older generations, which means that required knowledge and management competencies have changed for modern managers (Karsikas et al., 2022). Imaging leaders are challenged by ever-changing responsibilities and managerial roles. Their attitude, behavior, and resilience accomplishing these new standards are directly related to employees’ satisfaction. Background The current circumstances in healthcare have been shaped and attributed to the last three years of the COVID-19 pandemic. Multiple studies completed during this time focus on the impact of COVID-19 on employees in healthcare professions (Cogan et al., 2022; Kachadourian et al., 2022; Huang et al., 2021). Health professionals now find themselves in a challenging “new normal” that in and of itself warrants investigation. Specifically, many radiology departments are short staffed and overworked. In part, this occurred because significant numbers of healthcare workers were furloughed, left the field for other career paths, or retired due to the pandemic. According to Yuan‑Sheng Ryan Poon et al., “in the United States, the healthcare sector suffered a net loss of 460,000 workers between 1 February 2020 and November 2021” (2022, p.2). In conjunction, the training and education of new healthcare professionals slowed due to COVID-19 restrictions recommended by the CDC which limited the number of clinical/learning sites available (US Department of Health and Human Services, 2022). Thus, fewer replacements were available for those vacated positions. Imaging professionals who remain in the field find themselves rushed and overworked, all while the need for healthcare services continues to increase. In these conditions, professionals in leadership roles are faced with the immense challenge of maintaining employee engagement, performance, and well-being. Their leadership behaviors and skills are key to a radiology departments’ ability to function safely and effectively. It is important now, more than ever before, that leaders understand which of their behaviors correlate with the greatest positive impact on their employee engagement, performance, and well-being if they wish to change the working environment, attract new staff, and retain current technologists. If these behaviors are not taken into consideration, departments are likely to continue suffering from staffing issues, poor morale, compassionate fatigue, burnout, and sub-standard performance that ultimately impacts the department’s ability to function appropriately while offering safe, high quality healthcare (Hall et al., 2016 ). One study done by Martinussen and Davidsen (2021), identified a close relationship between leadership style and work environment, performance, and quality of patient care. It further concluded that a leadership style focused on professionalism combined with employee support resulted in greater positive results on dependent variables when compared with solely economic-operational styles. Another survey, completed by MRI technologists, identified positive responses from transformational and transactional leadership qualities versus a more 2 relaxed approach. Thus, there is a combination of leadership attitudes and behaviors including modeling, inspiring, challenging, enabling, and encouraging that support overall styles and cultures affecting employee engagement, performance, personal resilience and employee satisfaction. Statement of the problem Leadership, and the manner in which to be a leader, has its added complexities, challenges, and confusion since the onset of the COVID-19 pandemic. In other words, the way to serve and support employees is not always black and white, persuasive, or popular. As discussed previously, many healthcare workers are stretched thin and lack trust in leadership to ease their burdens. Kachadourian, et. al. (2022), revealed many healthcare workers elicited symptoms of posttraumatic stress disorder (PTSD), major depressive disorder (MDD) and generalized anxiety disorder (GAD) with high rates of burnout early within the pandemic (2022). As a possible solution, Probst et al. (2012) suggested managers focus on role extensions and improve leadership qualities to maintain staff and prevent burnout (Probst et al., 2012). Leadership actions may include reduced work hours and increased support among radiology staff (Huang et al., 2021). Purpose of the Study The purpose of this mixed-method study was to examine the relationship between leadership behaviors and employee satisfaction, as defined by variables of performance, engagement, and well-being. A survey was conducted among Radiologic Science professionals within the United States. Subjects were asked to rate their individually perceived levels of agreement or disagreement along a Likert Scale in response to several statements. Each 3 statement related to behaviors the participant perceives to be exhibited by leaders within their place of employment. These statements were also correlated to the perceived effect those behaviors have on personal and peer employment satisfaction, performance, and resilience. Aggregate scores for leadership were explored along with several independent subvariables of leadership, including the ability to Model, Inspire, Challenge, Enable and/or Encourage employees. Semi-structured interviews were used to express emotion, depth, and genuine experience. All transcripts were reviewed and coded to identify modifying or moderating variables that may be affecting leadership behaviors, employee satisfaction, performance, and/or resilience. Coded outcomes and examples of narrative were provided as data for qualitative analysis. Research Questions Our research sought to examine how specific markers of employee satisfaction were influenced by the perception of their leader’s behaviors in context with broader departmental policies. We turned an analytical eye to the metrics of employee performance, engagement, and well-being in the workplace. We suspected these specific markers make a palpable difference in radiology departments and in the broader healthcare system itself and therefore merited close inspection to encourage improvement in all areas if possible. Research Questions: Leadership Style Q1. Do the attitudes and behaviors of leaders directly involved in departmental culture and policy (specifically how they Model, Inspire, Challenge, Enable and Encourage), relate to the employee satisfaction as defined by their performance, engagement, and well-being? 4 H10. There is no relationship between attitudes and behaviors of leaders and employee satisfaction. H1a. There is a positive relationship between favorable attitudes and behaviors in leadership and employee satisfaction. Q2. Which experiences with leadership behaviors and attitudes (Model, Inspire, Challenge, Enable, and Encourage) within Radiologic Sciences professions have positively and/or negatively affected employees’ satisfaction (defined by performance, engagement, and well-being)? H10. There are no experiences had between leaders and professionals that affect employee satisfaction. H1a. There are experiences with leadership behaviors and attitudes within Radiologic Sciences professions that positively and/or negatively affected employee satisfaction. Q3. What future changes are perceived as most important in maintaining or improving leadership attitudes and behaviors for short- and/or long- term benefits in employee satisfaction? H10. There are no changes perceived as benefitting employee satisfaction. H1a. There are certain changes in leadership attitude and behavior that are perceived as most important in maintaining or improving employee satisfaction in the short term and/or long term. Nature of the Study A mixed method design was utilized to identify relationships between leadership behaviors and employee satisfaction in imaging departments. A survey was used to define and 5 quantify employee satisfaction based on employee performance, engagement, and well-being. Qualitative aspects of the study sought to understand the complex emotional response employees had to leadership behaviors and the ways behaviors may increase or decrease employee satisfaction. The use of qualitative and quantitative research methods combined allowed the research team to collect robust and credible information regarding the purpose of the study and was best practice in the study of complex human relationships. Significance of the Study The findings of this research provide insights from an imaging employee’s perspective on what leadership behaviors have positive or negative impacts on the medical imaging department. The positive and negative relationships discovered in this mixed-method analysis may serve as a tool for leaders in imaging departments to improve employee satisfaction through their engagement, performance, and wellbeing. Improving these aspects can lead to increased teamwork, positive workplace culture, increased patient care, improved competency in employees, retention and workplace satisfaction, as well as the personal well-being among employees. As a result, employees may enjoy better work-life balance, improved mental health, as well as increased personal achievement with decreased emotional exhaustion. Definition of Key Terms The following terms have been defined according to this mixed-method research study: Leadership Attitudes and Behaviors: Behaviors leaders exhibited that included the ability to Model, Inspire, Challenge, Enable, and Encourage. Model: A leadership behavior that sets an example for those they manage. 6 Inspire: A leadership behavior that encourages followers to achieve their potential by giving them the desire and ability to accomplish their assigned tasks. Challenge: A leadership behavior that allows for critical thinking and empowerment to achieve professional excellence. Enable: A leadership behavior that provides employees with the resources to perform their assigned tasks effectively and efficiently. Encourage: A leadership behavior that promotes desired actions through personal and department rewards and feedback. Employee Satisfaction: The extent to which employees feel happy, fulfilled, and content with their employment by feeling engaged in their work, able to perform their job, and feeling personal well-being. Employee Engagement: “The strength of the mental and emotional connection that employees feel towards the work they do, their teams, and the organization” (Ryba, 2021). Employee Performance: The ability of employees to do their job efficiently with high reliability behaviors, and a level of compassion. Employee Well-being: The ability of employees to balance their work with their personal life in a way they can sustain their mental, physical, emotional, and economic health throughout their career. Summary Leaders within medical imaging departments have an immense amount of responsibilities placed upon them to help guide their team to accomplish tasks efficiently and ensure their needs 7 are being met. Largely due to the COVID-19 pandemic, burnout rates are at an all time high and employee satisfaction has continued to decline. This has produced an undesirable work environment for many technologists, which has led to staffing shortages, workplace stress, and increased workloads. This research aimed to identify a correlation between imaging leadership behaviors and attitudes and employee satisfaction. This information was garnered through a literature review and mixed method analysis, which included surveys and semi-structured interviews administered to imaging professionals within professions associated with Radiologic Sciences in the United States. The findings of this research should be used to provide current and future radiology leaders with insight into the best methods for guiding employees. If utilized correctly, they have the potential to transform the environment within medical imaging departments. 8 Chapter 2: Literature Review In examining the relationship between leadership behaviors and employee satisfaction, our survey of literary sources showed a seemingly inexhaustible amount of research on leadership. If the volume of research was an indication of the importance we place on a subject, then leadership is near the top. It has been studied from every angle and from every time period dating to antiquity. But this vast history of literature also meant that terms and definitions have changed and evolved so much that, at the time of this study, there was considerable overlap of definitions and ideas leading to confusion and confoundment when discussing and researching these subjects, even among field experts. This exact problem was faced by our research team before beginning the study. Our first foray into the databases of Academic Search Ultimate, Healthsource, PubMed Central, among others using many common leadership terms resulted in a huge number of results that was ill defined and often irrelevant to our specific purposes. By using additional terms like “healthcare worker”, “radiology”, “burnout”, “retention”, and limiting research after 2015, we were able to narrow results into an acceptable time frame and along the subjects in which we were interested. One of the most comprehensive frameworks for defining and explaining leadership behaviors comes from James Kouzes and Barry Posner in their book, The Leadership Challenge. Kouzes and Posner describe behaviors in relation to effecting change and encouraging extraordinary accomplishments within organizations, which is certainly needed in healthcare facilities in the wake of the pandemic. Using this text as a guide, our review of the literature could then be conducted with relevant articles and studies selected and listed in a table with categories for each 9 behavior. These studies and tables were then reviewed an additional time and grouped into similar behavior clusters. Another work that provided a framework for our approach comes from Malcolm Gladwell’s, David and Goliath. In this piece, Gladwell explored how traumatic events and circumstances led to dramatic differences in people and predicted future behavior. He discussed Canadian psychiatrist J.T. MacCurdy’s work on London citizens’ response to the firebombing during WW2. Before the bombing, government leaders predicted extensive casualties and mass panic as the city shut down during paralyzing air raids. Psychiatric hospitals were set up on the outskirts of the city to deal with large groups of shell shocked citizens expected to flee the city en masse. However, to all the leaders’ surprise, the hospitals stood empty. London continued on with its day-to-day business at a relatively normal pace despite the continual bombings. To account for this contrary behavior, MacCurdy presented the idea of near and remote misses to explain how people are either crushed by the trauma of an event or energized by it (Gladwell, 2015). While there are no literal bombs going off in healthcare, the metaphoric bombs of the pandemic took their toll and how leaders respond may make the difference between their staff being a “near miss” vs. a “remote miss”. The following research shows which attitudes and behaviors can make that difference in radiology departments regardless of size or makeup. What is a leader? “True leadership lies in guiding others to success-in ensuring that everyone is performing at their best, doing the work they are pledged to do and do it well.” – Bill Owens 10 According to Nunes, Cruz, and Pinheiro (2012), leadership is the process by which an individual motivates a team of people to achieve common objectives. A leader is someone who motivates, guides, and inspires others to be their best self. They ensure that their team has sufficient support and the tools needed to achieve their goals. A good leader helps their team through challenging times and leads by example. Helping to balance both the goals of the employees with those of the department and what it takes to achieve them. Researchers have agreed that there is a positive relationship between leadership and employees’ job satisfaction, this relationship has its reflections on employee turnover and recognition (Nidadhavolu, 2018). The best leaders demonstrate these qualities: ● Honesty and ethical behavior ● Respectful ● Compassion ● Commitment ● Show support ● Encourage others ● Give recognition for efforts and achievements Leaders are required to motivate, guide, and inspire. A motivational leader recognizes the importance of hard work and encourages their team. They make their team feel valued and appreciated by learning about their needs. They applaud their strengths and focus on weaknesses together. This is all done with enthusiasm and passion. Guidance is provided to employees in many ways. According to Nunes, Cruz, and Pinheiro (2012) leaders help set goals and find ways 11 to execute them, provide positive team building, and show support throughout the process. A leader can also help guide their team through work and life difficulties. Inspiring others is a large part of a leader’s role. It’s the ability to influence others to strive for success and reach goals. The leader must demonstrate commitment and passion to inspire his/her employees to follow in their footsteps. A leader should pride themselves in their abilities to motivate, guide, inspire and support their team toward success. However, unlike personal pride, pride in leadership is distinguished because it moves from a focus on self to a focus on others (Nidadhavolu, 2018). Above all, leaders should create a work environment for their staff to thrive and excel at their job. Leader Performance Merriam-Webster dictionary defines a leader as a person who has commanding authority or influence (Definition of LEADER, n.d.). Leaders who harbor an environment that supports an individual’s experience of competency, relatedness, and autonomy will foster motivation and work engagement. This improves staff performance, energy, resilience, and creativity reducing levels of burnout (Poulsen & Poulsen, 2018). An established requisite for success in any radiology department is a leader’s measured performance which in turn has a direct affect on employee performance. Their influence on technologists’ job performance harbors a positive work environment. When measuring a leader’s overall performance, motivation, employee well-being, and satisfaction are taken into consideration (Van der Hauwaert et al., 2022). 12 According to M. Gagné, E.L. Deci (2005), there are two types of motivation affecting performance; autonomous and controlled motivation. Separating motivation into these categories has been found to be more useful at making predictions on performance than previously developed models (Vansteenkiste et al., 2008). The autonomous motivation model encourages leaders to behave in a way they desire, resulting in elevated performance, and increasing overall departmental satisfaction. It hinges upon the experience of one’s purposefulness and psychological freedom (Gagné and Deci, 2005). In contrast, a leader who is governed by performance-controlled motivation mainly performs as the result of external or internal pressure and is not self-determined to act in the best interest of the department. Consequently, a leader will perform activities because of a mandated requirement, decreasing overall performance. This results in pressure to engage in certain behaviors related to performance, such as avoiding conflict or to obtain recognition. Controlled motivation has consistently been shown to fail at producing important beneficial work outcomes, such as an increased sense of well-being, job satisfaction and sustained performance (Vansteenkiste et al., 2008). Autonomous motivation performance is considered the most effective model of leadership performance. Future research should continue to build on these studies and examine the determinants that drive the choice to enable high performance versus a coercive leadership style. Leadership Behaviors & Attitudes: Model A second leadership trait is Modeling. This behavior is also referred to as role modeling, idealized influence (Majeed et al., 2017), identification (Binyamin, 2020), leading-by-example (Gächter et al., 2018), and behavioral role modeling (Taiyi Yan et al., 2022). Modeling is “a way of influencing followers to engage in normatively appropriate behavior by setting an example of 13 appropriate, ‘do what is right,’ behaviors” (Hoch et al., 2018). Currently, researchers do not appear to be examining the issue of whether or not it is important for a leader to be a role-model. Rather, it appears to be an accepted tool which is applied in a variety of areas. For example, modeling is an element in many leadership theories. Researchers have noted that modeling is an important aspect of social learning theory (Bai et al., 2019; Dietz et al., 2020; Hoch et al., 2018). Social learning theory suggests that people learn how to behave through observing and imitating others (Bai et al., 2019). According to Bai et al., social learning occurs within each individual’s own mind by observing the behavior of others and relating it to resulting good or bad outcomes (2019). They also posited that social learning occurs on a group level when leaders establish a work culture (Bai et al., 2019). Similarly, Dietz et al. pointed out that social information processing theory states that people will adapt their behavior to the social setting they are in (2020). People naturally observe social cues as to the attitudes and behaviors which are considered appropriate in a given situation (Dietz et al., 2020). Binyamin referred to social influence theory which states that a person’s beliefs and attitudes are shaped through three basic processes (2020). One of the primary processes is identification, in the sense that individuals identify with others and shape their viewpoints accordingly (Binyamin, 2020). Social cognitive theory is similar to social influence theory. When a person has limited experience in an area, they can learn about it by observing others with more experience (Taiyi Yan et al., 2022). All of these are examples of modeling, where either individuals or groups learn how to behave based on the behavior of an example, or role model. Many researchers have discussed the importance of a role model behaving ethically. “(E)thical climate can potentially influence followers’ attitudes and behaviors because the 14 climate of a team taps into the crucial social learning processes of external and vicarious reinforcement” (Bai et al, 2019). In order to remedy a toxic workplace environment, Hoch et al. asserted that organizations must obtain new leadership (2018). They posited that it is a leader’s responsibility to behave ethically in order to promote ethical behavior in their followers (Hoch et al., 2018). Bai et al. pointed out that being ethical actually makes someone a better leader because people will be more willing to follow them (2019). An unethical leader can also cause a multiplier effect, as the organization will not only suffer from their bad actions, but also similar actions from those who follow them (Gächter & Renner, 2018). Majeed et al. referred to a leader’s demonstration of ethical behavior as an “idealized influence” (2017). Though idealized, good models should not necessarily behave as though they are superior to their followers. “Team power distance” refers to the degree to which team members feel their leader’s decisions should be respected and followed (Anand et al., 2018; Hu et al., 2018; Peng et al., 2021). According to Anand et al., power distance, “is the leader’s tendency to maintain power differential with followers due to the leader’s elevated status in the organizational hierarchy” (2018). Essentially, leaders with a high power distance are less approachable and more autocratic. Anand et al. believed that this results in poor role modeling, because the leader doesn’t know their followers personally and is unable to tailor their actions to each individual (2018). Additionally, employees don’t feel as much desire to please a socially distant leader and therefore have less motivation to act in the organization’s best interest (Anand et al., 2018). Hu et al. added that having a low power distance helps the leader to, “focus on identifying the talents of others, view themselves more objectively, appreciate others’ contributions, and display an openness to new viewpoints, thereby serving as positive role models” (2018). Peng et al., 15 however, disagreed (2021). They said that individuals in a high power distance organization (i.e. there is a large difference in the amount of power given to the leader compared to their subordinates) are actually more accustomed to directions from superiors and so more likely to follow their instructions (2021). They are, therefore, more likely to follow the attitudes modeled by the leader (Peng et al., 2021). There seems to be little doubt that modeling is an important aspect of leadership. It is a pivotal element in many leadership philosophies including social learning theory, social information processing theory, social influence theory, and social cognitive theory. The importance of ethical modeling is also emphasized in the research. As for the appropriate team power distance, it is still under debate. In any event, modeling remains a vital element of leadership. Leadership Behaviors & Attitudes: Challenge Another behavior that leaders have is to Challenge their employees by giving them an opportunity to use critical thinking and empowering them to achieve excellence. This concept comes from the transformational leadership style which is defined as “a leader who behaves like a figurehead or role model and drives common and shared goals and vision by offering a transparent and purposeful sense of working together” (Sitthiwarongchai et al, 2020). With this leadership style, this allows the leader the ability to work together with the employee and pave the way for them to feel motivated. This concept helps bring purpose to their work and allows them to get creative in their solutions to the problems they are faced with. By allowing healthcare workers to be creative with their solution, it can bring feelings of pride knowing that they are doing important work and what they are doing is truly making a difference. 