THE EFFECT OF THE COVID-19 PANDEMIC ON IMAGING PROFESSIONALS’ LEVEL OF BURNOUT AND SELF-ESTEEM By Tina Horbach Shaye Jackson Lisa Lucas Paige Lueck Susan A. Schiffbauer Aubree Warner A thesis submitted to the School of Radiologic Sciences in collaboration with a research agenda team In partial fulfillment of the requirements for the degree of MASTER OF SCIENCE IN RADIOLOGIC SCIENCES (MSRS) WEBER STATE UNIVERSITY Ogden, Utah December 10, 2020 Effect of COVID-19 Imaging Professional 2 THE WEBER STATE UNIVERSITY GRADUATE SCHOOL SUPERVISORY COMMITTEE APPROVAL of a thesis submitted by 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 Effect of COVID-19 Imaging Professional 3 THE WEBER STATE UNIVERSITY GRADUATE SCHOOL RESEARCH AGENDA STUDENT APPROVAL of a thesis submitted by This thesis has been read by each member of the student research agenda committee and by majority vote found to be satisfactory. Date _________________________ ____________________________________ Tina Horbach December 9, 2020 _________________________ ____________________________________ Shaye Jackson December 15, 2020 _________________________ ____________________________________ Lisa Lucas December 7, 2020 _________________________ ____________________________________ Paige Lueck _________________________ ____________________________________ Susan Schiffbauer December 3, 2020 _________________________ ____________________________________ Aubree Warner Effect of COVID-19 Imaging Professional 4 Acknowledgments We would like to express our sincere gratitude and appreciation to Dr. Tanya Nolan and Dr. Laurie Coburn for their continuous support, guidance, and encouragement throughout this project. Also a big thanks to the participants that contributed to the study and enabled this research to be possible. Finally, we would like to thank our families for their unending patience and support during the compilation of this Thesis. It would have not been possible without their strong support that this research would have been possible. Effect of COVID-19 Imaging Professional 5 Abstract Imaging professionals face unprecedented challenges providing quality patient care during the COVID-19 pandemic. Stress and burnout factors are at their maximum within the COVID-19 environment which leads to concern that there could be strong and lasting impact on imaging professionals’ personal safety, job satisfaction and quality of patient care. This study sought to understand what factors were perceived by imaging professionals to be related to burnout and changes in self-esteem and to understand what outside factors either increased or decreased those perceived levels. Twelve frontline imaging professionals from across the United States were solicited to participate in this qualitative study. Data was collected from responses about their experiences during the COVID-19 pandemic. The results indicate factors for burnout were present among participants wherein higher levels of stress and anxiety were associated with shortages of personal protective equipment (PPE) and fears of contracting and spreading the virus. None of the participants expressed indicators associated with a decrease in self-esteem. The strongest theme associated with self-esteem were participants’ increased levels of personal job satisfaction including appreciation for organizational support, teamwork, and self-efficacy. The conclusion of this study reaffirms the importance of perceived organizational support and the need for organizational wellness programs that support the mental and physical well-being of healthcare professionals. Wellness programs are necessary to mitigate the lasting effects of stress and anxiety which causes burnout and to promote self-care in healthcare workers in order to reduce factors that negatively impact their ability to provide quality of patient care. Keywords: COVID-19; Burnout, Stress, Self-Esteem, Self-Efficacy, healthcare professionals, imaging professionals, PPE Effect of COVID-19 Imaging Professional 6 Table of Contents Abstract…………………………………………………………………………………………... 5 List of Figures…………………………………………………………………………………….. 8 List of Tables……………………………………………………………………………………... 9 Introduction……………………………………………………………………………………… 10 Literature Review………………………………………………………………………………...12 Burnout…………………………………………………………………………………………..12 Effects of Burnout on the Healthcare Provider……………………………………………….13 The Effects of Burnout on Patient Care……………………………………………………... 14 Coping with Burnout………………………………………………………………………… 16 Self-Esteem……………………………………………………………………………………... 18 Self-Esteem and Self-Efficacy………………………………………………………………. 20 Organizational Self-Esteem and Resilience………………………………………………….. 21 The Impact of COVID-19 on Healthcare Professionals………………………………………....24 Physical Dangers of COVID-19……………………………………………………………… 24 The Cost of COVID-19………………………………………………………………………. 25 Traumatic Stress of COVID-19………………………………………………………………. 28 Summary………………………………………………………………………………………....31 Materials and Methods……………………………………………………………………...........33 Sampling…………………………………………………………………………………….... 34 Instruments…………………………………………………………………………………… 35 Data Analysis………………………………………………………………………………....36 Codebook………………………………………………………………………………….. 36 Ethical Considerations………………………………………………………………………... 37 Results…………………………………………………………………………………………… 38 Discussion………………………………………………………………………………………. 44 RQ 1. Burnout………………………………………………………………………………... 44 RQ 2. Self-Esteem……………………………………………………………………………. 50 RQ 3. Outside Factors………………………………………………………………………... 52 Effect of COVID-19 Imaging Professional 7 Conclusion…………………………………………………………………………………….....56 Limitations……………………………………………………………………………………. 60 References…………………………………………………………………………......................61 Appendix A. IRB Approval……………………………………………………………………...72 Appendix B. Burnout and Self-Esteem Questionnaire…………………………………………..73 Appendix C. Standard Media Release Form……………………………………………………..75 Appendix D. Weber State University Informed Consent………………………………………..76 Appendix E. Weber State University Photo/Video Release…………………………………….. 79 Effect of COVID-19 Imaging Professional 8 List of Figures Figure 1. Participant Demographics (Gender)………………………………………………………... 38 Figure 2. Years of Experience and State of Employment…………………………………………….39 Figure 3. Weighted Themes Across All Interview Data ……………………………………………..40 Effect of COVID-19 Imaging Professional 9 List of Tables Table 1. Definition of Themes……………………………………………………………………………40 Table 2. Research Questions and Common Themes Results…………………………………...…….42 Effect of COVID-19 Imaging Professional 10 The Effect of COVID-19 Pandemic on Imaging Professionals Level of Burnout and Self-Esteem COVID-19 is caused by SARS-CoV-2, a betacoronavirus, that is composed of a single-stranded ribonucleic acid (RNA) structure that belongs to the Coronaviridae subfamily, part of the Coronaviridae family (Sohrabi,et’ al, 2020). COVID-19 most commonly spreads through close contact and through respiratory droplets and aerosols that are produced when an infected person coughs, sneezes, talks, sings or breathes. Infection can also occur by touching surfaces that have been contaminated with droplets and then touching the face or mucous membranes. Individuals infected with COVID-19 can develop mild symptoms such as dry cough, sore throat, and fever with the majority of the cases resolving spontaneously. However, fatal complications such as organ failure, septic shock, pulmonary edema, severe pneumonia, and Acute Respiratory Distress Syndrome (ARDS) have been reported (Sohrabi, et’ al, 2020). The World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) has published advice on preventing and protecting the population and healthcare workers from the further spread of COVID-19, these include limiting travel, social distancing, basic hand hygiene measures, and the importance of using personal protective equipment (PPE) such as wearing masks. For healthcare workers, the CDC recommends adhering to standard and transmission-based precautions when caring for patients. Those precautions include hand hygiene, gloves, protective gowns, face masks or respirators, face shields and/or goggles. Imaging professionals and practices are facing unprecedented challenges that pertain to providing quality care for patients (Slanetz, Chapman & Motuzas, 2019) and maintaining self care to prevent emotional and physical exhaustion. Burnout, and the associated drop in self-esteem, are mental and physical challenges that were widely prevalent before the unrest of this Effect of COVID-19 Imaging Professional 11 pandemic (Bridgeman, Bridgeman, & Barone, 2018; Jonson et al., 2020; Philips, 2010; Shanafelt & Noseworthy, 2017). Risk factors for burnout in healthcare professionals have been reported to include more excessive job demands, lack of control, inadequate institutional rewards, limited social support, lack of equity, incongruous values, and misaligned job expectations (Slanetz, Chapman & Motuzas, 2019). Due to the high demands and risks associated with COVID-19 on healthcare professionals, it is reasonable to ask how it is affecting imaging