CORRELATION OF INTERPROFESSIONAL EDUCATION, BURNOUT AND SELF-ESTEEM AMONG MEDICAL IMAGING PROFESSIONALS by Ashley Barbadillo Jeremy Bennett Marius Betfiang Christina Black Zach Breslauer Katelyn Godfrey Alex LaFreniere Brittany Yowell 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 June 29, 2020 Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 2 THE WEBER STATE UNIVERSITY GRADUATE SCHOOL SUPERVISORY COMMITTEE APPROVAL This thesis has been read by each member of the following supervisory committee and by majority vote found to be satisfactory. ______________________________ Dr. Robert Walker, PhD Chair, School of Radiologic Sciences ______________________________ Dr. Tanya Nolan, EdD Director of MSRS ______________________________ Dr. Laurie Coburn, EdD Director of MSRS RA Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 3 Acknowledgments The summer 2020 graduating class would like to express our deepest gratitude to the faculty and staff of the Radiologic Sciences Department at Weber State University. We would like to thank Dr. Robert Walker, faculty sponsor and committee chair for the school of radiologic sciences. We would like to express our gratitude to the MSRS program director, Dr. Tanya Nolan, and the RA program director, Dr. Laurie Coburn for their guidance and support throughout our research. In addition, we would also like to thank Dr. Heather Chapman for her expertise in statistical data analysis. Finally, we would like to thank all of our family and friends who have helped to ground, guide, and encourage us throughout our educational endeavors. We could not have done any of this without you all. Keywords: Interprofessional education/collaboration (IPE/IPC), burnout, self-esteem, correlation, medical imaging, health professionals, healthcare, allied health, collaboration, Bergen Burnout Inventory (BBI), Interprofessional education collaboration (IPEC), Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 4 Table of Contents Abstract .......................................................................................................................................... 5 Literature Review........................................................................................................................... 6 Introduction ................................................................................................................................ 6 Burnout ....................................................................................................................................... 8 Self Esteem ............................................................................................................................... 11 IPE/IPC..................................................................................................................................... 14 Burnout, Self-Esteem, and IPE/IPC .......................................................................................... 17 Conclusion ................................................................................................................................ 20 Purpose ......................................................................................................................................... 22 Materials and Methods .................................................................................................................. 25 Approval for Research .............................................................................................................. 25 Materials/Instruments ............................................................................................................... 25 Research Protocol ..................................................................................................................... 28 Data Analysis ............................................................................................................................ 29 Inclusion/Exclusion Criteria ..................................................................................................... 31 Rationale .................................................................................................................................. 31 Limitations ................................................................................................................................ 32 Results .......................................................................................................................................... 33 Discussion .................................................................................................................................... 39 Recommendations ..................................................................................................................... 47 Conclusion ................................................................................................................................ 49 References .................................................................................................................................... 52 Appendix A. ................................................................................................................................. 60 Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 5 Abstract The purpose of this correlational quantitative study was to examine the perception of interprofessional education/collaboration (IPE/IPC), self-esteem, burnout and the relationship among them in medical imaging professionals. Understanding the correlation between these variables assists practitioners in maintaining better patient outcomes and reducing medical errors that are attributable to job dissatisfaction, low self-esteem, and burnout. Among the 396 participants, study results confirmed the expected positive correlation between IPE/IPC and self-esteem (r = 0.38, p<.001), and a negative correlation between self-esteem and burnout (r = -0.44, p<.001). Additionally, there was a stronger negative correlation between IPE/IPC sum scores with burnout (r = -0.47, p<.001). When using the IPEC Competency Self-Assessment Tool and BBI-9 subscales, the strongest negative correlation was seen between IPE/IPC and the feelings of inadequacy subscale (r= -0.48, p<.001). Results of the study lead the authors to conclude that experience in IPE/IPC practices may mitigate burnout in medical imaging professionals by way of increased self-esteem. Limitations of the study include a lack of uniform environment for survey participants, as well as possibility for inherent procedural and response bias. Recommendations for future research include analyzing differences in burnout rates between imaging sub-specialties, hospital and population size. Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 6 Literature Review Introduction The healthcare system in the United States has helped improve the health and wellbeing of the population (Millman, 1993). However, access to inclusive, comprehensive, and quality healthcare services is critical for promoting and sustaining health, preventing and managing disease, reducing unnecessary disability and premature death, and accomplishing health equity for the entire population (Zwarenstein et al., 2009). Correspondingly, the latter reiterates access to healthcare influences one's overall physical, social, and mental health status and quality of life. The goal of a healthcare system is to improve the health and quality of life; yet, several environmental, social, political and economic factors have had a negative impact on the healthcare delivery system over the past two decades (Eckelman and Sherman, 2016). Burnout syndrome is both social and environmental and may contribute to the negative impact the healthcare system has experienced. Burnout, a worldwide phenomenon, is due to the “physiological stress that…exceed[s] the adaptive capacity of a workforce member” (Lilly et al., 2019, p.1001). The financial ramifications of physician burnout are well documented. According to a recent report from the Annals of Internal Medicine, an annual baseline cost of roughly $4.5 billion is due to physician burnout (Han et al., 2019, p. 784). With physician shortages becoming more prevalent, combined with the adage synonymous with modern work environments; to “do more with less,” this issue does not have an optimistic forecast. In addition to financial costs associated with physician burnout, burnout also decreases the quality of patient care, decreases the number of patients served, and increases medical errors. Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 7 Since its inception in healthcare, interprofessional education/collaboration (IPE/IPC) has demonstrated a strong correlation with improved patient outcomes. More robust investigations are still needed to determine if a causal relationship exists between implementing IPE/IPC practices and improved patient outcomes. Despite the studies linking IPE/IPC and patient outcomes, there has been little research evaluating the link between IPE/IPC and healthcare professionals’ rates of burnout. An open dialogue between peers improves a sense of teamwork (interprofessional collaboration) and being an active participant in an effective team (defined by the efficacy of the team, team structure, and team culture) leads to an enhanced sense of occupational and personal self-esteem. These all help to safeguard the healthcare professional from falling susceptible to the symptoms of burnout. Thus, the purpose of this review is to define burnout, self-esteem, and IPE/IPC, how they relate to healthcare and each other. Superseding a review of the literature, the authors sought to analyze medical imaging professionals’ perceptions of the variables in an effort to discover whether IPE/IPC could mitigate the effects of burnout by way of increased self-esteem. Furthermore, medical imaging professionals perform an integral role in disease/pathology diagnosis, as well as contribute to the financial health of any medical facility. Even so, literature regarding burnout in health professions is largely focused on physicians and nurses. As burnout has long-standing ramifications in healthcare, and considering the importance of medical imaging, discovering ways to reduce and protect against the syndrome in these professionals is long overdue. Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 8 Burnout A broad definition of burnout states that “Burnout syndrome is a state of psychological stress that can result when external demands exceed the adaptive capacity of a workforce member” (Lilly et al., 2019, p.1001). Doulougeri et al (2016) state that burnout is a physiological syndrome involving a response to chronic emotional and interpersonal stressors at work. A commonly used tool that measures burnout is the Maslach Burnout Inventory (MBI). The MBI quantifies burnout according to three components: emotional exhaustion, depersonalization, and reduced personal accomplishment. Burnout is not an isolated problem; it is a world-wide issue. Although burnout is similar to clinical depression, it is its own distinct disorder. Burnout is prevalent in the healthcare field. In fact, a study by Kumar et al. (2016) concluded that the following healthcare specialties have the highest rates of burnout: “urology (63.6 %), physical medicine and rehabilitation (63.3%), family medicine (63.0%), radiology (61.4%), orthopaedic surgery (59.6%), dermatology (56.5%), general surgery subspecialties (52.7%), pathology (52.5%), and general pediatrics (46.3%)” (Kumar et al., 2016, p.37). The bulk of research literature on burnout within the healthcare field pertains to nurses and physicians, particularly due to the severe consequences of physician attrition. Vandenbroeck et al. (2017) conducted a study on 1169 Belgian physicians and 4531 Belgian nurses with the aim of investigating burnout and its relation to attitudes and well-being while on the job. They concluded that emotional exhaustion affected learning and development opportunities, as well as support among co-workers. The authors state that emotional exhaustion, stemming from the workplace, correlated with poor health and the desire to