The Effects of the COVID-19 Pandemic on Burnout and Self-Esteem Among Imaging Professionals. By Lordany Milanes, BS, R.T.(R)(VI)(ARRT) Mary Ann Green, BS, R.T.(R)(T)(ARRT) Dallin Peterson BS, RDCS (AE)(ARDMS), R.T.(R)(ARRT) Lisa Chesser-Nielsen, BS, R.T.(R)(M)(ARRT) Beverly Hernandez, BS, RDMS Jon Nunemacher, BS, R.T.(R)(VI)(ARRT) Kimberly Purcell BS, RDCS(AE)(ARDMS), R.T.(R)(CT)(ARRT) 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 9, 2021 2 THE WEBER STATE UNIVERSITY GRADUATE SCHOOL SUPERVISORY COMMITTEE APPROVAL of a thesis submitted by Lordany Milanes, BS, R.T.(R)(VI)(ARRT) Mary Ann Green, BS, R.T.(R)(T)(ARRT) Dallin Peterson, BS, RDCS (AE)(ARDMS), R.T.(R)(ARRT) Lisa Chesser-Nielsen, BS, R.T.(R)(M)(ARRT) Beverly Hernandez, BS, RDMS Jon Nunemacher, BS, R.T.(R)(VI)(ARRT) Kimberly Purcell, BS, RDCS(AE)(ARDMS), R.T.(R)(CT)(ARRT) 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. Laurie Coburn, EdD Director of MSRS RA ______________________________ Dr. Tanya Nolan, EdD Director of MSRS ______________________________________________________________________ Christopher Steelman, MS Director of MSRS Cardiac Specialist 3 THE WEBER STATE UNIVERSITY GRADUATE SCHOOL RESEARCH AGENDA STUDENT APPROVAL of a thesis submitted by Lordany Milanes, BS, R.T.(R)(VI)(ARRT) Mary Ann Green, BS, R.T.(R)(T)(ARRT) Dallin Peterson,BS, RDCS (AE)(ARDMS), R.T.(R)(ARRT) Lisa Chesser-Nielsen, BS, R.T.(R)(M)(ARRT) Beverly Hernandez, BS, RDMS Jon Nunemacher, BS, R.T.(R)(VI)(ARRT) Kimberly Purcell, BS, RDCS(AE)(ARDMS), R.T.(R)(CT)(ARRT) This thesis has been read by each member of the student research agenda committee and by majority vote found to be satisfactory. Date 8/9/2021 Lordany Milanes 8/9/2021 Mary Ann Green 8/9/2021 Dallin Peterson 8/9/2021 Lisa Chesser-Nielsen 8/9/2021 Beverly Hernandez 8/9/2021 Jon Nunemacher 8/9/2021 Kimberly Purcell 4 Abstract This study researched whether or not the COVID-19 pandemic influenced levels of burnout and self-esteem among radiologic imaging professionals and established if there was a relationship between the two. This study's problem and purpose assessed burnout and self-esteem and used the Oldenburg Burnout Inventory to evaluate emotional exhaustion and disengagement and also used the Rosenberg self-esteem scale to evaluate self-esteem. The research was designed as a quantitative study which describes the overall aspect of burnout and self-esteem of imaging professionals living in the United States who worked part-time and full-time during the COVID-19 pandemic and participated in an online survey. The key results showed 53% of imaging professionals reported overall burnout at a level 4 on a scale of 1-10, with the majority of 85% reporting moderate to severe burnout while working during the peak of the COVID-19 pandemic, although there was no significant measurable change in self-esteem. The conclusion of this research identifies that the COVID-19 pandemic did have an impact on radiologic imaging professionals regarding burnout, but less of an impact on self-esteem, and no measurable correlation between burnout and self-esteem. Future research recommendations are to further investigate long term effects on those individuals reporting high levels of burnout, and to follow trends that will provide more information. 5 Acknowledgements It is with the greatest depth of gratitude that this research cohort thanks our academic advisor, Dr. Tanya Nolan. She has been more than an educator. Dr. Nolan has been a mentor, champion of our ideas and the most encouraging sounding board. She fosters teamwork, encourages creativity and provokes thoughtful reflection on complex topics. We express our indebtedness to Dr. Nolan’s dedication as an educator. Her true calling as an educator may be reflected by many of us in this cohort as we look to perhaps become educators ourselves one day. To acknowledge your contribution to our education is something we honor, but we will cherish so much more in the building of our character you helped to shape. I personally would like to thank my family, friends, and this group in particular for making this possible. Without knowing it, each person in my life has contributed to making this accomplishment a reality. -Jon Nunemacher, BS, R.T.(R)(VI)(ARRT) I am ever so thankful to my family and co-workers for the encouragement and the never-ending, enthusiastic support of my educational journey. Without my mother Nikki, this would never have been possible. A great big thank you to Andrew for providing additional emotional support and being a wonderful sounding board. -Kimberly Purcell, BS, RDCS (ARDMS) R.T. (R) (CT)(ARRT) First and foremost I would like to thank my son Levi. Your constant encouragement and companionship throughout the night allowed me to stay motivated and work through this project. I would also like to thank my wife Nicole for supporting me through my accomplishments and consoling me during my defeats. I would also like to thank Dr. Tanya Nolan for her outstanding help, her guidance was crucial in writing this document. -Dallin Peterson,BS, RDCS (AE)(ARDMS), RT(R)(ARRT) This Master’s program has been a life-changing experience for me and would not have been possible without the encouragement and supervision that I received from so many people during this program. I would like to thank my research team, my family, and my newborn Olivia’s for their collaboration and support. Also, I am very grateful for professors: Dr. Laurie Coburn, Dr. Robert Walker and Dr. Heather Chapman for their motivation throughout this thesis and Dr. Tanya Nolan for being the best preceptor ever. -Lordany Milanes, BS, R.T.(R)(VI)(ARRT) The highlight of the pandemic has been the friendships formed with this amazing cohort and the privilege of working with them. They truly are the best. I am beyond grateful for my husband Joel, and my sons, Noah, Eli, Jack, and Logan, who believed in me, repeatedly cheered me on, and constantly told me how proud they were. A big thank you to my friend and coworker, Anne, who encouraged me to apply to the program when I was talking myself out of it. And finally to Dr. Tanya Nolan, who greeted us with a beaming smile week after week, and somehow convinced us that we were amazing at writing this thesis. -Lisa Chesser-Nielsen, BS, R.T.(R)(M)(ARRT) 6 I want to thank my family for supporting me and encouraging me throughout this journey. I am proud to be obtaining my masters degree after a full career working in the field of oncology. My children, Corey, Kelsey and Gavin encouraged me to continue my education and to not let this degree be the obstacle in obtaining my goal. I would not have been able to complete this without the support of my husband, Gordon, who displayed such patience with my lack of free time. I also want to thank my fellow students and their teamwork. I would like to thank Dr. Tanya Nolan for being such a wonderful educator and mentor. Your endless enthusiasm and encouragement made all the difference in our success. -Mary Ann Green, BS, RT(R)(T)(ARRT) I would like to thank my family and friends for their encouragement and support throughout this adventure. I have always wanted a masters degree, so I can move forward in my career and become a leader in my field. I am grateful to all of the professors in this program, particularly Tanya Nolan, who encouraged all of us, gave me advice and always with a smile, told us how amazing we have become. The best part of this research thesis is the friendships that were created with this wonderful research group. Lisa, Mary Ann, Kim, Dallin, Lordany, and Jon, it has been a privilege to work beside you, may we be lifelong cohorts. -Beverly Hernandez, BS, RDMS 7 Table of Contents Chapter 1: Introduction 9 Background 9 Statement of the Problem 10 Purpose of the Study 11 Research Questions 11 Nature of the Study 12 Significance of the Study 13 Definition of Key Terms 14 Summary 15 Chapter 2: Literature Review 17 Documentation 17 Chapter 3: Research Method 40 Introduction 40 Research Methods and Design 41 Demographic 41 Sample 42 Materials/Instruments 42 Operational Definition of Variables 43 Data Collection, Processing, and Analysis 44 Assumptions 46 Limitations 46 Delimitations 47 Ethical Assurances 47 Summary 48 Chapter 4: Findings 49 Introduction 49 Results and Evaluation of Findings 49 Summary 56 Chapter 5: Implications, Recommendations, and Conclusions 57 Implications 57 Recommendations 57 Conclusions 58 References 60 Appendices 69 Appendix A: Graphs and Tables 69 8 List of Figures Figure 1. OLBI Mean burnout scores 69 Figure 2. COVID-19 exposure correlation between burnout and self-esteem 69 Figure 3. Burnout timeline 70 Figure 4. Mean, median, mode burnout scores 70 Figure 5. Beginning of COVID-19 pandemic burnout score 71 Figure 6. Peak COVID-19 pandemic burnout scores 71 Figure 7. Post peak COVID-19 pandemic burnout scores 72 Figure 8. RSES mean self-esteem scores 72 Figure 9. Correlation between burnout and self-esteem aggregate scores scatter plot 73 Figure 10. Correlation between burnout and self-esteem aggregate scores 73 Figure 11. Top personal factors contributing to burnout 74 Figure 12. Top community related factors contributing to burnout 74 Figure 13. Top work related factors contributing to burnout 75 Appendix B 76 IRB 76 Oldenburg Burnout Inventory 79 Rosenberg Self Esteem Scale 80 9 Chapter 1: Introduction The COVID-19 pandemic has altered the human way of life on a global scale. This new virus, with so many unknowns, has placed an increasing number of burdens on many healthcare systems. Frontline imaging professionals who are routinely exposed to COVID-19 positive patients are experiencing an unprecedented amount of stress and fatigue. Increasingly large numbers of positive COVID-19 cases are filling hospitals to maximum capacity, thereby increasing the need for diagnostic imaging. Imaging professionals are being exposed to new and stressful situations, which may be contributing to burnout and reduced self-esteem. The focus of this research is to identify what the variables of burnout and self-esteem are, how they relate to one another, and how they are affecting imaging professionals Background COVID-19 was originally identified in December 2019 in Wuhan, China by Chinese authorities who notified the World Health Organization. This notification was from a case of pneumonia with an unknown cause that could not be explained by physicians. The virus is suspected to be spread from birds and mammals to people who are at risk from infection. Further human-to-human contagion then occurs from inhalation of airborne droplets, close contact with an infected person, or from contaminated surfaces. When a person is infected and receives treatment from the issues related to COVID-19, frontline healthcare professionals are then exposed to the virus. Overwhelming numbers of infected patients have flooded the healthcare systems, creating situations that are stretching the resources of healthcare providers and leading to burnout. However, it is not only the increase in patient care that is causing burnout, but other factors like overall increased workload, anxiety, stress, emotional exhaustion, depersonalization, and issues related to self-esteem (Algunmeeyn, Altakhineh, Azab, Babar, & El-Dahiyat, 2020). 10 Statement of the Problem Burnout levels among imaging technologists is alarming across the world. According to the Canadian Association of Medical Radiation Technologists (2021), before the COVID-19 pandemic, at least 57% of medical radiation technologists suffered from emotional exhaustion. The incidence of mental health illness among medical professionals in America is high due to the adverse effects of COVID-19 (Fernandez, 2021). In this regard, this paper seeks to answer the following research question. Has the COVID 19 pandemic increased the mental strain on imaging professionals, resulting in elevated burnout levels? Burnout can lead to adverse events, poor patient safety, reduced job performance, negative patient experience, and poor quality of care (Dall’Ora, Ball, Reinius, & Griffiths, 2020). Work overload is among the risk factors for burnout, and prior studies report that COVID-19 increased the degree of burnout among nurses (Garcia & Calvo, 2020). Burnout is associated with depression, anxiety, and stress, many of which translate to mental health problems (Salari et al., 2020). Although healthcare providers need to work, there are several social factors such as the fear of spreading illness to their loved ones and the fear of disease that make the current work environment uncomfortable. Therefore, there is a need to study burnout levels, particularly among imaging technologists in the United States. By understanding what leads to increased burnout levels, appropriate preventative measures can be taken in the future. Imaging technologists experiencing burnout may be denied the optimal health they need for both professional and personal achievements. If healthcare providers cannot care for their own mental and physical health, they may find it difficult to provide excellent patient care. When COVID-19 overwhelmed the US healthcare system, millions of Americans received inadequate or minimal healthcare. According to Fernandez (2021), stress, depression, anxiety, and exhaustion are common among frontline healthcare workers attending COVID-19 patients. There 11 is a need to analyze how COVID-19, and other pandemic level events, are affecting burnout and self-esteem among imaging technologists, as means to better prepare for similar situations, and to support professional resilience and quality patient care. Purpose of the Study The purpose of this quantitative study is to evaluate whether the COVID-19 pandemic is having an effect on levels of burnout and self esteem among radiologic imaging professionals and to establish if there is a relationship between the two. This study will utilize two survey instruments in the assessment of burnout and self-esteem. The Oldenburg Burnout Inventory will be used to measure burnout by assessing emotional exhaustion and disengagement. The Rosenberg Self-Esteem Scale will be used to evaluate self-esteem or how the individual feels about themselves. These instruments will be administered via e-mail, social media, and text message to radiologic imaging professionals. Participants will be limited to those within the United States. Research Questions Q1. Has the COVID-19 pandemic had an effect on burnout among imaging professionals? H10. The COVID-19 pandemic has had no effect on burnout among imaging professionals. H1a. The COVID-19 pandemic has caused an increase in burnout among imaging professionals. Q2. Has the COVID-19 pandemic had an effect on levels of self esteem among imaging professionals? H20. The COVID-19 pandemic has had no effect on levels of self esteem among imaging professionals. 