staff throughout their workday. Is burnout and lower self-esteem more prevalent as a result of the recent pandemic? The researchers sought to understand what factors were perceived by imaging professionals to be related to burnout; what factors were perceived to be related to self-esteem; and finally what outside factors either increased or decreased the variables of burnout and self-esteem among imaging professionals during the COVID-19 pandemic. With risk factors at a maximum within a COVID-19 environment (Slanetz, Chapman & Motuzas, 2019), there is significant concern these variables will continue to impact professional and patient care, safety, and satisfaction in ways that are untargeted and unmanaged. The goal of this research is to describe the effects and identify the perceptions and feelings held by imaging professionals as a result of the high demands COVID-19 has placed upon them, all with a current understanding of the relationships and magnitudes of variables attributed to self-esteem and burnout among certified professionals. A plan of mitigation may be developed to support the active professional while facing a pandemic environment. Support for the mental and physical well-being of imaging professionals has potential to result in appropriate self-care that extends to the overall quality of patient care (Bridgeman, Bridgeman, & Barone, 2018). Effect of COVID-19 Imaging Professional 12 Literature Review Professional burnout is characterized by high levels of emotional exhaustion, cynical attitudes, and a diminished sense of personal accomplishment at work. A number of studies have highlighted the problematic nature of burnout for healthcare professions. According to Chi (2014), healthcare is a particularly stressful occupation, one that often leads to burnout. Chi described how institutions that are ethical, trustworthy and transparent could reduce personal anxiety among the workers and how this could relate to decreasing burnout. It should be said that most organizations in healthcare recognize the need for employee satisfaction and work hard to mitigate risks related to burnout. Chi (2014) describes the values of leaders and their integrity to reduce burnout in healthcare careers, and describes the characteristics of a good leader and developing trust and how this can reduce burnout. A leader's characteristics contribute to their integrity and their competence and ability to lead the healthcare team. Guenette and Smith (2017) found low personal accomplishment scores amongst radiology residents in New England correlated with decreased job satisfaction and increased job burnout. Guenette and Smith compared other residency programs and found that surgical residents personal accomplishment scores were even lower than radiology residents. Burnout syndrome (Restauri, 2017) is increasing among physicians, and cultural and institutional changes are necessary to combat burnout in order to maintain the physician workforce. Stress is related to a healthcare professional’s job satisfaction and plays a significant role in burnout. Reingold (2015) studied the perceived stress levels and their causes among radiologic technologists, and posits that “when stress is not relieved, burnout will be inevitable” (p. 151). This study referenced the National Institute for Occupational Safety and Health (NIOSH) who identified occupational stressors to include long work hours, work overload, difficult and Effect of COVID-19 Imaging Professional 13 complex tasks, poor working conditions, time pressures and lack of break periods. They describe these occupational stressors as being “harmful physically and emotionally” (p. 150). In order to measure stress reduction using active coping skills, Reingold instituted a six week mindfulness-based stress-reduction (MBSR) interventional program. He then re-evaluated the stress levels of the participants following completion of the program and found that some technologists reported improved perceptions of stress levels, workplace safety and overall pleasantness. He also noted how the workplace environment had improved as stress levels were reduced among technologists. Conclusively, Reingold posits the difference between stress and burnout is that stress is reduced when stress-causing factors are removed, however burnout remains (p. 151). Effects of Burnout on the Health Care Provider Portoghese (2014) described job burnout and how it affects the body’s health and subsequent performance, and how it impacts the workplace. He determined that preventing job burnout was a better strategy than waiting to treat it after it had become a problem in the workplace. Schaufeli and Bakker (2004) researched the effect of job demands on healthcare workers’ levels of burnout and rates of employee turnover. They found job demands and lack of job resources were predictors for burnout (p. 296). In response, Schaufeli and Bakker (2004) examined how supportive management and positive engagement could assist employees in achieving workplace goals, maintaining positive work attitudes, increasing job-fulfillment, and reducing personal burnout. In an original article, Corbridge and Melander (2019) identify the affects of burnout and how it can lead to depression, PTSD, and suicide. The authors cite that the suicide rate among physicians is more than twice as high as the general population. With this in mind, the authors Effect of COVID-19 Imaging Professional 14 proposed that nurse practitioners (DNP) would have a decreased rates of burnout and mental health crisis because they receive deliberate instruction and practice interprofessional communication and collaborative skills. Corbridge and Melander (2019) theorized that DNP’s are ‘specially equipped’ to both lead and work in interprofessional teams. They also delegate tasks to team members so they are not overworked and begin to experience burnout. The authors advocate programs that encourage interprofessional, team-based practice that could help relieve burnout by sharing the care-taking responsibilities. An interprofessional approach recognizes that each individual on the healthcare team has unique skill sets and contributions. A culture of sharing the care-taking responsibilities can help reduce burnout by reducing the burden on any one professional. The Effects of Burnout on Patient Care Recent changes in healthcare delivery have raised concerns that provider burnout may worsen if increased patient care and administrative demands outpace resources. In an article published digitally in HealthcareITNews, Eddy (2019) quoted a study that found that physician depression and burnout was linked to medical errors. Therein, physicians expressed obtaining prior authorizations, regulatory and documentation requirements, malpractice concerns, and the rise of consumerism were elements leading to burnout. All healthcare workers and providers are overwhelmed with the demands of patient care, time-consuming paperwork and charting, long work hours, work overload, difficult and complex tasks, poor work conditions, time pressures, lack of breaks, poor management support and peer relationships. The University of Michigan Medical School in Ann Arbor conducted a study which indicated there was a cyclical effect between depression and medical care errors (Eddy, 2019). Effect of COVID-19 Imaging Professional 15 Medical errors resulting from a physician’s uncontrolled depression resulted in more depression that cycled back to more errors. This cycle has major implications on the quality of patient care offered by burnt out or depressed healthcare workers. In 2019, Miliard linked high rates of clinician burnout at the Mayo Clinic with the demands and difficulty of navigating electronic health records (EHRs). In support, Eddy (2019) reported physician’s burnout was positively linked to electronic health records and other technologies. This was especially true when the physicians were improperly trained or when the system was not ‘user-friendly’. Miliard (2019) contends that EHRs are not designed with healthcare workers in mind, but are designed more specifically for federal meaningful use mandates and billing imperatives. The American Medical Association (AMA) suggests that enhancing cumbersome EHRs would be key to preventing physicians from feeling a deep dissatisfaction and loss of control, both of which are demoralizing and effective in advancing burnout. The AMA advocates for new generations of EHRs designed to prioritize time with patients instead of navigating the system. Salyer’s (2016) meta-analysis examined the relationships between provider burnout (emotional exhaustion, depersonalization, and reduced personal accomplishment) and the quality (perceived quality, patient satisfaction) and safety of healthcare. A total of 82 studies, including 210,669 healthcare providers, were included in the analysis. Statistically significant negative relationships emerged between burnout and quality. Provider burnout shows consistent negative relationships with perceived quality (including patient satisfaction), quality indicators, and perceptions