leave the position. Another study by Portoghese et al. (2014) administered a questionnaire to 352 Italian hospital workers. The questionnaire measured exhaustion, cynicism, job control, and workload. The study concluded Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 9 that when job control is low, high workloads can result and may increase an individual’s levels of exhaustion and cynicism. The aforementioned study by Kumar et al. (2016) placed medical imaging and its sub-specialties as having the fourth highest rate of burnout in the healthcare field. Much of the research in the radiology subspecialties has been conducted in radiation oncology specifically. Studies by Probst, et al. (2012), and Leung & Rioseco (2016) both concluded that burnout is highly prevalent among radiation therapists. The United Kingdom’s National Health System reported that 38% of radiation therapists experienced emotional exhaustion and 49.5% of Australian/New Zealand radiation oncology trainees reported high degrees of burnout in any of the three elements. Due to the overpowering workload and newer technology, there is a high level of stress that is not being accounted for and poses severe risks. Because of the alarming rate of burnout, there have been measures to mitigate its effects on both healthcare systems and workers (Restauri et al., 2017). This is indicative of how burnout should be treated and where the efforts should be directed; the solution is to not just examine the individuals, but the healthcare system as a whole. Radiologists’ burnout levels are just as alarming as medical imaging professionals mainly because while physicians serve in leadership roles, little formal training is provided to them on how to become effective leaders (Restauri et al., 2017). When experts looked at burnout in radiologists, they found that as of 2016, burnout rates among radiologists are estimated to be around 50% with radiologists ranking 10th out of 25 medical specialties surveyed (Restauri et al., 2017). It is clear that burnout is present at every level of medical imaging. Medical imaging professionals have an important role not only to provide high quality images, but also to create a safe positive environment for patients who are waiting on potentially Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 10 life-altering test results. All of this, while responding to increasing patient volumes. These factors create a demanding clinical environment and can lead to burnout and compassion fatigue among medical imaging professionals (Mohammed et al., 2019). Mohammed et al.’s study in 2019 examined a busy outpatient CT department. It was acknowledged that these problems contributed to burnout and a Process Improvement Committee was created to examine how to reorganize the department in an effort to reduce burnout. The redesign of this busy outpatient center added personnel to address the multiple responsibilities of medical imaging professionals working primarily in computed tomography. The Process Improvement Committee sought to reduce burnout by addressing the stressors present in medical imaging professionals and their workflow (Mohammed et al., 2019). The insights gained from Mohammed et al.’s study lead toward examining evidence-based strategies to reduce burnout. Doulougeri et al. (2016) state that burnout is a symptom of organizational functioning and that organizations need to address the conditions that contribute to burnout. In order to increase well-being, Doulougeri posits six key areas of worklife that need to be approached: workload, control, reward, community, fairness and values. Portoghese et al. (2014) concluded that when resources are limited, workload should decrease, thus in turn increasing the workers self-control. In order to reduce burnout, there needs to be intervention programs in place. Vandenbroeck et al. (2017) state that in order to prove how effective burnout interventions are, randomized, controlled trials need to be administered. Kumar et al., (2016) stated that the best way to manage burnout is to have stress management programs. They found evidence that supporting stress management training, temporarily reduced workplace stress levels. Once burnout has set in, it is hard to reverse. Therefore, the best way to combat burnout is to prevent it. Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 11 Self Esteem When considering how self-esteem relates to the healthcare worker, we must first define self-esteem as a personal characteristic and define it in an organizational context. Rosenberg (1965) defines self-esteem as “an individual’s overall self-evaluation of his/her competencies.” Self-esteem, pertaining to the healthcare worker, can be expanded to consider competencies in the organizational or healthcare environment. Self-esteem, in the healthcare organization, is linked to the healthcare worker’s self-efficacy as evidenced in a study by Allen et al. (2018) that examined how participation in an interprofessional critical care simulation affected the healthcare students’ feelings of self-efficacy and self-esteem. A statistically significant positive correlational relationship was found between those with high feelings of self-efficacy and self-esteem. Sa et al. (2019) concluded that healthcare students with low self-esteem may be more susceptible to stressors associated with their studies as students. There is the possibility that this could be extrapolated to the workplace but requires more research and a more thorough review of the literature. Pierce et al. (2014) conducted a meta-analysis of the organizational concept of self-esteem and how it relates to the worker. Organizational self-esteem considers self-esteem in relation to the worker’s organizational structure and builds from Rosenberg’s original research in 1965. In the literature, a link has been thoroughly demonstrated between the onset of burnout and the self-esteem of the healthcare worker. Manomenidis et al. (2017) sought to answer this; the focus of their study was to determine if high self-esteem in nurses predicted a lower burnout rate among them. Convenience sampling by recruitment in a Greek hospital resulted in 183 respondents (91.5% response rate). The survey instrument administered was the Maslach Burnout Inventory (MBI), which measures the 3 elements of burnout: depersonalization, Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 12 emotional exhaustion and personal accomplishment. The MBI identified that 25.6% of the respondents had high emotional exhaustion, 25.1% having high depersonalization, and 27.3% having low personal accomplishment. Depersonalization and emotional exhaustion were found to be negatively correlated with self-esteem (r=0.-245 & r=-0.15, respectively), and personal achievement was positively correlated with it (r=0.34). The authors posited that the central problem for nurses working in the hospital environment is the dissonance between expectations cultivated during nursing studies and the reality experienced at work. The authors recommend that educational programs incorporate the working process along with nursing studies and should focus on strategies that create and enhance structures needed for improving nurses’ self-esteem and professional identity. Interprofessional education and collaboration could potentially increase the understanding of one’s role through professional identity, and resilience (to burnout onset) by way of increased self-esteem. Furthermore, a study by Gomez (2014) examined the relationship between self-esteem and burnout in general Internal Medicine physicians. Cooper-Smith’s brief burnout and self-esteem questionnaire was given to 85 internal medicine physicians in a Cuban hospital and found that 64.8% of the physicians were experiencing burnout in some capacity. In their study they found that self-esteem had a negative correlation with burnout and emotional fatigue. Physicians with lower self-reported self-esteem values experienced burnout and emotional exhaustion at a higher rate. Jurado et al (2018) also identified a link between low self-esteem and higher rates of burnout. Their study recommends further evaluation of burnout relative to individual personal characteristics that could influence it. A study by Lee et al. (2013) reported that low self-esteem individuals have limited resources for coping with work stressors, which results in increased psychological distress and difficulty controlling stressful events. This aligns with the work of Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 13 Maslach et al. (2001) that demonstrates when individuals suffer from increased psychological distress and possess limited coping mechanisms, emotional exhaustion is the first manifestation of these issues. This work also shows that emotional exhaustion that manifests from low self-esteem is often the first sign or manifestation of burnout. When examining self-esteem in the healthcare worker, there has been a minor relationship developed in the literature with interprofessional collaboration and interprofessional education. Manomenidis et al (2017) produced some statistical analysis in their study regarding rates of inter/intra-professional collaboration and its correlation with levels of self-esteem in Greek nurses. The authors used the Greek versions of the Inter-professional Collaboration Indexes, which demonstrate adequate reliability (INPC, and ITPC for this sample were α =.78 and α =.73 respectively). A moderate positive correlation was identified (r=0.19) between scores on the Rosenberg Self-Esteem Scale (RSES) and the INPC/ITPC indices. A study by Gunnarsdottier et al (2009) also reported that interprofessional collaboration was the strongest negative predictor of emotional exhaustion. The authors stated that relations with doctors are an important factor in nurses’ work engagement and clinical autonomy. Supportive and empowering relations with doctors leads nurses to have more positive attitudes towards their position and greater levels of organizational self-esteem. Self-esteem can be improved, but the amount of current literature is limited. In a study by Thomson et al (2015), the author addresses the need for not only self-esteem, but also group-esteem. After examining the relationship between interprofessional communication and group-esteem, it was found that increased focus on common team goals heightened feelings of worth and being valued among different professionals, while lessening the need for competition. In the clinical setting, it has been found that an individual’s self-esteem can often be tied to their Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 14 individual status within a group, and the group itself will band together in criticizing other healthcare professionals. Through the training of the participants with IPE/IPC, it was found that healthcare professionals felt more respected by other departments, causing their group, and self-esteem to increase. However, in a study by Skodova and Lajciakova (2013), there were no significant changes in self-esteem with either the control group or experimental group when subjected to psychosocial training. The author addressed the influence of personality factors regarding burnout and self-esteem and how the effect of psychosocial training can help to positively influence work coping strategies. A sample of 111 university-aged students in health care professions were divided into a control group and an experimental group. Through the use of the School Burnout Inventory, Sense of Coherence questionnaire, and Rosenberg’s Self-esteem scale before and after the psychosocial training, the researchers found that the level of burnout within the experimental group decreased and coherence increased, however there were no significant changes with either group on self-esteem. IPE/IPC Due to increasing specialization within healthcare, and the complexity of patient health problems, collaboration between members of different health professions has become vitally important to improving patient outcomes. Hall (2005) described each health care profession has a different background and culture which includes values, beliefs, attitudes, customs