16 This leadership style has four different aspects which are: idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration (Aryee et al, 2012). The aspect that allows the healthcare worker to feel challenged is intellectual stimulation. Intellectual stimulation is defined as “the capacity to challenge followers to question assumptions, take risks, think critically, and identify and solve problems proactively” (Aryee et al, 2012). By allowing healthcare workers some freedom in the way they perform their task, they may find a better solution to a problem. This can help the worker grow as an employee and as an individual and can lead to the employee feeling satisfied in their work. A study that was conducted in Thailand looked at the different leadership styles in the pharmaceutical industry and saw how they affected employee satisfaction. They state: Intellectual Stimulation (IS) is a style in which a leader challenges and encourages the status quo of employees by leading the subordinates and making them think out of the box to bring innovation and creativity in their work. He can force them to think about things differently and emphasize solving their problems and using the reasoning before implementing their solution (Sitthiwarongchai et al, 2020, p. 50). By challenging people to perform at their best, they begin to feel motivated to try to look for new ways to get better at their job. This can decrease the feelings of burnout and feeling pessimism about their work environment. Challenging people involves allowing them to use their own critical thinking to achieve tasks. Critical thinking is defined as “the art of thinking better and improving thinking” (Urhan et al, 2021, p. 3156). Critical thinking is an important skill to have and developing it will help people have success. In the field of radiology, technologists have to use critical thinking 17 everyday to solve problems to get the best diagnostic images for the physician. Improving diagnostic imaging is the number one goal for technologists because this will help get the physician the information they need in order for them to get a correct diagnosis for the patient. When people are challenged to exercise their critical thinking skills, it gives them the feeling of success and fulfillment when they are able to complete the task at hand. On the other hand, if their critical thinking leads them to an incorrect solution, then it can be a learning opportunity for the individual and others. If leaders can challenge technologists to use their critical thinking skills, then it will give them motivation to continue to try to find better solutions to the tasks at hand. Leadership Behaviors & Attitudes: Inspire Adding to the list, another key component of leaders is to inspire. Inspiration is defined as “to make someone feel that they want to do something and can do it” (Cambridge Dictionary, N.D.). In a survey, Garton identified 33 traits of an inspiring leader, but stated that only one attribute was needed in order to increase change within a leader. Centeredness is that one trait and is most significant (2017). It is important because it displays various qualities that equate to composure among leaders. When a leader has the trait centeredness, they are able to have a greater mindfulness state, which allows them to engage all parts of the mind to be fully present (Horwitch and Callahan, 2016). The leadership style that includes the characteristics of inspiration are transformational and engaging leadership. As stated above, transformational leadership is defined as “a leader who behaves like a figurehead or role model and drives common and shared goals and vision by offering a transparent and purposeful sense of working together” (Sitthiwarongchai et al, 2020). 18 Transformational leadership has the traits of idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration (Aryee et al, 2012). Idealized personal influence can be split up into an attribute or a behavior (Peciuliauskiene & Barkauskaitė, 2018, p.294). Peciuliauskiene and Barkauskaitė (2018) further explain that an attribute would be when the leader has a socialized charisma and a behavior would be when the leader has a charisma because of their specific behaviors. Both these characteristics from transformational leadership form an inspirational leader because they both result in people wishing to follow their leader’s footsteps (Peciuliauskiene & Barkauskaitė, 2018). Individual consideration is a “leader [that] attends to the needs and concerns of his followers by giving socio-emotional support” (Peciuliauskiene & Barkauskaitė, 2018, p.294). On the other hand, Schaufeli (2021) defined engaging leadership as a “leadership behavior that facilitates, strengthens, connects and inspires employees in order to increase their work engagement” (pg. 1). This is done by the leaders “enthusing their followers for their vision and plans, and by making them feel that they contribute to something important” (Mazzetti & Schaufeli, 2022, p.4) Engaging leadership differs from other forms of leadership in that it includes team unity and support for team talents. According to Mazzetti and Schaufeli (2022), teams that had an engaging leader “reported higher levels of happiness at work and trust in leadership, combined with lower levels of burnout than their colleagues who were led by poorly engaging leaders” (p. 4). When a leader is over a team, using engaging leadership will help inspire the team members, and will allow the team members to use their autonomy, be competent, and have relatedness which helps their personal engagement (Mazzetti & Schaufeli, 2022). 19 Geller (2022) stated in a quote about the difference between management versus leadership “...managers hold people accountable while leaders inspire people to be self-accountable.” Managers may lead through punishment where inspirational leaders influence their employees to recognize an issue and help them seek improvement for themselves and their team. Empowering individual employees increases their efficiency and their production (Garton, 2017). According to Geller (2022), leaders can inspire empowering behavior in people by providing opportunities to them, including responsibilities and tasks. Asking empowering questions assures that individual employees have the resources necessary to accomplish the tasks they are assigned to the best of their abilities. Leadership Behaviors & Attitudes: Enable Enabling in a common sense carries a negative connotation of endorsing poor behavior and attitudes, but the opposite is true as well. Enabling people to do their best work allows true excellence to be obtained. There is also a connotation that enabling is to permit someone to do something, as if a manager is some type of fickle regent sitting on a throne allowing events to happen only when subjects ask permission. While that connotation exists for good reasons, it will be expanded into its truer, wider spectrum. At one end, there is the manager who condoned, either implicitly or explicitly, negative behavior that harmed the overall team (Alrubaysh, 2022). At the other, enable is used in the sense of a leader who knows, “that they can’t do it alone. They need partners to make extraordinary things happen in organizations.” (Kouzes, 2012, p. 214). Enabling in this sense demands action from those with power and who are in the position to identify and remove obstacles from individuals and teams so they feel confident and capable to achieve more. Those obstacles can take many forms, including attitudes within the individual 20 themselves (Abdulkareem, 2021). Furthermore, enabling carries with it a component of boundary-less positions. Anyone can halt a process if they see an issue, (Ohno, 2019) which sounds simple, but in practice proves more difficult as embedded hierarchies and culture persist despite attempts to change them. These lead to expectations which are passed down and enforced, many times in ignorance of the original purpose. However, social-technical systems like Toyota’s Production System and derivatives of it demonstrate how a culture of trust permeating an organization can lead to increased effectiveness and profitability with employees reporting higher confidence and capability to effect change within a system (Asencio, 2016). As medical advances further connect us in what Sheldon Gaylin calls the coming of the corporation (2016), it is imperative that team members both possess and share a sense of capable and confident collaboration. The days of individual private practices dictating all aspects of care are becoming more rare. Increasingly, these clinics form small pit stops in a vast network of providers and specialists who need to collaborate towards the best outcomes for the patient (Gaylin, 2016). “Exemplary leaders understand that to create [this] climate of collaboration, they must determine what [each] group needs in order to do their work, and build the team around a common purpose and mutual respect” (Kouzes, 2012, p. 218). This of course is difficult to do from the safety and insulated isolation of an administrator position. It requires leaders who know what the day to day activities of the department are, and consistently work to make their processes and workflows better. Leaders who maintain the status quo because it is how they were trained or out of some sense that less senior techs must “do their time” do not imbue a department or team with any sense of a greater purpose outside of depressing work environments with outdated standards and policies. 21 One of the most challenging aspects of leaders who wish to enable positive behaviors are the intangibles which encourage or discourage teams towards a common goal. These behaviors are difficult to measure and encompass a wide range of activities which carry subtle meanings and implications of team attitude, decisions, and work environment and in which trust or distrust becomes manifest. This same trust is also a “strong, significant predictor of employee satisfaction” (Kouzes, 2012, p. 219) which was discussed earlier, so it is important to take those small unofficial interactions seriously. Leadership Behaviors & Attitudes: Encourage Working in healthcare sometimes requires an imaging professional to endure stressful environments and situations. Lack of gratitude for hard work and dedication can lead to burnout and dissatisfaction. According to Jalilianhasanpour et al, “the feeling of gratitude is one of the most essential emotions experienced in positive environments” (2021, p. 2). This author also suggests that gratitude promotes employee wellbeing, cooperation, and decreases negative emotions, such as jealousy and perceived injustice. Therefore, encouraging imaging professionals by showing them appreciation is one of the most invaluable methods for ensuring they are satisfied with their employment and career. Good leaders will consistently encourage their team members. Encouragement can be presented through various methods, including personal feedback, rewards, and monetary compensation and benefits. In healthcare, burnout and staffing issues are on the rise, and the imaging field is not exempt. Yet, it is evident that “frequent feedback and communication is the most helpful intervention when it comes to working in an understaffed facility” (Kasner, 2020, p. 478) and 22 leaders have the power to help reduce technologist burnout by “reassuring staff of their worth” (Dunlop, 2015, p. 541). They can accomplish this by honoring them and acknowledging their achievements and valuable contributions to the company. Jalilianhasanpour et al (2021) go on to say that leaders can acknowledge employees during group meetings, in newsletters, on social media platforms, recognizing an employee of the month with a prize, and by taking the time to have one on one meetings to thank them individually. Employees appreciate this recognition and appreciation for their hard work, but it must be done on a regular basis. A chief complaint of medical imaging employees is that they are overworked and underpaid. While money can certainly not buy happiness, Jalilianhasanpour et al postulate that “the lack of money can certainly lead to unhappiness” (2021, p. 4). This is especially true if an employee believes he or she is not being compensated fairly compared to fellow coworkers. Another contributor to employee dissatisfaction is a poor employment package, including benefit and incentive plans (Jalilianhasanpour et al, 2021). Ultimately, imaging professionals should receive fair market value pay and benefits in order to be happy with their employment. Leaders cannot always directly increase their employees’ salary, yet they certainly have the power to impact change by constantly advocating for them and ensuring they are kept up to date with any changes. An interview conducted by Hardy revealed that imaging professionals “work hard, wish they were paid more, and do not always feel appreciated.” (p. 18) Ultimately, fair compensation is important, but recognition and appreciation is imperative to their happiness and satisfaction (Jalilianhasanpour et al, 2021). Another interview conducted by Hardy suggested that simply “picking up the phone and thanking the [technologists] or texting messages of gratitude can go a 23 long way” (p. 18). It is evident that medical imaging leaders must encourage their team members if they desire to promote a positive work environment. Employee Satisfaction: Employee Engagement Employee engagement is a term used to describe the degree of emotional and behavioral energy an employee chooses to invest towards achieving the goals of an organization. It is a term that has garnered more attention in recent years as employers have come to understand its significance. This is specifically true of healthcare employers as evidenced in a review of the current literature on the topic. William Kahn’s (1992) paper “To be fully there: Psychological presence at work” was one of the first times the concept of what is now employee engagement was explored. Later, Shauffeli and Salanova (2001) built on this work hypothesizing “a three-factor structure of engagement (vigor, dedication, and absorption)” (2001, p.45) that has since become the standard characteristics by which engagement is identified. Since then, many studies have investigated employee engagement in both terms of the benefits it provides employers, as well as actions employers can take to foster engagement in their workforce. When examining the literature, common themes emerge in both of these areas. Employee engagement has shown to be positively influenced by two main sources that can be categorized as personal resources and organizational resources. Personal resources would include an individual's personality traits such as optimism and resilience (West, 2012), and organizational resources would include “physical, social, or organizational aspects of the job” (2012, p.11). However, for researchers’ purposes, it is important to note that organizational 24 resources are considered more influential than personal resources (Wall, 2015). Those resources controlled by the employer have been found to be similar throughout multiple studies. Over the years, research studies have put forward common themes that are significant predictors of employee engagement. Some of the most consistent appear to be a supportive management that is manifested by providing clear communication, endeavoring to make employees feel valued and respected, developing trust, and allowing for autonomy on the job. In addition, they agree on several more tangible ways employers can cultivate engagement, such as appropriate compensation, recognition and feedback, training, and proper resources and staffing levels that ensure workloads are reasonable (Almotawa et al, 2021; Gupta and J, 2017; Lowe, 2012; West, 2012). Interestingly, the paper “Employee (Dis)Engagement: Learning from Nurses Who Left Organizational Jobs for Independent Practice'' (Wall, 2015) takes a different approach that further demonstrates the cruciality of these factors. Within this study, the authors interviewed healthcare workers who had decided to leave their employment in order to determine the influencing factors. Again, but conversely, a lack of feedback, autonomy, role clarity, reward and recognition, adequate staffing and resources, managerial interest, and empowerment emerged as significant factors in their decision, and are therefore clearly significant in maintaining employee longevity, retention, and engagement. When considering the benefit of employee engagement for the organization, there was even greater consistency in the research. In each of the studies mentioned above, engagement was linked positively to employee productivity and performance, as well as decreased employee turnover and absenteeism, which all amount to the increased economic success of the 25 organization. Furthermore, from the patient perspective, satisfaction, quality of care, and safety are all improved. Perhaps most significantly of all, multiple studies also reported decreases in patient mortality when employee engagement was high (Gupta, 2017; West, 2012). Employee Satisfaction: Employee Performance An employee's work performance is greatly influenced by their satisfaction with the organization they are associated with. In order for a healthcare organization to be effective, employees should be working to their full potential. In an article published by Deriba et al., they state “job satisfaction of health workers is important for motivating employees and improving efficiency, as higher job satisfaction is known to improve employee performance and patient satisfaction” (2017, pp. 1-2). When employee performance is not at its full potential, the health care organization will be negatively affected through employees “decreasing productivity and increasing work accidents, intra-organizational conflict, employee turnover, tardiness, and grievances” (Deriba et al., 2017, p. 2). The cross-sectional study showed that if employees were recognized and praised for their hard work, it increased their job satisfaction, which ultimately increased their work performance (Deriba et al., 2017). A supporting article performed by Kuzey showed that job satisfaction and performance are affected by these four factors in order of importance: management's attitudes, pay/reward, job security, and colleague dimensions (2018). On the contrary, some studies show that there are “conflicting results concerning the relationship between job satisfaction and performance” (Kuzey, 2018, p. 50). With some researchers going so far to say that the measures themselves shouldn’t be used to predict specific job performance, (Murphy, 2019) but this debate has continued for over 60 years. One notable attempt to quantify this relationship was performed via meta-analysis on 74 studies by 26 Laffaldano and Muchinsky, who were surprised to find a median correlation of 0.17 - hardly a relationship at all (1985). Due to the ongoing lack of empirical evidence demonstrating the relationship between performance and satisfaction, there has been a push to test individual variables or consider them both relying on, and influencing each other in a dual path approach (From, 2006). All the above was done in an attempt to find valid tools and measures that can reliably and precisely predict future job performance, but with mixed results. Fortunately, in more recent times, researchers have begun to extract specific variables and test their connection to job performance and satisfaction with arguably more accurate and significant results. One such measure comes from social learning theory in the form of ethical leadership (Brown, 2005). Brown provides a framework via the umbrella term of ethical leadership for the range of behaviors associated with job performance and which has been studied broadly in real world applications (Byun, 2018). Ethical leadership has been shown to have a positive effect on job performance (Zheng, 2015), emotional exhaustion (Lin et al, 2023), and can have echoing effects throughout an organization (Byun et al, 2018). From the results of these studies, ethical leadership is one appropriate framework to measure job performance in radiology departments by defining it in relation to leader behaviors. Employee Satisfaction: Well-being Another key aspect in employee satisfaction is their well-being. This is defined as the ability of employees to balance their work with their personal life in a way that they can sustain their mental, physical, emotional, and economic health throughout their career. Well-being has been incredibly vulnerable in health care workers since the COVID-19 pandemic. Factors that 27 contributed to this include “pressure at work, large workloads and long shifts” (Nightingale et al., 2021, p.765). Long shifts that cause mental fatigue have negative effects on well-being and can be “correlated with potential for increased errors and decision making” (Nightingale et al., 2021, p. 800). Physical well-being has been affected in imaging departments such as mammography and sonography due to the repetitive nature of the exams performed. These employees may suffer from “work-related musculoskeletal disorders and pain” (Nightingale et al., 2021, p. 800). This study also states that emotional fatigue is a precursor to burnout, which is a “state of mental weariness which is a sustained response to chronic workplace stressors, leading to decreased effectiveness, reduced commitment, and negative effects on home life” (Nightingale et al., 2021, p. 800). Economic well-being has also been impacted because there was not an opportunity to earn additional income with the increased hours and workload employees faced. (Nightingale et al., 2021). All of these factors have contributed to decreased employee satisfaction and have resulted in many professionals leaving their jobs in medical imaging. Solutions should be discovered and implemented in order to improve employees’ well-being to ultimately increase employee satisfaction. Recovery is important to protect individuals’ well-being in order to maintain balance between employees' work and personal life. In a study by Poulsen and Poulsen, they identify internal (happening during work) and external (occuring after work) recovery options (2018). Daily internal recovery may look like “a short break during work hours, for example, a coffee break with colleagues” (Poulsen & Poulsen, 2018, p. 688). The study defines daily external recovery as “engaging in replenishing activities that help rebalance suboptimal systems and return stress-related reactions to pre-stressor levels before the next working period commences” 28 (Poulsen & Poulsen, 2018, p. 688). They suggest stress-relieving hobbies such as physical exercise. (Poulsen & Poulsen, 2018). In a qualitative study performed by Cogan et al., they found three themes that supported employee well-being: “self-care and peer support (checking in with each other), team cohesion and collaboration and visible and supportive management and leadership” (2022, p. 164). Participants stated that practicing self-care and leaning on each other, as well as management, improved their confidence and ability to manage stress during the pandemic (Cogan et al., 2022). This article supports the study by Poulsen & Poulsen showing that self-care, as well as peer and leadership support, can alleviate stressors and improve individual well-being. Summary In summary, successful leadership involves modeling desired behaviors, inspiring and motivating the team, challenging individuals to grow, empowering them to make decisions, prioritizing well-being, and driving performance towards achieving organizational goals. A combination of these attitudes and behaviors allows leaders to build strong, engaged, and high-performing teams. Reviewed literature indicates a leader should create a work environment for their staff to thrive and excel at their job. By modeling these behaviors leaders are “influencing followers to engage in normatively appropriate behavior by setting an example of appropriate, ‘do what is right,’ behaviors” (Hoch et al., 2018). They can challenge their staff by allowing those they lead to be creative with their solutions, which brings feelings of pride knowing that they are doing important work and what they are doing is truly making a difference. It is also important that “leadership behavior facilitates, strengthens, connects and inspires employees in order to increase their work engagement” Schaufeli (2021, p.1). 29 Literature reinforces time and time again “Exemplary leaders understand that to create a climate of collaboration, they must determine what groups need in order to do their work, and build the team around a common purpose and mutual respect.” (Kouzes, 2012, p. 218). When encouraging employees, “frequent feedback and communication is the most helpful intervention when it comes to working in an understaffed facility” (Kasner, 2020, p. 478). All of these behaviors and attitudes will affect an employee’s satisfaction, whether it be how efficient an employee’s performance is, how engaged they are with their organization, or the employee’s ability to balance their work with their personal life in a way that they can sustain their mental, physical, emotional, and economic health throughout their career. With all that said, there are still questions left unanswered determining the relationship between leadership behaviors and attitudes which have an effect on employee satisfaction specifically within radiology departments. Our research highlights the importance of determining this relationship between a leaders’ behavior and attitudes as it relates to employee satisfaction. By showing a correlation between these two variables, positive implementation can be made within radiology. 