of safety. Though the effects are small to medium, the findings highlight the necessity of effective burnout interventions for healthcare providers. Overall, healthcare providers with less burnout provide better quality of care for the patients. Effect of COVID-19 Imaging Professional 16 In Chou’s (2014) study, the researchers investigated the prevalence of burnout among different medical professions and examined the associated factors related to burnout. A total of 1,329 medical professionals were recruited in a regional hospital with a response rate of 89%. Findings showed that being young, working overtime, engaged in a job with high strain, frequent overcommitment and low social support were associated with high burnout. Above all, the three variables of job strain, overcommitment and lack of social support attributed most of the variance related to burnout. Vidotti’s (2018) and Gandi’s (2011) study supported these same findings. Unlike DNPs, high levels of burnout were found among nursing professionals. The results from these studies supported a need to reduce work pace and the number of patients per nurse. The following psychosocial factors and work variables were associated with the dimensions of burnout. Variables included greater demand, low control, low social support, dissatisfaction with sleep and financial resources, and sedentariness. Coping with Burnout Understanding the prevalence of burnout and its epidemic spread among healthcare professionals supports the need for a solution. Indeed, many healthcare professionals have learned resilience and selected plans and behaviors effective in handling burnout and its negative side-effects. Otto (2019) reviewed the negative effects of burnout, its prevalence among the working class, and effective coping strategies. His exploratory qualitative study found that employees engaged in a variety of active behaviors to prevent the adverse effects of burnout. Leisure activities, relaxation, refusing additional work responsibilities, and reflective meditation were all proactive means whereby workers reduced their burnout and exhaustion. Participants reported that not only work factors, but also private factors contributed to their feelings of burnout. Results of this study indicated that employees necessitated intentional and proactive Effect of COVID-19 Imaging Professional 17 actions necessary to maintain and/or increasing personal resources. These active coping mechanisms reduced psychological and physical demands in every environment including work, home, and personal domains. Another possible solution for burnout was considered by Hart, Paetow, and Zarar (2018), the purpose of their study was to implement a previously employed corporate wellness initiative to reduce burnout in Emergency Medical (EM) residents. Although the intervention had been successful for different samples of healthcare providers, the same program did not objectively improve burnout among EMs, and it was subjectively perceived as paradoxically worsening levels of EM burnout. This result may be related to the type of intervention chosen (individual vs. systems-focused), the design of the intervention itself, or the unique stressors faced by the EM population. In contrast, Naczenski, de Vries, van Hoof, and Kompier (2017) examined relationships between interventions using physical activity and levels of burnout through systematic review or meta-analysis. Their results suggest that physical activity does constitute an effective medium for the reduction of burnout among a variety of study populations. Despite sporadic efforts to decrease burnout, one solution was remarkable. Darban et al. (2016) studied an interventional plan that decreased burnout while maintaining cost effectiveness. The researchers discovered that a primary factor influencing the burnout of nurses was related to their difficult and complicated relations with patients and other members of their medical team. Participating subjects were randomly divided into two groups, a control group and an experimental group. The experimental group received training and education on communication skills. During the study, both groups were surveyed three times, initially upon recruitment, during the education series, and then again three months later. The control group demonstrated no change in their level of burnout, whereas, the experimental group showed Effect of COVID-19 Imaging Professional 18 drastic improvements in their levels of burnout. Since trainings in communication and collaboration have shown to be an effective and inexpensive way to reduce burnout among nurses who are at high-risk among health professionals, it may be recommended that this approach be adopted by healthcare management as a means to improve the quality of healthcare and patient services. Self-Esteem It is difficult to find a definition of self-esteem with which most can agree. While self-esteem is commonly studied it is, at the same time, such a personal concept of ‘self’ that it becomes difficult to pin down a definitive definition that can be agreed upon. As Smelser (1989) points out, “we have a fairly firm grasp of what is meant by self-esteem, as revealed by our own introspection and observation of the behavior of others. But it is hard to put that understanding into precise words” (p. 9). Baumeister et al. (2003) defined self-esteem as value individuals place upon themselves, the evaluative component of self-knowledge. This value is set in their own self-concept of effectiveness. As Tafarodi and Swann (1995) suggested, self-esteem (or self-competence) is connected to motivational concepts such as effectiveness, personal causation, and reaching for a sense of superiority. This definition is straight-forward enough, but other researchers have worked to find a more holistic model of self-esteem. Some have defined self-esteem in terms of worthiness (Mruk, 2006a; Mruk, 2006b). Rosenberg (1965) speculated that self-esteem was a positive or negative attitude towards one’s own self that helped them feel worthy or not. Leary and Baumeister (2000) agree, saying that self-esteem refers to one’s appraisal of one’s own value and worth. Another approach goes all the way back to James (1890/1983) who describes self-esteem as a relationship between a person’s accomplishments and aspirations. Therefore, self-esteem can be defined as “an individual’s sense of value or self-Effect of COVID-19 Imaging Professional 19 worth and refers to an individuals’ degree of liking or disliking for themselves” (qtd. in Chen, 2004, p. 376; Lane 2004). According to Mruk (2006a), this introduced the idea of competence as a measure of self-esteem. The idea is that as competence increases, self-esteem increases as a result (Mruk, 2006a). A third approach has been to define self-esteem as an interaction between a person’s sense of competence and worthiness. This approach recognizes self-esteem not as a one-dimensional idea, that instead it is a complex phenomenon, which involves internal as well as external drivers (Mruk, 2006a). In addition to the humanistic traditions, cognitive psychology has begun to explore self-esteem. Epstein’s (1985) Cognitive-Experiential Self-Theory (CEST) suggests that people use rational as well as experiential systems to process information. According to CEST, self-esteem is a longing to be viewed as “loveworthy” (Epstein, 2003, p. 302). This idea puts self-esteem between self-maintenance and self-enhancement, ideas that affect how we view ourselves (Mruk, 2006b). Another cognitive aspect of the idea of self-esteem is Harter’s (1999) developmental approach. In this approach, Harter views self-esteem as a relationship between competence and social approval (Mruk, 2006b). This idea is somewhat unique because it looks at competence and social approval through the lens of life stage cognitive development (Mruk, 2006b). Evolutionary research has made inroads into the study of self-esteem as well. This means people have to work in groups and communities to help support their self-esteem. Leary (1999) suggests that humans have developed the ability to regulate and modulate their behavior and relationships with others to help support their self-esteem. This means that self-esteem is a function that helps people avoid social exclusion (Leary & Downs, 1995). Effect of COVID-19 Imaging Professional 20 The philosophy of existentialism also has a place in defining self-esteem through Terror Management Theory (TMT). According to TMT, people are tortured with the knowledge of their own mortality. As a result, humans are terrorized by the knowledge that they can go at any time and without warning (Mruk, 2006b). According to Pyszczynski, Greenberg, Solomon, Arndt, and Schimel (2004), people need self-esteem as a self-defense mechanism against this knowledge. A sense of worth that allows people to transcend the terror of death and feel that they have significance and purpose. Self-Esteem and Self-Efficacy Having explored a definition of self-esteem, it is worth taking a moment to consider the connection between self-esteem and