12 H2a. The COVID-19 pandemic has caused a decrease in self esteem among imaging professionals. Q3. Is there a correlation between the aggregate score of Oldenburg Burnout Inventory and the aggregate score of Rosenberg’s Self Esteem Scale among imaging professionals during the COVID-19 pandemic. H30. There is no correlation between the aggregate score of Oldenburg Burnout Inventory and the aggregate score of Rosenberg’s Self Esteem Scale among imaging professionals during the COVID-19 pandemic. H3a. There is a direct correlation between the aggregate score of Oldenburg Burnout Inventory and the aggregate score of Rosenberg’s Self Esteem Scale among imaging professionals during the COVID-19 pandemic. Nature of the Study This quantitative study includes descriptive and correlational data analysis as means to study burnout and self-esteem during the COVID-19 pandemic. The data will be collected by use of two surveys: Oldenburg Burnout Inventory and Rosenberg's Self-Esteem Scale. This research design appropriately meets the research purpose and is supported by the literature with greater generalizability. Using this combination of surveys is an approach in understanding the the essence of the phenomenon (COVID-19)from the perspective of healthcare professionals who have experienced the diverse facets of the pandemic while, in turn, providing quantitative analysis of their levels of burnout and self-esteem at one point in time. The surveys will be administered to a sample of imaging professionals. Data from a convenient sample of 268 surveys were collected and analyzed with a statistical software 13 program (SPSS). The hypotheses were tested, and each alternative hypothesis was compared against the null. Descriptive statistics will be provided for support and detail. Burnout and self-esteem were measured using the OLBI and RSES survey instruments and the mean scores were obtained. A correlation was performed on COVID-19 exposure to burnout and COVID-19 exposure to self-esteem. Central tendencies of self reported burnout scores were analyzed in regard to different timelines throughout the pandemic. These included pre-pandemic, peak-pandemic, and present-pandemic status. A correlation was performed on aggregate scores from the OLBI and RSES to see if burnout and self-esteem were related. Lastly, descriptive statistics to evaluate which variables were affecting imaging professionals the most personally, in the workplace, and within their community were evaluated. Significance of the Study The researchers of this study wish to make significant contributions to the understanding of how imaging professionals are negatively impacted by their work during a pandemic. In this study of COVID-19 we investigate variables that are responsible for affecting burnout and self-esteem levels among healthcare professionals. This also provides insight into potential ways to improve the personal and work lives of the healthcare professional (HCP) and determine if more research is needed. The study looks at the burnout on HCPs which was already reported at increased levels prior to the pandemic. With a spike in the burnout level of this already compromised group, we need to determine the triggers or stressors so we can address them methodically and thoroughly as individuals, as community members and as organizations. The fears generated by the recent pandemic can also be reduced through community support, organizational support and clear communication. The community can learn how to deliver and receive information to solicit cooperation and compliance by its members. Organizations can learn from this study about how to strive toward a state of better preparedness, thereby reducing stress levels and even posttraumatic stress disorder of HCPs, allowing them to perform their jobs 14 more efficiently with proper equipment and training. Healthcare professionals are inherently resilient which is how they have operated with burnout in the past. Definition of Key Terms Burnout Burnout is a state of emotional, physical, and mental exhaustion caused by excessive and prolonged stress. It occurs when one feels overwhelmed, emotionally drained, and unable to meet constant demands. (Smith 2020) Compassion Compassion is defined as the emotional response when perceiving suffering and involves an authentic desire to help. (Seppala, 2013) Compassion Fatigue Compassion fatigue is a condition characterized by emotional and physical exhaustion leading to a diminished ability to empathize or feel compassion for others, often described as the negative cost of caring. It is sometimes referred to as secondary traumatic stress (STS).(Figley, 2002) COVID-19 Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. (WHO, 2020) Disengagement Disengagement refers to apathy, emotional withdrawal, or withdrawal from activities or groups, or to become uninvolved or detached. (merriam-webster.com) Healthcare Professional Any licensed physician, licensed medical practitioner, registered nurse, licensed nurse practitioner, licensed physician’s assistant, licensed nurse’s assistant, and other similar licensed professionals who work directly with patients. (Law Insider, 2021) Healthcare Technology Healthcare technology also known as healthcare tech refers to any IT tools or software designed to improve hospital and administrative productivity, give new insights into medicines and treatments, or improve the overall quality of care provided. (ForeSeeMedical.com) 15 PPE Personal Protective Equipment (PPE) is equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses. These injuries and illnesses may result from contact with biological, chemical, radiological, physical, electrical, mechanical, or other workplace hazards.(OSHA.gov) Self -Efficacy Self-efficacy refers to an individual's belief in his or her capacity to execute behaviors necessary to produce specific performance attainments. Self-efficacy reflects confidence in the ability to exert control over one's own motivation, behavior, and social environment. (Badura, 1977) Self-Esteem The term self-esteem is used to describe a person's overall sense of self-worth or personal value. In other words, how much you appreciate and like yourself. It involves a variety of beliefs about yourself, such as the appraisal of your own appearance, beliefs, emotions, and behaviors.(Cherry, 2019) Resilience Resilience is the process of adapting well in the face of adversity, trauma, tragedy, threats, or significant sources of stress.(APA, 2012) Summary To summarize, this study introduces the history of COVID-19 and the effects of the pandemic on healthcare professionals working in imaging departments across the country. The researchers explore how related problems such as information confusion, lack of protective equipment, new healthcare technologies and increased workload affect the healthcare professional. The purpose of the study is to discover and report on burnout caused by the pandemic, and to evaluate if the pandemic has affected self-esteem amongst imaging professionals. Information for the study will be gathered by administering surveys to imaging professionals across the country which include the Oldenburg Burnout Inventory and the 16 Rosenberg Self-Esteem Scale. Results will be analyzed to provide evidence to prove or disprove the hypothesis that the COVID-19 pandemic has contributed to increased levels of burnout and has negatively affected the self-esteem of healthcare professionals. 17 Chapter 2: Literature Review Documentation COVID-19 A timeline published by the American Journal of Managed Care (AJMC, 2020) reports that on January 9, 2020, the World Health Organization (WHO) announced a new Coronavirus related pneumonia in Wuhan, China. Within two weeks, cases had been reported around Asia and screenings began at international airports in the United States. By the end of the month Wuhan, along with neighboring cities, were under strict quarantine. On January 31, 2020, less than four weeks after the announcement of a new virus, the World Health Organization declared a global health emergency, followed three days later by the United States’ own declaration of emergency. By this time, nearly 10,000 confirmed cases had been diagnosed worldwide, with more than two hundred deaths. Due to the alarming levels of spread and severity of the outbreak, the World Health Organization declared the outbreak a pandemic on March 11, 2020, a mere two months after the first report of the virus. At the onset of the pandemic, the United States emphasized travel warnings and put international travel restrictions in place. The United States federal government put most decision making for pandemic-related control into the hands of each individual state, rather than creating nationwide regulations. Each state responded in a different way, depending on region and population. Responding to quickly spreading outbreaks in the country, many states and large cities began to enforce lockdown measures and limited travel for non-essential workers. The term ‘essential worker’ is an umbrella term given to those whose work was determined to be essential in keeping the infrastructure of the country working. Healthcare professionals, emergency personnel, those working in food service, janitorial, shipping, repair, energy, and providing public transportation were among those categorized as essential (NCSL.org, 2020). Healthcare professionals make up 30% (mass.gov) of 18 all essential workers, working in hospitals, emergency clinics, and long-term care facilities. Wang (2020) reports that in an early case study series from Wuhan, China, 29% of patients with COVID-19 were healthcare professionals and were assumed to have acquired the infection in a hospital. In January 2021, the United States reported more than 25 million confirmed cases, and 420,000 deaths related to the Coronavirus, 3,000 of whom worked in healthcare. As of June 2021, the number of COVID-19 related deaths had risen to 600,000. (CDC.gov) Testing, Tracing, Telehealth, and Vaccine Development As the pandemic escalated, the federal government and the states activated emergency funds and personnel. Bergquist, Otten, and Sarich (2020) reported that by July 2020, new testing technology was in place which enhanced COVID-19 testing. Intending to accelerate the vaccine development process, the federal government introduced "Operation Warp Speed" to provide financing for vaccine production. Numerous measures were taken to combat the spread of the virus, including business closures, increased development and adoption of telemedicine to reduce personal contact with those who may be infected, and research funding for treatment, testing, and development of vaccines. Some states developed new technological programs to track the spread of infections, including smartphone-based contact tracing (Bergquist, Otten, & Sarich, 2020). Advanced technological systems, while helpful, became stressful for several reasons. For example, although artificial intelligence (AI) was developed to learn and quantify COVID-19 symptoms in some countries, its efficacy was not guaranteed (Kumar, Gupta, & Srivastava, 2020). For smartphone-based contact tracing, the use of Bluetooth technology was questioned due to issues related to consent and privacy (Mclachlan et al., 2020). Although telehealth is essential in providing health care to those under quarantine regulations or those not allowed to visit the provider's office due to COVID-19 symptoms, insurance coverage and other policy gaps made it difficult for healthcare providers to use telehealth throughout the