and behaviors. Over time, professional cultures have advanced as the different professions developed, mirroring historical factors, as well as social class and gender issues. Educational experiences and the socialization process that occurs during the training of each health professional reinforce the common values, problem-solving approaches and language/jargon of each profession. Increasing specialization has led to even more additional engagement of the Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 15 learners into the knowledge and culture of their own professional group. Hence, these professional cultures contribute to the challenges of effective interprofessional teamwork. Because there is not a single healthcare professional that can meet all the needs of an individual, it is vital to have collaboration in order to fully treat a patient. The increased specialization with health care has led to the need for effective collaboration between teams, otherwise interprofessional collaboration. Karam et al (2018) state within fully functional and effective healthcare systems, interprofessional collaboration is an important component. Interprofessional collaboration (IPC) has been deemed as two or more healthcare professionals who have specific roles, perform interdependent tasks, and share a common goal; a negotiated agreement which values expertise and contribution that each individual brings to patient care. An effective inter- professional team dictates members are treated with respect, understand each other's roles, share knowledge and responsibility, and work together to deal with different client situations (Hall, 2005). Collaboration is an important practice in relationships between teams within an organization, as well as within teams across multiple organizations. Thus, IPC is a vital exercise between healthcare teams, and its competencies can be an important foundational practice for each healthcare provider. Interprofessional education (IPE) has been researched and touted as a means to develop interprofessional collaboration (IPC) within students of health professions. The World Health Organization describes IPC as a partnership between a team of healthcare workers and a patient regarding their health or social issues (WHO, 1988). An effective IPE program should develop communication and decision-making skills, both of which increase the level of cooperation and collaboration between team members and impact the inclusive outcome of the care provided by Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 16 joint teams. In addition, IPE/IPC boosts team members’ knowledge of one another’s roles and scope of practice, increases mutual trust and respect amongst colleagues, outlines the working arrangements, and helps balance workload. Moreover, the World Health Organization (2014) states that collaborative education will play an important role in mitigating the global health workforce crisis. A study by Buring et al. (2009) provided the objective of IPE/IPC is to develop knowledge, skills, and attitudes that elicit both interprofessional behaviors and competence. Another study by Macintosh et al. (2001) determined the purpose of IPE/IPC is to deliver an equal opportunity for each profession in the interprofessional education/collaborative team to share information and knowledge in a respectful and trusting environment. Darlow et al (2015) cited IPE/IPC as an important method of improving interprofessional practice and providing effective care to people with complex health problems. The proposed benefit of IPE/IPC is that when healthcare students and professionals have the knowledge and the ability to work together in a collaborative team, patient outcomes will be improved (Callahan et al.,2006; Darlow et al., 2015; Grey et al., 2017). There is strong support for IPE/IPC in the USA among many healthcare disciplines, including nursing (Darlow et al., 2015; Grey et al., 2017; Petitta et al., 2016; WHO, 2014). Most remarkably, healthcare could be supported through the collaboration of professionals, while every profession within a healthcare organization glances at interprofessional collaboration from different perspectives of patient care. Karam et al (2018) argued promoting interprofessional collaboration has become a high priority for policymakers in order to move towards coordinated care that provides efficient, high-quality out-patient care. Several factors are introduced which are believed to be key components Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 17 in enhancing collaboration. These components are communication, trust, respect, mutual acquaintanceship, power, shared goals, consensus, patient-centeredness, and task characteristics. Communication is key; it allows healthcare professionals to relay vital pieces of information both rapidly and effectively. Thus, the relationship of IPE/IPC is demonstrated in the literature in terms of both its importance and its effectiveness in improving collaboration between healthcare providers and efficiency of healthcare delivery. Burnout, Self-Esteem, and IPE/IPC Interprofessional education (IPE) has been lauded as a tool to facilitate interprofessional collaboration (IPC) in healthcare. As previously stated, the goal of IPE/IPC is to develop and prepare health care students in necessary interprofessional collaborative practices; namely, responsibility, accountability, coordination, communication, cooperation, assertiveness, autonomy, mutual trust and respect (Bridges et al., 2011). One cross-sectional study evaluated the improvement of teamwork in healthcare through IPE/IPC and found that 93.3% of students indicated that “basics of teamwork skills should be obtained prior to graduation,” and 96.2% of students thought interprofessional education would enable them to improve mutual trust and respect (Simin et al., 2010). Additionally, Haber et al. (2017) investigated the effectiveness of IPE/IPC in a clinical case study using oral-systemic health as a clinical population health example. The IPE/IPC simulation served as a method of testing interprofessional competencies for nurse practitioner, dental, and medical students. Faculty facilitators reported that IPE/IPC clinical simulations produced positive outcomes: specifically, IPE/IPC positively influenced professional collaboration, communication, and student understanding of patient care roles. The authors write of the importance of implementing IPE/IPC because “clinical practice patterns endure post-graduation” (Haber et al., 2017, p. 141). Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 18 Furthermore, current literature suggests an association between self-esteem and burnout. A 2013 analytical, cross-sectional study of 131 Turkish nurses was performed to assess the correlation of certain variables in the clinical experience of nurses; namely, burnout, self-esteem and quality of life (Erkorkmaz et al., 2018). The data was obtained from a 21 item Personal Information Form, the Maslach Burnout Inventory (22 items), the Rosenberg Self-Esteem Scale (10 items), and the Professional Quality of Life Scale (30 items). Nurses involved in the study reported feeling unaccomplished in their occupation, feeling unsuccessful and insufficient: suggesting that nurses who have a low degree of occupational-based self-esteem (OBSE) are at an increased risk of burnout. Moreover, an aforementioned study by Manomenidis et al. (2017) sought to determine a link between self-esteem and burnout, as well as identify if professional identity and interprofessional collaboration accounts for the prediction variance and burnout in nurses in Greece. Convenience sampling by recruitment in a Greek hospital resulted in 183 respondents (91.5% response rate). Using the Maslach Burnout Inventory, as a survey instrument, findings identified that 25.6% of the respondents had high emotional exhaustion, 25.1% having high depersonalization, and 27.3% having low personal accomplishment. Results also demonstrated a significant positive correlation between occupational burnout scores and the Self Esteem Scale, as well as moderate associations between total Self-Esteem score and the Inter-Intra Professional Collaboration Indexes. Correspondingly, all burnout scales had significant negative association with Inter- Intra Professional Collaboration indexes (Manomenidis et al., 2017). Based on the study’s results, the authors posit that individuals with low self-esteem may experience levels of stress, and ineffective coping of stress may lead to burnout development. However, individuals with high self-esteem may handle stress more effectively. Due to the moderate association Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 19 between self-esteem and IPC, as well as the significant negative correlation between burnout and IPC, Manomenidis et al. (2017) suggested education programs incorporate the working process along with nursing studies and focus on strategies that create and enhance structures needed for improving nurses’ self-esteem and professional identity. Interprofessional education and collaboration could potentially increase role understanding through professional identity, and resilience by way of increased self-esteem. The far-reaching individual, social, and institutional consequences of burnout syndrome have resulted in much of the recent literature investigating possible solutions now that the burnout issue has been clearly demonstrated (Bitran et al., 2019). Much of the literature on mitigating burnout has encouraged providers to practice mindfulness, yet Corbridge and Sheila (2019) notes the responsibility to fix the problem of burnout should not lie solely with the individual provider. In order to get at its root causes, burnout needs to be addressed at system and organizational levels. Thus, the authors suggested a workflow redesign with a focus on team-based care at the organizational level as a solution (2019). Team-based, interprofessional care is not only linked to improved patient outcomes, it has the potential to improve clinician well-being and mitigate burnout. Additionally, a cross-sectional study by Darban et al. (2016) looked at the effects of communication skills training on burnout in nurses. Using the Jackson and Maslach Burnout Inventory, 60 nurses randomly divided into two groups (control and intervention) were evaluated using a pre-test-post-test method before, during, and after an intervention consisting of a 2-day workshop of communication skills training. Findings showed a statistically significant decreasing trend in the intervention group (p=0.01), while mean burnout scores showed no significant difference in the control group (p<0.05). The authors found communication skills training to be an effective and Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 20 inexpensive way to reduce burnout in nurses, as well as improve the quality of healthcare services provided by them (Darban et al., 2016). Additionally, Hernandez-Marrero et al (2016) performed a mixed methods study that aimed to investigate the link between difficult ethical dilemmas encountered in palliative care, and burnout in Portuguese healthcare professionals working on these teams. Making difficult ethical decisions is common for healthcare professionals regardless of culture or geographic location and is associated with increased rates of emotional exhaustion in Portuguese ICU nurses (Hurst et al., 2007). Hernandez-Marrero et al’s 2016 study concludes that interprofessional collaboration, interdisciplinary discussions, deliberation, and the decision-making process within teams working in this setting helps safeguard these healthcare professionals against burnout when confronted with difficult ethical decisions. Moreover, another study by Gunnarsdottier et al. (2009) also reported that interprofessional collaboration was the strongest negative predictor of emotional exhaustion, the first manifestation of burnout syndrome. The authors stated that relations with doctors are an important factor in nurses’ work engagement and clinical autonomy. Supportive and empowering relations with doctors lead nurses to have more positive attitudes