self-efficacy. Research indicates that self-esteem is closely associated with perceived self-efficacy expectations (Lane 2004) and has linked changes in self-esteem to changes in perceived self-efficacy. Successful completion of tasks or enactive mastery experiences is “self-perpetuating of self-efficacy and self-esteem” (Gardner, 1998, p. 56). As Mruk (2006a) points out, self-esteem is connected with feeling a sense of competence, and through this competence, the ability to accomplish goals. This leads directly into self-efficacy. Previous research on the topic differentiates between the two ‘self’ concepts. In the1977 study, Self-Efficacy: Toward a Unifying Theory of Behavioral Change, Albert Bandura defined self-efficacy in the construct of social cognitive theory as “the conviction that one can successfully execute the behavior required to produce the outcome” (p. 193). In other words, self-efficacy is belief in one’s capabilities or one’s potential to accomplish a task. With this seminal work, Bandura, considered the “father” of self-efficacy, went on to explain, “efficacy expectations determine how much effort people will expend and how long they will persist in the Effect of COVID-19 Imaging Professional 21 face of obstacles and aversive experiences. The stronger the perceived self-efficacy, the more active the efforts” (p. 194). Bandura (1997) argued that one of the most important aspects of self-efficacy is that it is modifiable. Chen (2004) described self-efficacy as malleable and task specific. Chen stated that ‘general self-efficacy’ is a broader form of self-efficacy and has been characterized as a “relatively stable, generalized competence belief” which relates to a motivational component of job performance and towards “work self-esteem” (pp. 376, 390). As a result, it is a strong predictor of job performance (Gardner, 1998; Du, 2017; Sarpkaya, 2019). Furthermore, self-efficacy has a stronger correlation to performance than self-esteem (Lane, 2004). This is particularly important in the stressful environments that healthcare workers experience during the COVID-19 pandemic. Personal resources of self-efficacy affects both a healthcare workers’ level of self-esteem and the patient care they are able to provide. Bandura’s studies on self-efficacy has revealed that individuals who “persist in subjectively threatening or challenging activities will gain corrective experiences that reinforce their sense of efficacy...” (Bandura, 1977, p. 194). Organizational Self-Esteem and Resilience Sarpkaya (2019) studied the mediating effect of self-esteem between job satisfaction and life satisfaction. The researcher contended because adults spend so much of their time engaged in employment that work becomes a “sphere that regulates modern individuals lives and enables them to socialize with each other” (p. 214). Self-efficacy and self-esteem work together to affect attitude and performance and affect organization-based self-esteem. Organization-based self-esteem is an individual’s perception of their own worth and meaning as part of an organization. Effect of COVID-19 Imaging Professional 22 Individuals with high organization-based self-esteem feel important to the organization and they make a difference (Gardner, 1998) and are better prepared to overcome obstacles. A healthy, safe, and friendly work environment with well-organized, supportive hierarchy which can increase self-efficacy, foster well-being and eliminate the factors causing the occurrence of burnout (Nowakowska, 2016; Baird 2019). Researchers have indicated that study participants identified negative team members, negative conditions, and lack of organizational support as discouraging and hindrances to their hope (Duggleby, 2009) reducing self-esteem. Self-esteem has been correlated with social trust, optimism, job satisfaction, and resiliency (Bibi, 2017; Perez-Fuentes 2019a). Bibi (2017) states that people with high self-esteem have a higher level of trust in others (social trust). Resilience has been correlated to self-efficacy, self-esteem, social trust, optimism, and job satisfaction (Williams, 2017; Bibi, 2017). Resilience is the ability to change, adapt, and endure setbacks, problems, and high stress levels or situations (Bandura 1997; Bar 2018). Resiliency is also accepting responsibilities and persevering and taking control over personal learning and actions (Wahab, 2017). Healthcare professionals with resilience have an increased buildup of personal resources and are better able to “cope with workplace burnout and stress” (qtd. in Bar, 2018, p. 37). This is particularly important as research has revealed a generational difference in resiliency. In a 2017 study by Peterson, millennials scored lower in areas associated with resilience, specifically ambiguity, stress management, and self-reliance. Resilience has been described as time-bound and situational in nature. Young healthcare professionals have had “limited experience in learning to overcome adversity” (p.1). Resilience is a trait that also can be cultivated. Healthcare workers with increased buildup of personal resources realize that setbacks are inevitable and that they can control their emotional responses in difficult situations (Peterson, 2017). Healthcare workers Effect of COVID-19 Imaging Professional 23 who are unable to manage their negative emotions will not be able to maintain or increase their sense of self-worth (Caprara, 2013). The psychological stress and stigma experienced by frontline health professionals has the potential to reduce quality of sleep which has ramifications in impulse control and decision-making capabilities and indirectly contributes to lower self-esteem (Pérez-Fuentes, 2019b). In a related study, Pérez-Fuentes et al., (2019a) concluded that self-esteem was essential as a personal resource to the emotional and psychological well-being of healthcare workers. This discussion of resilience, notwithstanding the stressors placed upon healthcare workers during the pandemic, seem to be taking a toll. In a recent Italian study on stigma, self-esteem and the psychosocial consequences on frontline care providers working with infected COVID-19 patients, Ramaci (2020) posited that while social stigma and discrimination negatively correlated to fatigue and burnout, self-esteem positively correlated to satisfaction levels. Ramaci theorized that individual resources or personal reserves were important in protecting healthcare workers against negative effects and that individuals with strong self-esteem had increased hopefulness and higher resilient psychosocial outcomes (p.3). The authors found that while frontline healthcare workers were concerned about infecting family and friends providing care was emotionally difficult. Studies have shown that the level of patient care provided by healthcare workers who experience high levels of fear, stigma, and guilt are less precise or careful than they would normally be. Fear, stigma, and guilt lead to higher levels of stress and burnout and lower levels of satisfaction (p.9). On a positive note, the authors found that levels of fear and fatigue among COVID-19 healthcare workers decreased over time while satisfaction slightly increased. They noted personal characteristics of higher sense of self-esteem after experiencing adversity which contributes to resilient psychosocial outcomes. Effect of COVID-19 Imaging Professional 24 The Impact of COVID-19 on Healthcare Professionals The knowledge of COVID-19 is limited, but what is known is that the virus is highly contagious (Mo Y, et al., 2020). This combination of limited knowledge and high contagious properties add pressure to already stressed healthcare workers. Fear and anxiety in a pandemic situation is normal, however a study conducted by Taylor et al. (2020) identified and measured five factors that contribute to COVID-19 stress syndrome. They include “(a) fear associated with COVID-19 danger and fear of contact with fomites (objects and surfaces) potentially contaminated with SARS-CoV-2, (b) worry about the socioeconomic impact of COVID-19 in such areas as personal finance, disruption of the supply chain, (c) the xenophobic fear that foreigners are spreading SARS-CoV-2, (d) traumatic stress symptoms related directly to being around COVID-19 or having it constantly be on the mind in the form of related nightmares, intrusive thoughts and images, and (e) COVID-19 related compulsive checking and reassurance seeking” (p. 707). These five factors are interconnected in what Taylor, et al.,( 2020), referred to as COVID stress syndrome and as such indicate that COVID-19 stress is complex and involves different types of fears. Physical Dangers of COVID-19 COVID-19 is a dangerous and sometimes deadly virus that is caused by SARS-CoV-2, a betacoronavirus, and is composed of a single-stranded ribonucleic acid (RNA) structure that belongs to the Coronaviridae subfamily, part of the Coronaviridae family (Sohrabi,et’ al, 2020). Patients infected with COVID-19 can develop mild symptoms such as dry cough, sore throat, and fever with the majority