pandemic 19 (Goldschmidt, 2020). Withstanding these obstacles, Goldschmidt (2020) stated that advanced technologies, such as tele-monitoring and the use of video conferencing calls, helped primary care providers effectively attend to local communities during the COVID-19 pandemic. In addition, other technologies such as drive-thru testing enabled patients to be evaluated without leaving their cars (Hill, Campbell, Mutch, Koch, & Mackintosh, 2020). The Internet of Things (IoT) helped in reducing the spread of COVID-19 and enhanced patient monitoring and treatment. IoT supplied an integrated network for healthcare systems to fight the COVID-19 pandemic by linking personal medical devices to software on the internet. IoT has proven to be an excellent way to screen patients who may be infected, by relaying vital signs such as temperatures, heart rate, and oxygen levels. Patients who are COVID-19 positive can be monitored from a remote location with the use of a well-connected device. During any healthcare emergency, the device automatically sends an alert message to healthcare personnel. By using a statistical-based method, IoT may be able to predict healthcare emergencies related to this virus before they happen. The advantage of this technology is its ability to provide quality distance supervision by accessing real-time information. Based on the evidence presented above, creative measures taken to address the COVID-19 pandemic were stressful at times, but also effective in maintaining the health of the population. In December of 2020, two vaccines, Moderna's COVID-19 vaccine and Pfizer-BioNTech COVID-19 vaccines, became available to fight COVID-19. In the same month, other vaccines (Novavax, Janssen, and AstraZeneca) were being tested (CDC, 2021). Although each state has power to decide who would be vaccinated first, the CDC (2021) recommended healthcare personnel and residents of long-term care facilities to receive the vaccine. As of February 2021, more than 55 million doses of COVID-19 vaccine have been administered in the United States, according to data published by the US Centers for Disease Control and Prevention. 20 Factors Directly Affecting Healthcare Professionals During the COVID-19 Response Government and Corporate Policy A significant source of stress to frontline healthcare professionals during the pandemic was a perceived lack of response and constantly changing COVID-19 guidelines issued by the United States government. As reported by NELP.org (2020) on April 18, 2020, the CDC issued guidelines stating that an employer may require an exposed healthcare worker to continue working, providing they remain asymptomatic and additional precautions were implemented. This statement reversed the previous policy issued by the CDC one month earlier, which stated that people who had been exposed to COVID-19, should remain in quarantine for 14 days due to significant risk of transmission from asymptomatic and presymptomatic individuals. On November 19, 2020, the guidelines were updated again, reversing the suggested quarantine time for exposed employees, stating that an exposed healthcare worker must have a negative test and be asymptomatic before returning to work early only as a last resort until the 14-day quarantine period was over. Doubt in the governing bodies included feelings of mistrust amongst healthcare workers in the federal Occupational Safety and Health Administration (OSHA). According to Berkowitz (2020), OSHA did not issue any enforceable COVID-19 specific practices or policies that employers were obligated to implement as a means to protect healthcare workers. All issued guidelines were merely voluntary recommendations that employers might choose whether or not to follow. OSHA has not conducted any on-site inspections nor enforced, by means of consequences, any guidelines during the pandemic. Furthermore, the CDC does not have strict guidelines regarding separating COVID-19 positive patients from non COVID-19 patients. Jewett (2020) states that in hospitals around the country, healthcare workers reported having been exposed to COVID-19 after infected patients 21 had been placed in non-dedicated areas. In a survey of 21,000 nurses, 32% reported that there were no dedicated COVID-19 units in their facility. Many healthcare workers in these non-COVID-19 units were not provided with proper PPE by their employers, and felt that they were in danger of becoming infected with the virus. Without regulation, patients receiving care in hospitals or nursing care facilities, including those who had tested positive for COVID-19, were allowed to walk the hallways and mingle with other, non-infected patients and staff in states including California, Florida, New Jersey, Iowa, Ohio, Maryland and New York. Berkowitz (2020) reports that some states are adapting federal recommended guidelines into their own state-enforced policies, and are putting extensive protocols into place. The University of Nebraska Medical Center has implemented strict containment protocols, including isolation units with negative pressure capabilities and restricted access to these units by healthcare professionals trained in proper use of PPE and respirators. By using standard infection control techniques and proper protective equipment, staff at the university who care for COVID-19 patients have not, thus far, been infected. PPE Healthcare professionals were deeply affected by the reduced availability of PPE, and the changing guidelines regarding the use of PPE. Early shortages and inaccessibility to PPE was a major source of anxiety and fear for healthcare professionals. Cohen (2020) conducted a study to discover the factors related to PPE shortages at the beginning of the COVID-19 pandemic. The first factor cited by the study was the budget model of many healthcare systems, which are incentivised to minimize cost. The purchase and storage of excessive supplies is not feasible within the financial model. Second, the massive, acute need for PPE drained already depleted inventories. Third, the federal government failed to maintain a sufficient PPE stockpile and to distribute remaining supplies to facilities in need. Last, disruption to the global supply chain 22 created significant reductions in PPE being exported to the United States, which is highly dependent on imported medical supplies. PPE became scarce and competition between businesses, governments, and individuals to procure necessary PPE became increasingly competitive, which further reduced availability. As stated by the CDC (2020), the lack of sufficient N-95 respirators during the pandemic created the need to conserve supplies, resulting in CDC recommendations of reusing and extending the life of respirators meant for one-time use. In the early days of the pandemic, when PPE supplies were very low, CDC guidance extended so far as to recommend bandana type face coverings for healthcare professionals. These compromises to best practice created doubt and feelings of expendability amongst healthcare workers. Cohen (2020) summarizes that the system-wide shortage of PPE led to increased illness that was widely transmitted among staff, resulting in staffing shortages. Healthcare professionals were now faced with increased patient loads, including large numbers of severely ill patients, taxing both the quantity and quality of patient care. In contrast, many hospitals within the United States reported providing sufficient PPE to employees and training them in its use. Stewart et al. (2020) argued that most hospital employees had proper access to PPE kits, especially gloves, eyewear, masks, and gowns. The report states that sufficient access to PPE kits relieved safety concerns of employees and resulted in better care for their patients, specifically those who were COVID-19 positive. According to Brat et al. (2020), the United States ensured an effective supply of PPE kits, especially amongst those working in emergency and surgical units. The researchers state that proper PPE provided within the United States ensured better outcomes amongst healthcare professionals.. 23 Job Security and Healthcare Roles Job insecurity is an additional stress experienced by healthcare professionals during the COVID-19 pandemic. As Paavola (2020) reported at the beginning of the pandemic, many hospitals and healthcare systems suspended elective procedures to save bed capacity, supplies, and staff to treat COVID-19 patients. They also spent massive amounts of money to prepare for the perceived oncoming waves of critically ill patients, including the purchase of ventilators and PPE. Paavola (2020) cited that Baylor Scott & White Health spent $85 million to prepare. As a result, many systems lost large amounts of annual revenue, forcing them to reduce costs in terms of resources and manpower. Nationwide, hospitals and healthcare systems furloughed or layed off healthcare personnel. As of June 4, 2020, 266 hospitals across the country had reduced staff in the effort to remain financially stable. Seattle based UW Medicine announced 5,500 furloughs as of May 25, 2020. Southcoast Health, based in Massachusetts, furloughed ten percent of their healthcare staff. Along with massive furloughs came permanent lay-offs. Mount Sinai Medical Center in Miami Beach Florida permanently eliminated 208 employees, and in doing so saved their system $11.1 million in payroll expenses for the year. Baylor Scott & White Health, who spent $85 million to prepare for the pandemic, eliminated 1,200 positions, and furloughed an unspecified amount of its workforce. Paavola reports that many furloughed employees were able to retain healthcare benefits, and were also called back to work when patient volumes rose. In contrast, several other healthcare systems maintained all employees, but with reduced hours or by repurposing or re-assigning employees to different positions or locations. In a letter to its trustees, Intermountain Healthcare(2020) in Utah explained that the organization did not lay off any medical personnel, but in facing extreme financial loss of over $435 million in revenue due to reduced surgeries, inpatient admissions, ER and clinic visits, reduced wages for 24 some physicians, physician assistants, and nurse practitioners by 15% (Gabbler, 2020), and paused matching contributions to employee 401k accounts. Many non-clinical employees were pushed toward or offered early retirement. Many employees who were reassigned to work in different departments felt ill-prepared for the roles to which they had been re-assigned, many of which required skills that they had not been trained in or had not regularly used. Healthcare professionals throughout all departments experienced a loss of control over their work schedules and fears for their future role in the workplace due to the uncertainty the ongoing pandemic continued to create (Elsevier, 2020). The Evolution of Data and Human Response The newness of the virus meant that there was no solid evidence about the way it was spread, and as the pandemic spread, misinformation was rampant. Reports of the virus lasting on surfaces for weeks were circulating, and there was much discussion on whether the virus was airborne, or spread by droplets. Information was updated as the world learned more about the virus, and in April of 2020 the CDC (2020) updated their website to reflect the newest information about how the virus spreads. The updated CDC report states that the virus most commonly spreads by respiratory droplets between people who are in close contact with one another, by surface contact, or by aerosolized, airborne particles which may travel farther than 6 feet and may be inhaled through the nose or mouth. The update reports that COVID-19 symptoms begin to appear two to fourteen days after exposure, and described mild symptoms of the disease which include fever chills, cough, dyspnea, muscle or body aches, headache, loss of smell or taste, congestion, sore throat, nausea, vomiting and diarrhea. The CDC went on to describe severe, life threatening signs which require immediate medical care such as dyspnea, low oxygen saturation, persistent chest pressure, bluish lips or face, confusion, and inability to wake or stay awake. Respiratory failure, septic shock and 25 multiple organ dysfunction are symptoms of critical illness. The NIH (2020) reports that certain comorbidities increase the risk of severe infection. These comorbidities include being over 65 years old, having cardiovascular disease, chronic lung disease, sickle cell disease, diabetes, obesity, cancer, kidney disease, or being a recipient of a transplant. With evolving data, The World Health Organization (WHO) stated that health care systems are not only battling the pandemic, but they are also in the midst of battling an “infodemic”. Siebenhaar, Kother and Alpers (2020) examined the impact of COVID-19 information on societal compliance with preventive measures for containing and spreading the disease. From the onset of the pandemic in February of 2020, there have been non-stop news cycles on national television, social media sites, government agencies, and various websites regarding the pandemic. Seibenhaar (2020) reports that information regarding