30 Chapter 3: Research Method Our research seeks to examine how specific markers of employee satisfaction are influenced by employees’ perception of their leader’s behaviors in context with broader departmental policies. We turn an analytical eye to the metrics of employee performance, engagement, and well-being in the workplace. We suspect these specific markers make a palpable difference in employee satisfaction and therefore merit close inspection to encourage improvement in all areas possible. The purpose of this mixed-method study is to examine the relationship between leadership behaviors and how they affect employee satisfaction, as defined by the variables of performance, engagement, and well-being. A quantitative survey and qualitative semi-structured interviews were conducted among professionals within the field of radiographic science. Surveyed subjects were asked to rate their individually perceived levels of agreement or disagreement along a Likert scale in response to several statements. Each statement is related to the behaviors the participant perceives to be exhibited by leaders within their place of employment. The statements are correlated to the perceived effect those behaviors have on personal and peer employment satisfaction, performance, and resilience. Aggregate scores for leadership Models were explored along with several independent subvariables of leadership, including the ability to Inspire, Challenge, Enable, and/or Encourage their employees. Qualitative semi-structured interviews were included to express emotion, depth, and genuine experience. The qualitative transcripts were reviewed and coded to identify modifying or moderating variables that may be affecting leadership behaviors, employee satisfaction, 31 performance, and/or resilience. Coded outcomes and examples of this narrative provided data for qualitative analysis. Population Our study was designed to examine the relationship between leadership behaviors/attitudes and employee satisfaction within the field of Radiology. Therefore, it was decided the relevant population for this study would include a cross section of imaging professionals from various modalities in as broad a region within the United States as we could reasonably accomplish. Imaging professionals make up a significant number of healthcare workers in the United States. According to the Bureau of Labor Statistics, in 2021 there were 216,386 Radiologic /CT Technologists, 78,640 Sonographers, 38,070 MRI Technologists, 16,400 Radiation Therapists, and 17,140 Nuclear Medicine Technologists employed in the United States, with projected employment growth between 6-10% over ten years. The American Registry of Radiologic Technologists currently has over 350,000 registrants. In addition, there are 90,000 Sonographers registered with the American Registry for Diagnostic Medical Sonographers. These numbers indicate the size and job diversity of the population which our study hopes to draw from to provide meaningful insight into current job satisfaction as it relates to leadership style. Sample Given this is a mixed method study, the research team had two separate sampling groups that were pulled from the population. Both components of the study employed a convenience sampling methodology in the collection of data. This method was determined to be appropriate for the study size and type being conducted, and was selected given its low-cost nature, time 32 restraints for research, and ease of response collection. Our intention was to elicit at least one hundred responses to our survey and conduct six in-depth interviews. With the intention to collect data from as wide a cross-section of imaging professionals as possible, we utilized a digital survey that could be accessed nationwide. We then recruited respondents from our individual professional contacts via email, as well as imaging social media platforms with a QR code link. Inclusion requirements for both portions of the study comprised current employment within the field of medical imaging and residency within the United States. Technologists from all modalities and facility types were included, as well as all appropriate education / certification levels. Students, retired technologists, and those in management positions were excluded from the study. In addition, for the qualitative segment of the research, further selection criteria that were considered were obtaining a spread of age, years of experience, facility type and modality. Materials/Instruments The variables in this study were measured using a survey and structured interview. Subjects were invited to participate in a research study on how attitudes and behaviors of leaders relate to employee satisfaction and were given the option of participating in either a fifteen minute survey or a thirty minute structured interview. Both instruments included a demographics section including job title, primary clinical practice, years of work experience, worksite, second worksite (if applicable), academic level, modality, registry status, gender, age, ethnic background, location, marital status, dependents, gross income, number of technologists in department, and leader description. Participants gave informed consent before participating in either the survey or the interview. 33 For the quantitative instrument, subjects entered the survey through an internet link and were provided with a brief description of each variable prior to the corresponding set of statements that measure that specific variable (Appendix A). Subjects were then asked to respond to each statement on a 5-point Likert scale from Strongly Agree to Strongly Disagree. The survey consisted of a set of thirty-two questions which were carefully developed by our research team of medical imaging professionals who, based on their professional experience, determined the qualities that would measure each variable. There were two parts to the survey. The first part was a leadership characteristics survey, which aimed to measure the leadership characteristic variables: Model, Inspire, Challenge, Enable, and Encourage. There were four statements listed under each of these five variables, for a total of 20 statements for this section of the survey. There was at least one negatively worded statement in each set of four. The second part was an employee satisfaction survey, which aimed to measure the employee satisfaction variables: performance, engagement, and well-being. There were four statements listed under each of these three variables, for a total of 12 statements for this section of the survey. There was also at least one negatively worded statement in each set of four. For the qualitative instrument, subjects participated in a structured interview. The structured interview questions were created or selected using specific leadership behaviors derived from the quantitative instrument Likert scale questions. The questions were structured to measure responses in two different areas. First, what a leader’s current behavior is and how it relates to the participant’s satisfaction as defined by the sub-variables performance, engagement, and well-being. Second, what future behaviors from leadership are desired from participants to improve their satisfaction along the same sub-variables (Appendix B). Questions were designed 34 to be open ended while at the same time specific enough that responses could be later categorized and coded towards the desired behaviors. The ultimate purpose of these questions being to further explore the results of the quantitative survey by explaining how specific actions can contribute or detract from employee performance markers and how strong those relationships can be in the future. Those being interviewed were given a consent form prior to the interview (Appendix C). The one-time interview link was sent over the Zoom video web conferencing platform. Zoom was chosen due to its current popularity meaning a majority of respondents would be familiar with the platform thus, making responding more likely and easy. Furthermore, Zoom provided security features for anonymity and recording for researchers to refer back to if needed. At the same time the Zoom interview took place, a recording & transcribing tool named Otter.ai was used to transcribe interview audio in real time. Once Otter recorded the interview using AI algorithms, researchers compared each transcription against each interview’s audio and made edits for clarity, accuracy, and anonymity. The zoom videos were then stored in a secure archive and the deidentified transcriptions in a secure database to await coding. Researchers used a hybrid coding approach to mark each transcription into behavior categories in line with the behaviors measured in the quantitative survey. Once grouped, responses were then organized by strength of relationship and frequency. This was then compared to the quantitative data to find similarities and inferences into which behaviors can have the most impact for Radiology departments in both positive and negative ways. Examples and direct quotes from the results were used to explain some of the responses seen in the quantitative survey, especially in the most frequently reported responses. 35 Operational Definition of Variables The attitudes and behaviors of leadership. This was the predictor and independent variable, and the results were ordinal. In this study, we sought to measure the degree to which current leaders in the field of Radiographic Science employ research-based characteristics of leadership. When we refer to the attitudes and behaviors of leadership, we are referring to the manner in which they interact with their subordinates on a daily basis. These interactions may consist of setting an example, training, disciplining, and/or rewarding the employees they lead. In order to measure these characteristics, we employed the sub variables of Model, Inspire, Challenge, Enable, and Encourage. For the quantitative study, the attitudes and behaviors of leadership were measured using a scalar Likert scale. For each sub variable, there were four defining statements, and the respondents were asked to rank their level of agreement with each statement on a scale from 1-5. The levels of agreement were 1. strongly disagree, 2. disagree, 3. neutral, 4. agree, and 5. strongly agree. Negative statements were reverse scored. Since there were four questions for each sub variable and five possible points of agreement for each question, there were 20 possible points for each sub variable. There were five sub variables, so the total possible points for leadership attitudes and behaviors was 100. For our qualitative study, we performed semi-structured interviews with six subjects. The subjects were asked to discuss their opinions of how each sub variable of leadership is or is not embodied by the leaders in their workplace. They were also asked about future behaviors in each sub category which might be beneficial. Responses were recorded, triangulated, and coded into common themes based on principles of grounded theory. 36 Employee Satisfaction. This was the criterion and dependent variable, and the results were ordinal. Employee satisfaction refers to the degree of enjoyment employees find in their work. Employee satisfaction is demonstrated when the employee does not dread coming to work each shift, performs tasks willingly, and feels that their job contributes to their own sense of fulfillment. In order to measure employee satisfaction, we utilized the sub variables of performance, engagement, and well being. For the quantitative study, employee satisfaction was also measured on a Likert scale. There were three sub variables, and there were four statements pertaining to each sub variable in the survey. The respondents were asked to rate their level of agreement with each statement on a scale from 1-5. The levels of agreement were 1. strongly disagree, 2. disagree, 3. neutral, 4. agree, and 5. strongly agree. Negative statements were reverse scored. As there were four statements and a possible five points each, each sub variable was worth 20 points. And, as there were three sub variables, the total possible number of points for employee satisfaction was 60. For the qualitative study, in addition to the discussion of each of the sub variables of the attitudes and behaviors of leadership, the interviewers discussed each of the sub variables of employee satisfaction with each subject. These participants were also asked to comment on how those behaviors affected their (the subject’s) performance, engagement, and well-being in the workplace, and responses were recorded, triangulated, and coded into common themes based on principles of grounded theory. Data Collection, Processing, and Analysis A mixed method design was utilized to identify relationships between leadership behaviors and employee satisfaction in imaging departments. A survey was used to define and 37 quantify employee's perceived leadership characteristics including Model, Inspire, Challenge, Enable, and Encourage as related to employee satisfaction characterized and measured with employee performance, engagement, and well-being. The survey was 48 questions in length and included demographic information and statements regarding leadership characteristics and employee satisfaction measured on a Likert scale on which participants could choose to agree or disagree to varying degrees from 1-5. All data was input into Qualtrics and exported to SPSS for analysis. Any incomplete survey or survey without informed consent was removed from the analysis. We performed a two tailed Pearson correlation to determine the likelihood of a relationship between the predictor, leadership attitudes and behaviors, and the criterion variable employee satisfaction. We also performed one way analysis of variance tests to determine if a subject’s responses varied depending on their level of education, years of work experience, number of jobs worked, the type of facility they worked in, or their job specialization (i.e. CT, MRI, US, etc.). Semi-structured interviews were used to understand the complex emotional response employees have to leadership behaviors and the ways behaviors may increase or decrease employee satisfaction. Researchers conducted 6 semi-structured interviews through video conferencing software (e.g Zoom). A standardized set of open-ended questions were used with each interview, and each interview was approximately 30 minutes in length. Each participant was given ample opportunity to answer each question, and all interviews were recorded and transcribed by Otter.ai algorithms. Researchers reviewed the interview transcripts on the sentence level, developed a matrix of common themes and frequency, and organized triangulated 38 themes research questions. A variety of codes were identified, and each code was evaluated for redundancy and clarity. Assumptions In order to conduct this study, the following assumptions were made by the researchers: 1. The participants were honest with their responses. 2. The participants were mentally competent enough to properly respond to the survey/interview questions. 3. The participants thoroughly read and understood the survey/interview questions. 4. The participants adequately represented the target population. 5. The participants consistently answered questions about the same leader. Several steps were taken to ensure we could make these assumptions. Informed consent was an important first step in this process. Additionally, we thoroughly wrote and edited the survey and interview questions to be as clear and concise as possible. We also used a variety of questions, some worded positively and others worded negatively, to ensure participants were thoroughly reading the questions and not providing impulsive responses. Any surveys that would significantly alter the data, such as those that did not complete a significant portion of the survey or those that are retired, were excluded from the study. Finally, because this study specifically measures employee satisfaction in healthcare workers within the field of radiologic sciences, only those who met that criteria were invited to participate. Limitations While more than the desired sample size was obtained, this amount only represents a small fraction of active registered imaging professionals. Researchers attempted to garner 39 responses from as many areas of the country as possible, and from multiple modalities to ensure responses would represent a cross section of modalities and experiences present in radiology to mitigate modality bais. This approach was also used to obtain results that are applicable to as many technologists and leaders as possible, regardless of their facility, organization, or makeup. Because of the anonymous nature of the survey, no safeguards could be implemented to stop multiple responses from the same person. It is possible that a respondent could take the survey multiple times, although given the length of the material and the anonymous nature of the survey there is little benefit outside personal enjoyment of surveys, for someone to do so. The survey was estimated to take 15 minutes to complete, but no extensive testing was done to confirm this. Depending on a participant’s ability and work/life load the survey may represent a significant investment of time. Questions were created based on ease of comprehension and specificity to help eliminate any lengthy reading or comprehension lapses in responding individuals. Furthermore, researchers did not possess unlimited time and resources for this study. Researchers worked along commonly accepted guidelines and with best practices, but pre-established deadlines ultimately meant researchers were unable to test all possible variations of instruments and that the resulting analysis and conclusions reflect this limitation as well. The survey was conducted online with access to the internet required for individuals to participate, which may have excluded some possible participants. Additionally, a QR code was utilized to offer easy access to the survey in order to gather as many responses as possible. Older technologists may not be aware of, nor know how to use a QR code to access the survey. An accompanying survey link URL address was sent out with the QR code on invitational emails 40 and texts to give an additional option for participants to enter the survey. Researchers anticipate these limitations will be minor due to the central nature of technology in the participants’ careers and roles within healthcare. Due to the anonymous nature of the survey no attempts to verify a participant’s status or licensure was made. Invitations were made to known medical personnel and the nature of this study being mostly of interest to imaging technologists would discourage participation from any large number of dubious actors. This is the first time this survey instrument was utilized and no testing was performed on the instrument itself. Extensive debate and refining took place before distribution to ensure that the instrument would be understandable to a majority of respondents, but there is no evidence suggesting this instrument is more understandable or superior to another survey instrument. Delimitations The survey was completed by 245 participants in the radiology field. Three participants only took the pre-survey but did not complete the rest of the survey, and were therefore excluded. Additionally, six participants did not give consent and were excluded. 43 participants did not complete the entire survey and were excluded. Two participants listed their job as retired and were excluded. Finally, two more participants did not respond to a significant portion of the survey and were therefore excluded. The remaining total was 189 participants. Going through the survey answers, some questions were not answered by the participants. These missing values were placed with ‘0’. There were also several participants who chose to write in their response rather than choose from the drop down menu. These participants had their write-in response as part of the drop down menu so we changed it accordingly. One participant 41 answered that they belonged to several different races so the response was changed to ‘mixed’. When questioning the participants job title, the responses with less than 5% of the participants were consolidated into an ‘other’ category, which include: Administrator/Manager, Supervisor/Assistant, Chief Technologist, Program Director, Clinical Coordinator, Clinical Instructor, Director, Clinical Research Coordinator, and No Response. The question regarding the participants’ primary clinical practice was consolidated as well. All the responses with less than 5% were put into an ‘other’ category which included Cardiovascular Interventional, Mammography, Nuclear Medicine, Vascular Interventional, Research Center, and No Response. The same process was applied to the question regarding the participants’ worksite. The categories that were placed in the ‘other’ category were Armed Forces, Imaging Center, Mobile Unit, Maternal Fetal Medicine, Research Center, Other, and No Response. There were also a small number of responses for the answer ‘Rural Hospital 1-25 beds’ so that was combined with the ‘Small Hospital 25-100 beds’ response in a new category called ‘Small Hospital 1-100 beds’. The question regarding the participants’ education had two write-in answers which were consolidated into an ‘other’ category. The two write-in answers were In School, and Australian Degree plus a Graduate Diploma. Finally, the last question that needed consolidation was the question regarding who is your leader. The responses with less than 5% were consolidated into the ‘other’ category. This list includes Radiologist/Physician, VP, and Other. This concluded cleaning the data for statistical analysis. 42 Ethical Assurances Institutional Review Board (IRB) approval safeguards the well-being of participants and requires researchers adhere to ethical values. Prior to data collection, this study’s objectives and methods were submitted to and reviewed by the Weber State University IRB and accepted as low risk and exempt. Subjects were invited to the study based on whether they were employed in medical imaging within the United States. It was intentional to invite participants who would meet the objectives of the study and personally benefit from the study’s outcomes. Before participation, all participants were provided the appropriate informed consent. Even after consent was given, participants had the ability to withdraw from the study at any point without risk of retaliation or retribution. Each participant was informed that some questions may be sensitive in nature and uncomfortable to answer because it related to their work experience. Thus, participants were informed of their right to privacy and confidentiality. All participants’ personal data was kept private, as required by law, to the best of the researchers’ abilities. Absolute confidentiality cannot be guaranteed. However, no participant names, addresses, or other identifying information was collected and maintained. All surveys, transcripts, and other survey data were coded and in sole possession of the researchers under password protection at all times. All data will be destroyed within 2 years of the study’s completion. Summary This mixed-method study examined the relationship between leadership behaviors and how they affect employee satisfaction. The population for this study included a cross section of imaging professionals from various modalities within the United States. 43 Both components of the study (quantitative and qualitative) employed a convenience sample due to its low-cost nature, the time restraint for the data collection, and ease of response collection. Inclusion criteria was based on current employment within the field of medical imaging and residency within the United States. Exclusion criteria included those who were students, retired technologists, and those in management positions. The study’s independent variable was the attitudes and behaviors of leadership and the dependent variable was employee satisfaction. The mixed-method design was used in order to determine the relationship between these variables. Prior to any data being collected, the IRB approved the research study to determine how leaders affect employee satisfaction. Participants could voluntarily withdraw at any time and consent was given from each participant. The survey created in Qualtrics, was 48 questions in length which included demographic information and statements regarding leadership characteristics and employee satisfaction. It was measured on a Likert scale where participants could agree or disagree to a statement on a scale of 1-5. Any incomplete data from the survey was removed from the analysis. SPSS was utilized and aggregate scores of the independent and dependent variables were correlated to determine a relationship between the two. Descriptive statistics were used to further explore the perceived level of leadership behaviors and employee satisfaction. The survey was completed by 245 participants and after removing any incomplete surveys, 189 participants were left and were included in the statistical analysis. Any survey that had partial missing values were assigned a zero in place of the missing data. The interview portion of the study explored the emotional and intricate responses of the participants’ satisfaction based on their leader’s behaviors. The interviews had a standard set of open-ended questions and each interview was approximately 30 minutes in length. The interviews were recorded and transcribed 44 by Otter.ai. The interviews were reviewed and a matrix was formed of common themes and the frequency of the themes were coded. A variety of themes were discovered and documented. Assumptions for the study stated that participants were who they said they were, they would be honest in their answers, they were mentally competent, that each participant read and answered all the questions about the same leader, and that our study was created to be clear and concise. Questions were formatted in a positive and negative way to keep readers engaged. Participants were not included in the study if they did not meet inclusion criteria. Limitations to the study include: sample size, unlimited access to the survey, time restraints of the data collection, being in a digital format only, being unable to verify participant identification, and limited pilot study testing. 45 Chapter 4: Findings The purpose of this mixed-method research study was to answer three questions. First, to find whether there were any relationships between attitudes and behaviors of leaders (specifically how they Model, Inspire, Challenge, Enable, and Encourage), with technologists’ satisfaction in the workforce (specifically, their performance, engagement, and their well-being). Second, to see whether there were any positive or negative relationships between said leadership attitudes/behaviors to said employees’ satisfaction. Third, to explore what future changes may be the most important for maintaining or improving the leadership attitudes and behaviors for shortand/or long-term benefits to employee satisfaction. For quantitative analysis, participants were asked to complete a survey answering questions on how their leader Models, Inspires, Challenges, Enables, and Encourages their technologists. They were then asked questions about their own performance, engagement and well-being in the workplace. Their responses generated quantitative data that were cleaned and statistically analyzed in SPSS which showed a moderate positive correlation between leadership’s attitudes/behaviors and employee satisfaction. Overall, statistical analysis indicated that the strongest leadership behavior affecting employee satisfaction was to Encourage, followed closely by Inspire. During qualitative data collection, six participants completed a 30-45 minute semi-structured interview. Participants were asked three general and follow up questions relating to each leadership quality. To begin, participants were asked whether they perceived their respective leader as having specific leadership qualities (Model, Inspire, Challenge, Enable, and Encourage) and how this quality was demonstrated. Second, researchers and participants 46 discussed how this attribute was perceived to have a positive or negative impact on their employee satisfaction. Last, participants were asked whether there were any future changes their leaders might make to improve employee satisfaction. After the interviews were performed, transcripts were analyzed to identify common themes between interview subjects. Overall, there were several themes found in each attribute, each containing themes that positively affected the employee’s satisfaction, and themes that negatively affected the employee’s satisfaction. Results Quantitative Findings A total of 245 participants took our survey. Of this total, three participants did not meet our participation criteria, and were excluded. Other exclusions included; six participants who did not consent, two participants who listed their current job title as retired, 43 participants who did not complete the survey, and two participants who failed to respond to a significant number of questions. After an applied inclusion and exclusion criteria, a total of 189 participants remained. Of those 189 participants, nearly half (N=84, 44.4%) were sonographers. Comparing the percent of respondents vs. the industry as a whole, CT and x-ray techs appear to be underrepresented. Only 29.6% of respondents worked in x-ray and CT, whereas these modalities constitute 59% of the industry as a whole. Sonographer responses were almost the complete opposite. Whereas the representative sample for x-ray and CT technologists constitutes roughly half of the actual percentage in the total population, sonography respondents were more than double the number seen in the industry. Sonographers constitute about 21% of the industry, but 44.4% of survey respondents were sonographers. 