of the cases resolving spontaneously. However, fatal complications such as organ failure, septic shock, pulmonary edema, severe pneumonia, and Acute Respiratory Effect of COVID-19 Imaging Professional 25 Distress Syndrome (ARDS) have been reported (Sohrabi, et’ al, 2020). Currently there is no vaccine or specific drug to treat COVID-19 but there has been a great focus on the measures to prevent the spread of the virus. The spread of COVID-19 has resulted in widespread fear and anxiety. Fear of contracting the virus and the spread of COVID-19, and the quality of life and ever changing information regarding COVID-19 have intensified anxiety levels. People are searching for answers and explanations. The origin of COVID-19 has been linked to Wuhan, China with many people using terms, such as, ‘Wuhan Virus’ or ‘Chinese Virus’ resulting in tension against people of Asian descent. Because this virus has been identified as foreign, for some individuals, their feelings have been expressed as xenophobia, prejudice, and violence against Asian Americans (Tessler et al., 2020). There have been a large number of physical assaults against Asian Americans and ethnically Asian individuals in the United States directly related to COVID-19 (Tessler, et’ al 2020). There have also been reports of attempted murder and threats of vandalism and property damage to Asian American businesses. This may be an additional burden on Asian Americans beyond the anxiety, economic instability, and the risk of illness all Americans have experienced during the COVID-19 pandemic (Tessler, et’ al, 2020). The Cost of COVID-19 COVID-19 appeared suddenly, taking a devastating toll on the economy. Yamin (2020) cited one of the reasons for the hard hit lies in the fact that more than four-fifths of the workforce are in countries under severe restrictions of distancing and lockdown in an effort to prevent the spread of the virus. Among the consequences of these severe restrictions are business closures causing unemployment and loss of work hours. Healthcare facilities stopped performing elective Effect of COVID-19 Imaging Professional 26 and non-urgent procedures resulting in healthcare workers using their vacation time in order to make up for the loss in hours. When their vacation time was depleted it resulted in loss of wages. Bai-Zare (2020) stated that labor and capital costs constituted 41.3% and 4.0% of hospital operating costs, respectively. It is also noted that operating room, laboratory, diagnostic radiology, general routine inpatient care, intensive care unit, outpatient clinic, and emergency room incurred approximately one-third of the hospitals’ total operating costs. With a decline in hospital visits and the canceling of elective procedures, revenue decreased. This result motivated employers to reduce costs which included cutting labor costs. Cai et al. (2020) described the psychological impact of COVID-19 on the frontline healthcare workers versus the non-frontline healthcare workers in China during the pandemic for 15 days in February. They suggested that due to an increasing number of patients, long hours of intensive work and less sleep time, inadequate PPE, and the risk of infection played a tremendous impact on the physical and mental exhaustion which resulted in mental health problems. The rate of mental health problems such as anxiety, depression, and insomnia were significantly increased in frontline medical workers when compared to non-frontline medical workers but was still lower than the general population. They implied that this may be due to the lack of access to personal protection equipment in the general public as compared to the frontline medical workers. Misra-Hebert et al. (2020) analyzed the impact of COVID-19 on healthcare professionals as compared to non-healthcare professionals who were tested for SARS-CoV-2 in one health system with two geographic locations, Ohio and Florida. The researchers found that the odds of having a positive COVID-19 test were not significantly different for healthcare professionals when compared to non-healthcare professionals. In fact, healthcare professionals had lower odds Effect of COVID-19 Imaging Professional 27 of subsequent hospitalization (6.9% healthcare professionals vs 27.7% of non-healthcare professionals) but no statistically significant differences in ICU admission (1.8% healthcare worker vs. 10.8% in non-healthcare worker) when compared to non-healthcare professionals once they tested positive (p.20). Misra-Hebert et al. stated that the overall proportion of COVID-19 positive tests in healthcare professionals was low and decreased during the study period corresponding with system-wide implementation of risk-mitigation measures such as universal masking and physical distancing. They stated that recent studies have estimated a less than 5% risk to healthcare professionals was due to the inadvertent exposure to patients not known to be SARS-CoV-2 positive at the time of exposure and the healthcare professionals was without appropriate PPE thus suggesting that the risk is low to contract COVID-19 while exposed in a work environment. This is supported by a Spanish study by Lazaro-Perez et al. (2020) that quoted a 2018 study by West, Dyrbe, and Shanafelt study which stated that, prior to COVID-19, nearly 50% of health professionals in the United States were experiencing work-related stress and exhibited symptoms of burnout due to emotional exhaustion, high rates of depersonalization, and a reduced sense of accomplishment or a heightened sense of ineffectiveness. During their experience with COVID-19 in Spain, Lazaro-Perez reported that high levels of anxiety due to lack of PPE in the face of death, particularly during the temporary period of high levels of mortality, were experienced by 79.4% of health professionals (p. 12). Lack of PPE was found to be the greatest predictor of anxiety and related to high levels of burnout, depersonalization and emotional exhaustion. These findings suggest that healthcare professionals are vulnerable to events related to their patients. Effect of COVID-19 Imaging Professional 28 Cai et al. also reported that the psychological symptoms during COVID-19 pandemic were consistent with other studies among healthcare professionals and reported that 29.8% suffered from stress, 13.5% from depression, and 24.1% from anxiety (p. 213). These results could be considerably different depending on the geographical area and how the pandemic has affected that area. Mental health problems in the frontline medical workers might be due to the increase in physical and mental stresses such as, inadequate PPE, negative emotions from patients, quarantine, and lack of contact with their families. They did not observe a significant increase of the frontline healthcare workers seeking help or receiving treatment for mental health related issues. The authors concluded that there is a drastic need for COVID-19 related mental health treatment as early as possible including medical teams to provide psychological support as well as external material and spiritual support. Barello (2020) describes the huge psychophysical impact of COVID-19 on the healthcare professional in Italy early in the pandemic. They described the levels of professional burnout and physical symptoms and how that directly involved the care of patients with COVID-19 at the peak of the pandemic in Italy. They reported high levels of emotional exhaustion and depersonalization and suggested that the patient care provided by healthcare professionals experiencing this emotional distress was suboptimal. The authors study was conducted early in the pandemic and suggested the need for support of the healthcare professionals who are at a high risk of negative health consequences. Traumatic Stress of COVID-19 Vagni et al. (2020) studied the effects of hardiness, stress and secondary trauma on healthcare workers and emergency workers during the COVID-19 pandemic and how those Effect of COVID-19 Imaging Professional 29 factors differed between the two groups. In order to understand the potential effect of secondary trauma and PTSD, Vagni et al. referenced studies performed after the 2003 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), 2014 Nigerian Ebola viral disease, and the 2015 Middle East respiratory syndrome (MERS) outbreaks. Those studies found that 18 to 57% of healthcare professionals either experienced or were at risk of experiencing severe emotional distress during and immediately after the outbreak. Sometimes even after a moderate amount of time had passed. Vagni et al. also noted that in past outbreaks, healthcare professionals who had good levels of supplies and necessary hospital training experienced lower levels of stress. Healthcare professionals that were faced with the problem of limited or lack of PPE experience lower levels of self-efficacy (p. 2). Vagni et al. proposed that healthcare professionals may be affected more by COVID-19 than emergency workers. They showed higher levels of organizational-relational, emotional, cognitive and physical stressors