the virus which is viewed by the public elicits an emotional response. If the information is perceived as threatening, it can produce aversive emotions, like stress. With so many different media outlets, vast quantities of information are often contradictory and cause uncertainty that elevates a person’s level of distress. Siebenhaar (November 5, 2020) goes on to state that “distress may generally induce adaptive behavior in support of crisis management, unless individuals respond to it by avoiding information”. Information avoidance occurs when a person completely avoids listening to, reading about, or gathering any further information. The act of compliance and/or avoidance are both coping mechanisms used to manage an emotional response. Siebenhaar (November 5, 2020) categorized two behavioral groups: (1) Those who actively cope with distress by surveilling threatening information and take appropriate measures to survive it, and (2) those who have avoidance anxiety and use passive coping mechanisms wherein they miss out on important updates and may even underestimate the seriousness of the situation. The passive process involved in information avoidance often leads to non-compliance, 26 either intentionally or unintentionally. Lack of compliance with preventative measures has been shown to interfere with pandemic crisis management, whose goal is successful viral containment. Conclusively, the researchers found “information avoidance a maladaptive response to exacerbated distress”. One method to learn how information should be presented to the public to encourage compliance is by using a predictive tool. According to Kowalski and Black (2021), the Protection Motivation Theory of Health (PMT) is a model that can help predict an individual’s compliance with health promoting behavior. Kowalski and Black explain that PMT uses a person’s cognitive evaluation of the consequences to determine one’s response to their health-related choices. All individuals have an anticipatory regret response whereby they might, sometime in the future, regret not having done something that could have prevented or thwarted a health threat. People are more likely to regret inactions as opposed to actions. Because of this anticipatory regret, when public health information focuses on the community’s vulnerability to the virus, it may have little impact. The authors suggest that the message is best focused on understanding the severity of the virus and the efficacy of the health behaviors in decreasing the spread of the disease to achieve better compliance. By focusing public information on one controlled and effective aspect of the pandemic, the result may be greater compliance and less avoidance with increased supportive behaviors that prevent the spread of COVID-19. Burnout in Healthcare Professionals Burnout is a state of emotional, physical, and mental exhaustion caused by excessive and prolonged stress. Excessive stress, related to COVID-19, has been recognized globally as a concern for the physical and mental well being of healthcare professionals. Freudenberger and Maslach, in the mid-1970's, defined burnout as “a state of physical, emotional, and mental 27 exhaustion that results from long-term involvement in work situations that are emotionally demanding”(Khasne, August 2020). High levels of burnout have been associated with suboptimal judgment in patient care. HCP burnout is detrimental to the professional and to the patient (Khasne et al., 2020). Restauri and Sheridan (2020) warned that increasing burnout levels may lead to medical mistakes affecting the patients’ safety. As a result, burnout has contributed to decreased patient satisfaction with the HCP and increased litigation. There are several research studies that help provide a baseline understanding of burnout among healthcare workers before the start of the COVID-19 pandemic. In 2010, Singh, et al (2016) evaluated burnout levels among radiographers, sonographers, and radiologists. The survey was administered to radiographers belonging to the Australian Institute of Radiology, sonographers belonging to the Australian Sonographers Association, and Radiologists belonging to the Royal Australian and New Zealand College of Radiologists. The survey was administered to 5196 radiographers, 3974 sonographers and 1618 radiologists. However, only 613 radiographers, 121 sonographers and 35 radiologists completed the survey. They utilized the Maslach Burnout Inventory (MBI) to evaluate burnout in areas of emotional exhaustion, depersonalization, and personal accomplishment. Their findings revealed higher than average burnout levels among this group. They also measured other factors such as work experience, education experience, marital status, gender, and hours of overtime worked, and amount of time educating students. The factors that had statistical significance were amounts of overtime worked and time spent educating students. It was found that those who worked more overtime and spent less time in education roles experienced more emotional exhaustion and higher levels of depersonalization respectively. In 2019, health technology company Philips performed a study to measure stress and burnout among imaging technologists. To do so, they used the Emotional Exhaustion Subscale of 28 the Maslach Burnout Inventory. The results showed that an alarming 36% of radiologic technologists in the United States were at a moderate or high level of burnout. The study goes on to ask technologists to identify their causes of stress that lead to burnout. Of the technologists surveyed, 40% reported workload and 35% reported lack of appreciation as their major cause of stress. These studies demonstrated that burnout was an issue among radiology staff even before the COVID-19 pandemic occurred. The studies link increased levels of burnout to increased workload, increase in overtime hours, and lack of appreciation. With the COVID-19 pandemic bringing a surge in patient volumes and higher workload for radiology staff, concerns of increased burnout are valid and pertinent. Burnout and COVID-19 Understanding burnout resulting from the pandemic is significant when trying to maintain quality healthcare in the future (Khasne et al., 2020). Although job security and a lack of available work hours were previously cited as a source of elevated stress for health care professionals during COVID-19, a contrasting source of stress occurred when health healthcare professionals were faced with too much work. Beyond job security or over-work, there are numerous other factors which have led to burnout. In a study conducted in 60 different countries, it was reported that 51% of the 2,707 participating healthcare professionals declared having experienced burnout during the pandemic. These professionals’ burnout was reportedly caused by the manner in which their home life was impacted due to their workload, feeling as if they were being pushed beyond their scope of practice to get the job done, being exposed to positive COVID-19 patients, being asked to make life prioritizing triage decisions, and lacking access to proper PPE. (Abern, et al., 2020). 29 Burnout can also be exacerbated by limited organizational support. (Abern, et al., 2020) Ideally, the factors leading to burnout may be diminished if the healthcare organization provides support to its staff. Best preventative practices include hiring more employees whenever possible, skill based training, maintaining adequate levels of PPE, providing supportive strategies for families, and offering resources for employees’ mental health. Reduced hospital resources, the threat of COVID-19 exposure to both the healthcare professionals and their families, longer shifts with larger workloads, lack of sleep, poor work-life balance, and lack of communication and information are all overwhelming healthcare professionals. Indeed, these conditions have contributed to increased fatigue, anxiety, stress, and burnout among current healthcare teams (Kaye et al., 2020). Methods of evaluating healthcare professionals who are experiencing burnout include assessing the exposure, understanding perceptions, noticing when the workload increases, and monitoring for emotional exhaustion (Abern, et al., 2020). Emotional exhaustion Demerouti et. al., (2001) report that emotional exhaustion is a consequence of prolonged physical, affective, and cognitive weariness and includes feelings of emptiness, overwork, a strong need for rest, and physical exhaustion (Tan, 2020). Leiter and Maslach (1988) state that chronic job stress leads to emotional exhaustion. Restauri and Sheridan (2020) describe the COVID-19 pandemic as the perfect storm that intersects chronic workplace stress and acute traumatic stress from the pandemic. As outlined by Esterwood and Saeed (2020), these psychological effects are numerous and have both short and long-term effects. Immediate effects, reported in relation to COVID-19, include post-traumatic stress disorder (PTSD), anxiety, fear, low self esteem and distrust (Esterwood & Saeed, 2020). As the pandemic continues beyond one year, there is also an increased potential for long term PTSD. 30 Emotional exhaustion is not unique to the United States healthcare professional. Severe professional-related stress is a global problem (Khasne et al., 2020). As discussed in the previous section, a lack of PPE, staffing shortages, and the fear of contracting and spreading the disease has added to HCP levels of burnout. Lai et al. (2019) studied HCP during COVID-19 in China, and they discovered their participants were more likely to have signs of depression, anxiety, insomnia and distress. This research supports another study completed in India by Khasne et al. (2020), in which researchers questioned HCP on the extent of burnout they experienced during the COVID-19 pandemic as compared to that of their pre-COVID-19 work environment. The results of the Indian study showed that “compared to normal circumstances, there was a significant increase in pandemic-related burnout”. Disengagement and Compassion fatigue Disengagement, along with exhaustion, is another component of burnout. Disengagement refers to withdrawing oneself from work and the creation of negative attitudes towards one's work or work-related tasks (Demerouti et al., 2001). Some researchers, such as Leiter and Maslach (1988) state that chronic job stress leads to emotional exhaustion, which results in depersonalization and disengagement. Healthcare professionals want to feel proud about their jobs, their performance, and their organization. Researchers who study disengagement report that the process often begins when a staff member starts to feel that their needs or expectations are not being met by their organization’s management (Sherman, 2012). Loehr and Schwartz add that adequate rest is essential to full engagement. Emotional fatigue depletes physical energy and makes healthcare professionals more vulnerable to negative emotions. Increased overtime due to staffing shortages during the pandemic are likely to have resulted in limited sleep and both physical and emotional fatigue. 31 In contrast, rather than disengagement from one's work, others may become deeply involved, so much that they develop compassion fatigue. Compassion fatigue (CF) has been described as the convergence of secondary traumatic stress resulting from exposure to a traumatized individual and cumulative burnout, Cockerm (2016). Alharbi (2020) reports that CF is associated with those who have been affected by severe emotional distress. Individuals exposed daily to high pressure and high risk situations, such as in times of a pandemic, may become immersed in the suffering and the traumatic experiences of those they help. In time, these healthcare professionals begin to perceive and believe in their inabilities to alleviate the suffering of those entrusted to their care. Those at greatest risk for compassion fatigue are HCPs because they often put the needs of their critical patients above their own. Compassion fatigue is especially high for those who work in environments where there are daily interactions with patients whose outcomes are bleak. On many intensive care COVID-19 designated floors with high patient mortality rates, healthcare professionals feel frustrated and helpless because they believe their actions will make no difference to their patients’ outcome (Alharbi, 2020). This detachment can impact the standard of care, co-worker relations, and lead to serious mental health conditions, such as PTSD. Aron Steward, PhD (uvmhealth.org, 2020), states that CF is a biological response that occurs when a person is so exhausted-physically, emotionally, and psychologically, that there is no longer any reserve to feel for another person. A healthcare professional feels they have nothing left to give and become emotionally depleted. CF carries a heavy personal toll, including isolation from others, anger, low morale, reduced ability to feel sympathy or empathy, a diminished sense of enjoyment, and an impaired ability to make decisions and care for patients (Cocker, 2020). Healthcare professionals with CF are also likely to use detrimental coping measures such as increased absenteeism, excessive eating, drinking, or drug use. Current coping recommendations to frontline healthcare 32 professionals are to maintain a work-life balance, practice mindfulness and meditation, and offer support to other healthcare professionals when possible. Managerial interventions that promote individual resilience and educate at-risk individuals about these coping strategies are also considered beneficial. Organizational Disengagement Organizational cynicism is another aspect of disengagement that healthcare professionals are experiencing in the workplace. According to Durrah et al. (2019), organizational cynicism is a feeling of dissatisfaction towards an organization when employees believe the organization's management lacks honesty, justice, and transparency. These feelings of hopelessness result in employee dissatisfaction and lack of confidence within the organization. Work cynicism is associated with burnout in the workplace and defined as an indifferent attitude towards one’s work. Employee performance is negatively impacted when the organization is viewed as insincere, and focused on the needs of the company with little regard to the individual. One way this was seen amid the COVID-19 pandemic, is in the lack of communication taking place between the healthcare organization and it’s employees. Management has had a difficult time fostering camaraderie between employees throughout the pandemic. As stated earlier, with management making cuts to pay, employment status, and asking employees to perform more tasks with less resources, it is difficult for the healthcare professional to feel valued. Organizational Engagement Durrah et. al.