47 However, upon analysis, there did not appear to be a statistically significant difference in leadership and satisfaction scores between the various modalities (see Figure 1). Figure 1 Respondents reported a variety of clinical settings. The largest group (N=60, 31.7%) reported working in a medium sized hospital, which we defined as being between 100 and 499 beds. Those who worked in large hospitals (N=43, 22.8%), defined as being more than 500 beds, were close to the number who worked in a clinic or outpatient setting (N=46, 24.3%) (see Figure 2). Upon analysis, there wasn’t a statistically significant difference in leadership or job satisfaction scores among participants in various clinical settings (see Table 1). 48 Figure 2 Table 1 Participants by Clinical Setting Mean Leadership Mean Satisfaction Clinic/Outpatient 71.2 42.5 71% 71% Small Hospital 78.6 41.6 79% 69% Medium Hospital 73.1 42.2 73% 70% Large Hospital 73.4 41 73% 68% Physician Office 76.6 43.6 77% 73% Other 75.1 43.8 75% 73% Leadership % Satisfaction % The majority of participants held either a bachelors or associates degree (93.2%, N=177 overall) (see Figure 3), and reported that they are registered in the discipline in which they work (94.2%, N=178). The participant’s level of education did not correlate with statistically significant differences in perceived leadership or job satisfaction (see Figure 3). 49 Figure 3 Among the participants, most had in the range of 1-20 years of experience. Here again, neither perceived leadership nor job satisfaction demonstrated a significant difference according to years of experience (see Figure 4). Figure 4 50 Income was also surveyed, and a large majority of participants reported an annual income in the $50,000-$100,000 range. This coincides with the mean annual wages for Radiologic Technologists and Technicians, $70,240, Magnetic Resonance Imaging Technologists, $81,530, and Diagnostic Medical Sonographers, $84,410, as reported by the U.S. Bureau of Labor Statistics (2022a, 2022c, 2022d) (see Figure 5). Figure 5 51 Survey demographic information included the participant’s gender, race, and age (see Figure 6). Figure 6 The majority of participants identified as female (84.7%, N=160) and were of White/Caucasian race 91.5% (N=173). Respondents resided in 35 different US states, the highest percentages in Utah (34.9%, N=66), Oregon (13.2%, N=25), and Idaho (11.6%, N=22). Throughout the survey, participants were asked to think of the leader with the most influence over them on a daily basis when asked about “their leader”. Although there were several different answers, the majority were split evenly between Chief Technologist/Lead and Administrator/Manager. It is interesting to note these two levels of leadership are significantly different in their scope and presumably impact, but were equally selected as most influential day to day (see Figure 7). 52 Figure 7 The total possible score for each leadership category was 20. A high score indicates that the survey taker thought their leader performed well in that category. The mean score for Model was 16. For Inspire, it was 15.1. For Challenge, it was 14.5. For Enable, it was 12.9. Finally, for Encourage, the mean score was 15.1. In aggregate, the total mean score for all of the leadership qualities combined 73.6 out of a possible 100. As the majority of respondents listed their primary leader as either Administrator or Lead Technologist, some insight might be gained by comparing the results among those groups directly. According to the Levene’s test for the Equity of Variances, there is not a significant difference between the means for the groups who selected Administrator and those who chose Lead Technologist in almost all of the categories for both leadership and job satisfaction. The only variable which did demonstrate a significant difference was ‘Encourage’, with a p- value of 0.037. For those who identified an Administrator as their primary leader, the mean Encourage 53 score was 16 out of 20. For those who identified their primary leader as a Lead or Chief technologist, the mean Encourage score was 14 out of 20. The total possible score for each job satisfaction category was also 20. A high score signifies that the participant was satisfied in the given area of their work. The mean score for Performance was 12.2, for Engagement it was 15.9, and for Well Being the mean score was 14. The total mean score for all job satisfaction factors combined was 42.1 out of 60 (see Table 2). Table 2 Leadership and Job Satisfaction Sub Variable Results Sub Variable Mean Standard Deviation Leadership Qualities Model 16 3.4 Inspire 15.1 3.8 Challenge 14.5 3.4 Enable 12.9 2.1 Encourage 15.1 3.6 Total Leadership 73.6 13.3 Job Satisfaction Qualities Performance 12.1 1.6 Engagement 15.9 2.5 Well Being 14 3.2 Total Satisfaction 42.1 4.9 54 The primary hypothesis of our study was that there is a positive relationship between favorable attitudes and behaviors of leadership and employee satisfaction. We ran a two-tailed Pearson correlation to determine the likelihood that a relationship exists between perceived leadership and job satisfaction. Ultimately, we found a moderate positive correlation of 0.520 with a p value of <0.001 between perceived leadership and job satisfaction (see Figure 8). Figure 8 Two-Tailed Pearson Correlation between Leadership and Job Satisfaction Our second hypothesis was that certain leadership behavior and attitudes would exhibit relationships to employee job satisfaction. We ran a two tailed Pearson correlation to examine the relationship between each of our leadership qualities (Model, Inspire, Challenge, Enable, and Encourage) and overall job satisfaction. All of our examined leadership qualities demonstrated a positive relationship with job satisfaction. Encourage and Inspire demonstrated the strongest 55 relationship to job satisfaction. Encourage had a correlation of 0.535 with job satisfaction at p=<0.001. Inspire was close, with a correlation of 0.503 at p=<0.001. The next strongest relationships were Challenge, with a correlation of 0.473 at p=<0.001, and Model with a correlation of 0.361 at p=<0.001. The weakest relationship was with Enable, with a correlation of 0.109 at p=0.134. This p value is so high it does not achieve statistical significance (see Table 3). Table 3 Job Satisfaction to Leadership Qualities Job Satisfaction Model Inspire Challenge Enable Encourage Pearson Correlation 0.361* 0.503* 0.473* 0.109 0.535* p-value <0.001 <0.001 <0.001 0.134 <0.001 *Correlation is significant at the 0.05 level (2-tailed) Qualitative Findings The research aimed to evaluate three questions concerning leadership behavior and attitudes, and their relationship with employee satisfaction. The first research question asked if there was a positive or negative relationship between leadership attitudes and behaviors with employee satisfaction. The second research question asked what experiences with certain leadership attitudes and behaviors affected employee satisfaction. The last research question aimed to determine what future changes in these behaviors and attitudes would improve employee satisfaction in the short and long term. The six interviews discussed these questions and were broken up into the five attitudes/behaviors of a leader. Although there were only six 56 participants, the research extracted many themes from each which will be described in detail and compared to trends in the quantitative data. Model. Model was the first leadership behavior/attitude that was examined in the qualitative interviews. When asking the six participants how their leader showed good modeling nine themes were apparent. Three themes derived from the interviews stated that their leaders were good at communication, two had regular meetings, one stated there was good feedback, one stated employee advocacy, one stated positive attitudes, and one that their leaders lead by example (see Table 4). Table 4 Positive Model Themes Positive Modeling Themes Frequency Communication 3 Regular meetings 2 Feedback 1 Employee advocacy 1 Positive attitude 1 Lead by example 1 On the contrary, participants who stated their leaders did not exemplify good modeling reported nine themes: two stated no communication was present between staff and leadership, two stated no meetings were held, two showed hands off management styles, one showed there 57 was no transparency, one showed no advocacy, and one had no leadership guidance (see Table 5). Table 5 Negative Model Themes Negative Modeling Themes Frequency No communication 2 No meetings 2 Hands off management style 2 No transparency 1 No advocacy 1 No leadership guidance 1 When asked if these styles of modeling affected their satisfaction half of the participants stated yes and half stated no. Then they were asked if the way their leaders communicated with them or the lack thereof had an impact on their satisfaction and five stated that it had a negative impact on their satisfaction while only one participant said it had a positive impact (see Table 6). 58 Table 6 Leader’s Communication and Impact on Satisfaction Communication Impact on Satisfaction Frequency Negative Positive 5 1 Everyone agreed that communication is a driving factor for satisfaction. They were then asked what their leader could do in the future that would increase their satisfaction in the workplace and three participants said there isn’t any change they would like to see, whereas the other three participants suggested the following themes: two showed the need for open communication, one wanted management who cared, and one wanted a leader who wouldn’t ask their employees to do anything they wouldn’t do themselves. When asked if there was something specific their leader could do in order to improve satisfaction, two themes showed communication being important, one showed a need for mental/physical breaks at work, one showed that participants wanted encouragement, and one showed a desire for opportunities to grow their career (see Table 7). 59 Table 7 Future Behaviors That Would Increase Satisfaction Behaviors Frequency No change 3 Open communication 2 Caring/genuine management 1 Lead by example 1 Examples of Specific Behaviors Frequency Communication 2 Mental/physical breaks 1 Encouragement 1 Opportunities for growth 1 Inspire. The second leadership behavior/attitude inquired about was a leader’s ability to Inspire. The first question asked participants how their leader inspired them, and two out of the six participants stated their leaders did not inspire them. The other four participants said they were inspired by their leaders in the following ways: they gave opportunities for career development, they led by example, they utilized their employees for speaking engagements, they were complimentary of their staff’s work, and they are open to suggestions (see Table 8). 60 Table 8 Do Leaders Inspire Employees Inspiration Frequency Positive Negative 4 2 When asked if the way their leader inspired them had an impact on their satisfaction. The two participants that said their leader did not inspire had felt a negative impact on their satisfaction. The other four participants with inspiring leaders stated their satisfaction was improved because of the support and recognition their leaders showed them. When asked how their leader could communicate changes or goals in the future to increase their satisfaction. Seven themes were seen on this topic, two of the themes wanted leaders to have genuine concern for their employees, two wanted open communication with direction and time frames for department goals, two wanted encouragement and positivity, and one wanted a committee to create case studies to improve technologist’s knowledge (see Table 9). Table 9 How Leaders Can Communicate Goals in the Future to Increase Satisfaction Themes Frequency Genuine concern 2 Open communication 2 Encouragement and positivity 2 Committee for educational case studies 1 61 Challenge. The third leadership behavior/attitude that was discussed was Challenge. The first question was in what ways do the participants’ leaders make changes to the department to improve employee satisfaction? Two of the participants stated that their leaders did not try to implement positive change to improve satisfaction and were not open minded to suggestions, two of the participants stated that change occurred without a thorough plan and the plan was never accomplished, and two stated that their leaders’ were open to employees’ suggestions and valued their input (see Table 10). Table 10 What Ways Leaders Make Changes To The Department To Improve Satisfaction Effectiveness of Change Frequency Positive Negative 2 4 Participants were asked if their leadership gave them room to challenge the status quo. Five answered that their leaders were not open to receiving feedback and only one participant stated their leaders were open to receive feedback in order to create changes to the department (see Table 11). 62 Table 11 Leadership Allowing Staff to Challenge the Status Quo Receptive to Feedback Frequency Yes No 1 5 Frequency Support in Trying New Things Yes No Conditional 1 5 1 Participants were asked if their leaders supported them as they tried new things to help improve their satisfaction and workplace and five responded that they do not get support and two responded yes, they have support. However, one of those two felt as though it was conditional and the support did not last long-term. Participants that were able to implement changes felt like they did not receive any grace if they failed. We then asked participants how they want to be challenged in the future. Four participants wanted to be challenged and two did not want any more challenge in their work, whether it was from being close to retirement or being unable to take on any other challenges at their stage of employment. The themes that were discovered from the four participants who wanted to be challenged showed all of them wanting to have continued education and learning, in addition, two stated that they wanted opportunities to grow and advance their career within the organization (see Table 12). 63 Table 12 Desire for Employees to be Challenged Desire for Challenge in the Workplace Frequency Yes No 4 2 Enable. The fourth leadership behavior/attitude that was evaluated was Enable. The first question asked participants if there were obstacles at work that affect their job performance and satisfaction. Ten themes were seen in this question, three demonstrated a need for proper training, three that adequate staffing was needed, two for an improved workload, and two needed functioning or more efficient equipment (see Table 13). Table 13 Obstacles in the workplace Obstacles Frequency Proper training 3 Adequate staffing 3 Improved workload 2 Functioning/efficient equipment 2 Can Leaders Remove Obstacles Frequency Yes No 6 0 64 All six participants believe their leader could remove the obstacles but don’t, and one of the participants said their leader will get any equipment that is needed but will not help with any other workplace obstacles. The participants who have obstacles to remove stated ideas that could help remove the obstacles would be: more time for exams, additional rooms/staff, more efficient workflow, and long-term strategies that solve the issues completely. We then asked what future resources would improve their satisfaction in the workplace and eight themes were identified. Four stated better training, two stated the need for properly working equipment and appropriate staffing levels, one wanted more open communication, and one wanted a more competitive salary (see Table 14). Table 14 Future Resources to Improve Satisfaction Resources Frequency Training 4 Working equipment 2 Open communication 1 Competitive salary 1 Encourage. The fifth and last leadership behavior/attitude explored was Encourage. The first question asked participants what rewards, bonuses, or recognition their leaders currently do for them. Ten themes were seen between the six participants as follows: six showed staff to staff shout outs, two themes were tokens/prizes, one theme got one on one recognition, and one had departmental recognition (see Table 15). 65 Table 15 What Recognition is Given to Employees and its effects Recognition Frequency Staff to staff shout outs 6 Tokens/prizes 2 1 on 1 recognition 1 Departmental recognition 1 Recognitions Impact on Satisfaction Frequency Positive Negative 3 3 We asked if these efforts of recognition in general affected their satisfaction and three participants stated it did, however it was important that the recognition happened more frequently. Those who stated it did not affect their satisfaction stated that getting a small bonus or small gesture of recognition was not effective enough in increasing their satisfaction because it didn’t change the fact they felt overworked and undervalued. When asked how their leadership could encourage their staff in regards to feedback and rewards, two participants wanted to see monetary compensation and more vacation days, one stated that monetary bonuses were superficial and did not give them the desire to be better, and one wanted to see more personal responsibility in order to create growth in their career. We also asked how they would like to specifically receive the feedback or rewards, and seven themes were seen between the participants. Three themes showed participants wanted the removal of harmful rewards and metrics, two wanted to see growth and feedback, one showed they want leaders to follow 66 through on employee suggestions, and one wanted activities such as potlucks to give employees something to look forward to (see Table 16). Table 16 How Leadership can Encourage Employees Themes Frequency Monetary compensation/vacation days 2 Personal responsibility 1 Removal of harmful rewards/metrics 3 Feedback for growth 1 Implement employee suggestions 1 Workplace activities 1 Evaluation of Findings Using quantitative and qualitative studies, responses varied greatly on how leadership can impact their employees. While the survey results did show a positive correlation between perceived leadership and job satisfaction, the responses were unexpected, and revealed the opposite of what was originally hypothesized. Survey results demonstrated that the majority of the individuals were actually satisfied with their leadership and employment, as demonstrated by the mean job satisfaction score which was 42.1 out of 60 possible points, which equals about 70%. Yet, most (43.4%) participants agreed that they suffer from burnout and are emotionally and physically exhausted, compared to the 33.8% who disagreed with the statement. These results seem to contradict each other, but there are several reasons why this could have occurred. 67 One possibility is that despite efforts to ensure that participants were giving their responses based on the leader who had the power to make the most change to the issues they felt needed to be addressed, it is possible that many responded with a supervisor or team lead in mind. Many immediate supervisors or team leads are excellent leaders and do whatever is in their power to support their team, but unfortunately do not have the power to make many of the systemic changes necessary to support an effective medical imaging department and promote job satisfaction. It is possible that these employees are satisfied with their team and immediate supervisor, but not with upper management. One member of the research team happens to be a team lead in her department and mentioned that after the survey several of her team members revealed they had given responses based on her behavior, yet the actual problem lies with upper management. This could also have introduced bias in the results. Although participants were informed that the survey would be anonymous, another possibility is the fear of repercussions from their employment if negative feedback was provided. Finally, it is possible that the original overarching hypothesis was wrong altogether and burnout is due to something other than leadership. It is possible that there is another factor that was not considered, or maybe it just comes with the territory of working in the healthcare field. Burnout and physical and emotional exhaustion are clearly issues within medical imaging and healthcare as a whole, but it could be due to factors such as patient load, which cannot easily be changed without drastic population education and systemic changes. One of the recurring themes throughout all sections of the qualitative study was communication. The lack of communication fuels a range of negative perceptions throughout measured behaviors. Every action and inaction leaders take, sends a message to those they lead. 68 Leaders should be aware of how those perceptions shape departmental culture. Many of the principal areas of concern and improvement, both in the present and future, could be framed in a communication context and point to the importance of leaders using effective communication with their teams. In the domain of Modeling behavior, participants’ responses were split. On the written survey, Model received the highest average score, indicating that the respondents felt that their leaders performed better in that category than in any of the other leadership qualities we examined. This is interesting to note because when we compared each leadership attribute to satisfaction on the quantitative study, Model was ranked fourth with a correlation of 0.361 at p=<0.001. Encourage, Inspire and Challenge all were ranked above with scores of 0.535 at p=<0.001, 0.503 at p=<0.001 and 0.473 at p<0.001 respectively. This shows that technologists who took the survey think their leaders demonstrate the attribute of Model, but it didn’t have as big of an impact on their satisfaction. The live interviewees were more mixed, with three stating that their leaders exemplified good modeling behavior and three saying they did not. Interestingly, those who indicated they did not want any changes in modeling behaviors were also those who reported their leader as having a less involved approach. Since imaging professionals often work in a solo, task orientated environment, it may well be that their workplace is suited to leaders who give more autonomy to those they lead. A leader’s modeling behavior did not matter to these individuals because they were self-directed in their tasks and required little to no input from their leader. The results from both the qualitative and quantitative studies indicate that Model is not the strongest attribute a leader could develop if they want to improve their employee satisfaction in the radiology field. 69 Effective communication was also emphasized in the Inspire category. Those who said their leaders do not inspire them all cited a lack of communication as the root cause. However, our quantitative results show that inspiration is the second most important leadership behavior correlated to job satisfaction. Clearly, this is not an area leaders can afford to ignore and communication was crucial for leaders to make the most immediate impact on their employees. It is very difficult to inspire someone when there is no communication. In the Challenge domain, there were seemingly contradictory responses in the live interviews, but when combined with later responses from the Enable domain, point to a common phenomenon that exists throughout many industries in addition to healthcare. Interviewees were asked if there were obstacles to their job which their leader could remove. A majority reported there were obstacles their leaders could remove, but did not. On the other hand, the majority of survey participants (58%) agreed that their leader does help remove obstacles preventing them from performing effectively. However, clearly there is still room for improvement, with 42% of participants not being able to agree with this statement. Upon further questioning, the following themes of how leaders make changes to improve satisfaction emerged from qualitative responses, with responses evenly split among participants: leaders made no changes, changes were implemented with no real plan or purpose, and changes were valued and planned. Even though the above responses were different, what did not change across these themes is how leaders went about these changes– all but one participant reported an entirely unilateral approach to change, with leaders not accepting or valuing any feedback. There could be many reasons why leaders do not solicit or value feedback which would require further research to investigate, but responses given indicated at least two leaders seemed to view it as a challenge to their authority which is a 70 common issue not unique to healthcare leaders. Nonetheless it was seen negatively in the responses given by our employee interviewees. Surprisingly, this attitude towards change also coincided with those interviewees who responded that their leader’s example did not impact their satisfaction. Responses from these same individuals in other areas made it clear that the lack of engagement from leaders was anticipated. That expectation, combined with the solo nature of the job, led to the development of apathy about a leader’s impact. The attitude of “show up, do your job well, and go home” was prevalent in these individuals. This sentiment was encountered more readily amongst radiographers who are close to or looking at retirement. While working to fill the holes in their ranks left by the pandemic, leaders must also address the differing needs of various demographics within their departments. Adequate training of new personnel so that they can adapt to their roles within the department competently and confidently is going to be important as is helping mid-career and those at or nearing retirement. One third of those interviewed and about one third (31.1%,N=59) of those surveyed, had over 16 years of experience. These individuals represent a unique challenge to departmental leaders. They have been working long enough to have seen multiple directors and managers come and go. They are likely peers of, or senior to, any manager who would be running the department. They have a lot of experience in their respective modalities and constitute the bulk of skills and experience in their departments. These long timers have usually mastered their modalities and, for some, that is enough. These individuals make up the first tranche of live interview subjects from this subgroup who did not want to be challenged at work anymore. They wanted to prepare to leave the clinical setting and so were averse to taking on more responsibility. This contrasts 71 sharply to responses from younger participants who wanted more opportunities to move into advanced modalities and grow into administrative roles. The second tranche of live interview subjects not wanting to be challenged reported being challenged in all the wrong ways: to shorten exam times and do more exams, but maintain the same quality expected from a full exam whereas the quantitative results showed 16.9% (N=32) disagreed with the statement they, “are given plenty of time to perform exams correctly.” This may be similar to previously discussed situations where fear of reprisals, lack of experience, or overblown critiques may be present. Regardless, these types of challenges in a work environment fit squarely in the realm of malevolent metrics and will be discussed later as part of the Encourage section. The third tranche of interviewees not wishing to be challenged more indicated they were in the “sweet spot”, meaning they were being challenged in a desired way. Additionally, one respondent felt the challenges presented to them were meaningful to both them and the department. Those in the third tranche also reported having higher satisfaction with those challenges and their roles typically involved sharing their experience with others. Moving on to those who wanted to be challenged, two out of three respondents said they wanted new education opportunities. This included moving into advanced modalities, but it also included taking on roles outside a clinical environment. Administrative roles like scheduling, equipment maintenance, and radiation compliance were some examples put forth as desirable. The other responses from those wishing to be challenged dealt with making room for the growth of new employees specifically. One participant with experience in managing a radiation compliance program for their facility wanted to move to a different role by training a 72 replacement. Another indicated a desire for more opportunities for new employees to move into advanced modalities and/or take on more responsibility within the department. They felt that, regardless of size of task, more responsibility would result in ownership and pride being established among employees and the department as a whole. Leaders can be creative with roles that radiographers are tasked with since it is likely workforce losses from the COVID-19 pandemic have left holes in departments nationwide. (Lehman, 2015; Morgantini, 2020; Rehder, 2021; Yuan-Sheng et all, 2022). The absence of these workers is sharply noted by those who are still working. Adding to this, over a third of total survey participants (37.6%,N=71) in both methods had less than five years experience, and those with less than 10 made up 55.3% of quantitative results, which would help explain why themes of growth and opportunity were so prevalent throughout the Encourage and Enable sections. Many of the implications surrounding Enable and Encourage will not be new to leaders or administrators. Desires for more staff to ease overall workloads were almost universally expressed in qualitative interviews and are likely already known to leaders. 