than emergency workers (p. 9). Although emergency workers usually begin treatment before they know the patient has COVID-19, they do not have to work with these patient’s for extended periods of time. They are not able to see the patient’s entire intervention, whether this includes the progress and/or decline of the patient, hoping they get past their COVID-19 sickness. Emergency workers and frontline healthcare professionals (i.e. nurses and imaging professionals) are all presented with the same problems during this pandemic; they include lack of PPE, no formal operative protocols for a pandemic of this size and severity, and new lockdown protocols which necessitates dealing with sometimes difficult family members that do not understand why these protocols are in place. These lockdown protocols requiring hand-sanitizing, masking and temperature checks also make it more difficult going into and out of work and moving from building to building. High stress and arousal conditions require Effect of COVID-19 Imaging Professional 30 workers to rely on personal stores of resilience during these COVID-19 times. The authors of this article suggest that a safe and efficient work environment should promote a personal sense of control that can maximize healthcare professionals' resilience during a global health crisis. Morgantini et al. (2020) found that healthcare professionals who deal with large levels of adversity, increased workloads, and high levels of stress during the COVID-19 pandemic are more likely to experience burnout. They found the highest levels of burnout occurring in the locations where the pandemic was surging at the time of data collection. Not all healthcare professionals are going to experience burnout during the pandemic in the same manner because it is dependent on their occupations, the patient population, how the pandemic is affecting their workplace and PPE supplies. Most healthcare professionals are reporting burnout due to work affecting their household activities, feeling pushed beyond their level of training that they have previously been okay working with, their level of exposure to COVID-19 patients, and making life prioritizing decisions due to supplies shortages, such as ventilators. Healthcare professionals are feeling large amounts of anxiety due to access to adequate PPE, unknowingly bringing the infection home, and lack of updated information about the virus. The realization that burnout can affect a person’s physical health as much as it can affect your mental health is quite unnerving for many healthcare professionals as well. Physical ailments found to be related to burnout include musculoskeletal pain, gastrointestinal and respiratory issues, fatigue, and headaches. Healthcare professionals should be provided additional training, organizational support, support for the healthcare professional’s families, PPE and mental health resources to make sure to reduce burnout now and in the future. Effect of COVID-19 Imaging Professional 31 Summary The COVID-19 pandemic has a vast impact on the healthcare professional’s level of burnout and self-esteem. Heath et al. (2020), identifies ‘...chronic exposure to stressors is burnout.’ Recognizing burnout in healthcare professionals is important to assure the well-being of the worker which affects the quality of patient care. The consequences of burnout in clinicians has been associated with predisposition to depression and anxiety, substance abuse, increased risk of medical errors and poor clinical decision-making (Heath et al., 2020, p. 1). A number of past studies have highlighted the problematic nature of burnout for a variety of healthcare professions. Bridgeman, Bridgeman, and Barone, (2018) recognized the burnout syndrome in healthcare professions increasing due to the pressures on healthcare providers, including the challenges of clinical work, time constraints, competing demands, lack of control over work processes and scheduling, and conflicting roles and relationships with leadership. As stated, professional burnout is characterized by high levels of emotional exhaustion, cynical attitudes, and a diminished sense of personal accomplishment at work. The level of burnout depends on many different parameters such as their occupations, the geographical area, management support, the prevalence of COVID-19 population, COVID-19 education, the adequate amount of PPE, and the anxiety about contracting and infecting their families. A person’s physical health can also be affected by burnout manifesting as musculoskeletal pain, prolonged fatigue, headaches, gastrointestinal and respiratory issues (Morgantini, 2020) all of which could lead to a reduction in job satisfaction, employee absence, and decreased performance which could include a lower quality of patient care. Self-esteem can be defined as how one perceives themselves and if they feel worthy. Satisfaction levels are positively correlated to self-esteem. During this COVID-19 crisis, the Effect of COVID-19 Imaging Professional 32 emotional toll and feelings of helplessness faced by healthcare workers affect how they feel about themselves and their worth. The COVID-19 pandemic increases the healthcare worker’s level of stress, anxiety, and increased work loads which increases the level of burnout and decreases the level of self-esteem. Ramaci (2020) reflected that the stigma, self-esteem and the psychosocial consequences on frontline care providers and their families due to working with infected COVID-19 patients strongly correlate to fatigue and burnout. Studies have shown that healthcare professionals who are experiencing high levels of burnout due to fear, stigma, and guilt provide lower quality patient care than under normal conditions. This result was substantiated by Nowakowska (2016) who found that occupational stresses reduce levels of self-efficacy and is one of the main causes of decreased quality of work. Healthcare professionals experiencing lower levels of self-efficacy are more likely to experience burnout (Nowakowska, 2016). Sadovich (2005) said that high levels of job satisfaction and positive perception of the work environment reduces burnout syndrome (p. 95). Ramaci suggested that individual resources or personal reserves were important in protecting healthcare professionals against negative effects (p. 9). The literature infers that there is a great need for COVID-19 related mental health treatment and support programs as early as possible including medical teams to provide psychological support as well as external material and spiritual support. Programs such as the mindfulness-based stress-reduction (MBSR) interventional program help reduce stress thus improving the workplace environment. Studies indicate that individuals with strong self-esteem had increased hopefulness and higher resilient psychosocial outcomes. Personal resources of self-efficacy is a strong predictor of self-esteem. Previous research has found a statistically significant relationship between levels of self-efficacy and burnout (Nowakowska, 2016). Self-esteem is essential to the psychological well-being of Effect of COVID-19 Imaging Professional 33 healthcare professionals. As a result, self-esteem may have a mediating effect on burnout. Prior studies have correlated self-esteem as a low-level mediator (Sarpkaya, 2019) to job satisfaction which positively influences job performance (Pérez-Fuentes, 2019b) and patient care. Materials and Methods This qualitative research was designed to use a phenomenological approach to understand the perceived levels of burnout and changes in self-esteem during the COVID-19 pandemic. The analysis was conducted by student researchers under the direction of Dr. Tanya Nolan, Associate Professor and Director of the Master of Science in Radiologic Sciences (MSRS) program at Weber State University in Ogden, Utah. Data was collected from participants' responses to interview questions conducted via a Zoom video conference platform. A convenience sample was drawn from healthcare professionals currently working in general radiology and computed tomography (CT) who are or have worked directly on the front lines with COVID-19 patients. The sample size of this qualitative study included twelve participants. Research Questions The design of this qualitative research was to investigate and identify three key areas to which COVID-19 is affecting frontline radiology professionals across the United States. First, researchers sought to identify how radiology professionals working within the healthcare setting with patients infected with COVID-19 perceived their level of self-care and personal burnout. Secondly, researchers proposed to identify how the COVID-19 environment had changed radiology professional’s perception of personal self-esteem and related self-efficacy. Sub-variables of distress, sympathy/empathy, personal satisfaction and exhaustion were carefully evaluated within subject responses to meet the aforementioned research purposes. Lastly, Effect of COVID-19 Imaging Professional 34 researchers explored outside factors that may