(2019) describes how organizational pride is the opposite of organizational cynicism. Organizational pride, is a positive feeling toward the institution for which a person works. Professional communication and team collaboration are tools that encourage open communication and collaboration between employees and management. When these tools are in 33 place and openly used, employees are more likely to develop organizational pride and become engaged in the workplace. O’Daniel and Rosenstein (2008) defined team collaboration as HCPs and management assuming complementary roles and cooperatively working together, sharing responsibility for problem-solving and making decisions to formulate and carry out plans for patient care. Collaborating as a team and making decisions together in an environment where employees have an active role in decision making may lead to organizational pride rather than organizational cynicism. Organizational pride is achieved through the HCPs personal accomplishments, coupled with a team based approach to tasks and problems. The feeling of “I can do it” is elevated when fellow HCPs work together on the same problem. The HCPs self-efficacy is also elevated because they believe in their ability to achieve goals set before them. In their 2019 study, Philips asked imaging professionals, “What motivated you to choose your current profession?” In the United States, 73% of respondents stated “helping people”as a reason for choosing their profession. (Philips, 2019) As the pandemic continues past the one year mark, the public who once hailed HCPs as heroes, now accuses them of lying and manipulating the public. As primary motivations to excel within the profession fade, so also fades the HCP’s sense of personal accomplishment and self efficacy, which are both tied to self-esteem. Personal Self Esteem Self-esteem is the ability to see one's self worth, based on evaluation of social and communal worth, self-evaluation and self-efficacy. HCP themselves face new challenges with the COVID-19 pandemic in determining their social place and communal worth. There are studies from other pandemics we can relate to, such as how Korean nurses felt about Middle East Respiratory Syndrome (MERS). The HCPs faced stigmatisation during the MERS pandemic. A study of Korean nurses “pointed out the hypocrisy that some healthcare workers experienced 34 when they were publicly commended for their work but privately discriminated against” (Billings, 2020). HCP also were faced with feelings of being “cowardly” as reported by Emergency Nurses during the human swine influenza outbreak when they refused to treat an infected patient (Lam, 2021). These feelings of discrimination and cowardice affect the HCPs feelings within society as they view their communal worth. Routinely HCPs “...voluntarily act to help others in the face of recognized personal risk when they are routinely exposed to infectious diseases” ( Cox, 2020 ). The new pandemic challenged the HCP to re-evaluate their self-worth. When HCPs were questioned about their experiences of working the frontlines, many HCPs “described aspects of the work as enjoyable and rewarding and appeared to derive job satisfaction from work they found “important” and “meaningful” (Billings, 2021). Ultimately, in regards to self-evaluation, HCP’s “...dedication and commitment outweigh the risk” of working during the pandemic (Pablo, 2020). “The gratitude of others; patients, their families and wider society was noted to increase their sense of fulfillment” (Billings, 2021). “Self-efficacy refers to an individual's belief in his or her capacity to execute behaviors necessary to produce specific performance attainments. Self-efficacy reflects confidence in the ability to exert control over one's own motivation, behavior, and social environment.” (Bandura, 1977). In an article by Molero, Perez-Fuentes and Gazquez (2018), the authors state “there is a positive relationship between self-efficacy and self-esteem in which positive beliefs about one’s efficacy increase one’s sense of self-worth as stressful situation of a heavy workload are coped with successfully”. Additionally, Billings et. al (2021) found “Overcoming such immense challenges tested the participants and imbued some with a sense of greater professional confidence and competency”. This greater knowledge and gained skill sets made HCPs feel better equipped to face the next pandemic and helped them to gain confidence in their own 35 resilience. The HCP’s confidence in their ability to perform during a pandemic can be tested when working conditions are not ideal. Burnout not only relates to a high volume of work, but also to feelings of frustration generated by not being able to attend adequately to the needs of the patient or offer them quality service, Molero et al. (2018). Feelings of inadequacy jeopardize self-efficacy. The conclusion of the Molero study was that “Workload has a significant positive relationship with burnout, while self-efficacy and self-esteem act as protective variables [and] ...workload has an indirect effect on self-esteem, mediated by beliefs about self-efficacy, and the joint effect of self-efficacy and self-esteem can buffer the negative effect of workload on burnout.” Healthcare professionals who learn to maintain healthy self-esteem and self-efficacy display greater resilience to burnout and high burdened workloads. HCPs during the COVID-19 pandemic have unfortunately been faced with both high job demands and lack of resources. To summarize, HCPs need to perform their jobs with a moderate to high level of self-esteem and self-efficacy in order to protect themselves, their patients and their organization from the negative effects of burnout and high workloads. Community Self-esteem According to Ramaci et al. (2020), there is a stigma in the community setting around healthcare professionals who care for patients with COVID-19. The authors used a behavioral health definition calling stigma “a mark of disgrace that sets a person apart from others''. The nature of working with a highly contagious patient population increases the prejudice of the community. Social stigma makes it challenging for HCPs to recover when emotions like shame and embarrassment play into the equation. Society stereotypes the HCP linked to COVID-19 patients with a discriminatory label. HCP may be conceived as carrying around a contagion and 36 being a “Plague spreader”. This stigmatization leads to higher stress and burnout rates, and these emotional stressors ultimately have an impact on the HCP’s view of their professional life. Although some communities have tried to rid healthcare workers of any stigma by calling them “Healthcare Heroes”, Cox (2020) says that use of the term “Healthcare Heroes” can actually have a negative connotation for HCPs in the community setting. There are limitations in the extent to which these professionals owe the community. The article states that HCPs, while dedicated to their work, “are not duty bound to do absolutely everything in their power to benefit their patients at any level of personal risk”. Healthcare professionals undertake an inherent risk merely by going to work each day. With added exposure to COVID-19 patients, their risk for personal safety is appreciably higher. Social reciprocity is an important community accord and commitment that supports all human interests. HCPs risk their lives at work believing that the general public will play a supporting role. Reciprocity comes when the public adheres to health safety precautions, such as wearing masks, hand hygiene and social distancing, to demonstrate their support. Cox (2020) states, “The hero narrative fails to remind the public and healthcare institutions of their own moral duties and in its focus on individual healthcare workers' selfless sacrifice, it does not recognize that their duty to treat is irrevocably tied to reciprocal societal obligations.” Organizational self-esteem Organizational based self-esteem is present when a well-established company establishes a certain set of job outcomes, job satisfaction, organizational commitment, and mood outcomes. These measures can be either positive or negative depending on the individual's understanding of the organization. The acceptance is widely known that people who have a high organizational based self-esteem believe they are valued members of the organization and that self-esteem molds employee’s attitudes, motivation, and behaviors. (Brougham & Harr, 2016) 37 Billings et al. (2020) compiled a rapid review of 40 qualitative studies on the healthcare professionals’ experiences during pandemics. The authors shared that the HCPs colleagues and peers provided an important source of mutual support through shared training and camaraderie. By taking the time to sit together, discuss and decompress over the day's events, the HCPs were provided an opportunity for valuable group reflection, which normalized the situation and provided reassurance to one another. Conversely, this same type of community gathering in a different setting might be a source of stress to coworkers. When an organization allows unfair distribution of work or allows HCPs to refuse to work in certain situations, it may create division amongst the staff. Feelings of resentment and hostility may diminish the HCPs self-esteem and reflect poorly on the organization. Healthcare professionals want their hard work and sacrifices to be recognized by the organization Billings et al. (2020). Resilience Khalid (2016) studied the emotions of HCP in the Middle East during the MERS-CoV epidemic and found that 80% of the staff had an “innate professional and ethical obligation that drove staff to continue working during the epidemic”. As HCP continue to “fight the fight”, it is necessary to find strategies to help them deal with burnout. Healthcare professionals need support with coping and well-being strategies, along with hospital leadership providing system-based interventions (Restauri, 2019). Fleming and Ledogar (2008) explain that resilience is a positive adaptation to adversity. Resilience involves positive outcomes while being subjected to situations with high amounts of risk, and then recovering from those situations. Resilience exists within the individual, in the family, and within the society or community. Development of resilience in the individual can be obtained through protective mechanisms such as high self-esteem, self-efficacy, and good 38 communication skills. For some, resilience is thought to be more of a process rather than an innate trait. Meaning, that resilience can be taught, learned, and practiced. Resilience includes “building a positive self-image, reducing the effect of risk factors, and breaking a negative cycle to create more opportunities for the individual”. Resilience also exists at cultural and community levels (Khasne et al., 2020). Resilience, in this sense, is defined as the capacity of a distinct community to encounter disturbance and reorganize while maintaining key cultural components. Reorganization includes support among peers and educators, and positive reinforcement from authoritative figures which builds rapport, trust, and friendship. By developing resilience early on, healthcare professionals will be able to increase their self-esteem and effectively reduce the toll that future pandemics have on individuals and communities. As resilience can be learned, we can also utilize the assistance of the employers to teach and create interventions to reduce burnout, decrease stress and enhance