42.3% of surveyed participants agreed that they are often too short-staffed to provide quality service, compared to the 41.3% that disagreed. Essentially, over half of the participants with a non-neutral answer believe they are too short-staffed to provide quality service. This is significant since, providing non-quality service, could have multiple ramifications including poor patient satisfaction scores, decreased revenue, negative patient and/or family experience, harm to a patient, or even the death of a patient. What is baffling when considering the previous response however, is the response to the statement “I am given plenty of time to perform exams correctly.” 66.7% of participants agreed 73 with this statement, which does not seem to make sense when juxtaposed with the fact that most agreed they are short-staffed. How are participants too short-staffed, but do not feel rushed to perform exams? One possibility for the discrepancy could be in the wording of the statement. Maybe participants feel that they technically do have the time to perform the exams correctly as far as accuracy and quality imaging, but they are providing the bare minimum in terms of patient experience in order to complete exams accurately and within the allotted time frame. In this case, the staffing issues could be leading to burnout and exhaustion from having to take on the extra workload of missing staff and the remaining employees are unable to “provide quality service,” as in being caring and compassionate with their patients. Another possible explanation lies in the work site/modality and manager expectations. It is possible that managers for certain sites/modalities where the majority of exams are routine or non-emergent know that staffing is an issue and expect longer exam times or are able to alter exam scheduling to accommodate reduced staff. This is obviously not an option in emergency departments. Another possibility for the discrepancy is that technologists may have indicated they were short-staffed in the sense that there are not enough technologists hired on to help cover vacations and time-off for team members instead of being short-staffed on a day to day basis. Despite studies showing how maintaining a low turnover rate is beneficial for outcomes and costs (Gates, 2007; Jones, 2004; Jones 2005; O’Brien-Pallas et al., 2006; Stone et al., 2003; Waldman et al., 2004), based on responses received, training remains a major challenge for the majority of respondents. Unfortunately, some staffing issues may be more systemic than any one individual leader can address. Training programs may maintain low enrollment rates to avoid oversaturating the market with new radiographers. In addition, many other issues may fall well 74 outside a leader’s ability to solve, but all of these problems affect both them and the departments they lead nonetheless. Adequate equipment was also discussed. Although only 12.2% (N=23) of survey respondents indicated dissatisfaction with the equipment available to them, half of live interview responses wanted newer scanning equipment and the other half wanted ergonomic equipment. Ergonomic equipment improves quality of life and employee health long term. While ergonomic equipment may not increase patient throughput directly, employees who expressed a desire for it recognized the value for staff in knowing that a leader is making long term investments in their health and comfort. Leaders ignoring the long term health of their teams will regret their myopic approach later on as staff transfer or leave. The leadership behavior which showed the strongest correlation to satisfaction in our quantitative study (r(187)=0.535, p=<.001) was Encourage. It is interesting to note that participants did feel differently on how their leader encouraged them based on who they thought was their leader. According to the Levene’s test for Equity of Variances, there is a significant difference in Encourage with a p value of 0.037. The average score was higher for the technologists who thought the Administrator/Manager was their primary leader rather than the Chief Technologist/Lead with the average scores being 16/20 and 14/20 respectively. These are two vastly different roles because the Administrator/Manager is usually over multiple modalities while the Chief Technologist/Lead is only over the single modality that they primarily work. This discrepancy could be from the fact that an Administrator/Manager may have more power to be able to offer rewards to their technologists while a Chief Technologists/Lead cannot. They usually do not have the ability to offer cash bonuses or increase wages. 75 Our qualitative live interviews discussing this domain naturally turned towards compensation structures and programs. When asked what encourages staff the most, there was a split between those who did not think money made a difference and those who reported it did. Among those who thought it did not make a difference, the most surprising theme to researchers was the significance of smaller gestures of gratitude and appreciation. These all held more weight than anticipated, while the subjects felt that monetary rewards only matter in certain situations. An important note is that the gestures needed to be sincere and appropriate. If insincerity was attributed, participants reported even more negativity than if no gesture was given. In the subgroup that reported money and compensation did make a difference there were conflicting responses as well. How cash bonuses were delivered was an area that mattered to participants. While all agreed that receiving money was better than no bonus, the majority said cash bonuses at the end-of-year do little to compensate for poor working conditions throughout the year. One participant voiced a preference for smaller, more frequent cash bonuses and gift cards over a larger end- of-year bonus because it made getting through the day to day grind more bearable. This aligns with those smaller gestures mentioned above that were seen as more sincere. More senior participants wanted more vacation time and paid time off in lieu of cash bonuses. If the bonus was perceived as part of the yearly cost of living raise in wages, they were not viewed as positively as a separate dedicated bonus for employees. And one participant described how bonuses at their facility were equal among all employees regardless of employee performance. They described the chilling effect this had on high performers within the department and actually discouraged employees from doing more the following year. The 76 implications of all of the above are that individualized bonuses, recognition, and compensation matter to employees, as does how they are delivered. While the interviewees’ views varied on financial encouragement, the most repeated form of encouragement was recognition within the department. This could take many forms. Responses included recognition at department meetings, shoutout boards, pins or tokens (presented to all staff or to the individual), recognition at the department or facility level, etc. These responses varied so greatly among participants that the only implication researchers can offer is for leaders to determine what type of recognition each individual prefers. This again demonstrates the importance of real communication between leaders and their team members. One final theme from Encourage that was mentioned more frequently than others in the live interviews was the removal of what can be described as harmful rewards or metrics. As the last example from the previous section noted, these may have a deleterious effect on a leader’s attempts to rally those they lead. Furthermore, harmful rewards may undermine how a leader is perceived within a department more than any other domain discussed thus far. Linking rewards and recognition to increased workloads, shortened patient exam times, and other undesirable goals alienates staff and expresses a disconnect between management and day to day activities. During interviews, almost every participant reported they wanted to provide quality patient care, but the reported harmful metrics like timing exams and overscheduling patients work counter to that goal, and create unnecessary frustration and stress. Leaders would do well to find compensation structures that adequately address large workloads that their teams will support. Based on the above research, leaders should discuss compensation structures and programs with their team and actively listen to suggestions and ideas. Along with getting buy-in from team 77 members, leaders can develop the added benefit of a reputation of responsiveness and effective leadership by removing malevolent metrics and focusing on building stronger teams ready to meet patients’ needs in a positive, sustainable manner. Summary In summary, effective leaders lead by example. They demonstrate the behaviors, values, and principles they expect from their team members. By setting a positive example, leaders inspire trust and respect, encouraging others to follow their lead. Minimal or absent leader communication fuels a range of negative perceptions throughout measured behaviors. Acting leaders should be aware of how communication perceptions shape departmental culture. This will in turn have a positive impact on the ability to inspire and motivate their teams. Leaders who communicate a compelling vision for the future, will foster a sense of purpose and direction. Through their passion and enthusiasm, they ignite the same level of commitment and dedication in their team members. Removing obstacles in the workplace is crucial for fostering a productive and efficient environment where employees can thrive. Leaders should encourage open and transparent communication for those they lead. Creating channels where employees can voice their concerns, share challenges they face, and suggest improvements. Leaders should identify and streamline inefficient processes that hinder productivity. Simplify workflows and remove unnecessary steps to make tasks more manageable and less prone to obstacles. Education opportunities are also important, especially for those with less than 10 years in their respective fields. These opportunities are aimed at enhancing employees skills, knowledge, and competencies, ultimately benefiting both the individual’s career growth and the organization’s overall performance. 78 Encouragement is the number one leadership behavior that affects employee satisfaction. Leadership encouragement is being able to motivate and inspire individuals to develop their leadership skills and take on leadership roles or responsibilities. Effective leaders understand the importance of nurturing leadership potential within their team and actively promote a culture that encourages individuals to grow and excel as leaders. By expressing encouragement, gratitude, and appreciation through smaller gestures provides a powerful way for leaders to boost morale, motivate their staff, and create a positive work environment. These gestures don't have to be grand or expensive; it's the thoughtfulness and sincerity that mattered to the respondents. Recognizing this, leaders should also be aware of potential harmful rewards or compensation structures that may have detrimental effects on employee morale, trust, and engagement. When leaders tie rewards to metrics that contradict the core values and goals of the organization or the well-being of employees, it can create a sense of disillusionment and disconnect between management and staff. 79 Chapter 5: Implications, Recommendations, and Conclusions The purpose of this mixed-method study is to examine the relationship between leadership behaviors and employee satisfaction, as defined by variables of performance, engagement, and well-being. Our research findings suggest that employees' belief in their leaders exemplifying certain attitudes (Model, Inspire, Challenge, Enable, and Encourage) is associated with increased satisfaction, performance, engagement, and wellbeing. Limitations of note are the various types of leader’s the respondents report to, the majority of respondents were sonographers, and resided in three states (Utah, Oregon, and Idaho). Implications Research results show that when employees believe that their leader exemplifies the five attitudes (Model, Inspire, Challenge, Enable, and Encourage), they have an increase in satisfaction (performance, engagement, and wellbeing). The qualitative data also showed that poor leadership attitudes affected their satisfaction in a negative way. These results build on existing research that shows that leadership behaviors have an impact on the imaging department. The leadership trait with the highest correlation seen is Encourage. The qualitative data stated that 50% of those who participated said the way their leaders encouraged them had a positive effect on their satisfaction. These findings suggest that leaders should pay special attention at encouraging their staff, specifically in terms relating to rewards and feedback. Qualitative data showed that frequent feedback, monetary compensation, increased personal responsibility, implementation of employee suggestions, and workplace activities are suggestions that could improve satisfaction. The second highest correlation for leadership traits was inspiration. This was the highest rated behavior seen in the qualitative data where 66.6% of 80 participants stated their leaders inspired them. These findings show that individuals thrive when support and recognition is given. Leaders should exemplify genuine concern for their staff, have open communication, and be encouraging to those that work in the department. The third highest leadership trait was Challenge in the quantitative data and the qualitative data showed 33.3% of participants stated they felt their leaders were effective in producing change in the department. Leaders should focus on increasing their ability to challenge employees in regards to continued education and opportunities for growth in their employees’ career at the organization. Model had the fourth greatest correlation and in the qualitative interviews, 50% of participants stated the way their leader Modeled had a negative impact on their satisfaction. This evidence shows that leaders can do a better job at Modeling and specific themes in order to achieve this include having open communication, genuinely caring for the staff, and leading by example. The last leadership behavior that was researched was Enable and it did not have a great enough correlation to be statistically significant. These results support the qualitative data showing that 100% of the participants stated that their leaders could remove obstacles that would enable them to perform better however, none of them do. This is an area that should be focused on when trying to improve satisfaction. Resources that were stated as important to imaging technologists were additional training, proper equipment, open communication, and competitive salaries. A limitation that should be noted is that the most common type of leader that was thought of when completing the survey was either a chief technologist or administration/manager. These roles are completely different in the sense of actually being able to facilitate change within a department but shows how effective these two levels of leadership have on an employee’s satisfaction. Another limitation to the study is that a majority of participants were sonographers 81 and although there are similarities across all the different imaging modalities, sonographers may have different needs than those who work in other areas of radiology. A third limitation to the study is that the population was predominantly white and with participants most commonly located in Utah, Oregon, and Idaho. Technologists in other parts of the country with a more diverse population may have different needs from leadership than those who participated in this study. Studies show that since COVID-19, health care and medical imaging in particular are suffering from staffing shortages, burnout with compassion fatigue, and increased patient load. This research aimed to see how leadership could mitigate these issues and our findings suggest that the better the leadership demonstrates the behaviors analyzed, the greater the employee satisfaction which will ultimately help to decrease the issues departments have been dealing with. This is significant because these results should be considered in medical imaging facilities in order to provide a healthy environment for employees to thrive in. Recommendations When beginning the research project, it was asserted that the employment landscape of medical imaging had been negatively impacted by the COVID-19 pandemic leaving a “new normal” of being overworked and understaffed. This premise was demonstrated strongly as interview participants almost universally confirmed that they need more staff to ease workloads, and lack the appropriate amount of time to perform exams. Leadership would be wise to take heed of these employee concerns and demonstrate an active priority of hiring and properly training new staff as this is likely a huge contributor to employee burnout and dissatisfaction. 82 We inferred that because departments are increasingly overworked, maintaining employee job satisfaction was of vital importance to both recruit and maintain staff, which in turn ensures radiology departments function safely and effectively. We put forward that leadership behaviors have the ability to influence job satisfaction, and our results have borne out a moderately positive relationship between perceived positive qualities of a leader and employee satisfaction. In practice, behaviors such as Encourage and Inspire that were shown to correlate strongest with satisfaction, could be utilized by imaging leadership in its various forms to improve morale and engagement in their departments. In addition, the qualitative portion of the research specifically detailed methods these behaviors could be implemented that are most meaningful to employees, (see Table 15 and 16). At their core, both these behaviors seem to be demonstrated to employees through communication. Those who said their leaders do not inspire them, all cited a lack of communication as the root cause. In the case of Encourage, communication was reflected in the ideas of receiving consistent feedback and recognition as the most repeated themes. Recognition could take many forms; acknowledgement at department meetings, shoutout boards, tokens presented from other staff, recognition at the individual, department or facility level. A more complex but important theme of Encouragement appears to be rewards. The most obvious reward an employee receives is their compensation, however, interviewees split between those who did not think money made a difference and those who did. A more consistently positive application of rewards seemed to be smaller gestures of gratitude and appreciation. Instituting sincere and appropriate gestures seems to be an effective way for leadership to both reward and demonstrate good communication by reinforcing they know the type of recognition 83 important to the individual and how they prefer to receive it. Attaching strings to rewards in the form of harmful metrics such as timing exams or volume of exams performed should be avoided as this removes the sense of genuine appreciation that makes the gesture effective. While developing and maintaining job satisfaction remains an important challenge to tackle, there are various potential research avenues involving the connection to leadership behaviors that could be further explored. During the development of our survey, a great deal of time was dedicated to the discussion of exactly whom employees identify as the leader with the most day to day or daily influence over their work with notable and varied number of responses. Although no significant difference in satisfaction was seen between the two predominant categories of leader, it would be interesting to further investigate the idea of what types of leaders are perceived as the most influential to the employee. However, this variety in response could be a reflection that our survey did not include specific enough definitions / directions, which could in itself present an additional opportunity for improvement and continuation of our research. If continued, this research could be improved upon by mitigating the limitations previously identified. Lack of time due to our deadline was a predominant limiting factor. Although a larger than desired sample size was obtained, with additional time to invest in the topic, a potentially larger and broader pool of participants could be reached further expanding the application of the research. This sample was almost 50% Sonographers which, although no significant difference across modality was observed, could have skewed our intention to investigate all of Radiology. In addition, the instrument could be further refined and then tested to ensure ease of use and clarity, which would improve confidence in its results. Additional 84 means of ensuring only technologists were included as participants could be explored and implemented again, increasing confidence in the results. While the demographic information collected such as years of experience, modality, education, or workplace did not reveal any statistically significant relationships between job satisfaction or perception of leadership, these are all areas that could potentially benefit from more extensive investigation. Conclusions While ~70% of survey respondents reported that they experienced positive job satisfaction, there is still room for improvement for the field of Radiology. Using both quantitative and qualitative processes, we evaluated employees’ perceptions of their leaders which employees defined most often as management or lead technologists. Our research results showed that there was a correlation between a leader’s actions with respect to four of the five attitudes, and employee satisfaction in terms of performance, engagement, and wellbeing. The most significant of these attitudes was Encourage, followed by Inspire, Challenge and then Model. Although in the survey, the leader's attitude to enable their employees was not found to be statistically significant to correlate to employee satisfaction, the qualitative data showed that there were obstacles leaders could remove to improve satisfaction for radiographers, and removing those obstacles could enable employees positively. The key takeaways for leaders are to focus on their communication skills, recognition systems, and rewards structures. These fundamental aspects made much of the difference we observed in our results and we commend these items to leaders to seriously consider in their own behavior and its influence upon those they lead. Excellency is found in mastering the fundamentals and as leaders introspect, they should begin a dialogue with their teams. Ideally, our findings will be a genesis for discussion 85 and analysis within departments to compare their own attitudes and behaviors in order to identify what works best for their facility and team makeup. Department discussions around important themes identified in our study like communication, compensation, and recognition will give leaders the insights they need to increase satisfaction from average to exceptional. In addition, workplaces would benefit by implementing the suggestions made by employees, including with respect to training in advanced modalities and providing continuing education, focusing on positive metrics used to measure job performance and not negative ones that interfere with patient care, and providing more frequent monetary rewards in the form of gift cards or small monetary bonuses throughout the year instead of only in an annual bonus. Rewarding leaders for their ability to communicate with their employees would be an improvement in employee morale and create a workplace that could improve retention. Furthermore, data shows an integral part of satisfaction building is to show gratitude in sincere and meaningful ways. Findings indicated that gratitude and appreciation were not mere platitudes, but defining characteristics employees valued and to which