have either increased or decreased the variables of burnout and self-esteem among imaging professionals during the COVID-19 pandemic. Researchers specifically sought information and understanding on how changes in hours worked, role responsibilities, and institutional or management support may have affected the health professionals’ perceptions of burnout and self-esteem. Q1. What factors (mental, emotional, or physical) were perceived by imaging professionals that related to variables of burnout during the COVID-19 pandemic? Q2. What factors (mental, emotional, or physical) were perceived by imaging professionals that related to variables of self-esteem during the COVID-19 pandemic? Q3. What outside factors (including working hours, role responsibilities, and institutional or management support) affected perceived variables of burnout and/or self-esteem during the COVID-19 pandemic? Sampling Researchers used multiple platforms to recruit a convenience sample of participants for the interview process. These included using social media (i.e.Facebook), private messaging, email invitation, and personal invitation of Radiologic Technologists (RT) or Computed Tomography Technologists (CT) who met the inclusion criteria to participate in a one-on-one recorded Zoom format interview. All invited subjects voluntarily completed a media release and informed consent prior to the onset of the interviews. Our hypothesis was that inclusion criteria set for stratified sampling of the convenient population would provide the appropriate and comparative data necessary to explore our Effect of COVID-19 Imaging Professional 35 variables of interest. A total of twelve subjects were interviewed. Respondents were not limited in gender, but were limited between the ages of 18 to 70. Eligible subjects were employed as Radiologic Technologists (RT) or Computed Tomography Technologists (CT) in the healthcare industry with personal experiences working with COVID-19 patients. Participants lived and worked within varied geographical regions of the United States. Instruments Student researchers engaged in the Master of Science in Radiologic Sciences (MSRS) program at Weber State University designed the interview questions for this study. The questions were developed to explore participants' experiences and perceived levels of burnout and self-esteem during the COVID-19 pandemic. Interview questions helped uncover more generalized feelings about frontline radiographer risks and job expectations during the COVID-19 pandemic, and how changes in burnout and self-esteem affected their ability to provide patient care. The questions also investigated possible connections between work satisfaction, employees' sense of value and self-esteem, perceptions of added risk and the use of PPE. See Appendix B for a complete list of interview questions. Participants took part in one-on-one interviews via Zoom and answered questions to establish age, gender, state of employment, area of practice, and years in their current role. Participants were then asked questions that allow them to explore and express their personal opinions and experiences regarding perceived burnout and self-esteem during the COVID-19 pandemic. The interviews were recorded, transcribed, and stored in a password protected electronic Box allowing for continued research and analysis to be continued after the interviews Effect of COVID-19 Imaging Professional 36 were completed. A time limit of one month was allotted for the gathering of original data from the twelve respondents. Data Analysis Qualitative data was collected from the Zoom interviews and analyzed for common codes and themes using appropriate computer assisted qualitative data analysis (CAQDAS) software available through Weber State University. Categorical themes were identified through inductive thematic coding in a constructivist framework by framing a network of interlocking ideas gleaned from the responses of imaging professionals regarding their experiences with burnout, self-esteem, and COVID-19. Steps were taken to develop appropriate interview questions including, alignment with the research questions, constructs of the theoretical frameworks, and current literature. Reliability and validation in this qualitative study were addressed through a piloted analysis of the first three completed interviews. All investigative data was triangulated between similar online research, comparative analysis of different interviewer’s participant responses, and feedback from WSU faculty and health professionals not directly associated with the project. Data from the interviews helped investigators find common themes among frontline employees across the country pertaining to their experiences and impressions while dealing with the COVID-19 pandemic to provide a broad understanding of frontline employees' first hand experiences. Codebook. Through data cleaning, a codebook was created whereby common themes were an umbrella to secondary reporting factors. All reported factors were perceived as supportive, associated, or causative for the common theme. For example, the common theme, Effect of COVID-19 Imaging Professional 37 distress, has high association with the reporting factor of a lack or misuse of PPE. Researchers reviewed interview transcripts on the sentence level, developed a matrix of common themes and frequency, and organized these themes under the research questions. Review of the transcripts was done multiple times by each member of the research team. Once codes were determined, these codes were checked for redundancy and clarity. Definitions of final themes were determined as guidelines for the reader. Ethical Considerations The study was approved by the Weber State University Institutional Review Board (IRB) (Appendix A). The study, including the collection and long-term storage of data, was the responsibility of principal researcher and team lead, Dr. Tanya Nolan, Associate Professor and Director of the Master of Science in Radiologic Sciences (MSRS) program at Weber State University. The student researchers received no direct financial compensation or incentive for completing this study other than the reward of completing a Master’s Thesis and obtaining a Master’s Degree in Radiologic Sciences. The interviews were strictly voluntary and participation held minimal risk. Subjects were informed of minimal risk and gave verbal consent prior to participating in the Zoom interview. To assure and maintain confidentiality, no subject personal data was recorded. Participants also signed a standard informed consent documents which included a disclosure about any risks and benefits associated with the study, the purpose of the research, and details for requirements for participation. Examples of the consent forms given to each participant are located in Appendix C, Appendix D, and Appendix E. Each participant was assigned a number to de-identify electronic data. Interviews were transcribed by Otter.ai before being secured within a password-Effect of COVID-19 Imaging Professional 38 protected electronic Box accessible only by the research team. No data was shared outside the research group. Additionally, no identifying details are included in any publication of this study. Qualitative data was extracted and any quotations are attributed to an assigned subject’s number, ensuring the maintenance of anonymity. At the conclusion of the study, the primary investigator will maintain the password-protected electronic Box for a period of two years. After which, all data will be destroyed according to institutional policy. Results The demographics of this sample included both genders, eight of the sample identified as female, and four of the sample identified as male (Figure 1). Figure 1. Demographic Information Respondents' ages ranged from 24 to 57 years and the reported years of experience in the imaging sciences ranged from 1 to 37 years. A breakdown of years of experience reported by participants includes 1 to 10 years (75%), 10 to 20 years (5%), 20 to 30 years (10%), and 30+ Effect of COVID-19 Imaging Professional 39 years (5%) of experience in radiological imaging with the median years of experience being 5 years. The sample population was recruited from areas across the United States and included participants from the east coast, mid-west, Rocky Mountain region, and the west coast with 25% of the participants coming from the Rocky Mountain region (Figure 2). Figure 2. Years of Experience and States of Employment The sample consisted of ARRT certified imaging professionals working with patients being evaluated or treated for COVID-19 within the radiology department or Computerized Tomography (CT) department. Responses from the twelve participants to each interview question were transcribed and analyzed for common themes and “weighted” by the number of times the themes were expressed during the interviews (Figure 3).Effect of COVID-19 Imaging Professional 40 Figure 3. Weighted Themes Across All Interview Data These themes, as agreed upon by the researchers, were then defined based on respondent