towards their position and greater levels of organizational self-esteem. Conclusion Review of the literature shows alarming statistics of burnout syndrome worldwide, affecting more than fifty percent of healthcare providers. Specifically, Kumar’s (2016) study of burnout in physicians listed radiology as having one of the highest rates of burnout with a prevalence of 61.4%. The prevalence of burnout is concerning, as the syndrome has been linked to poorer health in providers, higher rates of turnover, as well as increased costs and prevalence of medical errors (Vandenbroeck et al., 2017). Additionally, poor self-esteem has been linked to Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 21 higher rates of burnout in health professionals (Manomenidis et al., 2017). This has spurred the current movement to look for solutions. As previously stated, burnout syndrome is difficult to reverse; therefore, the best way to combat this phenomenon is to prevent it. Interprofessional communication and the practice of teamwork has piqued the current literature’s interest as a solution. Corbridge’s (2019) article and Darban’s (2016) study suggest the practice of team-based care and exhibition of interprofessional communication competencies help to mitigate and protect against burnout in health providers, as well as increase self-esteem. Moreover, several studies have shown the practice of IPE/IPC is an effective tool to prepare and develop health care students in the necessary IPC skills that will ultimately facilitate team-based care in their profession (Bridges et al., 2011; Haber et al., 2017). Therefore, if IPE/IPC helps to facilitate IPC, and the practice of IPC has shown to increase self-esteem and decrease burnout in health providers, then perhaps the integration of IPE/IPC is the ultimate prevention tool and solution to burnout syndrome in health professionals. The current literature has clearly identified burnout is an issue in healthcare workers, but there are gaps in the literature relating IPE/IPC to self-esteem. In much of the research, self-esteem seems to be directly linked to burnout; meaning if a person has low self-esteem, they are more likely to experience burnout. However, there is little literature to show how IPE/IPC can help a healthcare worker’s self-esteem. Many studies also seem to have a relatively small population size, several only using 1 or 2 hospitals. There is also a limitation on the population sample: while a majority of articles focused on groups such as physicians, NICU nurses, or students, very little has been done with radiology. For future studies, additional analysis of the possible relationship between IPE/IPC, burnout, and self-esteem is necessary. This seems to be one of the next steps in evaluating ways Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 22 to mitigate burnout among healthcare professionals. Furthermore, additional research needs to be done within the field of radiology. Several studies have addressed that radiology has a high percentage of burnout, however the studies to back these claims up are sparse. Moreover, interprofessional communication between various health professions also needs to be addressed. There are clear communication gaps between departments in the healthcare setting. A program for IPC between departments should be researched with control groups and active participants, with the hopeful outcome of decreasing burnout and increasing self-esteem in medical imaging professionals. Purpose The purpose of this correlational quantitative study is to evaluate how IPE/IPC correlates with the concept of self-esteem and the prevalence of burnout among medical imaging professionals. Although poor self-esteem can certainly lead to burnout, there are distinctions between the two. Understanding how these variables are connected could increase patient safety and job/work satisfaction while reducing employee/professional errors that are attributed to stress, burnout, and low self-esteem. The goal is to determine if IPE/IPC offers a prophylactic effect against burnout in medical imaging professionals. We will statistically analyze the data which has been collected from the surveys completed by active imaging professionals and students. We will then determine what correlations, if any, emerge between the studied variables. The hypothesis that can be drawn from review of the literature is thus: that improved access and quality of IPE/IPC has a direct relationship with self-esteem and an indirect relationship with burnout among healthcare professionals. The null hypothesis would be that IPE/IPC has no effect on self-esteem or burnout in healthcare professionals. The expected effect Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 23 is increased self-esteem resulting from improved interprofessional collaboration and communication. The literature demonstrated that improved self-esteem in healthcare workers has a correlation with reduced burnout among healthcare professionals. This is the indirect relationship stated in the first hypothesis derived from the literature review. There are studies that have identified burnout as a problem, although there are areas where information is missing. One of these areas is population size. Several of the conducted studies have had sample sizes in the thousands, which focused on nurses and/or physicians. The available studies linked to radiology are smaller, both in number of studies and sample sizes. Unlike other studies, this study will focus on currently employed imaging professionals and students studying advanced imaging modalities. The participants will be among a wide group of imaging professionals throughout the United States and some international radiology professionals. The research questions that we seek to answer include, but are not limited to: RQ1. What percentage of imaging professionals are experiencing burnout (Vandenbroeck et al., 2017)? H10. At least 50% of imaging professionals are experiencing burnout. H1a. Less than 50% of imaging professionals are experiencing burnout. RQ2: What relationship, if any, is there between burnout rates and self-esteem and/or interprofessional education? H20. IPE/IPC has no significant correlation with self-esteem or burnout; self-esteem has no significant correlation with burnout. H2a. IPE/IPC has a positive correlation with self-esteem and a negative correlation with burnout. Self-esteem has a negative correlation with burnout. Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 24 RQ3: What differences, if any, is there between the experience of burnout among medical imaging modalities? H30. There is no difference between modalities experiencing burnout. H3a. There is a difference between modalities experiencing burnout. Burnout syndrome is difficult to reverse once it has set in; therefore, identifying whether IPE/IPC has a mitigating effect on burnout that will substantially improve an imaging professional’s ability to provide the best care possible. Many studies have addressed the high rate of burnout, however, the number of articles backing up these claims is very limited. With the current shortage of medical imaging professionals that existed prior to COVID-19, understanding which risk factors contribute to such a high rate of burnout and job dissatisfaction will ultimately lead to better patient outcomes and improved financial stability. More than 50% of all healthcare workers worldwide are faced with burnout syndrome, with an even higher percentage (61.4%) of burnout strictly among radiology workers (Vandenbroeck et al., 2017). The significance of these numbers is concerning, as multiple studies have shown that burnout has been linked to poorer health in providers, higher rates of turnover, as well as increased costs and prevalence of medical errors. Due to medical imaging being an understudied area in healthcare, current literature lacks focus on imaging professionals from all modalities. Medical imaging is diverse and unique: unlike other professions, medical imaging professionals begin their careers upon graduation. As such, they are often exposed to stress and burnout at a faster rate. Medical imaging professionals play a vital role in all aspects of the healthcare system: the field contains multiple diverse and unique modalities from mammography to interventional radiology that plays a pivotal role in the Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 25 diagnosis and management of acute and chronic conditions. Without medical imaging professionals, physicians would not be able to properly diagnose and treat patients. The purpose of this study is to identify the incidence of burnout in this population, the factors that lead to burnout and to possibly identify a correlation between burnout, self-esteem, and particularly burnout in imaging professionals that have been inter-professionally educated. In order to conduct our research, we will statistically analyze data collected from surveys sent out to active imaging professionals and advanced imaging modality students. The goal of this analysis was to determine if any correlations emerge between any of the studied variables. Another goal is to provide areas of improvement for radiology that may also be implemented to other fields, that will in turn improve healthcare in its entirety. Since medical imaging plays a vital role in patient outcomes and the financial health of a healthcare system, it is vital to discover methods that help protect and mitigate against burnout in medical imaging professionals. Materials and Methods Approval for Research Approval was sent to the Institutional Review Board (IRB) by faculty of the Radiologic Sciences department at Weber State University. The IRB reviewed the research as low risk and granted the approval for research in December of 2019. Materials/Instruments To study the relationship between IPE/IPC, burnout, and self-esteem in medical imaging professionals, three types of questionnaires (made available through Qualtrics) were sent out to potential participants by either email (personal emails) or posted on social media (Facebook, LinkedIn, ASRT communities). All answers were kept anonymous and confidential. In addition, there was no compensation for any unexpected injury to each participant. Data was collected Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 26 from surveys taken from December 11, 2019 to April 20, 2020. The three questionnaires that were used in data collection are detailed below. To obtain data relating to subjects’ inter-professional education and collaboration, the IPEC competency self-assessment tool Version 3 (July 2015) by Lockeman et. al (2018) was included in the survey instrument. This version of the tool has been reduced from 42 items on the original version while retaining the psychometric strengths, encouraging participants to provide accurate answers and to complete the survey in its entirety. The current version still addresses the 42 core competencies detailed by the IPEC competencies published for the United States. This instrument provides information about both interprofessional interaction and interprofessional values while maintaining the psychometric strengths of the original 42-item study. It provided a measure to determine the success of the various educational programs at preparing students for collaborative practice through interprofessional education (Lockeman et al., 2016). Originally proposed by Lockeman in 2015, this survey had 42 items and was assembled around two factors, interprofessional values domain and interprofessional interactions domain. In the latest version 3 revised in 2018, there are only 16 items that include 2 of the original 4 domains. This version was developed because the researchers found differences in scores by domain that can be used to build future curricula (Dow et al., 2014). They also conclude that this tool provides valuable insights about the effects of different curriculum approaches to interprofessional education (Dow et al., 2014). From this questionnaire, the even items concern the interprofessional values domain while the odd items pertain to the interprofessional interactions domain and are coded by the shading of the question cells in the table. Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 27 Based on their education or experience in the healthcare environment, participants answered the 16 questions on the IPEC tool. Participants selected and circled the number that corresponds with the level of agreement or disagreement of the statement, 1 being “I strongly disagree” and 5 being “I strongly agree” for each of the 16 statements. Lockeman et al. (2018) concluded that the interprofessional interaction subscale primarily consisted of items from the teams and teamwork domain, with one item each based on competencies from the interprofessional communication and values/ethics domains; and scores varied by year of enrollment. Their study further establishes the validity, reliability, and usability of an assessment tool based on interprofessional competency. To assess burnout, the 9-item Bergen burnout inventory (BBI-9) (Salmela-Aro et al., 2011) was also implemented. It has been demonstrated to be a promising instrument in evaluating burnout in healthcare professionals and during scientific studies. The instrument employs a 6-point Likert scale, instructing participants to respond to the questions in a range from “I completely disagree” to “I completely agree”. The BBI-9 is an established, validated, and reliable Likert scale tool (Mandy et al., 2004) used to evaluate an individual’s level of burnout by focusing on three contributing factors: (1) exhaustion at work (emotional component); (2) cynicism toward the meaning of work (cognitive component); (3) and a sense of inadequacy at work (behavioral component) (Feldt et al., 2014). Each of these components receives 3 questions that pertain to it in the BBI-9. Similar to the Maslow Burnout Inventory (MBI), the BBI was designed to measure burnout in all occupations. The original version consisted of 25 items, which was then shortened to 15 items. The significant difference between this version of the BBI and the MBI are the revisions to language that focus on feelings of inadequacy at work to address criticisms of the MBI (Feldt et al., 2014). The 15 item BBI was Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 28 recently abridged to 9 items to improve the psychometric properties of the tool and to discourage response bias. Lastly, the self-esteem scale of Rosenberg (1965) published by Robinson et al. (1991) is 10 questions in length and was used for assessing global self-esteem. Ten statements are included in the self-report measure that pertains to self-worth and self-acceptance. A four-point scale ranging from “strongly agree” to “strongly disagree.” See Appendix A for examples of questions. The Rosenberg Self-Esteem measures factors that relate to self-esteem. The measure is to reflect the measure of one’s self worth and respect. The Rosenberg Self-Esteem Scale (RSES) excels when considering the psychological point of reflection but not the cognitive abilities of the subject. The results from this are typically very positive or very negative. The RSES results will have an impact on the culture, intellect, and self-worth. For this scale it can be misleading depending on who is getting questioned and if they view themselves in a positive or negative way. Research Protocol Sampling was based on convenience and done through social media, emails, and word of mouth and each participant was only permitted to take the survey once upon completing an informed consent. This method was chosen due to the wide network of students conducting the research, with the majority of researchers currently working in hospitals and clinics serving both urban and rural patient populations throughout the United States. Through the connections between ASRT communities, medical imaging professionals, and as a testament to the network built by Weber State University’s Radiologic Sciences department, surveys have reached medical imaging professionals internationally. The researchers felt a response from both domestic and international participants was essential to obtain a broad sample population. Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 29 The population this study was aimed at is actively working medical imaging professionals including imaging students. The goal was to collect a minimum of 200 completed questionnaires. Several hundred questionnaires have been sent out via social media and email. Out of a total of 476 participants who agreed to consent and started the survey, 396 completed through the IPEC inventory and only 383 completed the survey through the BBI-9 and self-esteem inventory. Of the 93 who did not complete, 33% with zero percent completion were excluded and 66% who started and did not complete were incorporated partially. The demographics portion of the survey instrument was designed to obtain information about the participants relating to sex, specific imaging modality, years worked in it, and level of schooling. These demographics were chosen to more accurately analyze the samples regarding their imaging modality and experience. It was decided that medical imaging professionals who are not actively working were excluded due to skewing of the data. The entire study was aimed at the previous five graduating classes with data collection occurring over a one-year time period. The mean age range of participants in this study was 44 years old. All medical imaging modalities were included in the survey with both male and female respondents represented. Data Analysis For the purpose of our study, a Pearson r correlation of the sum scores for all three variables (IPE/IPC, burnout, and self-esteem) was performed, as well as regression analysis of the sum scores versus various demographics of the research sample (i.e. age, gender, hospital type, level of education, modality, and community size). Data was obtained using the aforementioned tools (i.e. IPEC competency, Rosenberg Self-esteem scale, and the BBI) to evaluate each variable separately. The hypothesis is that IPE/IPC will have a direct correlation with self-esteem and an indirect correlation with burnout among medical imaging professionals. Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 30 The null hypothesis is that IPE/IPC has no correlation to self-esteem and/or burnout among medical imaging professionals. Rationale for performing the aforementioned statistical analyses are as follows: a Pearson r allowed us to measure the strength of a linear relationship between the two variables, which determine whether or not our hypothesis regarding the effect of interprofessional education on burnout and self esteem is correct. Furthermore, a regression analysis is the only method that is considered predictive and can provide the necessary p values to prove significance in relation to the null hypothesis (Pearson Correlation and Linear Regression, 2015). Collected data was run through a software system called Statistical Package for the Social Sciences (SPSS), IBM SPSS Statistics 25. Highly regarded as a powerful, user-friendly system that requires little training, SPSS allows users to “plug and chug” large amounts of complex statistical data for analysis. The end result is data that is easy to manage and share across a variety of platforms; however, the program is not without its limitations. A major disadvantage of SPSS is that the internal functionality of the analyses is not displayed to the user. This is due to the program's original intended use for social science studies, where researchers are more concerned with the output than the internal algorithms used for analysis. The trade-off for the user-friendly interface is the inability to visualize these internal algorithms. Unlike Excel, SPSS treats each column as a variable. SPSS was concluded to be the best way for this study to analyze, minimize risk and improve efficiency among the researchers. Both Microsoft Word and Microsoft Excel were utilized to assist in creation of the visual aids accompanying the BBI-9 results. Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 31 Inclusion/Exclusion Criteria Upon obtaining the raw data, rationale for inclusion and exclusion of our data sample was as follows: • Duration in seconds: responses shorter than 150 seconds (2.5 minutes) were excluded due to inferred lack of sincerity in participants’ answers to the questions in all three surveys. • Completion: surveys with a 0 percent completion were excluded for lack of helpful data. • Recorded date: surveys completed after March 15, 2020 were excluded due to the possibility of the effects of COVID-19 on burnout bias in healthcare professionals. This date was chosen as it was the date that Weber State University closed its campus due to the pandemic. Rationale The use of an observational, cross-sectional study design allowed the researchers to produce a convenience sample of medical imaging professionals working worldwide in the years 2018-2020, permitting this study to examine the levels of both burnout (Salmela-Aro et al. 2011) and self-esteem (Blascovich, J. & Tomaka, J. 1991) in the participants, and correlate that to their competency related to collaborative practice through individual self-assessment (Lockeman et al. 2016). These survey instruments were selected for their high degrees of reliability and validity. For the Rosenberg Self-Esteem Scale, Dobson et al (1979) reported a Cronbach’s alpha of ⍺ = .77 for their sample regarding internal consistency, and Silber and Tippett (1965) reported a test-retest correlation of .85 after a 2-week interval. The Bergen Burnout Inventory (shortened version, 2011) was developed to measure burnout in all occupations and is based on the theoretical three-dimensional burnout definition of exhaustion (3 items), cynicism (3 items) and feelings of inadequacy (3 items). The BBI-9 has been demonstrated to have high degrees of Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 32 consistency with low group and time invariance, as well as good internal consistency with Cronbach’s alpha coefficients of ⍺= .85 or higher across 6 samples in a study by Feldt et al in 2014. Lastly, the IPEC Competency Self-Assessment Tool was selected to measure inter-professional collaboration competencies due to the fact that it is produced by the premier institution advocating for IPE/IPC. The National Center for Interprofessional Practice and Education conducted a study on their tool in 2011, which produced good factor structure and internal consistency with Cronbach’s alpha values of ⍺ >.90 for all factors. Demographics of the medical imaging professionals were assessed based on the goals of the study. A convenience-based sample is appropriate in this setting because it allows this study to reach a reasonable portion of the population of medical imaging professionals in the United States and those tangentially connected to Weber State University’s Radiologic Sciences program throughout the world. This study recognizes the limitation that convenience-based sampling places on the external validity and generalization of the results, but in assuming a population similar to the one sampled, a correlation produced in this study would likely be generalizable. Administration of the surveys primarily through digital channels (emails and social media) allowed this study to attain its reasonable sample size by reaching medical imaging professionals outside of the United States. Limitations By using this procedure, we cannot completely guarantee that all possible participants will personally receive an email. Also, we cannot guarantee that some participants will answer the items truthfully due to various response biases that can be present in these survey instruments, such as social desirability bias, as well as the length of the survey instrument potentially resulting in survey fatigue that could result in a response bias subtypes such as Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 33 acquiescence bias, and extreme or neutral response bias. Inter-professional education will be measured based on a conceptualization of interdisciplinary collaboration among different medical imaging professionals (different disciplines). Each individual