they responded. This same survey model for both quantitative and qualitative methods could be duplicated on a larger scale, with a focus on surveying a more diverse population, particularly in terms of geography, race, and modality. In addition, further studies could be done focusing more on leadership from specific subsets of the population, such as the leadership of managers, or the leadership of lead technologists. Finally, our study is a snapshot of the current challenges faced by radiology departments in the wake of a pandemic that exacerbated existing problems and brought with it new challenges. Continuing into the future, there will be new challenges along with accompanying 86 changing undercurrents of culture and customs that will necessitate dynamic responses from leaders who consistently and continually include their teams in the process of change as they work to build better teams, communities, and systems of care. 87 References Almotawa, A., & Shaari, R. (2021) FActors influencing employee engagement in healthcare sectors: Psychological pain management approach. Journal of Pain Management, 14(2):167-169 ISSN: 1939-5914 Nova Science Publishers, Inc Alrubaysh, M. A., Alshehri, M. H., Alsuhaibani, E. A., Allowaihiq, L. H., Alnasser, A. A., & Alwazzan, L. (2022). The leadership styles of primary healthcare center managers and center performance outcomes in Riyadh, Saudi Arabia: A correlational study. Journal of family & community medicine, 29(1), 56–61. https://doi.org/10.4103/jfcm.jfcm_400_21 Aryee, S., Walumbwa, F. O., Zhou, Q., & Hartnell, C. A. (2012). Transformational Leadership, Innovative Behavior, and Task Performance: Test of Mediation and Moderation Processes. Human Performance, 25(1), 1–25. https://doi.org/10.1080/08959285.2011.631648 Asencio, H., & Mujkic, E. (2016). Leadership behaviors and trust in leaders: Evidence from the U.S. federal government. Public Administration Quarterly, 40(1), 156–179. http://www.jstor.org/stable/24772946 Brown, M. E., Treviño, L. K., & Harrison, D. A. (2005). Ethical leadership: A social learning perspective for construct development and testing. In Organizational Behavior and Human Decision Processes (Vol. 97, Issue 2, pp. 117–134). Elsevier BV. https://doi.org/10.1016/j.obhdp.2005.03.002 88 Byun, G., Karau, S. J., Dai, Y., & Lee, S. (2018). A three-level examination of the cascading effects of ethical leadership on employee outcomes: A moderated mediation analysis. Journal of Business Research (Vol. 88, pp. 44–53). Elsevier BV. https://doi.org/10.1016/j.jbusres.2018.03.004 Cogan, N., Archbold, H., Deakin, K., Griffith, B., Sáez Berruga, I., Smith, S., Tanner, G., & Flowers, P. (2022). What have we learned about what works in sustaining mental health care and support services during a pandemic? transferable insights from the COVID-19 response within the NHS Scottish context. International Journal of Mental Health, 51(2), 164–188. https://doi.org/10.1080/00207411.2022.2056386 Deci, E. L., Ryan, R. M., & Vansteenkiste, M. (2008). Self-determination theory and the explanatory role of psychological needs in human well-being. Oxford University Press. Definition of LEADER. (n.d.). Retrieved December 1, 2022, from https://www.merriam-webster.com/dictionary/leader DeLay, L., & Clark, K. R. (2020). The Relationship Between Leadership Styles and Job Satisfaction: A Survey of MR Technologists' Perceptions. Radiologic Technology, 92(1), 12–22. Deriba, B. K., Sinke, S. O., Ereso, B. M., & Badacho, A. S. (2017). Health professionals’ job satisfaction and associated factors at public health centers in West Ethiopia. Human Resources for Health, 15(1). https://doi.org/10.1186/s12960-017-0206-3 89 Dunlop, J. (2015). Meditation, stress relief, and well-being. Radiologic Technology, 86(5), 535-55; quiz 556-9. Gladwell, M. (2015). David and Goliath: Underdogs, misfits, and the Art of Battling Giants. Back Bay Books. Gagné, M., & Deci, E. L. (2005). Self‐determination theory and work motivation. Journal of Organizational behavior, 26(4), 331-362. Garton, E. (2017). How to Be an Inspiring Leader. Harvard Business Review. Gates, M., & Jones, C. (2007). The costs and benefits of nurse turnover: A business case for nurse retention. OJIN: The Online Journal of Issues in Nursing, 12(3). https://doi.org/10.3912/ojin.vol12no03man04 Gaylin, S. (2006). The coming of the Corporation and the marketing of Psychiatry. Psychiatric Services, 36(2), 154–159. https://doi.org/10.1176/ps.36.2.154 Geller, E. S. (2022). MANAGING BEHAVIOR VS. LEADING PEOPLE: Evidence-Based Lessons to Achieve & Sustain an Injury-Free Workplace. Professional Safety, 67(4), 30–37. Gupta, M., J. A.. (2017). Development of Employee Engagement Model in a Tertiary Care Hospital. International Journal of Nursing Education (Vol. 9, No. 4, p 77). DOI Number: 10.5958/0974-9357.2017.00100.3 90 Hall, L., Johnson, J., Watt, I., Tsipa, A., O’Connor, D. (2016). Healthcare Staff Wellbeing, Burnout, and Patient Safety: A Systematic Review. PLoS ONE, 11 (7). DOI:10.1371/journal.pone.0159015 Hardy, K. Shoring Up the Front Line: Burnout Prevention for Radiologic Technologists in the Wake of COVID-19. Radiology Today, 21(7), 18. Horwitch, M., & Callahan, M. W. (2016, June 9). How leaders inspire: Cracking the code. Bain & Company. Retrieved March 25, 2023, from https://www.bain.com/insights/how-leaders-inspire-cracking-the-code Huang, H. L., Chen, R. C., Teo, I., Chaudhry, I., Heng, A. L., Zhuang, K. D., Tan, H. K., & Tan, B. S. (2021). A survey of anxiety and burnout in the radiology workforce of a tertiary hospital during the Covid‐19 pandemic. Journal of Medical Imaging and Radiation Oncology, 65(2), 139–145. https://doi.org/10.1111/1754-9485.13152 7 Iaffaldano, M. T., & Muchinsky, P. M. (1985). Job satisfaction and job performance: A meta-analysis. Psychological Bulletin (Vol. 97, Issue 2, pp. 251–273). American Psychological Association (APA). https://doi.org/10.1037/0033-2909.97.2.251 Jalilianhasanpour, R., Asadollahi, S., & Yousem, D. M. (2021). Creating joy in the Workplace. European Journal of Radiology, 145. https://doi.org/10.1016/j.ejrad.2021.110019 Jones CB. The costs of nurse turnover: part 1: an economic perspective. J Nurs Adm. 2004 Dec;34(12):562-70. doi: 10.1097/00005110-200412000-00006. PMID: 15632752. 91 Jones CB. The costs of nurse turnover, part 2: application of the Nursing Turnover Cost Calculation Methodology. J Nurs Adm. 2005 Jan;35(1):41-9. doi: 10.1097/00005110-200501000-00014. PMID: 15647669. Kachadourian, L., Murrough, J., Kaplan, C., Kaplan, S., Feingold, J., Feder, A., Charney, D., Southwick, S., Peccoralo, L., DePierro, J., Ripp, J., & Pietrzak, R. (2022). A prospective study of transdiagnostic psychiatric symptoms associated with burnout and functional difficulties in COVID-19 Frontline Healthcare Workers. Journal of Psychiatric Research, 152, 219–224. https://doi.org/10.1016/j.jpsychires.2022.05.034 Karsikas, E., Meriläinen, M., Tuomikoski, A.-M., Koivunen, K., Jarva, E., Mikkonen, K., Oikarinen, A., Kääriäinen, M., Jounila-Ilola, P., & Kanste, O. (2022). Health care managers’ competence in knowledge management: A scoping review. Journal of Nursing Management, 30(5), 1168–1187. https://doi.org/10.1111/jonm.13626 Kasner, S. (2020). Technologist stressors and supportive responses. Radiologic Technology, 91(5), 477 Kuzey, C. (2018). Impact of Health Care Employees' Job Satisfaction on Organizational Performance Support Vector Machine Approach. Journal of Economics and Financial Analysis, 2. https://doi.org/DOI:10.1991/jefa.v2i1.a12 Lehmann, P., Meystre, N. Richli, & Mamboury, N. (2015). Factors for lifelong job retention among Swiss radiographers. Radiography (London 1995), 21(2), 181-187. doi:101016/jradi201411002 92 Lin, C.-S., Jin, M., Huang, P.-C., & Xiao, R. (2023). Does it take two to tango? The joint role of high-performance work systems and ethical leadership. Journal of Business Research (Vol. 156, p. 113536). Elsevier BV. https://doi.org/10.1016/j.jbusres.2022.113536 Lowe, G. (2012). How Employee Engagement Matters for Hospital Performance. Health Human Resources (Vol. 15 No.2 p 29) Martinussen, P. E., & Davidsen, T. (2021). ‘Professional-supportive’ versus ‘economic-operational’ management: The relationship between leadership style and hospital physicians’ organisational climate. BMC Health Services Research, 21(1), 825. https://doi.org/10.1186/s12913-021-06760-2 Mazzetti, G., & Schaufeli, W. B. (2022). The impact of engaging leadership on employee engagement and team effectiveness: A longitudinal, multi-level study on the mediating role of personal and team resources. PLoS ONE, 17(6), 1–25. https://doi-org.hal.weber.edu/10.1371/journal.pone.0269433 Morgantini, L. A., Naha, U., Wang, H., Francavilla, S., Acar, Ö., Flores, J. M., Crivellaro, S., Moreira, D., Abern, M., Eklund, M., Vigneswaran, H. T., & Weine, S. M. (2020). Factors contributing to healthcare professional burnout during the COVID-19 pandemic: A rapid turnaround global survey. PLOS ONE, 15(9). https://doi.org/10.1371/journal.pone.0238217 Murphy, K. R. (2019). Performance evaluation will not die, but it should. 93 Human Resource Management Journal (Vol. 30, Issue 1, pp. 13–31). Wiley. https://doi.org/10.1111/1748-8583.12259 Nidadhavolu, A. (2018). Impact of Leadership Styles on Employee Job Satisfaction and Organizational Commitment – A Study in the Construction Sector in India. Undefined. https://www.semanticscholar.org/paper/Impact-of-Leadership-Styles-on-Employee-Job-a nd-%E2%80%93-A-Nidadhavolu/700175ac79f0239437d5cfc536ede055166a7d29 Nightingale, J., Burton, M., Appleyard, R., Sevens, T., & Campbell, S. (2021). Retention of radiographers: A qualitative exploration of factors influencing decisions to leave or remain within the NHS. Radiography, 27(3), 795–802. https://doi.org/10.1016/j.radi.2020.12.008 Nunes, A. J. S., Cruz, M. R. P. da, & Pinheiro, P. G. (2012, July 19). Fiedler’s Contingency Theory: Practical Application of the Least Preferred Coworker (LPC) Scale. Papers.ssrn.com. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2113000 O'Brien-Pallas L, Griffin P, Shamian J, Buchan J, Duffield C, Hughes F, Spence Laschinger HK, North N, Stone PW. The impact of nurse turnover on patient, nurse, and system outcomes: a pilot study and focus for a multicenter international study. Policy Polit Nurs Pract. 2006 Aug;7(3):169-79. doi: 10.1177/1527154406291936. PMID: 17071704. Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. (2022). Impact of the COVID-19 pandemic on the hospital and outpatient clinician workforce: challenges and policy responses. (Issue Brief No. HP-2022-13). 94 Peciuliauskiene, P., & Barkauskaitė, M. (2018). Emotional Support Abilities and Transformational Leadership of Senior School Students. SGEM International Multidisciplinary Scientific Conferences on SOCIAL SCIENCES and ARTS Proceedings, 5, 293–300. https://doi.org/10.5593/sgemsocial2018/3.4 Poulsen, M., & Poulsen, A. A. (2018). Optimizing motivation and reducing burnout for Radiation Oncology Trainees: A Framework Using Self-determination theory. Journal of Medical Imaging and Radiation Oncology, 62(5), 684–691. https://doi.org/10.1111/1754-9485.12725 Rehder Kyle, Adair, Kathryn C. Sexton, J. Bryan; The Science of Health Care Worker Burnout: Assessing and Improving Health Care Worker Well-Being. Arch Pathol Lab Med 1 September 2021; 145 (9): 1095–1109. doi: https://doi.org/10.5858/arpa.2020-0557-RA Ryba, K. (2021, March 2). What is Employee Engagement? What, Why, and How to Improve It. Employee Success Software. Retrieved November 9, 2022, from https://www.quantumworkplace.com/future-of-work/what-is-employee-engagement-defin ition Schaufeli, W. (2021). Engaging leadership: How to promote work engagement? Frontiers in Psychology, 12. https://doi.org/10.3389/fpsyg.2021.754556 Simon, E. (2021). Leadership in Pandemic. MEDSURG Nursing, 30(5), 349–352. 95 Sitthiwarongchai, C., Wichayanuparp, W., Chantakit, P., & Charoenboon, P. (2020). Impact of Organization's Leadership Style on Motivation of its Employees. Systematic Reviews in Pharmacy, 11(3), 48–56. https://doi.org/10.5530/srp.2020.3.06 Stone, P.W., Duffield, C., Griffin, P., Hinton-Walker, P., Laschinger, H.K.S., OBrien-Pallas, L., et al. (2003, November 3). An international examination of the cost of turnover and its impact on patient safety and nurse outcomes. Proceedings of the 37th Biennial Convention, Sigma Theta Tau International. Toronto, Ontario; Canada. Urhan, E., Zuriguel‐Perez, E., & Harmancı Seren, A. K. (2021). Critical Thinking Among Clinical Nurses and Related Factors: A Survey Study in Public Hospitals. Journal of Clinical Nursing, 31(21-22), 3155–3164. https://doi.org/10.1111/jocn.16141 U.S. Bureau of Labor Statistics. (2022-a, May). Diagnostic medical sonographers. U.S. Bureau of Labor Statistics. https://www.bls.gov/oes/current/oes292032.htm U.S. Bureau of Labor Statistics. (2022-b, September 8). Healthcare occupations : Occupational outlook handbook. U.S. Bureau of Labor Statistics. https://www.bls.gov/ooh/healthcare/home.htm U.S. Bureau of Labor Statistics. (2023-c, May). Magnetic Resonance Imaging Technologists. U.S. Bureau of Labor Statistics. https://www.bls.gov/oes/current/oes292035.htm U.S. Bureau of Labor Statistics. (2022-d, May). Radiologic Technologists and technicians. U.S. Bureau of Labor Statistics. https://www.bls.gov/oes/current/oes292034.htm 96 Van der Hauwaert, Hoozée, S., Maussen, S., & Bruggeman, W. (2022). The impact of enabling performance measurement on managers’ autonomous work motivation and performance. Management Accounting Research, 55, 100780 Volume 55 Waldman, J.D., Kelly, F., Sanjeev, A., & Smith, H.L. (2004). The shocking cost of turnover in health care. Health Care Management Review, 29(1), 27 Wall, S. (2015). Employee (Dis)Engagement: Learning from Nurses Who Left Organizational Jobs for Independent Practice. Nursing Leadership Volume 28 Number 3. West, M (2012). Employee engagement and NHS performance. The Kings Fund Yuan‑Sheng Ryan Poon, Yongxing Patrick Lin, Peter Grifths, Keng Kwang Yong, Betsy Seah, & Sok Ying Liaw. (2022). A global overview of healthcare workers’ turnover intention amid COVID-19 pandemic: a systematic review with future directions. Human Resources for Health, 20(70). https://doi.org/10.1186/s12960-022-00764-7 Zheng, D., Witt, L. A., Waite, E., David, E. M., van Driel, M., McDonald, D. P., Callison, K. R., & Crepeau, L. J. (2015). Effects of ethical leadership on emotional exhaustion in high moral intensity situations. The Leadership Quarterly (Vol. 26, Issue 5, pp. 732–748). Elsevier BV. https://doi.org/10.1016/j.leaqua.2015.01.006 97 Appendix A: Quantitative Survey Instrument Leadership Characteristics Survey: All of the following statements illustrate a specific leadership characteristic we seek to measure in regard to the leader, supervisor, or manager whom you feel has the greatest impact on your day to day professional activities. Each leadership characteristic (bold) is defined for you prior to the statements we have selected to establish this characteristic. Please respond to each statement on a Likert scale from Strongly Agree (5) to Strongly Disagree (1). MODEL definition: A leadership behavior whereby an ideal example is set for those who follow. 1. My leader treats me and my peers with respect. 5. Strongly Agree 4. Agree 3. Neutral 2. Disagree 1. Strongly Disagree 3. Neutral 2. Disagree 1. Strongly Disagree 2. I respect the abilities of my leader. 5. Strongly Agree 4. Agree 3. My leader demonstrates tolerance and appreciation of unique differences among members of the team. 5. Strongly Agree 4. Agree 3. Neutral 2. Disagree 1. Strongly Disagree 4. My leader’s behavior is inconsistent with the behavior expected of employees. 5. Strongly Agree 4. Agree 3. Neutral 2. Disagree 1. Strongly Disagree INSPIRE definition: A leadership behavior that encourages followers to achieve their potential by giving them the desire and ability to accomplish their assigned tasks. 1. My leader inspires me to do a good job. 5. Strongly Agree 4. Agree 3. Neutral 2. Disagree 1. Strongly Disagree 98 2. My leader promotes a shared vision within the department. 5. Strongly Agree 4. Agree 3. Neutral 2. Disagree 1. Strongly Disagree 3. I am dissatisfied with the recognition I receive for doing a good job. 5. Strongly Agree 4. Agree 3. Neutral 2. Disagree 1. Strongly Disagree 4. My leader inspires me to achieve my professional goals. 5. Strongly Agree 4. Agree 3. Neutral 2. Disagree 1. Strongly Disagree CHALLENGE definition: A leadership behavior that allows for critical thinking and empowerment to achieve professional excellence. 1. When appropriate, I can act on my own without asking for approval. 5. Strongly Agree 4. Agree 3. Neutral 2. Disagree 1. Strongly Disagree 2. My leader challenges me to learn and use new methods and technology that improve my skills. 5. Strongly Agree 4. Agree 3. Neutral 2. Disagree 1. Strongly Disagree 2. Disagree 1. Strongly Disagree 3. I am not involved in decisions that affect my work. 5. Strongly Agree 4. Agree 3. Neutral 99 4. My leader helps me find opportunities to advance. 5. Strongly Agree 4. Agree 3. Neutral 2. Disagree 1. Strongly Disagree ENABLE definition: A leadership behavior that provides employees with the resources to perform their assigned tasks effectively and efficiently. 1. I am provided with the equipment and supplies I need to perform my job effectively. 5. Strongly Agree 4. Agree 3. Neutral 2. Disagree 1. Strongly Disagree 2. I often feel like we are too short-staffed to provide quality service. 5. Strongly Agree 4. Agree 3. Neutral 2. Disagree 1. Strongly Disagree 2. Disagree 1. Strongly Disagree 2. I am given plenty of time to perform exams correctly. 5. Strongly Agree 4. Agree 3. Neutral 2. My leader helps remove obstacles which prevent me from performing effectively. 5. Strongly Agree 4. Agree 3. Neutral 2. Disagree 1. Strongly Disagree ENCOURAGE definition: A leadership behavior that promotes desired actions through personal and department rewards and feedback. 1. My leader makes me feel like a valued member of the team. 5. Strongly Agree 4. Agree 3. Neutral 2. Disagree 1. Strongly Disagree 2. My leader provides me with positive feedback and/or rewards. 5. Strongly Agree 4. Agree 3. Neutral 2. Disagree 1. Strongly Disagree 100 3. My leader advocates for fair compensation for the work I do. 5. Strongly Agree 4. Agree 3. Neutral 2. Disagree 1. Strongly Disagree 3. Neutral 2. Disagree 1. Strongly Disagree 4. My leader is overly critical of my work. 5. Strongly Agree 4. Agree Employee Satisfaction Survey: All the following statements illustrate an aspect of employee satisfaction. Each variable of employee satisfaction (bold) that we seek to measure is defined for you. Please respond to statements related to each variable on a Likert scale from Strongly Agree (5) to Strongly Disagree (1) PERFORMANCE definition: The ability of employees to do their job efficiently with high reliability and a level of compassion. 1. I perform my professional tasks and duties effectively. 5. Strongly Agree 4. Agree 3. Neutral 2. Disagree 1. Strongly Disagree 2. I feel compassion fatigue and have difficulty empathizing with my peers and patients. 5. Strongly Agree 4. Agree 3. Neutral 2. Disagree 1. Strongly Disagree 3. Neutral 2. Disagree 1. Strongly Disagree 3. Neutral 2. Disagree 1. Strongly Disagree 3. I am reliable at my work. 5. Strongly Agree 4. Agree 4. I rarely make mistakes. 5. Strongly Agree 4. Agree ENGAGEMENT definition: A mental and emotional connection that employees feel towards the work they do, their teams, and the organization. 1. I feel connected to my peers and team. 5. Strongly Agree 4. Agree 3. Neutral 2. Disagree 1. Strongly Disagree 101 2. I am mentally engaged in my work on a daily basis. 5. Strongly Agree 4. Agree 3. Neutral 2. Disagree 1. Strongly Disagree 2. Disagree 1. Strongly Disagree 2. Disagree 1. Strongly Disagree 3. I do not feel emotionally attached to my organization. 5. Strongly Agree 4. Agree 3. Neutral 4. I am proud of my work and my profession. 5. Strongly Agree 4. Agree 3. Neutral WELL-BEING definition: An employee’s ability to balance their work and personal life and sustain mental, physical, emotional, and economic health. 1. I have a good balance between my work and my personal life. 5. Strongly Agree 4. Agree 3. Neutral 2. Disagree 1. Strongly Disagree 2. I suffer from burnout and am emotionally and physically exhausted. 5. Strongly Agree 4. Agree 3. Neutral 2. Disagree 1. Strongly Disagree 3. Neutral 2. Disagree 1. Strongly Disagree 3. Neutral 2. Disagree 1. Strongly Disagree 3. I have good mental health and effective coping mechanisms. 5. Strongly Agree 4. Agree 4. I am financially stable. 5. Strongly Agree 4. Agree 102 Appendix B: Quantitative Informed Consent WEBER STATE UNIVERSITY INFORMED CONSENT IRB STUDY #AY22-23-251 The Role of Medical Imaging Leaders in Employee Satisfaction You are invited to participate in a research study on how leader’s responses, attitudes, and behaviors related to employee satisfaction in medical imaging departments. You were selected as a possible subject because you are currently employed in the medical imaging field. 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, Ryan Anderson, Erica Brown, Dulce Carter, Leah Johnson, Kirk McKinlay, Tabatha Moore, Abbey Pitt, and Lexie Thompson of the Weber State University Masters of Science in Radiologic Sciences. STUDY PURPOSE The purpose of this study is to examine the relationship between leadership responses, attitudes, and behaviors and how it affects employee satisfaction. NUMBER OF PEOPLE TAKING PART IN THE STUDY: If you agree to participate, you will be one of 100 subjects who will be participating in this research, all of whom are currently employed as medical imaging professionals at various healthcare facilities in the United States. PROCEDURES FOR THE STUDY: If you agree to be in the study, you will do the following things: Participants in this study will take a short survey consisting of anonymized demographic information and several statements. For each statement, the participant will indicate how strongly they agree or disagree with it. All responses will be kept anonymous. RISKS OF TAKING PART IN THE STUDY: The risks of completing the interview are feeling uncomfortable answering the interview questions as they may touch on sensitive topics relating to your employment and overall health. Possible loss of confidentiality. BENEFITS OF TAKING PART IN THE STUDY 103 You will not receive payment of any kind for taking part in this study. ALTERNATIVES TO TAKING PART IN THE STUDY: Please understand that your participation in this study is completely voluntary and your willingness to participate is appreciated. Instead of being in the study, you have the option to decline your participation. If at any time in the study you wish to withdraw, you are able to. COSTS/ COMPENSATION FOR INJURY There is no cost in participating in this investigation. 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 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 in which the study may be published and databases in which results may be stored. 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, Weber State University, 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 Leah Johnson at 208-390-2151 Tabatha Moore at 937-416-4771 or the researcher’s mentor 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. 104 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: Date: Printed Name of Person Obtaining Consent: Signature of Person Obtaining Consent: Date: (must be dated by the subject) 105 Appendix C: Qualitative Survey Instrument Semi Structured Interviews: Each interview will be held via ZOOM and recorded with consent. All responses will be coded for common themes. MODEL DEFINITION: A leadership behavior whereby an ideal example is set for those who follow. MODEL EXAMPLE: My leader sets an example for others to follow, has open communication, and enthusiasm. They are involved in our daily routine, have meetings often as well as follow-up meetings for any staff concerns. They are transparent with the staff in positive and difficult situations. ● MODEL QUESTION 1: What type of example does your leader set for your workplace? Does their example improve your work performance? Your engagement? Your wellbeing? ● MODEL QUESTION 2: Does the way your leader communicates with you and the enthusiasm that they show influence your satisfaction or performance in the workplace? ● MODEL QUESTION 3: How would observing your leader in the future influence your performance and satisfaction and engagement? What specific thing do they do that would influence your job performance? Your satisfaction? Your engagement in the workplace? INSPIRE DEFINITION: A leadership behavior that encourages followers to achieve their potential by giving them the desire and ability to accomplish their assigned tasks. INSPIRE EXAMPLE: Your leader shares their vision of the future with you and it makes you excited to continue your career with the organization into the future. Their passion for making a difference is evident and it encourages you to be excited for the future and what the organization stands for. ● INSPIRE QUESTION 1: Can you think of specific ways/things your leader does that inspires you? How have these examples affected your satisfaction, performance, and engagement? ● INSPIRE QUESTION 2: How could a leader communicate changes or progress towards a shared common goal to you that would improve your performance, engagement, and satisfaction? CHALLENGE DEFINITION: A leadership behavior that allows for critical thinking and empowerment to achieve professional excellence. CHALLENGE EXAMPLE: Your leader challenges the way things are done and consistently finds and is open to opportunities to improve processes and systems. They take risks, and experiment with new ideas in order to find positive changes. They make it clear that others 106 can challenge processes and systems as well and ensure they have the resources to implement changes and experiment. ● CHALLENGE QUESTION 1: In what ways do leaders make changes to your department to try and improve your performance, satisfaction, and well-being? ● CHALLENGE QUESTION 2: How does your leader give you room to challenge the status quo or think outside the box? ● CHALLENGE QUESTION 3: In what ways do your leaders support you when you try new things? Are you provided grace when you fail? Why or why not? ● CHALLENGE QUESTION 4: How would you like to be challenged in your work? ENABLE DEFINITION: A leadership behavior that provides employees with the resources to perform their assigned tasks effectively and efficiently. ENABLE EXAMPLE: Your leader enables you to participate in new opportunities and engage in collaborative activities. They advocate for resources to support your unit, organizational goals, leadership development, and mentoring. They create a culture of opportunities that is open and supportive to employee input and initiative implementation. ● ENABLE QUESTION 1: Are there specific obstacles at work that affect your job performance? Do you believe your leader(s) could remove these obstacles and help you do your job more effectively? If yes, how? ● ENABLE QUESTION 2: What additional resources would help improve your job performance? ENCOURAGE DEFINITION: A leadership behavior that promotes desired actions through personal and department rewards and feedback ENCOURAGE EXAMPLE: Your leader encourages input into key decisions at different levels of the organization, appreciates your contributions, and celebrates your accomplishments. Your leader also creates an environment where employees are rewarded for their accomplishments, makes eye contact, and establishes personal connections with you. ● ENCOURAGE QUESTION 1: What does your leadership do in terms of rewards/bonuses or recognition? Do you feel their efforts effectively improve your performance, engagement, and wellbeing? ● ENCOURAGE QUESTION 2: What can leadership do to better encourage staff in regards to feedback or rewards and how would you like to receive them? 107 Appendix D: Qualitative Informed Consent WEBER STATE UNIVERSITY INFORMED CONSENT IRB STUDY #AY22-23-251 The Role of Medical Imaging Leaders in Employee Satisfaction You are invited to participate in a research study on how leader’s responses, attitudes, and behaviors related to employee satisfaction in medical imaging departments. You were selected as a possible subject because you are currently employed in the medical imaging field. 