the opportunity for resilience to grow in HCPs. The Practice of Resilience As COVID-19 difficulties have increased day by day, researchers have begun to see weakened resiliency amongst healthcare professionals. Gilrain, et al.,(2020) states that targeting self-resiliency early may be the key factor to reducing the psychological effects of the COVID-19 pandemic. Coping mechanisms are a beneficial tool that healthcare professionals can use to maintain resiliency. Each person deals with stress differently, so coping mechanisms for each individual may be different as well. Positive coping strategies for healthcare professionals to promote self-resiliency include social and family support and showing compassion for others. Compassion has a positive impact on self well-being and can be one of the remedies for burnout. (Gilrain, et al 2020). Some may find ways of offering compassion by associating with religious or volunteer groups. One may practice “The Pause”, which is a method of taking a moment to 39 breathe and focus for a moment, which prepares the caregiver to offer compassion to the next patient. (Hofmeyer, et al 2020). Others may consider learning more about mindfulness, grounding techniques, meditation, biofeedback, yoga, and learn how to access telehealth services for peer support and counseling. Debriefing is a team based coping strategy to unload emotions after a stressful day or experience. Having a conversation with co-workers about the events during the shift can decrease anxiety and grief. Finding “Battle Buddies”, Healthcare workers pairing up to talk about COVID-19 on a level that family and friends may not understand. (Bradley, et al 2020). Management may consider participation in“Hear Me, Protect Me, Prepare Me, Support Me, Care for Me, and Honor Me,” a coping skills program directed at healthcare leadership to help employees. (Ayyala, et al 2020) Healthcare professionals’ resiliency is a useful weapon in the personal fight against COVID-19 stressors. While social and work-related responsibilities may overwhelm their self-esteem and increase burnout, coping mechanisms allow most HCPs to retain their resiliency. 40 Chapter 3: Research Method Introduction The purpose of this research is to evaluate the levels of burnout and self-esteem among imaging professionals, and to establish if a relationship exists between the two. By understanding these variables and how they have affected our target sample, researchers will be able to understand how the COVID-19 pandemic has influenced imaging professionals and identify whether there is a need to intervene and identify areas for future research. Q1. Has the COVID-19 pandemic had an effect on burnout among imaging professionals? H10. The COVID-19 pandemic has had no effect on burnout among imaging professionals. H1a. The COVID-19 pandemic has caused an increase in burnout among imaging professionals. Q2. Has the COVID-19 pandemic had an effect on levels of self-esteem among imaging professionals? H20. The COVID-19 pandemic has had no effect on levels of self-esteem among imaging professionals. H2a. The COVID-19 pandemic has caused a decrease in self-esteem among imaging professionals. Q3. Is there a correlation between the aggregate score of Oldenburg Burnout Inventory and the aggregate score of Rosenberg’s Self-EsteemScale among imaging professionals during the COVID-19 pandemic? H30. There is no correlation between the aggregate score of Oldenburg Burnout Inventory and the aggregate score of Rosenberg’s Self-Esteem Scale among imaging professionals during the COVID-19. 41 H3a. There is a direct correlation between the aggregate score of Oldenburg Burnout Inventory and the aggregate score of Rosenberg’s Self-Esteem Scale among imaging professionals during the COVID-19 pandemic. Research Methods and Design The research method is quantitative in nature. An online survey was utilized to acquire data for descriptive and correlational analysis between aggregate scores of burnout and self-esteem among imaging professionals. The survey included a demographic questionnaire, and two previously published instruments designed to evaluate burnout and self-esteem. These instruments include the Oldenburg Burnout Inventory and the Rosenberg Self-esteem Scale. The hypothesis supposes that respondents would demonstrate an increase in burnout and decrease in self-esteem throughout the pandemic. If the data shows no pattern, no correlation exists and the null hypothesis must be accepted. Respondents included imaging professionals from different geographical locations with varying populations and health care. Completed surveys were reviewed, and complete data was input into SPSS software to be statistically evaluated and interpreted. Demographic The demographic this study targeted included those who are currently working within the imaging profession and have been exposed to factors related to the COVID-19 pandemic. Imaging modalities included radiography, interventional cardiology, interventional radiology, MRI, CT, X-ray, mammography, sonography, radiation therapy, and nuclear medicine. All respondents were currently working and employed within the United States. It was required that volunteers be greater than 18 years old, and no protected populations were included. The sample was such to maximize the exposure of volunteers who had experienced factors related to the COVID-19 pandemic. 42 Sample A convenience sample of registered imaging professionals within the United Statesworking 24 or more hours a week and who had performed exams on COVID-19 patients were included in the research analysis. The online survey QR code and internet link was distributed to ACERT institutional members via email, posted at local hospital imaging departments, highlighted at local and national forums for radiologic societies, and posted on social media platforms by MSRS students. As part of the Weber State University MSRS Research Agenda, the survey was made available to three types of participants which included students and educators in radiologic science, and imaging professionals. However, the scope of this research team was limited to the imaging professional, and all surveys completed by students and educators were excluded from analysis. Materials/Instruments The instruments used to collect data involved a demographic questionnaire which included questions regarding participants ethnicity, race, gender, age, primary imaging modality, years of experience in the profession, employment status, and several self-defined questions regarding self-reporting levels of burnout pre, peak, and present related to pandemic status on a scale of 1 to 10, 1 being low burnout and 10 being high burnout. The Oldenburg Burnout Inventory is a 16-question instrument that evaluates disengagement, and exhaustion based on a 4-point Likert scale. The OLBI contains several reverse questions to better evaluate the parameters surrounding burnout and prevent careless answering. The sum of the questions, including the reverse questions, results in a score from 16-64 to rate the participants level of burnout. The OLBI demonstrates high levels of reliability within the exhaustion and disengagement subscales with Cronbach Alpha scores of 0.87 and 0.81 respectively (Reis et al., 2015). 43 Self-esteem was measured using the Rosenberg Self-Esteem Scale (RSES). This scale is a 10-item survey that evaluates the participants' views about how they regard themselves. It is based on a 4-point Likert scale ranging from strongly disagree to strongly agree. The sum of the questions, including the reverse questions, results in a score from 0-30 to rate the participants self-esteem score. The Rosenberg Self-Esteem Scale Cronbach alpha score ranges from 0.77 to 0.88 making it a relatively reliable scale for measuring self-esteem (University of Maryland, 2021). Operational Definition of Variables There are many operational variables to explain the effects of imaging professionals from the pandemic or COVID-19. The definitions of the variables are helpful when trying to understand how they correlate to the pandemic. One of the main operational variables is burnout. Burnout can be defined as long term or prolonged exposure to job requirements that appears when the stress from these requirements is no longer able to be endured (Algunmeeyn, Altakhineh, Azab, & Babar, 2020). COVID-19 is a disease caused by a variant of coronavirus that originated in China and spread worldwide. The burnout arising from the COVID-19 pandemic is suspected to be caused by caring for patients infected with the virus while dealing with the other sub-variables in the burnout category (Algunmeeyn, Altakhineh, Azab, & Babar, 2020). The sub-variables of burnout are emotional exhaustion and disengagement. Emotional exhaustion is a factor of burnout, and is the feeling of being emotionally drained by the stressors that come with work. Disengagement refers to a detachment of one from themselves. These all tie into the other main operational variable which is self-esteem. Self-esteem is the ability to see one’s self worth. The sub-variables for self-esteem are HCP self-esteem, organizational self-esteem, and community self-esteem. HCP self-esteem is one’s self worth as an individual versus the organizational self-esteem which is how the organization sets in place multiple 44 parameters for what its mission and views describe. Community self-esteem is regarding the community’s involvement and setting around the healthcare professionals. Burnout (dependent variable) - Burnout is a stress response that is composed of several sub-variables including emotional exhaustion and disengagement. Measured with the OLBI which consists of 16 questions based on a 1 – 4 Likert scale ranging from strongly disagree to strongly agree. The sum value of the responses evaluates the level of burnout the participant is experiencing. Self-Esteem – (dependent variable) Self-esteem is how the individual sees one’s self worth. Measured with the Rosenberg Self Esteem Scale which consists of 10 questions that evaluate how the individual feels about themselves. These questions are based on a 1 – 4 Likert scale ranging from strongly agree to strongly disagree. The sum value of the responses evaluates the participants self-esteem. Covid exposure (Independent variable) - How often the individual was exposed to COVID-19 positive patients in the workplace. Data Collection, Processing, and Analysis The survey consisted of a consent form, a demographic questionnaire described above, the Oldenburg Burnout Inventory, and the Rosenberg Self-Esteem scale. Once constructed, we administered surveys through online hyperlinks and QR codes reaching out to local radiology departments, posting them on radiological society forums, and through social media outlets. Responses were coded into SPSS statistical software as anonymous raw data. We received 268 responses from participants. We excluded 36 surveys based on their answer to question 9 which asked if they are a student, educator, or imaging professional. Since the scope of our study was to evaluate imaging professionals the latter were excluded. Of the remaining responses there were 45 nine international participants from countries other than the United States. These responses were excluded because our scope involved imaging professionals within the United States. International responses would also have been statistically insignificant as there was not a large enough sample group. We then excluded 26 participants who had less than 100% completion of the survey in total. Lastly 2 more participants were excluded because they selectively and incompletely filled out the OLBI. They were excluded to remove any biased results from the data. After the data was cleaned, 195 valid survey responses were used to evaluate burnout and self-esteem scores. The research questions were designed to identify if the COVID-19 pandemic has had an effect on burnout and self-esteem among imaging professionals. To do this, a statistical analysis was run to evaluate the mean scores of the OLBI. We obtained the mean values by comparing the OLBI scores to the frequencies of each participant's scores. Central tendencies were evaluated involving burnout scores from the demographic questionnaire concerning level of burnout pre pandemic, peak pandemic, and presently during the pandemic. A statistical analysis was then run to evaluate the mean value of the RSES scores. The mean values were obtained by comparing the RSES scores and the frequencies of each participant's scores. The next research question was to identify if a relationship existed between burnout and self-esteem. A Pearson correlation analysis of the data was performed to compare the participants’ OLBI scores to their RSES scores to identify if high burnout scores are related to low self-esteem. Correlations were also run against burnout and self-esteem based on how many COVID-19 patients they were exposed to per day. For the self-reported burnout scores at the three specific times, pre-pandemic, peak pandemic and post-peak pandemic, the denominators for each group are slightly different. There were four surveys where the three responses were blank, one omitted the