instrument has its own limitations that have been evaluated in the cited research and can potentially affect the generalization and validity of these results to a small level. In particular, the BBI-9 tool used to assess for burnout in the participants has a lack of scoring criteria in terms of sum scores. The two studies cited in this paper by Salmela-Aro et al. (2014) and Feldt et al. (2014) both provide a mean sum score for the participants by categories within their sample. They do not, however, provide a threshold by which burnout can be definitively assessed by either sum score or mean scores in the way that the other iterations of this inventory do (the 25-item BBI and the 15-item BBI). For consistency, data displayed in this study in Figure 1 follows the same rationale utilized to display burnout scores that Feldt et al. (2014) utilized, rather than sum score (by mean score rather than sum score). Results The mean age of respondents to the survey instrument was 44 years, with a mean number of years of experience of 18 years (although there was a standard deviation of 13 years for this data point). Regarding respondent gender, there was a ratio of 25% male respondents and 74.5% female respondents (2 respondents selected ‘Prefer not to Answer’). The survey was administered to both professionals and students, with 6.3% of respondents being students (n=25). Other demographics considered in the statistical analysis were highest level of education attained, community type (urban or rural), place of employment and imaging modality or specialty of the respondent. Of the respondents, the majority had received a Bachelor’s Degree as their highest level of education (n=166, 41.9% of respondents), practice in an urban community Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 34 (n=278, 70.2% of respondents), and work in either a Mid-sized Hospital or Large Trauma Center (n=120, 30.3% of respondents for both response options). Of those who responded to the survey items regarding modality, most were either radiography technologists (n=269, 67.9% of respondents) or computerized tomography technologists (n=134, 33.8% of respondents). It should be noted that respondents were allowed to select more than one option from the modality category because multi-modality medical imaging professionals are common (and often necessary) in various settings. The results of this study confirmed the expected positive correlation between IPE/IPC and self-esteem, as well as the negative correlation between self-esteem and burnout among medical imaging professionals. These results are discussed below: Figure 1. Bergen Burnout Inventory (BBI-9) Mean Item Scores Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 35 Figure 1 above describes the mean response scores for each of the 9 items on the BBI-9. The items on the BBI-9 are divided into 3 subscales: exhaustion, cynicism, and feelings of inadequacy. Items 1, 3, and 7 score the exhaustion (emotional component) subscale, items 2, 5, and 8 score the cynicism (cognitive component) subscale, and items 4, 6, and 9 score the feelings of inadequacy (behavioral component) subscale. The survey instrument in its entirety is included in Appendix A. BBI-9 sum score thresholds and their meanings have not been given by the authors of the inventory, so mean score per item is displayed for this sample to convey meaning rather than sum scores. Higher mean scores on the BBI-9 items indicate that the participants identified with the statement more as a whole. Items 1 (“I am snowed under with work”) and 9 (“Honestly, I felt more appreciated at work before.”) had particularly high scores relative to the other items in this sample. This is still a fairly neutral response to the items, as there is no neutral “Agree nor Disagree” type response on the BBI-9. Pearson correlations were run in SPSS on the sum scores of the major variables and their subscales to assess for the influence that the variables may have on each other. Although the effect sizes were small, all correlations were of statistical significance (p<0.001). IPEC sum scores correlated positively with self-esteem sum scores, r = 0.38, r2= 0.14. Self-esteem sum scores were also found to correlate negatively with burnout sum scores, r = -0.44, r2=0.2. These observed correlations are in line with the hypothesis but are not as compelling as expected. Of note is the correlation of IPEC sum scores with burnout, which resulted in a stronger, negative correlation, r = -0.47, r2= 0.22. Considering IPEC and the BBI-9 subscales, the strongest negative correlation was seen between IPE/IPC and the Feelings of Inadequacy subscale, r= -0.48, r2= 0.23, with the other subscales scoring somewhat similarly (see Table 1). Furthermore, Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 36 self-esteem and burnout showed similar correlations to those seen with IPE/IPC and burnout, though they were all of a lesser extent. Table 1: Correlation coefficients (r), significance values (p), and effective sizes (r2) for all inventory sum scores, including subscales Regarding the IPEC subscales, the IPEC interactions subscale had a stronger negative correlation with burnout than the values subscale, r = -0.5, r2= 0.25, and r= -0.38, r2= 0.15, respectively. Both subscales weakly correlated with self-esteem scores, with effect sizes both r2<0.1. A matrix of scatter plot diagrams is further utilized to demonstrates the relationships between BB-9, Self-Esteem, and IPEC variables (see Figure 2). Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 37 Figure 2. Correlation matrices: BBI-9, self-esteem, and IPEC sum scores Multiple linear regression analysis was performed to evaluate the prediction of burnout from self-esteem and IPE/IPC. The regression equation for this relationship is: Predicted Burnout = 73.11 - 0.379*IPE - 0.664*Self-Esteem With 95% confidence intervals for the slopes, -0.487 to -.279 (IPE) and -0.859 to -0.469 (Self-esteem) not containing the value of zero, this shows that both IPE (t = -7.49, p<0.001) and self-esteem (t = -6.69, p<0.001) are significantly related to burnout. It should be noted that the histogram for this regression analysis had a slight departure from normality within the first Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 38 standard deviation down from the mean, but otherwise met the assumption of normality (see Figure 3). Figure 3: Histogram of residuals showing that the assumption of normality has been met The adjusted R2 value for this regression was 0.29 indicates that 29% of the variance in burnout is accounted for by self-esteem and IPE/IPC. This represents a small amount of variance, which suggests that other factors not accounted for in this analysis affect burnout. Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 39 These regressions were also calculated considering various demographics from the survey. Statistically significant differences were found in only two of the surveyed demographics when included in the regression analyses: years of experience in the Radiologic Sciences profession and whether the respondent was an Interventional Radiography (IR) technologist. Years of experience (p=0.035) produced an unstandardized coefficient of B=0.208 and a standardized coefficient of ꞵ=0.253 with burnout sum scores. IR technologists produced a significant result (p=0.016) with an unstandardized coefficient of B= 2.85 and standardized coefficient of ꞵ=0.103 with BBI-9 sum scores when considering self-esteem and IPEC sum scores in IR technologists. Considering the standardized coefficients, years of experience contributed more effect to burnout than whether or not the respondent was an IR technologist. The demographics that did not produce statistically significant variance by linear regression analysis were employment community type, place of employment, gender, age, modality and level of education. Discussion According to previous literature, burnout syndrome has been shown to affect healthcare professionals worldwide. Concerning the field of medical imaging, Kumar (2016) found that 61.4% of those working in radiology were experiencing burnout. Additionally, Kumar found radiology had the fourth highest rate of burnout within healthcare, with specific focus on radiation oncology. Upon conduction of our study, respondents answered a survey that focused specifically on burnout. Results from the BB-9 inventory showed the mean of answers were nearest “Partly Agree,” while the greatest proportion of responses were closer to “Completely Disagree” and “Disagree.” Regarding research question 1, our results were found to be opposite of previous literature’s findings: indicating that more than 50% of the respondents are not Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 40 currently experiencing burnout. This may be due to a variety of factors; for instance, the authors could not control the environment participants took the survey in. Participants might feel less burnt out relaxing at home than working a busy, short-staffed shift. Additionally, the nature of the survey tool could have unintentionally excluded participants who are currently experiencing high levels of burnout: medical imaging professionals who are burnt out may naturally have less time and energy to take a survey in their free time. Ultimately, the profession of medical imaging is diverse and complicated; the authors acknowledge there may be many unknown and uncontrollable factors that contribute to an imaging professional’s experience of burnout. Regarding research question 2, the authors sought to analyze whether burnout rates in medical imaging professionals were correlated with IPE/IPC and self-esteem. Previously aforementioned studies by Corbridge (2019) and Darban (2016) suggest the practice of team-based care and utilization of interprofessional communication competencies help mitigate and protect against burnout in health providers, as well as increase self-esteem. Additionally, Manomedis et al. (2017) examined the relationship between inter-professional collaboration and self-esteem in Greek nurses and found a moderate positive correlation (r=0.19) between scores on the Rosenberg Self-Esteem Scale (RSES) and the INPC/ITPC indices. This led the authors to conclude that interprofessional education and collaboration could potentially increase the understanding of one’s role through professional identity--a central aspect of self-esteem. As such, the posed hypothesis of our study was that IPE/IPC had a positive correlation with high levels of self-esteem and a negative correlation with burnout in radiologic professionals. The null hypothesis would indicate that there is no significant correlation between the IPE/IPC and self-esteem. According to the Pearson correlations performed between IPEC and self-esteem, IPEC sum scores correlated positively with self-esteem sum scores (r = 0.38, r2= 0.14), indicating Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 41 statistical significance. However, it should be noted that the effect size of the correlation was small. Considering the relationship between IPE/IPC and burnout, review of the literature led the authors to hypothesize a negative correlation between IPE/IPC and burnout levels in medical imaging professionals. According to Bridges et al. (2011) and Haber et al. (2017), the practice of IPE/IPC is an effective tool to prepare and develop health care students in the necessary IPC skills that will ultimately facilitate team-based care in their profession. Greater understanding of professional roles and the practice of team-based care may help to mitigate burnout syndrome in imaging professionals. As predicted in the second hypothesis, interprofessional education is negatively related to burnout (r=-0.47 for IPEC sum and BBI-9 sum, figure 3). Previous studies scrutinizing the relationship between IPE/IPC and burnout among different healthcare professionals, including nursing, have reported similar results (Vandenbroeck et al., (2017); Erkorkmaz et al., (2018)). This implies that when medical imaging professionals work in collaborative healthcare teams and collaborative environments, they will also report improved