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, Ryan Anderson, Erica Brown, Dulce Carter, Leah Johnson, Kirk McKinlay, Tabatha Moore, Abbey Pitt, and Lexie Thompson of the Weber State University Masters of Science in Radiologic Sciences. STUDY PURPOSE The purpose of this study is to examine the relationship between leadership responses, attitudes, and behaviors and how it affects employee satisfaction. NUMBER OF PEOPLE TAKING PART IN THE STUDY: If you agree to participate in this study, you will be one of ten subjects, all of whom are currently employed as medical imaging professionals at various healthcare facilities in the United States. PROCEDURES FOR THE STUDY: If you agree to be in the study, you will do the following things: Meet with researchers who will conduct a semi-structured interview with you individually over a video conferencing software (e.g Zoom). A standardized set of questions will be used for each interview and it is anticipated that the interviews will last 20-30 minutes, but there will be allocations for you to thoroughly answer all interviewer's questions. RISKS OF TAKING PART IN THE STUDY: The risks of completing the interview are feeling uncomfortable answering the interview questions as they may touch on sensitive topics relating to your employment and overall health. Possible loss of confidentiality. BENEFITS OF TAKING PART IN THE STUDY You will not receive payment of any kind for taking part in this study. 108 ALTERNATIVES TO TAKING PART IN THE STUDY: The only alternative option in participating in this study is removing yourself from the study. These interviews are conducted on an at will basis throughout the entire study. Participants may remove themselves from the study at any point and request that their information be removed from the study without any penalty. COSTS/ COMPENSATION FOR INJURY This study is conducted on an at will basis for the duration of the study and as a result, no costs or compensation for injury will be provided by researchers, the institution they represent, nor any other third party. If by participating in this research you suffer an injury or any type of distress, you will be responsible for seeking medical care and for the expenses associated with any care received which are not covered by your health insurance provider. CONFIDENTIALITY Efforts will be made to keep your personal information confidential. However, we cannot guarantee absolute confidentiality. Your personal information may be disclosed if required by law. Your identity will be held in confidence in reports in which the study may be published and databases in which results may be stored. Recordings of the interviews will only be viewed and seen by researchers in order to transcribe and code them. At which point, the videos will be stored in a secure database to be destroyed within a two year period after completion of the study. The coded transcriptions will be stored securely on databases and only researchers will have access to them. Any portion of transcriptions that can be used to re-identify study participants will be censored or removed to ensure confidentiality is maintained. 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, Weber State University, 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 researchers Abbey Pitt at 208-421-1074 or Kirk McKinlay at 206-851-4059 or the researchers’ mentor Dr. 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 and may leave the study at any time. Leaving the study will not result in any penalty or loss of benefit. Your decision whether or not to participate in this study will not affect your current or future relations with Weber State University. 109 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: Date: (must be dated by the subject) 110 Appendix E: Code Book - Themes & Frequencies Leadership Attitudes and Behaviors MODEL THEMES Model type (good example) P2- Feedback P2- Communication P2- Frequent meetings P3- Communication P3-Employee advocacy P3- Meetings P5- Communication P6- Positive attitude P6- Leads by example Model type (bad example) P1- Not transparent P1- No communication P1- No advocacy P3- No meetings P3- No communication P3- No guidance P3- Hands off/no engagement in workplace P4- Hands off/no engagement P4- Not a ton of meetings Does their example have an impact on P1- No satisfaction (yes or no) Less engaged (P1) P2-Yes Likes structure (P2) Likes check in (P2) Likes to voice problems in private (P2) P3- Yes Good people skills and managing (P3) P4- No negative impact on satisfaction (P4) P5- No less engaged (P5) P6- Yes More willing to work due to leaders example and keeps everyone positive (P6) Does the way their leader communicates P2- Yes impact satisfaction? (yes-positive or P3- No no-negative) P4- No P1- No P5- No P6- No How would observing their leader in future P1- Don't want to be asked to do things a FREQUENCY 3- Communication 2- Meetings 1- Feedback 1- Employee advocacy 1- Positive attitude 1- Leads by example 2- No communication 2- No meetings 2- Hands off, not engaged in day to day workplace 1- Not transparent 1- No advocacy 1- No guidance 3- Yes 3- No 5-No 1-Yes 3-No changes 111 impact their satisfaction? leader wouldn't do P1- Open communication P3- Management that cares P4- Communication P2- No change P5- No change P6- No change P1- Allows for mental/physical breaks P3- Encouragement P3- Good communication Specific things their leader could do in P4- Communication future to influence their satisfaction? P6- Opportunities to grow INSPIRE Themes Specific ways their leader inspires them? P2- Opportunity for career development (Yes or No) P4- Leads by example P6- Utilizes employees for speaking engagements P5- Complimentary P5- Open to suggestions P1- No inspiration due to lack of communication P3- Does not inspire The way the leader inspires has an impact P2- Yes: feels supported on their satisfaction P4- Yes: recognition P5- Yes: recognition/compliments P6- Yes: that their opinion mattered/confidence P1- No: felt like just a number P3- No: no cheerleader How could their leader communicate P1- Genuine concern for employees changes or progress to shared goals that P2- Committee to share new cases would impact their satisfaction P3- Positive spin on situations P3-Encouragement/kudos P4- Knowing the direction and time frame of goals P5- Open communication P5- Employee advocacy P5- Encouragement/positivity P6- Concern for employees CHALLENGE Themes What ways do their leaders make changes to P1- Shut down the department to improve satisfaction? P2- Involve all stakeholders in process P3- Not open to feedback P3- Insecurity and no feedback wanted 2- Open communication 1-Management that cares 1-Leader who wouldn't ask anything they wouldn't do 2- Communication 1- Mental/physical breaks 1- Encouragement 1- Opportunities to grow Frequency 4- Yes 2- No 4- Yes 2- No 2- Genuine concern for employees/advocacy 2- Open communication with direction and time frame of department goals 2Encouragement/positivity 1- Committee to share new cases for career growth Frequency 4- No challenge 3- Change for change's sake 3- Culture of change 112 P4- Will implement new, but no feedback asked P5- Unresponsive to suggestions Room to challenge status quo (yes/no) Support to try new things? (yes/no) Grace if they fail? How do they want to be challenged? Doesn't want to be challenged ENABLE Are there specific obstacles at work that affect their satisfaction/performance? 2- No change occurs in department 2- Change is valued 2- No plan/ not executed properly 5- No feedback wanted 1- Collaborator P2- Yes. Involves all stakeholders in process P1- No, shuts down P3- No, Not open to feedback P3- No, Insecurity and no feedback wanted P4- No, will implement new, but no feedback asked P5- No, Unresponsive to suggestions P2- Initially yes, but not long term 5- No P2- Can address workflow despite difficulty of 2- Yes work P5- No support for learning new equip,modalities, techniques P6- No blame if new thing doesn't work P2- No support drives out those who want to change P3- No follow through (long term support) P4- Preconceived plan and not flexible P4- No blame game 2- Yes P6- Culture of change, see if it works mantra 2- No P3- Hypocrisy, lead by example P5- No support in change (due to COVID) P1- Learning new exams 4- New Education P2- New education/skills/certs/modalities 2- Make room for growth P3- Better at what you do (image quality) P4- Growth outside clinical environment P4- Train someone to replace me so I pursue something new P4- Give new techs opportunities to do more P1- Go faster to fit more patients in 40 min 2- Winding down exam in 20 1- Wrong type of P5- "Winding down" to retirement challenge P6- Being challenged enough, in sweet spot 1- In right spot P6- Post growth--> title not important THEMES FREQUENCY P1- Asking for ergonomic chairs (equipment) 3- Training P1- No workflow for open spots in schedule 3- Staffing (workload) 2- Workload P1- Felt like a mule (workload) 2- Equipment P2- Not current obstacles 113 P2- Growth stagnation from lack of staff (workload) P3- Cheaper equipment easy to get, better larger pieces hard, no staffing (workload) (staffing) P4- Lack of training and on-boarding for new techs P5- No training/on-boarding P5- Unorganized training process P6- Huge turnover, always on call, no staff Do they believe their leader could remove P1- Yes, but don't 3- Can, but don’t these obstacles? P3- Yes, but don't 1- No P4- Yes, but don't P6- No How could their leaders remove it? P1- Block out for add-ons 2- More time, rooms, etc. P1- Add more locations/rooms 2- Workflow P4- Lack of protocols leave even senior techs 1- Long-term strategies confused P5- Always ER interface issues, but they work to remove them. P6- Focused on long term solutions What additional resources would improve P2- More staff 4- Training their satisfaction? P2- Opportunity to train other mods 2- Staff/equipment P3- Staff and equipment 1- Communication P4- Attending radiologist more engaged with 1- Salary residents P4- More training for resident rads -esp/ if QC studies P5- More organized training process P6- More communication on long term solutions P6- Competitive salaries ENCOURAGE THEMES FREQUENCY What rewards, bonus, recognition do leaders P1- Shoutouts from staff to staff 6- Staff to staff shoutouts give to their employees? P1- Honest encouragement 2- Token/prize P2- Shoutouts in team meetings 1- 1 on 1 recognition P2- No recognition, led to lack of motivation 1- Department recognition P2- Money doesn't reflect amount of work done P3- Small things (shoutouts) (union so no bonus) P3- Staff shout outs to each other P3- Pin or token or recognition from all staff to one 114 P4- Union so no bonus or recognition P5- If staff mentioned on survey they get a small prize P6- Wall of fame (staff pics and birthdays P6- Friend wall (staff shared experiences in/out of work P6- Recognition board, staff shout outs Do these efforts effectively improve P1- If they appreciate us, we work harder. It 3- Yes satisfaction? Yes goes a long way 2- Yes, but more frequent P2- Who doesn't like money? frequent gift cards over year end bonuses P2- Feedback matters P4- High priorities leads to more engagement P6- We're close and feel like family Do these efforts effectively improve P1- A little bit of money doesn't do anything 3- Cash don't count satisfaction? No for well being 1- Doesn't change P1- Valued and appreciated is better than anything monetary bonuses P4- Mule- got what they needed out of you and moved on P5- Doesn't change it either way, it's nice to hear, but fluff What can leadership do to better encourage P1- Bonuses are in the end superficial - no 2- Compensation (more staff in regards to feedback or rewards? desire to be better vacation time) P4- Assign responsibility (create growth) 1- No bonus P5- More vacation 1- Growth P6- Monetary compensation is important do they want to receive the feedback or P1- We're at bottom, don't add more work 3- Remove harmful rewards? P1- Workloads that lead to quality patient care rewards and metrics P3- Ask staff what they like, what they want, 2- Encourage growth what they see 1- Follow through on staff P4- Know staff abilities and play to your suggestions, needs, wants strengths/weaknesses to keep staff engaged 1- Activities P5- Fun activities -potluck, waffle night, piece of pie makes things more bearable-- be there with staff P6- Remove annual bonuses that elevate lazy employees and discourage engaged employees 115 Appendix F: Code Book Variable Model Question Link SubVariables Codes MQ 1a What type of example does their leader set? M1_type_good Direct Quotes P2-There's positive feedback, whether we're doing a good job or not, there's always feedback in that communication between the staff and the management. P2- They always do rounds depending on what type of procedures they have going on that morning so they can adequately organize and staff for every department. P2-Quarterly staff meetings, one on one to see where you're at, how are you doing mentally, physically, emotionally, and if there's any problems that you didn't want to voice during the group meetings. P2- Communication is always good there. P3- I've had a micromanager of a manager that was very business oriented and was into the details. They fought really hard for us even though they were hard on us. They fought very hard for us to make sure that we had everything that we needed and that we had meetings so that we all could communicate. They were very open and transparent, P5- He is very communicative. P5- So if there are issues ... he makes all of us aware of the situation ahead of time, so that we can try to avert any problems. P6- the current leader that I have for sure exemplifies a lot of those traits. She works very hard...maintains a positive attitude...very encouraging with all of it...the first one to get her hands. So we don't necessarily feel like she's just passing down things for us to do. She's a part of getting the work done as well. Variable Question Link SubVariables Codes Model MQ 1a What type of example does their leader set? M1_type_bad Direct Quotes P1- No transparency with the staff P1- No open communication P1- No advocacy P3- My current leadership team, we do not have meetings. We do not have open communication. We don't see them. P3- Don't have any guidance that you need P3- They're out of touch with what's really going on in the department because they're never there and they don't see it, and they tried to run it from behind the door. P4- Hands off P4-Autonomy was nice...engagement has dwindled off to almost nonexistent 116 P4- We don't really see him [leader] P4- Six staff meetings throughout in a calendar year Variable Question Link SubVariables Codes Model MQ 1b Does their example impact satisfaction? M1_IOS_Y Direct Quotes P2- It keeps structure so rather than letting a problem take, like weeks or months to resolve P2- Check ins what they call it a check in not a meeting but they just it's like a quick 15 minutes or less just a quick check and see how you're doing, how are your problems if it's getting any better. I think that's always a good, good thing to implement. P2- I'm allowed to voice those concerns a little more privately. P2- Helps motivate me to feel better about the workplace. It encourages people to not only be heard, but you feel like problems are actually getting solved. Because then it gets brought up to the bigger meeting at the end of the month. So other people can then step in and say hey, I have an idea about how we can solve this rather than feeling like you have to voice your concerns in a bigger larger group setting which can be a little intimidating sometimes and your mental state isn't being attacked or feeling like you're drowning in that situation if you don't have help or support from other co workers. P3-(past management) Yes, but she also had her sidekick. It was a very good balance of people skills and managing and that was actually the best time because it had that little soft touch to it, but still got things done. P4- Absolutely...I would say it is probably having more of a negative impact with engagement, enthusiasm, productivity... P5- I feel that I would be much less much less engaged. If he was not as responsive as he is. P6- Absolutely. I feel like myself and my team...are a lot more willing to work...when someone that we feel is part of the team...and not just this kind of doling out work. P6-It does, it causes you to have a much more positive and upbeat mindset emotionally, mentally. It keeps you from feeling kind of beat down. Variable Question Link SubVariables Codes Model MQ 1b Does their example impact satisfaction? M1_IOS_N Direct Quotes P1- No. Makes me less engaged. And my well being at the end of the day is just, I just feel drained and mentally and physically drained. Variable Model Question Link SubVariables Codes MQ 2 Does the way their leader communicates impact satisfaction? M2_IOS_Y Direct Quotes P2- There's always an open line of communication, whether it's through cell phone, or there's this app called 117 sling where most of our communication is through. We have an app where, hey, when you have a second, can you look at this posting and kind of get back to me when you're available? Not necessarily like through text, feeling like you have to come home with work all the time. Which is really good. P3- Absolutely. If you have good communication, then you feel like you're involved in the team. P4- Absolutely. I would say the communication with faculty and administration at our institution is probably one of the things that is lacking the most. And that I would say is probably having more of a negative impact. Impact currently, with staff productivity, enthusiasm, engagement, things like that. Variable Question Link SubVariables Codes Model MQ 2 Does the way their leader communicates impact satisfaction? M2_IOS_N Direct Quotes P1- If there were more communication, I feel like the entire staff would be more inclined to want to be more productive. P3- We do not have good communication. Our information is usually disseminated like, here's an email we received or forwarding to you. You read it and you interpret it as you should. P4- Absolutely. I would say the communication with faculty and administration at our institution is probably one of the things that is lacking the most. And that I would say is probably having more of a negative impact. Impact currently, with staff productivity, enthusiasm, engagement, things like that. P5- No, probably not no. P6- I've had leaders in the past that were not very good with keeping us informed on various things like protocol...scheduling...makes you feel like you're not part of a team and that you're not valued as much. Variable Model Question Link SubVariables Codes MQ 3a How would observing their leader in future impact their satisfaction? M3_OBS_FIOS_ Direct Quotes P1- I would never want my leader to ask me to put myself in a situation that they wouldn't want to be in as well P1- Open communication and advocacy for the staff would be first and foremost the most important thing, rather than just do whatever makes other people do whatever makes the supervisors happy as in, again, quantity over quality. P3- because it doesn't seem like management cares, we've had staffing issues. We have equipment that should have been replaced 12 years ago that's breaking down and we don't see you know, behind the scenes, what management's doing for us to help us P3- When it appears that they don't care, I've had to find that spot where I don't care. P4- Number one is communication. Variable Question Link SubVariables Codes Model MQ_3a How would observing their leader in future M3_OBS_FIOS_passive 118 impact their satisfaction? Direct Quotes P2- I can't think of anything right now. It seems like everything is pretty out and open. I haven't seen the problem occur right now. P5- There's really nothing that he could necessarily do... that would influence or affect my role or my well being or attitude. P6- Right now, I think she's doing a very, very good job. Variable Model Question Link SubVariables Codes MQ_3b Specific things their leader could do in future to influence their satisfaction? M3_FT_IOS_W Direct Quotes P1- There's no room for a mental break. If we had a leader who, or supervisor or lead who, you know, said no to add ons, and no to more and more and more and more patients, there would be a little bit of a mental break in there P3- You still need that, that guidance in the background for certain things and policies and, and just to say hey, you guys are doing a great job. Keep up the good work. P3- I'm pretty intrinsically motivated. So, I don't let that influence the way I do my job and the way I take care of my patients. P3- You can communicate continuously but if it's not good communication, that does more harm than good P4- Communication is absolutely, I think the number one thing that could be could be falling into that category. P6- She could bring some people from the team in and give them a little bit more leadership opportunities themselves. To help grow their skills and their confidence. Variable Question Link SubVariables Codes Inspire IQ 1a Specific ways their leader inspires them? I1_Type_good Direct Quotes P2- Personal career development. I, for example, in the last check in she asked me, What can we do to help you grow in your career? It’s nice feeling supported in that way? P4- Leading by example, and never asking an employee to do anything that he would not be willing to do himself. P6-She has a good way of utilizing several of us in speaking engagements, when either administration makes rounds or when we have outside groups, whether it be from the community or schools that come to the hospital. She brings individuals, myself included, out to speak and engage with those people and it makes you feel very inspired. P5- Is complimentary of my work. And he comes to me, he actually comes to me to collaborate. And, yeah, try and come up with solutions for problems. How to get the best images possible on a not ideal patient or in a bad situation. So, yeah, but I feel like my abilities are recognized by him. 119 Variable Question Link SubVariables Codes Inspire IQ 1a Specific ways their leader inspires them? I1_Type_bad Direct Quotes P1- Not at all. Period. There's no discussion of that. Because there's no staff meetings, there's no discussion of what is best or how we can best take care of our patients? There's no inspiration. It's just just keep adding, just keep taking more patients P1- before I got there, they'd had staff meetings, gave their input, gave their requests, and nothing was done about it. P3- none whatsoever Variable Question Link SubVariables Codes Inspire IQ 1b Does it affect their satisfaction? I1_IoS_yes Direct Quotes P2- it encourages me, it definitely motivates me to feel like I'm part of a team bigger than what I thought I was getting myself into. It motivates me to keep learning and not feel stuck. Just to feel that they support me and to know that there's options in growth. I think that's really important. P4-Personally...it was nice to have the recognition...but also on a team cohesiveness. The department was much much more much more of an efficient working unit. P5- He is complimentary of my work and he comes to me to collaborate to...come up with solutions for problems...so I feel like my abilities are recognized by him. P6- Like your opinion matters, and kind of instills that confidence in you that she believes in you. That somebody recognizes your ability and trusts you to be the face of the representation of your department. Variable Question Link SubVariables Codes Inspire IQ 1b Does it affect their satisfaction? I1_IoS_no Direct Quotes P1- You just feel like a number and it decreases morale for sure. And you just feel like somebody who's there to just just keep going, you just pump just keep putting out patient numbers as many as you can fit in a day. It's not about in my experience it's not quality of care it's quantity of patience. And so that definitely decreases your morale when all you can scan a patient and you come out and there's three more waiting because they just keep filling up your schedule. And there's really no in my I mean, there's really no morale boost. No Hey guys. Ah, you're doing a great job, we appreciate what you're doing for us there really isn't not from, you know, my experience there even in other outpatient facilities that I've worked at there isn't, there may be a day of pizza like, Hey, guys, thanks. You know, just keep adding more patients. But there, there really isn't any P3- if you don't have that cheerleader behind you, then it's definitely like, why am I doing this? P4- (from leader isolating) I would say the overall satisfaction has, has definitely diminished Variable Question Link SubVariables Codes 120 Inspire IQ 2 How could their leader communicate changes or progress to shared goals that would impact their satisfaction IQ2_FT_IOS Direct Quotes P1- Somebody just genuinely asking how, how are things going? How are you feeling about, you know, the current situation? How are you feeling about the patient load? What is your input? What could we do to make our department better? And then taking that and actually applying it to our workday versus okay, I'm, I may be hearing you, but I'm not really listening. P2-It would be really cool if this workplace were able to develop some kind of committee in building or sharing cool cases, but you can still learn off of those, like really unique cases that we rarely come across. There's growth in learning on how to further image or better have diagnostic quality on that exam P3-Taking the positive spin on things like and just kudos for a job well done. P3- We have surveys and the surveys are like, has anybody told you you've done a good job in the last week? And mine always no, because they don't. take with a grain of salt. I'm not one of