post-peak pandemic 46 score, one omitted the pre and post response and one omitted the peak pandemic response. The research includes the scores when the response was partially completed. Assumptions Several assumptions about the study population were made. One is that participants are currently working within a radiologic modality at the time of completion. The researchers made this assumption by asking the participant if their employment status is PRN, Part-time, Full-time, etc. Another assumption is that the participants had previous work experience, were employed prior to the COVID-19 pandemic, and could evaluate and report their relative burnout and self-esteem levels prior to the pandemic, during the peak of the pandemic, and at the current point of the ongoing pandemic The last assumption is that the responses were each performed by different individuals. While retaining anonymity within the survey, we were able to see which IP address was used to take the survey. If a duplicate IP address was used, the response was evaluated to identify any duplicate surveys or if the responses indicated multiple people using the same device to take the survey. We did not identify any duplicate survey results; therefore, we assume they were all different participants. Limitations There were several limitations within our study. The majority of our survey participants were located in similar geographical areas. Utah, California, Arizona, and Florida being the most common states with trace responses throughout the other states. In particular, the racial demographic within our sample varies little, and does not accurately represent the racial diversity of imaging technologists in the United States. In regards to measuring self-esteem in relation to COVID-19, limitations include having no pre-pandemic baseline to determine self-esteem levels prior to the pandemic. Another limitation is the presence of recent developments that may affect 47 our sample population, such as availability of vaccines to healthcare professionals as well as the public. This recent change may affect the data we are assessing in unpredictable ways. Lastly, the COVID-19 pandemic has been affecting the population since January, 2020. From the onset of the pandemic to the time the research was conducted, attitudes towards the situation may have changed, altering personal perception of the pandemic’s peak when answering survey questions. Delimitations To reduce error within our study, we limited our sample to those who are currently employed and working in the healthcare setting. Those who worked through the COVID-19 pandemic but have since retired have been excluded from this study. We also acknowledge that there are many variables outside of those related to the COVID-19 pandemic that are related to burnout and self-esteem within individuals. However, the goal of this study is to evaluate burnout and self-esteem levels among our sample and see if a relationship exists between them. We have also reduced error by choosing appropriate survey tools in measuring burnout and self-esteem. Both the OLBI and the RSES have high validity and reliability. Making them accurate and consistent tools to use in evaluating our sample. Ethical Assurances This study has received approval from the Weber State University Institutional Review Board (IRB)( See Appendix B). The IRB will be notified of any unanticipated effects on subjects which become apparent during the course of, or as result of, the experimentation and the actions taken. All participants will be required to electronically sign an informed consent form. Participants will be notified of the very limited risk involved in participation. Personal information of participants will be held confidentially. A copy of the informed consent can be found in Appendix B. Survey results will be held in a secure online database for several months 48 while the data can be collected. The investigators and their mentor will have access to these results. After the data is collected and the study is published, all data will be destroyed. Summary In summary, our research questions are to find out what the burnout and self-esteem scores are among imaging professionals and compare them to previous scores. We also wanted to identify if there is a relationship between burnout and self-esteem. We constructed a survey which included a demographic questionnaire, the Oldenburg burnout Inventory, and the Rosenberg Self-Esteem Scale. We administered this online survey to imaging professionals by posting links and QR codes to local radiology departments, online radiologic society forums, and through social media outlets. Our survey responses were coded into SPSS statistical software and our data was sifted through to evaluate our sample accurately. We ran several statistical tests to evaluate the mean scores of the OLBI results and the mean scores of the RSES scores. Central tendencies from demographic questions regarding burnout scores based on pre pandemic, peak pandemic, and present pandemic status were evaluated. Afterward, correlation analysis was performed to see if COVID-19 exposure, burnout, and self-esteem had any relationship associated with them. 49 Chapter 4: Findings Introduction This study includes findings for the OBLI and RSES surveys, which report burnout and self-esteem levels. A Lickert scale survey obtained self-reported overall burnout scores at three specific times throughout the COVID-19 pandemic: beginning, peak and post-peak pandemic. Additionally, the survey asked participants to select the top three factors contributing to burnout in the categories of personal life, community, and work related reasons, and offered ten possible responses. These OBLI and RSES surveys provided the information necessary to find correlation, if any, between burnout and self-esteem amongst imaging professionals. Results Covid-19 and Burnout The first research question asked whether the Covid-19 pandemic had affected burnout levels among imaging professionals. To establish the level of burnout amongst imaging professionals who had experienced factors of the COVID-19 pandemic, the OLBI was administered and a frequency count of the scores was obtained. Scores of burnout demonstrated the level of burnout self-reported by participants at the time they completed the survey. All survey responses were collected between April 16, and May 13, 2021). The lowest score obtainable on the OLBI is a 16, indicating low burnout, and the highest score is a 64 indicating high burnout. Among respondents, the mean score was 39.9 with a standard deviation of 7.2 (see Figure A1). To investigate whether a higher exposure to COVID-19 patients resulted in higher levels of burnout among imaging professionals, a Pearson correlation between COVID-19 exposure and OLBI burnout scores was performed. Results indicated a Pearson correlation coefficient of 50 r = 0.049 and an r² = 0.2% with a p value of .491 indicating a very weak correlation between COVID-19 exposure and burnout scores (Figure A2). In that levels of burnout may have been reported differently over time during the pandemic, respondents were also asked to self-report regarding their personal burnout pre-pandemic, peak-pandemic, and presently during the pandemic. Scores were recorded on a likert scale of 1 - 10, 1 indicating low burnout and 10 indicating high burnout (Figure A3). Mean burnout scores were 4.17 for pre-pandemic, 6.64 for peak pandemic, and 5.28 for present pandemic status. Median scores were 4.00, 7.00, and 5.00 respectively. Mode scores were 3.00, 10.00, and 8.00 respectively (Figure A4). Results indicate a low to moderate level of pre-pandemic burnout, between the range of 0-6 with 80% of the respondents (Figure A4). The pre-pandemic high burnout level was 20% in the 7-10 range. At the peak of the pandemic, those surveyed reported significantly increased levels of burnout (See Appendix A, Figure 5) with the respondents rating their perceived moderate to severe burnout of scores 4-10 among 86% of respondents and severe burnout between the levels of 7-10 with 58% of those imaging professionals. The results of the OLBI, however, place the majority of respondents (See Appendix A, Figure 1) among moderate levels of burnout. One possible explanation for this discrepancy in results may be differing interpretations of burnout by the respondents. Burnout, when not given a specific definition, may be interpreted as many different factors. Given the OLBI, with specific questions asking a person to define his or her feelings and attitudes, the answers to questions regarding burnout may be different than a generalized perception of what burnout is. Another assumption is that the OLBI portion of the survey did not specify how a person was feeling regarding burnout at that exact time of taking the survey, versus how they felt during the peak of the pandemic. After the peak of the pandemic (See Appendix A, Figure 6), when compared to the time post peak when the survey was issued, respondents reported a reduction of high burnout 51 severity, demonstrated by a 27% reduction, dropping from 67% to 40%, with fairly even reports of personal burnout between levels 1 - 8 in the post peak timeline. These survey results are very similar to a study conducted in Australia that is previously mentioned in the literature review. Using the Maslach Burnout Inventory (MBI) method, researchers concluded that burnout was a factor among healthcare workers by establishing a baseline prior to the pandemic and noting that their findings revealed higher than average burnout levels during the time of the pandemic. Covid-19 and Self-Esteem The second question the research asked was if the COVID-19 pandemic had an effect on levels of self-esteem among imaging professionals. Using the RSES instrument, results show that the mean score was 17.4 with a standard deviation of 4.6 (See Appendix A, Figure 8), obtained by a frequency count. The lowest score attainable on the RSES is 10, indicative of high self-esteem in the individual, and the highest possible score is 40, which is indicative of low self-esteem in the individual. These findings provided the baseline self-esteem levels among the sample. To identify if exposure to COVID-19 patients resulted in low self-esteem among imaging professionals, a Pearson correlation between COVID-19 exposure and RSES scores was performed. Results indicated a Pearson correlation coefficient of r = 0.185 and an r² = 3.4% with a p value of 0.01 indicating a low correlation between COVID-19 exposure and self-esteem scores (See Appendix A, Figure 2). Although there was no specific literature focusing on the association between self-esteem and COVID-19, we expanded on recent studies to fill the gap. According to Fernadez (2021) healthcare providers have suffered from burnout, which has adversely affected their mental and physical health. There is a high likelihood for individuals to suffer from mental strain due to burnout. Mental strain is one of the factors that can lead to low self-esteem.After recruiting and collecting data from imaging professionals, we conducted data analysis to determine if there was, 52 in fact, a correlation. The results were reviewed to assess if the COVID-19 pandemic had an effect on the levels of self-esteem among imaging professionals and discovered that there is extremely low correlation between COVID-19 exposure and self esteem. The average of 17 on a scale of 40 indicates relatively high self-esteem among survey participants. Thus, the results show that exposure to the COVID-19 pandemic is not likely to affect self-esteem levels amongst imaging professionals. When conducting our analysis, we were limited by the lack of recent studies examining the association between the COVID-19 pandemic and self-esteem among imaging professionals. The search to understand more about this topic leads to the next area of research. Correlation between Burnout and Self-Esteem The third research question seeks to establish a relationship between burnout and self-esteem among the sample population. A correlation was run between aggregate burnout scores based on the OLBI and aggregate self-esteem scores from the RSES. The findings resulted in a Pearson correlation coefficient of r = 0.42, and an r² value of 0.175 with a p value of <.001. This indicates a low positive correlation between increasing burnout and poor self-esteem. (See Appendix A, figures 8 & 9). Hence, the effect of this correlation is small and could have occurred by chance. According to a study from Kupcewicz and Jóźwik (2020), findings suggest that lower self-esteem rates among Polish nurses is a predictor for higher instances of burnout syndrome. Their findings also demonstrated a low correlation with a Spearman’s rank correlation test value of - 0.26. The results from our study coincide with the results from the study performed by Kupcewicz and Jóźwik (2020). It is important to note that a low score on the RSES is indicative of high self-esteem in the individual, and a high score is indicative of low self-esteem among the individual. This explains the positive correlation score which differs from previously referenced studies. This discrepancy is due to how RSES