satisfaction toward their job. This may be because job satisfaction is considered as an outcome of collaborative practice (Sharp, 2006; Yeager, 2005). Moreover, as part of the effective interprofessional collaborative practice in any healthcare organization, health team members must have a basic understanding of each other’s roles as responsible and independent individuals, along with an understanding of each member’s separate and shared scopes of practice. This understanding will result in low burnout levels and greater job satisfaction. A previous study (Martinussen et al., 2012) also showed the effect of a collaborative approach in healthcare organization, which can lead to “more effective and efficient work by and improved satisfaction among healthcare professionals.” This aligns with Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 42 the correlation found between the IPEC “Interactions” subscale and burnout, which was stronger than the correlation with the subscale “Values”. The interactions subscale is comprised of items focusing on the Teams and Teamwork domain of IPE; the general competency statement from this domain is “apply relationship-building values and principles of team dynamics to perform effectively in different team roles to plan and deliver patient-/population-centered care that is safe, timely, efficient, effective, and equitable” (Interprofessional Education Collaborative, 2016). Furthermore, regarding the relationship between self-esteem and burnout, Maslach (2001) states that emotional exhaustion, which manifests itself from low self-esteem, is often the first sign or manifestation of burnout. In a study conducted by Manomenidis et al. (2017) using the Maslach Burnout Inventory, it was found that 25.6% of its respondents had high emotional exhaustion, 25.1% had high depersonalization, and 27.3% had a sense of low personal accomplishment. Depersonalization and emotional exhaustion were negatively correlated with self-esteem, while personal achievement was positively correlated with self-esteem. The authors state that individuals with high self-esteem may handle stress more effectively. Additionally, as evidenced through multiple studies, it has been found that lower self-esteem has been linked with higher rates of burnout and emotional exhaustion. In the study by Maslach et al. (2001), it was found that individuals who suffer from increased psychological distress, with limited coping mechanisms, first exhibit emotional exhaustion. Maslach states that emotional exhaustion is the first sign of burnout. Using the Qualtrics survey to correlate IPE/IPC to burnout and self-esteem, results of our study confirmed a negative correlation between self-esteem and burnout among radiologic science professionals. In other words, lower levels of burnout seem to correlate with higher Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 43 levels of self-esteem. This echoes Manomenidis et al.’s (2017) findings; that emotional exhaustion is negatively correlated to self-esteem. As emotional exhaustion is a key component in burnout syndrome, this may explain the negative correlation between self-esteem and burnout. Finally, the authors note that while correlations between IPE/IPC, burnout and self-esteem were of statistical significance, due to effect size, results were not as compelling as expected. Research question 3 sought to identify whether there were differences in levels of burnout between medical imaging modalities. Our survey collected general demographics from the respondents, including the type of primary modality they work in. The authors were curious as to whether results would demonstrate that certain modalities might experience burnout at greater or lesser levels when compared to others. Such information would prove valuable: if some modalities experienced burnout more than others, then what are the contributing factors? Vice versa, if some modalities experienced burnout less than others, then are there possible contributing factors that might protect these modalities from burnout that are not present in others? Such information would prove valuable for future study. Using a linear regression analysis, it is demonstrated that only two demographics had any statistically significant values. Those demographics consist of the number of years’ experience as an imaging professional, and if the individual works as an interventional radiography technologist. When interpreting the data, years of experience had a statistically significant level of effect in the regression analysis considering burnout level within the participants. This was not a large effect, with an unstandardized coefficient value of ꞵ=0.253. For each year a participant worked, it could be attributed to a 0.253-point increase in BBI-9 sum scores; for a small effect size, this shows that the longer individuals have been in medical imaging, the more likely they Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 44 are to experience burnout. This could be due to the long hours that some may work, compounded over the years. Considering differences in burnout experience between modalities, the only modality to produce any statistically significant result was Interventional Radiology. In other words, IR technologists were the only ones whose modality had any effect on burnout rates, making them higher. IR technologists produced a significant result (p=0.016) with an unstandardized coefficient of B= 2.85 and standardized coefficient of ꞵ=0.103 with BBI-9 sum scores when considering self-esteem and IPEC sum scores in IR technologists. This may be due to a variety of factors. For example, the type of physical work and level of trauma that these medical imaging professionals see may be a contributing factor. Interventional radiology (IR) technologists work in a uniquely difficult modality, often working long hours after their shifts with call schedules and understaffing present in the work environment as well. IR technologists also have to keep up with the rapid technological advancements characteristic of medical imaging while making sure they understand all of the various wires, catheters and procedures that interventional radiologists require to complete their work. While this also unsurprisingly presented a statistically significant result in regression analysis considering burnout, it did not present a profound effect on burnout sum scores in this sample. Other factors that can explain this might be similar to what Walvoord (2006) found in sonographers. When examining factors contributing to occupational stress, Walvoord outlines staff shortages, compassion fatigue, work conditions and job satisfaction that have been shown to cause burnout. In addition, lack of proper training, years of experience and age can be other factors of burnout in IR technologists. Limitations Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 45 There are limitations to the application of this study, due to a variety of factors that are inherent in research. There have been studies that look at the effects of IPE/IPC on patient outcomes and its relationship between physicians and support staff; however, nothing has directly evaluated its effect on individuals working in the imaging profession or its correlation to workplace burnout. This has resulted in limited data for our team to compare and evaluate our findings with other studies but has also demonstrated the strong need for additional evaluation in this discipline. Some extreme outliers were removed from data because the research team determined that the responses were likely misrepresented due to the exceedingly short time taken to complete the survey. There are certain biases that the study’s designers have had to take into account. Many of the biases that are inherent in research were minimized by using tools that have been well-established, and by eliminating a time limit for participants to complete the questionnaire. The tools used in the survey have been well-established, but limitations do exist. For example, the BBI-9 tool does not provide a threshold by which burnout can be assessed by a sum or mean score in the same manner that the 25- or 15-item BBI tool can be measured. By using established tools, however, the study’s authors have attempted to minimize design, procedural, and measurement biases, although these biases are impossible to completely eliminate. Design biases exist due to the study’s design having a predisposition for individuals who are more computer literate and may exclude those who lack proficiency in this skill-set or discourage those where English is not the respondent’s native language. Persons who receive the email invitation may choose to not participate in the survey for a number of reasons outside of the researcher’s control. Procedural bias may exist for certain populations that simply do not have the time to complete the survey in one sitting or without interruption, which is why we see Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 46 some responses that took many days to complete. This may create additional stress for participants to focus on completing the survey in a timely fashion, rather than clearly reading and comprehending the questions being posed. Measurement bias can occur when participant’s responses are inaccurate due to difficulty recalling their emotional state in the past compared to the present. Additionally, there may be circumstances that occur outside the workplace that may skew participants' responses. These cannot be fully eliminated, only acknowledged by the authors and minimized by the study design. Despite the research team’s best efforts, response bias will always exist. This is due to study participants feeling (on either a conscious or subconscious level) a need to respond based on what they perceive to be the responses the researchers are hoping to gather. Respondents aim to provide answers that are consistent with this perceived goal, thus skewing results. This is an example of social desirability bias that can impact the results of the survey. The main limitations that this study demonstrates is the limited involvement of individuals working in specific, diverse modalities. This does not account for the fact that many individuals are cross-trained and did not indicate their primary modality, but rather listed any modality that they were trained in (or management), which makes interpreting the data difficult. In addition, participants do not offer any information concerning how long they have been working at this particular clinic, or in their current primary modality. This creates some ambiguity on the results and can skew the data. Finally, there is a lack of a consistent definition of the workplace environment for survey participants. Participants were asked to define their work environment as “urban”, “rural”, or “other”, without being provided a clear definition of each category. To further muddy this issue, there is no consistency concerning “place of employment” and how much time is spent working Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 47 as an imaging professional. Many imaging professionals working in smaller clinics may have additional duties including, but not limited to medical assistant work, clerical duties, or acting as a patient care coordinator. The stresses that these additional roles may place on the answers of the study participant are not taken into account and can alter responses. The participant’s shift may also influence their response. Do imaging professionals working graveyard shifts have different responses than their counterparts who work swing shifts or day shifts? Does the amount of time spent on-call impact participants' responses? Imaging professionals work in a variety of capacities, some working more autonomously while their counterparts in other modalities and settings may work more closely with a physician. The differences in levels of interaction and its effect on burnout and self-esteem are beyond the scope of this research. These are all additional variables that display limitations of this study. Recommendations The search for meaningful ways to address the issue of burnout with allied health professionals has become an increasingly prevalent subject in recent years. Physicians and nurses have been ubiquitous in these studies; none have attempted to address burnout and possible prophylactic measures to guard against it with imaging professionals. Imaging professionals work in a variety of specialized and specific capacities, each with different levels of patient interaction, physician interaction, education level required, ancillary responsibilities, and type of setting seen in. Imaging professionals work in clinic settings, small hospitals, and major trauma centers in both rural and urban environments. If interest for future study is the possible difference between types of population environment: do imaging professionals who work in urban settings experience greater rates of burnout than those who work in rural settings? Do differences in hospital size have any significant impact on burnout and self-esteem? Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 48 Future studies should further investigate these differences to better understand and address burnout among imaging professionals and the relationship between IPE/IPC, self-esteem, and burnout rates. Future research should attempt to address the relationship between self-esteem on the quality of the workplace compared to the quality of workplace on one’s self-esteem, and if a link exists between the radiologist’s burnout rate and the rate of burnout amongst imaging professionals employed in that department. To better understand the environment these imaging professionals work in, future research should evaluate individual primary working modalities as each subspecialty has specific individual characteristics. This fact is demonstrated by the increased burnout rates of interventional radiology technologists. What specifically about this modality has led to increased rates of burnout with these professionals, and what can be done to safeguard against burnout? Can it be demonstrated that self-esteem has been determined by the workplace environment, or is there a predetermined level of self-esteem that depends on the characteristics of individuals that choose to work in these professions compared to their counterparts in nursing retards the positive effects of IPE/IPC on burnout rates? Additionally, to better understand the environment these imaging professionals work in, future research should evaluate individual primary working modalities as each subspecialty has specific individual characteristics. This fact is demonstrated by the increased burnout rates of interventional radiology technologists. What specifically about this modality has led to increased rates of burnout with these professionals, and what can be done to safeguard against burnout? Can it be demonstrated that self-esteem has been determined by the workplace environment, or is there a predetermined level of self-esteem that depends on the characteristics of individuals that Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 49 choose to work in these professions compared to their counterparts in nursing retards the positive effects of IPE/IPC on burnout rates? Finally, of particular recent interest is the effect of COVID-19 on burnout rates in medical imaging professionals. The pandemic has taken the healthcare world by a storm, and the mental, physical, and emotional toll it has taken on imaging professionals may yet to be fully understood. Due to the virus, healthcare systems re-structured their staffing which caused an immense amount of uncertainty and stress. Chronic and increased amounts of stress are significant factors that contribute to burnout. With burnout prevalent prior to COVID-19, how has the virus affected a syndrome that already had far-reaching effects on system, personnel and patient health? These are all compelling topics for future study in a population that is often under-looked. Conclusion Burnout syndrome is a widespread phenomenon that has serious ramifications in the world of healthcare, including poorer patient outcomes. Increasing efforts have been made to evaluate the cause and discover a “cure” for the syndrome that has affected almost 50% of health care workers. Studies have shown self-esteem to be an important predictor in levels of burnout (Manomedis et al., (2017); Gomez, (2014)). Moreover, IPE/IPC has been lauded as a tool to foster greater understanding of professional roles, which seems to be directly correlated to improved patient outcomes (Callahan et al., (2006); Darlow et al., (2015); Grey et al., (2017)). While much research has been conducted evaluating the effect of IPE/IPC on patient outcomes, literature is lacking that evaluates the possible effect IPE/IPC may have on self-esteem and burnout. Additionally, there is a plethora of literature surrounding physicians and nurses, however, there is a lack of focus on medical imaging professionals. Therefore, the primary Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 50 objective of the study was to evaluate the relationship between IPE/IPC, self-esteem, and burnout in medical imaging professionals, as well as examine the differences between medical imaging modalities. The primary hypothesis was thus: that IPE/IPC has a positive correlation with self-esteem and a negative correlation with burnout. Specifically, the expected effect was experience with IPE/IPC would be directly correlated with high levels of self-esteem, and high levels of self-esteem would be indirectly correlated with levels of burnout in medical imaging professionals. The statistical analyses performed confirmed the expected hypothesis, however, with less effect than expected. Of note is the somewhat stronger correlation found between IPEC and burnout, than the correlation between self-esteem and burnout. Moreover, when evaluating the relationship between IPEC and the BBI-9 subscales, the strongest negative correlation was seen between IPE/IPC and the Feelings of Inadequacy subscale (Figure 1). Considering there is a lack of literature evaluating the effect of IPE/IPC on burnout and self-esteem, future research should seek to analyze the variables in a more controlled setting as a way to confirm or deny the findings in this study. Additionally, since results did indeed show a negative correlation between IPE/IPC and burnout, further analysis of burnout subscales that are more affected than others would prove valuable when determining how the use of IPE/IPC may specifically affect the psyche of burnout syndrome in health professionals. Finally, future studies should focus on the field of medical imaging: health professionals who are often under looked, but diverse and integral to the ever-changing world of healthcare. Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 51 Declaration of conflicting interests The authors of this article declare no conflict of interest. Funding This research was supported and funded by the Department of Radiologic Sciences at Weber State University. 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Demographic Survey Age: _____ Gender: 🞐 Male 🞐 Female 🞐 Other 🞐 Prefer not to answer In which area(s) of Radiologic Sciences do you currently practice or hold certification? (Choose all that apply) 🞐 Computerized Tomography Years of practice_____ 🞐 Mammography Years of practice_____ 🞐 Magnetic Resonance Imaging Years of practice_____ 🞐 Nuclear Medicine Years of practice_____ 🞐 Radiography Years of practice_____ 🞐 Radiation Therapy Years of practice_____ 🞐 Cardiac, Medical, or Vascular Sonography Years of practice_____ 🞐 Student If employed, years of practice_____ School of Radiologic Sciences Program_____________ 🞐 Other Years of practice_____ Which is the highest level of education you have attained? 🞐 Associates Degree 🞐 Bachelors Degree 🞐 Masters Degree 🞐 Doctoral Degree 🞐 Other In which state do you practice? _____________________ Is your professional employment located in an urban or rural community? 🞐 Urban 🞐 Rural 🞐 Other: _____________________ How would you characterize your place of employment? 🞐 Clinic / Instacare 🞐 Smaller Hospital Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 61 🞐 Mid-sized Hospital 🞐 Large Trauma Center 🞐 Other: ______________________ IPEC Competency Self-Assessment Tool VERSION 3 (July 2015) Lockeman, Dow, & Randell, 2018 INSTRUCTIONS: Based on your education or experience in the healthcare environment, select/circle the number that corresponds with your level of agreement or disagreement on each item. Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree 1. I am able to choose communication tools and techniques that facilitate effective team interactions. 1 2 3 4 5 2. I am able to place the interests of patients at the center of interprofessional health care delivery. 1 2 3 4 5 3. I am able to engage other health professionals in shared problem-solving appropriate to the specific care situation. 1 2 3 4 5 4. I am able to respect the privacy of patients while maintaining confidentiality in the delivery of team-based care. 1 2 3 4 5 5. I am able to inform care decisions by integrating the knowledge and experience of other professions appropriate to the clinical situation. 1 2 3 4 5 6. I am able to embrace the diversity that characterizes the health care team. 1 2 3 4 5 7. I am able to apply leadership practices that support effective collaborative practice. 1 2 3 4 5 8. I am able to respect the cultures and values of other health professions. 1 2 3 4 5 9. I am able to engage other health professionals to constructively 1 2 3 4 5 Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 62 manage disagreements about patient care. 10. I am able to develop a trusting relationship with other team members. 1 2 3 4 5 11. I am able to use strategies that improve the effectiveness of interprofessional teamwork and team-based care. 1 2 3 4 5 12. I am able to demonstrate high standards of ethical conduct in my contributions to team-based care. 1 2 3 4 5 13. I am able to use available evidence to inform effective teamwork and team-based practices. 1 2 3 4 5 14. I am able to act with honesty and integrity in relationships with other team members. 1 2 3 4 5 15. I am able to understand the responsibilities and expertise of other health professions. 1 2 3 4 5 16. I am able to maintain competence in my own profession appropriate to my level of training. 1 2 3 4 5 Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 63 The Bergen Burnout Inventory (BBI), 9 Items Multidimensional Non-proprietary Burnout Measure Shortened Version tested and published by Salmela-Aro, Rantanen, Hyvonen, Tilleman, & Felt (2011) 1 Completely Disagree 2 Disagree 3 Partly Disagree 4 Partly Agree 5 Agree 6 Completely Agree 1. I am snowed under with work (EXH) 2. I feel dispirited at work and I think of leaving my job (CYN) 3. I often sleep poorly because of the circumstances at work (EXH) 4. I frequently question the value of my work (INAD) 5. I feel that I have gradually less to give (CYN) 6. My expectations for my job and to my performance have reduced (INAD) 7. I constantly have a bad conscience because my work forces me to neglect my close friends and relatives (EXH) 8. I feel that I am gradually losing interest in my customers (patients) or my other employees (CYN) 9. Honestly, I felt more appreciated at work before (INAD) EXH exhaustion, CYN cynicism, INAD inadequacy Interprofessional Education, Burnout and Self-Esteem among Medical Imaging Professionals 64 The Self-Esteem Scale (Rosenberg, 1965) Permissions granted by Princeton University Press Published in a Textbook Edited by Robinson, Shaver, and Wrightsman, 1991 Strongly Agree Agree Disagree Strongly Disagree 1. I feel that I am a person of worth, at least on an equal basis with others. 2. I feel that I have a number of good qualities. *3. All in all, I am inclined to feel that I am a failure. 4. I am able to do things as well as most other people *5. I feel I do not have much to be proud of. 6. I take a positive attitude toward myself. 7. On the whole, I am satisfied with myself. *8. I wish I could have more respect for myself. *9. I certainly feel useless at times. *10. At times, I think I am no good at all. *Reverse scored items