their favorite people P4- One thing that I have heard time and time again, is just knowing what the direction is. P4- If there was a clearly defined mission plan, or even just a six month goal, a year goal and a five year goal...and these are the changes that we plan to implement...it would dispel a lot of confusion for people. P5- Management doesn't share information and will tell specific people bits of information but they don't share department wide, even if it is something that affects everyone within the department... we're supposed to have monthly staff meetings, which are held during the week. I work on the weekends...there are about nine of us who work weekends only so we don't go to the meetings because we'd have to go in on our days off. Management doesn't even keep notes of the staff meetings to let us know what is discussed in staff meetings. So it feels like we're always in the dark. P5- A good manager is a champion of his or her employees, and will stand up for them and always back them. Even if they did something wrong. Back them when talking to physicians or upper management or patients or whoever always, always back your employees and then talk about it later. P6- Monthly rounding so my director or assistant director takes turns rounding with each individual employee within the department. And they ask us questions like what's going well for you? What are some talents you know, challenges you have faced? What are what's a connection or how have you made an impact on a particular patient or employee? Variable Inspire Question Link SubVariables Codes IQ 2 How could their leader communicate changes or progress to shared goals that would impact their satisfaction IQ2_FT_IOS_passive Direct Quotes 121 P5- He makes makes all of the techs on this particular shift feel about as good as possible about the work environment we're in P5- I send emails to my manager, to my manager, asking for specific answers to concerns that I have and I do not receive a response P6- Makes you feel like your needs are being heard and that they're at least attempting to be met. Some things can't be done immediately..., but it does give you a sense of like your needs are at least attempted to be met. Variable Challenge Question Link SubVariables Codes CQ 1 What ways do their leaders make changes to the department to improve satisfaction? C1_WaysSat Direct Quotes P1- If I were to speak on a personal level, as far as challenging me to be better tech there really isn't. P1- I feel like there is no experimentation in trying to implement new ways to improve the department. In other words, we talked about more time for exams. I have not seen in our workday, anybody apply more time to particular exams that might be longer, that might need more attention, that might need more patient care than a quick 30 minute exam slot. P2- There wouldn't be growth or we wouldn't know what I would be doing wrong or right if I didn't get feedback whether it was positive or negative, from both radiologists, from my co-workers, from the main manager and administration. So I feel like communicating whether it's positive or negative, I think it should be there no matter what. P3- I want to say if it ain't broke, don't fix it. type of thing, but it is broke. And if I ignore it, I don't have to fix it. P3- I think roundings are important and, or even just going around your department and looking at things talking to people. P4- Just go full steam ahead and ask for forgiveness later, which is nice, because there's a lot of opportunity, but the caveat to that is there is no implementation of any sort of plan. It's we will work out the details later. P5- The big challenge that they tried to overcome to improve our well being is just to improve the staffing levels. P6- If we see a process that could be changed to either make it more efficient, or, with cost savings. They give us the ability if we bring an idea to light they listen to us P6- It makes you feel valued. It makes you feel like you're more than just a hired hand. You know, it makes you feel like you're part of the team and you're part of the solution. Variable Challenge Question Link SubVariables Codes CQ 1 What ways do their leaders make changes to the department to improve satisfaction? C1_WaysSat_passive Direct Quotes P2- from my previous experience, there was always meetings about how we can improve the workflow. And as a team as with my co workers, we would bring up solutions that we thought was compatible with the workflow 122 space, so I feel like by implementing rules and actually sticking to those rules, it would help change or make a starting, starting have a change chain to maintain those changes so that they don't keep getting worse. Variable Question Link SubVariables Codes Challenge CQ 2 How does their leader give them room to challenge status quo? C2_RoStatquo_yes Direct Quotes P2-they would say yes, yeah. Well, we're open to doing that. We will implement these rules, but that was only communicated to the staff working for example, the sonographers working in the back, however, the front desk receptionist, also should be part of that discussion, and they were not implementing those rules. And so with being miscommunicated throughout the whole department, it just constantly was a vicious cycle of these changes not happening and it was very disappointing for everyone. Variable Challenge Question Link SubVariables Codes CQ 2 How does their leader give them room to challenge the status quo? C2_RoStatquo_no Direct Quotes P1- Shut down. It is immediately shut down in front, you know, especially the here and now like the current situation P3-They are not open to feedback or suggestions. Sometimes they are if they are, they'll listen to you but then nothing ever happens. P3- I tried to make suggestions on things we need, [and they say] don't tell me how to do my job. And you have that insecurity of people that don't want feedback from other people who have been there for a long time. P4- He is going to implement something new and doesn't really ask for a lot of feedback, waits to see more on outcome based performance and if it crashes and burns go back to the drawing table. P5- The manager says he is but when I bring up problems and potential solutions, what I think would be a solution. I get no response. Variable Challenge Question Link CQ 3a SubVariables Codes What ways do their C3_Ways_New_thing_positi leaders support them ve to try new things? Direct Quotes P2-Yes, because we were allowed technically to voice our concerns. However, once those concerns were brought up, and supposedly we have meetings to change these potential problems, the thing is that the rules were never stuck upon never were acted upon for long term. Say it would work for a month and then the next month, they would just go right back to the initial problem of workflow P2- Where I'm currently at there's more support in this organization that I'm with and so now I feel more happy, more at peace. Knowing that yes, there are days that are still difficult, but I at least can go to someone and 123 actually do something about those concerns I have P5- In the past, I was supported more as far as training and new new techniques, new equipment- those are the things that inspired me P6- [after trying participants' ideas turned out to be less efficient] We just kind of went back to how things were. And there wasn't there wasn't any feeling like, wow, they're disappointed in me that I'm the one that brought this up... it was more approached like, Well, that didn't work but keep coming to us with your ideas Variable Question Link Challenge CQ 3a SubVariables Codes What ways do their C3_Ways_New_thing_negati leaders support them ve to try new things? Direct Quotes P2- In the past? No. They didn't support and that was detrimental to my mental and physical health, which is one of the reasons that was the main reason why I quit. P3- If they implement something, a change, they don't have follow through P4- It's usually "I've already got my plan formulated". It's never it's never in a condescending, rude way. But usually those type of ideas that are coming from staff. He has his hand in it somehow it's never completely employee driven. Variable Challenge Question Link SubVariables Codes CQ 3b Do their leaders give them grace if they fail? C3_Grace_yes Direct Quotes P4- I wouldn't say the blame game. There's definitely frustration...just a fact that you know, it's a chaotic situation... It was just stressful emails, stressful phone calls, but nothing ever directly pinned on one individual. P6 - Culture of the hospital of change it to see if it works, if it doesn't and we go back, you know, at least gave us the opportunity to try things Variable Question Link SubVariables Codes Challenge CQ 3b Do their leaders give them grace if they fail? C3_Grace_no Direct Quotes P3- If you're going to give us guidance and directives, you have to lead by example (they do not follow this) P5- I did not feel supported by management and I know that COVID has played a part in it Variable Question Link SubVariables Codes Challenge CQ 4 How do they want to be challenged at work? C4_FCh_want 124 Direct Quotes P1-I think, challenged in the sense of, Ooh, let's try this cool new exam. I think we can do it, show me how to do it and I'll do it. Challenged in the sense of, hey, can you get this 40 minute exam done in 20 minutes or, you know, can you fit this additional patient in and just see where it goes? No. P2- Continuing my education and learning new skills? Whether it's scanning and becoming proficient in vascular or learning a new set of skills P3- Would like to be challenged in improving my image quality P4- The ability or opportunity to have any sort of growth outside of just the clinical environment, whether that is taking on more administrative roles ...[or] Any sort of process improvement where we're engaged with faculty about maybe revising protocols, optimizing imaging techniques. P4- Take on some new challenges or something different within the clinic and even if that was passing on my current role to somebody else to train them to do it so I could explore different opportunities. But I think what he really relies on is if you're really good at your job, he wants you to keep doing it. P4- [Growth]beneficial for multiple people in the department. There's people that would love to come into this field and take on more responsibility and start moving up, maybe through different different routes. Variable Challenge Question Link SubVariables Codes CQ 4 How do they want to be challenged at work? C4_FCh_passive Direct Quotes P1- Challenged in the sense of, hey, can you get this 40 minute exam done in 20 minutes or, you know, can you fit this additional patient in and just see where it goes? No. P5- No...I am at the point in my career where I am actually winding down. I am working toward retirement. And so, my goal is to just make it to retirement. P6- I'm kind of in a sweet spot right now. Where I'm given opportunities to make some changes and to be a leader without the official title and the headache of it...I get the benefit of being able to kind of show off how much knowledge I have and helping to mold these people into being the best techs that they can be. But, you know, at the end of the day, if things don't work out, it's not necessarily on my head. P6- The title is not important to me. Now, if you would have asked me that five or 10 years ago, I probably would have had a different opinion. But the older I get, the more I recognize that I am the leader that I am, regardless of what my title is. I enjoy teaching people and I enjoy helping people gain knowledge. Variable Enable Question Link SubVariables Codes EN 1a Are there specific obstacles at work that affect their satisfaction/performa nce? EN1_SOTS Direct Quotes P1- Superficially, we've been asking for ergonomic chairs since I got there. P1- There's no black and white protocols for if there's no openings on our schedule 125 P1- (feeling overworked) I just felt like a number. I just feel like a, like a mule? Like, just do it. I don't care if you don't like it, you know, it's more like, yeah, I just feel like undervalued. 100% just a number. P2- Not in my current situation P2- (in the past) Very focalized mindset very narrow mindset of even if you do mention that you are interested in learning more vascular or learning a different set of skills that they are open to allowing you to do those because whether it's interrupting the schedule that they have set out for for a month. It makes it hard for people to grow and feel like they have an opportunity to grow if not everyone is staffed appropriately. P3- we need sponges, table pads, and having accessories like that readily available, you ask they'll give it to you no problem. Needing equipment to do our job equipment that functions properly, that isn't breaking down, that's more of a challenge. Not having enough staffing. P4- Lacking in training and on-boarding for new technologists. P5- Looking at it from the perspective of a new employee. They could do a whole lot better because there is no real training or orientation process. P5- Where I work is a teaching hospital. It's huge. We have lots of research protocols. We have lots of very specific exams that we do that require a fair bit of knowledge and focus and concentration and ... It's a challenging place to work and what would make it better is a more organized training process. P6- About a year ago, like much of the medical field, we went through a huge turnover where people were just quitting in droves. And you just didn't have enough help..., you were vastly understaffed. You know, we were all on call. We were all just, we were completely worn out. Variable Enable Question Link SubVariables Codes EN 1b Do they believe their leader could remove these obstacles? EN1_Remobsat_yes Direct Quotes P1- (in relation to new chairs) the first thing (management) said was, No, that's never gonna happen. P3- Oh, absolutely. They are unnecessary obstacles P4- Logistical end, I couldn't ask for more from our supervisor. If we need a new piece of equipment or anything that has a $ sign attached to it. He makes it happen. We never struggle in that area P6- We kept asking for help, help, help, help help...Our hospital wouldn't really buy into the whole travel tech thing. Which was frustrating because we were all just working so hard. I mean, we were working 50-60 hours a week. We couldn't understand why the hospital wouldn't essentially come off their pocketbook, to pay us, to pay some travel techs to come and help us to take some of the load off of us. Variable Enable Question Link SubVariables Codes EN 1b Do they believe their leader could remove these obstacles? EN1_Remobsat_no Direct Quotes P4- (In relation to the leader) He is at times the obstacle. Variable Question Link SubVariables Codes 126 Enable EN 1c How could their leaders remove obstacles? EN1_Howremobsat Direct Quotes P1- For us specifically putting blocks on our schedule to accommodate potential add ons, we asked for that at our last meeting immediately shut down, hey, just block it so that they can't fill it with appointments. And that way, if we do have an add on, we can take it because we do have openings, and we're not adding additional patients to an already full schedule. That would be great. P1- There's discussion of opening other locations for ultrasound right now, we're the only location that does ultrasound. If they opened other rooms at other locations, that would kind of take a little bit of the workload off of us specifically at our location. P4- Even for seasoned technologists, there's things that come up where we're all scratching our heads, like, I don't know anything about this and we have been told multiple times you can read a protocol and sometimes the protocols aren't that great. P5- There are always problems with the emergency department ordering exams that are not emergent and still expecting them to be done in what they think is a reasonable time, which we think is highly unreasonable. But that is one thing that management has really tried to work on and improve. So I do have to give them credit and kudos for for that P6- What they did do and what we didn't realize at the time was they were working on getting it passed within the budget and with the board to where they did a good sign on bonus for people who would come on full time. Variable Enable Question Link SubVariables Codes EN 2 What additional resources would improve their satisfaction? EN2_FT_IOS Direct Quotes P2- (past) Well being staffed accordingly would have number one, right. But after that, I think just being allowed to train up there for about a week to learn a different set of skills (growth in department/career) P3- Staffing and equipment P4- Having our attendings be more actively engaged with our residents to know the workflow, the department what's going on...we have residents not know what they're doing and it puts us in the position of training doctors. P4- When we have a resident show up for a four week rotation through Nuc Med and they're expected to be QC-ing studies, and they have never seen them before and there is no attending in the room with them, that's where it becomes an issue from day one. They lack training. P5- What would make it a lot better is a more organized training process. P6- Ultimately, while we didn't get the immediate results we wanted, we got better results. Because we now are fully staffed with tech's who are going to be here for years to come. P6- [saying]We're working on it works for a couple of weeks. But you know, six and eight months later, it kind of caused the domino effect. Everybody was so tired and we didn't see a change come in. So then more people kept quitting, which just expanded the problem. P6- especially here... we're still working on bringing the salaries up to match 127 Variable Encourage Question Link SubVariables Codes EC 1a What rewards, bonus, recognition do leaders give to their employees? EC1_RBR Direct Quotes P1- There is a reward program where if you see, you know, one of your fellow employees, whether you're in whether you're in radiology or not, you can kind of say, Hey, I think you did a good job P1- As far as directly from my supervisor, no, there's no encouragement. Other than, Hey, guys, we can make it through this day. I know it's a crappy day. We hear that occasionally. P2- Every time there's a team meeting, they will say to that person directly, like for example, participant 2, you did an excellent job in handling this situation when this patient was upset. And so they'll go around and say, one by one, who did a great job. P2- (past) In the prior experience, there wasn't a lot of recognition at all. I felt very unmotivated to go to work because I felt like there was no record with recognition. P2- There was only Christmas bonuses at the very end of the year, which I mean, you are still grateful to have. I felt like money isn't the end all do all to show the gratitude that we have worked all year long. And I feel like it's the monthly basis recognition to know that I am doing a good job to have that good feedback. P3- I don't think it takes much to put like a little sign up to communicate. Great job everyone. Don't forget us during x-ray tech week. Positive communication and reinforcement. Every once in a while, a little kudos on the board. P3- We're County, we don't have or they don't have the capabilities of rewarding with bonuses and recognition P3- We have had like this board where there was something about stars, but it was more of each other, the employees giving kudos to each other. P3- (interview did this, not management) I would have these little contests where I would have people when they see something that their coworker did that they're like, Wow, that was really super cool. I called it that. It was it's, it's actually not something I call but it's something I stole it's called The Power of One and so like, you would have all these cool things that people would write down and submit that they've seen their coworkers do, and then we would vote on which one they thought was the most deserving. And then I would give them a little a little pin or a little, a little thing for their sweatshirt that just hit the power of one it was like here's a little token of appreciation for going above and beyond for your patients or your co workers P4- We're union so that basically doesn't exist P5- Patient surveys that that are sent out when we are mentioned by name by a patient we get we get a prize, which is usually something small (hand sanitizer, soap, water bottle) P6- My leader... has put up all the colorful paper she has put up pictures of everybody, individually with our names under there and our birthdays P6- She has a friend wall, where if any of us have taken pictures together she makes a point to like put those up there. P6- There's a recognition board where any of us can set up there. Hey, you know, Abby, thanks for the great job that you do. Thanks for being a team player. The hospital doesn't do bonuses...., but my group is real good about celebrating each other's birthdays, wedding, baby, we're very, very close down here. We all feel like family. So that's important. 128 Variable Question Link SubVariables Codes Encourage EC 1b Do these efforts effectively improve satisfaction? EC1_IOS_yes Direct Quotes P1- (past experience) They understood that when they showed their appreciation towards us that we were willing to work much harder for them even without being asked. They knew that they told us on not only verbally, but physically made sure we understood that we were valued, that we were more than just a number. He was very respectful to us, or they were very respectful to us, our time, our efforts. And we all have us as a team. It was a small team. But we all knew and appreciated that and we all would go above and beyond anything that they asked because we know that they appreciated it and that that made the day go round. That was my only time in my whole life that I was happy to get up and go to work. I didn't mind the hard work. I didn't mind the long days, I didn't mind the overload of patients, because I knew at the end of the day, they appreciated it. It went a long way P2-I mean, of course, who doesn't like money right? If they're handing out gift cards, or little extra bonus checks by the end of the month, then of course, I'll have a positive drive to go back to work every three months rather than like a yearly group bonus. I think that would be the biggest is feedback and money P2- (interview if you had to choose one of those which one's more important?) Feedback P4 - If it's something that's highly prioritized, he will definitely engage with that staff or staff members on a more frequent basis. And I would say it's you know, it's positive, it definitely is positive. P6- We're very, very close down here. We all feel like family. So that's important. Variable Encourage Question Link SubVariables Codes EC 1b Do these efforts effectively improve satisfaction? EC1_IOS_no Direct Quotes P1- Not at all? No. P1- We'll throw you a little bit of a money, a little bit of bonus, but that doesn't really do anything for your overall well being P1- On a personal level, I would rather feel more valued as an employee and more respected than a dollar or pizza day, or even, you know, bonus for scanning more patients, because at the end of the day, scanning more patients means more money for you, and I'm still tired and burnt out. P4- After you've completed a project, and he's moving on to something else that you might not be involved in, you might not have any interaction with him for months on end. So you kind of feel not that you're getting pushed off to the side, but just they got out of you what they needed and it's time to move on to the next. P5- It's not enough to affect my job satisfaction or it doesn't. The prospect of them doesn't doesn't make me do a better job P5- It's nice to hear, it's nice to be recognized when you do a good job, but it doesn't really affect my job satisfaction. Variable Question Link SubVariables Codes 129 Encourage EC 2a What can leadership do to better encourage staff in regards to feedback or rewards? EC2_FIOS Direct Quotes P1- We've talked about bonuses as a team, we've talked a lot about bonuses, and that's a whole other conversation that can get real deep, to just kind of reward those who want to scan their hearts out and do more than is asked. I feel like that can be beneficial and make you kind of want to, but I feel like if you don't feel appreciated, that's just a superficial benefit. I feel like it's more of them saying, Hey, we're gonna pay you to just keep going keep scanning, it's helpful, but it's, it doesn't really encourage you to want to be a better employee, P4- People when they have routine departmental tasks delegated to them, they take ownership of it. And that is when they will start to shine by coming up with process improvement things that are efficient. P5- Another week of vacation. P6- I keep going back to money but monetary compensations are important. Variable Encourage Question Link SubVariables Codes EC 2b How do they want to receive the feedback or rewards? EC2_URFIOS Direct Quotes P1- We're all just kind of coming down to the bottom line of, please just don't burn us out. Please just don't overload us with patients. And don't just keep adding on to our workload. P1- I would rather scan less patients, I would rather have that mental and physical break in between or know that I have the time to do quality patient care and do a good job on my exam, then feel like I have to be rushed, much more over everything else. P3- Picking the brains of your employees and saying, hey, what would you guys like? What would you like to see, how can we make you feel like you are important and they that we value you being here as an employee of our facility P4- that comes with the manager or the supervisor play to your strengths and weaknesses. If you can find somebody that is interested and or has the technical prowess...and you can see that they're going to excel in it even if they maybe don't want to at first...it has to be assigned, and then again, it's a test if it doesn't work out, if the employee really doesn't like doing it and or they're not capable of doing it, then you can move on to something else but having accountability to keep somebody engaged outside of just the bare basic job function that they have P5- I also would try to do things like have a potluck or have a waffle night to just try and engage people and keep them fed and in my experience, food goes a long way to making people feel better. P5- A piece of pie can make a lot of things more tolerable P6- Here a few years ago, my hospital went to an annual bonus situation where your annual bonus does not necessarily reflect the work that you've done over the year. Unfortunately, it has brought the people who don't put in as much effort and it has put them in the same category with people who put in all the effort. So when everybody's kind of compensated the same... it brings the ones who are putting in all the effort-- it makes them start going, wow, why am I doing all this? 130