and OLBI results were coded within our statistical 53 analysis. A possible explanation for the low effect size of RSES/OLBI correlation may be resilience of the HCP. As was discussed in the literature review, Fleming and Ledogar (2008) explain that resilience is a positive adaptation to adversity. Resilience involves positive outcomes while being subjected to situations with high amounts of risk, and then recovering from those situations. Development of resilience in the individual can be obtained through mechanisms such as high self-esteem, self-efficacy, and good communication skills. Other contributing factors In addition to the three research questions, researchers sought to understand the cause of burnout among participants. To better describe the environment and circumstances of participants, the survey demographics were expanded and asked respondents to indicate factors which caused them burnout and stress. They were given a list of ten possible choices and asked to select the top three factors contributing to burnout in the categories of personal life, community, and work related reasons. The most influential personal life factors that participants listed among reasons for burnout were their personal and family responsibilities (16.7%),their personal risk of contracting COVID-19 (16.5%), and their significant others’ (i.e. family) risk of contracting COVID-19 (16.5%). (See Appendix A, Figure 10) Abern et al (2020) stated that personal challenges including financial struggles from lost or reduced working hours, loss of adequate childcare, and acquiring groceries and other household goods necessary to provide for a family during the pandemic are all factors that contribute to the stress of personal and family life, which is validated in this research by participants’ top ranked contributor being that of personal and family responsibility. During the pandemic, HCPs faced heightened anxiety of contracting COVID-19 due to the fact that they were frequently caring for infected patients at work, sometimes without proper 54 protective equipment and poor patient isolation policies, thereby increasing their personal risk of contracting the virus. HCPs were fearful of exposing their families and loved ones to contagion brought home from work, which led to self-isolation and purposeful distancing in the hopes of preventing the spread of the disease to those at home. The researchers next asked participants to select the top three factors contributing to community related burnout during the COVID-19 pandemic. Results show that the top three factors contributing to community related burnout are first, unclear and fluctuating information and government guidelines (26.9%), community response and compliance to COVID-19 recommendations (19.8%), and community perception of the HCP) (17.7%) (See Appendix A, Figure 11). During the early days of the pandemic, constant and confusing changes in guidelines from governing bodies created confusion and distrust among the population. According to Berkowitz (2020), OSHA did not issue any enforceable COVID-19 specific practices or policies that employers were obligated to implement as a means to protect healthcare professionals. As the recommendations changed from week to week, public adherence to policy was difficult to attain due to refusal to comply with regulations that many neither trusted nor believed to be useful. Social reciprocity by the public was wanted and needed from imaging professionals as they risked their lives every day at work, hoping that the community would comply with mask mandates and adherence to social distancing guidelines. Some HCP’s working in intensive care units dealt with new, very serious and frightening situations, but were being confronted outside of work with talk of conspiracy theories and even denial of the existence of the virus. The newly coined phrase, Healthcare Hero, is also a likely source of burnout. Although applauded from the balconies, walking by ‘Healthcare Heros Work Here’ signs draped across the entryway of the hospital, and offered discounts in retail and food establishments for bravely working at the frontline of the health crisis, HCP were also vilified and harassed for being perceived as 55 spreaders of contagion to those who feared contracting the virus. The results from this category show that these three factors had a significant impact on HCP burnout. Last, the top three work related factors leading to burnout during the COVID-19 pandemic. Results show that the largest contributor to burnout in this category was frequent changes in work policy and procedures (26.2%), closely followed by increased workloads (26%), and lack of leadership and managerial support (13.3%). (See Appendix A, Figure 12). Also, mentionable as a contributing factor to burnout was a lack of proper PPE (10.8%). HCPs went to work each day as the landscape of the pandemic was changing. Policies, procedures and guidelines set forth one day did not necessarily carry over to the next as little was initially known about COVID-19, it’s transmission, or effective treatments. Therefore, policies changed as new information was received. OSHA did not publish enforceable guidelines or visit places of work but rather had a soft stance of voluntary recommendations as a means to protect HCPs (Berkowitz, 2020). The Center for Disease Control (CDC) reversed its guidelines within one month regarding positive, asymptomatic HCPs and quarantine. (CDC, Nov 2020). As the steady stream of information flowed in, hospital administrators had to filter through WHO, CDC, federal, state, and hospital policies to determine which guidelines and regulations took precedence, and pivot their approach to the situation. Some employees contracted COVID-19 themselves or were caring for sick family members, which meant they could not work. Additionally, staff who had children attending school or daycare which closed were required to miss work to homeschool or provide childcare. Due to staffing shortages, unfilled shifts were expected to be covered by remaining staff, adding to the already burdensome workload (Kaye et al., 2020). With frequent policy and guideline changes and increased workload, it is unsurprising that a significant contributor to burnout was lack of leadership and managerial support. Lack of leadership manifested as slow responses to changing information, failure to act quickly in 56 securing proper PPE, and failure to understand the significance of situational factors including increased stress levels, compassion fatigue, and the necessary isolation of infected patients. PPE shortages caused by budget policies and limited supply chains (Cohen 2020) reduced access to proper protective gear, which, in turn, led to impaired safety practices and lowering of well known safety standards, including multi-day use of single-use face masks, a practice that became endorsed by the CDC. Summary Burnout was queried in two separate sections of the survey, once with the OLBI and the other asking for perceived levels of burnout throughout the pandemic (See Appendix A, Figure 13). At the peak of the COVID-19 pandemic, self-reported burnout levels of the majority were high, differing from the OLBI scores which reflected a moderate level. These differences can be explained by the direct questions of the OLBI leading the respondent through exhaustion and disengagement scenarios, however, if asked directly about their burnout level, they may have considered stress and various other factors when considering their response. The mean results from the Rosenberg self-esteem scale show that overall self-esteem is relatively high among imaging professionals with low correlation to COVID-19 exposure. The results of the study demonstrated the resilience of the HCP by reduced burnout levels post peak. The results of the survey showed a weak correlation between the OLBI and RSES, which was not anticipated. Results from the survey regarding personal, community, and work-related burnout indicate multiple expected factors that added to the overall burnout of imaging professionals during the pandemic. 57 Chapter 5: Implications, Recommendations, and Conclusions Implications The first question asked, and the main hypothesis of this research, is if the COVID-19 pandemic increased rates of burnout amongst imaging professionals. The results show that burnout levels did, in fact, increase during the peak of the pandemic, then reduced afterward as the case numbers steadily decreased. We can imply from these results that although the pandemic created new stressors for imaging professionals, they continued to work under difficult circumstances until levels of perceived burnout were eventually reduced. These results show resilience amongst the population of healthcare professionals. We see this resilience continued when we asked if the COVID-19 pandemic affected the self-esteem of imaging professionals. Results from the RSES showed little change in self-esteem at all during this time, which we found surprising, yet understandable given the daily challenges that those working in healthcare face on a daily basis. We can imply from this result that the self-regard of the imaging professional is not excessively tied to his or her work, and may indicate that self-efficacy and professional competency is a greater factor when determining resilience in stressful situations. Our last question, regarding a correlation between burnout and self-esteem, was inconclusive, which implies that there may be no significant relationship between burnout and self-esteem. Recommendations Future research studies associated with the effect of COVID-19 pandemic in association with race should seek to examine the potential challenges linked with assessment of burnout rates among imaging professionals of varying races in healthcare settings. This research will help to determine the accuracy and reliability of data from previously conducted studies regarding the rate of burnout based on ethnicity or racial group, as well as explaining the underlying factors in the observed patterns. 58 Results from this study demonstrate lack of PPE being a large contributing factor to burnout, therefore, our recommendation to healthcare entities and government is to secure a greater surplus of PPE and other protective equipment as well as increasing supply streams. To further support this recommendation it would behoove the leadership of the healthcare entity to ensure proper training and competencies in regards to the use of PPE are updated and completed regularly. We recommend elimination of uncertainty through poor communication due to lack of planning by the creation of protocols, guidelines and regulations regarding supply shortages during pandemics. We also recommend that the stream of information being released by media sources and government entities should be organized and synchronized to eliminate mis-information while leadership from the CDC and WHO determine which information is accurate or false. It would be reasonable to suggest all individual states follow a federal pandemic crisis plan to eliminate confusion from differing state actions with the caveat that each individual state’s minimal needs were addressed. Recently the Delta variant of the COVID-19 virus began rapidly spreading. This variant of the virus is more contagious, has infected those who have already received the vaccine, and is spreading amongst younger age groups. Positive cases have reached 100,000 per day, and in some states in the U.S. infection rates equal or surpass the initial peak rates seen in the early days of the pandemic. We recommend further research on burnout levels of healthcare professionals as the ongoing pandemic continues to affect their lives. Conclusions After reviewing all results from the online survey we see that imaging professionals during the COVID-19 pandemic have shown an increase in mental, psychological, and physical stress which correlates to burnout. This is not unexpected, as previous research has suggested that healthcare professionals who deal with large levels of difficulty, increased workloads, and high levels of anxiety during the COVID-19 pandemic are more likely to experience burnout 59 (Morgantini et al., 2020; Ramaci, 2020). This research recognizes that the COVID-19 pandemic did have a significant influence on radiologic imaging professionals regarding burnout; however, the results for self-esteem were not substantial. As the COVID-19 pandemic has progressed and new strains of the virus are spreading worldwide, more evidence about burnout and imaging professionals has become accessible. One goal of this study was to identify aspects of life that contribute to burnout based on those experiences of the HCP. Learning this information can assist leaders of healthcare organizations to know where resources are most needed and where they can use those limited resources to support and assist the HCP during times of crisis to provide greater stability and structure. Knowing what caused increased stress amongst HCPs during the pandemic can help us to better prepare, assess, and react should a similar situation occur in the future. 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