expressions (Table 1). Table 1 Definition of Themes Theme Weight (# of times expressed) Definition Expressed Topics No Change in responsibilities or hours 38 Responsibilities and hours remained consistent pre- and post-COVID-19 Consistent role responsibilities Consistent Expectations Change in responsibilities or hours 25 Change in day to day job responsibilities and hours Change in hours, Redeployment/PRN Increased precautions/PPE Distress 61 Feelings of stress, anxiety, concern, apathy, frustration COVID: Personal risk/transmission Effect of COVID-19 Imaging Professional 41 Lack of PPE Job security Management support Coworkers Patients General public response Exhaustion 16 Feelings of physical or mental fatigue Fatigue Physical pain Emotional overload Psychological effects Empathy/Sympathy 28 Feelings of compassion Feelings of care, concern, and sensitivity toward patients/coworkers Increased Performance Satisfaction 52 Individual belief in their ability to complete role responsibilities with competence and satisfaction. Personal accomplishment and helping patients Positive associations with coworkers Feelings of confidence and self-efficacy Decreased Performance Satisfaction 8 Individual belief that they were restricted in completing their role responsibilities with competence and satisfaction. Lack of personal accomplishment Negative coworkers Communication Lack of PPE Positive Feelings towards Management 24 Perceptions of trust, appreciation, and support toward management Job security Protected (PPE) Good communication Support Negative Feelings Toward Management 7 Anger, dislike, resentment, distrust, or disturbance toward site administration and governance. Policy changes/communication Lack of PPE Last, these themes were related back to the original research questions so as to understand the health professionals’ perceptions of burnout and self-esteem, along with their associated variables, as subjectively experienced and witnessed by the participant within a COVID-19 era (Table 2). Effect of COVID-19 Imaging Professional 42 Table 2 Research Questions and Common Themes Results Research Question Common Themes Reported Factors Q1: What factors (mental, emotional, or physical) were perceived by imaging professionals that related to variables of burnout during the COVID-19 pandemic? ● Distress ● Empathy or sympathy ● Exhaustion ● PPE ● Coworkers ● Inconsistent Management ● Poor Communication ● Exhaustion ● Long hours Q2: What factors (mental, emotional, or physical) were perceived by imaging professionals that related to variables of self-esteem during the COVID-19 pandemic? ● Increased performance satisfaction ● Decreased performance satisfaction ● Change in responsibilities ● Recognition ● Self-efficacy ● Organizational Support ● Coworkers ● Empathy Q3: What outside factors (including working hours, role responsibilities, and institutional or management support) affected perceived variables of burnout and/or self-esteem during the COVID-19 pandemic? ● Increased or decreased performance satisfaction ● Change or no change in responsibilities or hours ● Positive or negative feelings toward management ● Organizational Support ● Good Communication ● Fear of contagion ● Long hours ● Redeployment ● PPE Themes that emerged from the first research question that relate to burnout include: distress, empathy or sympathy, and exhaustion (Table 2). Factors contributing to these overarching themes included the lack of PPE, fear of contracting the virus or bringing it home to Effect of COVID-19 Imaging Professional 43 family, co-worker attitudes, inconsistent management, poor communication, exhaustion and long work hours. The most common response and overarching theme related to burnout was distress to include feelings of stress, anxiety, concern, apathy or frustration. The least weighted response was coded as physical and mental exhaustion (Table 1). Themes developed from the second research question that relates to self-esteem includes: increased satisfaction, decreased satisfaction, and change in responsibilities (Table 2). Factors contributing to these overarching themes included the recognition received, self-efficacy, organizational support, coworkers, and empathy. The most common response and overarching theme related to self-esteem was increased satisfaction to include personal accomplishment, helping patients, and positive coworkers. The least response for self-esteem was decreased performance satisfaction which included personal accomplishment, negative coworkers, communication, and lack of PPE (Table 1). Themes that emerged in answer to the third research question that relate to outside factors that either increased or decreased variables of burnout and self-esteem includes: increased performance satisfaction, decreased performance satisfaction, a change or no change in job responsibilities and hours, and having positive or negative feelings towards management (Table 2). Factors contributing to these overarching themes included organizational support, good communication, fear of contagion, long hours, redeployment, and use of or lack of PPE. The most common response and overarching theme related to outside factors that increased or decreased the variables of burnout and self-esteem was increased job satisfaction to include personal accomplishments and helping patients, positive co-workers, and feelings of confidence and self-efficacy. The least common response related to factors that increase or decrease the Effect of COVID-19 Imaging Professional 44 variables of burnout and self-esteem was negative feelings toward management to include policy changes, lack of communication and lack of PPE (Table 1). Discussion RQ1. Burnout All participants reported on some level of burnout or its associated characteristics. Distress was the most experienced and perceived theme among participants during the COVID-19 pandemic. Distress was defined as reported stress, anxiety, concern, apathy, and/or frustration. Feelings of distress also encompassed the feelings of apathy or frustration these participants felt toward fellow co-workers during the pandemic. Many of the participants, at the onset of the pandemic, described some frustration with their co-workers due to individual fears and the unknown of how policies would consistently change on how to protect themselves from infection. Findings, as with Eddy (2020), supported that these healthcare workers felt overwhelmed with the demands of patient care, their work overload, poor work conditions, time pressures, poor management support, and stretched peer relationships. Feelings towards peers were further diminished by policies that changed privilege and hierarchy within their hospital culture. Participant 6 stated, “A lot of my techs, they don't want to do COVID patients, and some of them do the COVID patients. One does one chest x-ray, another one says they did two. So, they keep arguing with each other.” This resulted in management having the imaging professionals log COVID patients and who completed the study so that there were equal responsibilities with COVID patients. Some participants reflected on how they were assigned numbers to rotate staff assigned to image infected patients as means to equalize their risk of exposure. Participant 6 went on to say, “So I made a list for them. Recorded Effect of COVID-19 Imaging Professional 45 using the medical record number, with the date and the time and that you did the COVID patient so I will know that everybody is doing their fair share.” Due to staffing changes controlled by management, the system of equalized exposure was nearly null and void whereby some employees were effectively exempt from imaging any COVID-19 positive patients. Furthermore, participants reported that, early in the pandemic, they had increased distress with feelings of anxiety toward their management due to the procedural uncertainty. Many managers lacked the knowledge of how to protect the frontline workers from contracting the virus nor how to extend, stockpile, or reuse PPE. Early on, protocols were changing so rapidly as to be altered from beginning of the shift to the end of the shift. In this crisis, management could not meet the standard of good leadership as indicated by Chi (2014) wherein ethical, trustworthy, and transparent leadership was a means in reducing stress, fear, and anxiety as cause to employee burnout. Participant 4 felt extensive distress, bordering on anger, toward their management. The participant was told at the beginning of a shift, “Here is a mask, make it last.” To which they thought, “Why will you not protect us?” In this participant’s early experience, best practice for PPE was rapidly changing. However, new protocols reflecting these best practices would take days before implemented within the radiology department. The participant mused, “Why don’t we have the same resources that nursing had?” Participant 3 reported having been frustrated after being exposed to a potential COVID-19 patient during an initial chest x-ray. The exposure occurred because there was a lack of consistent COVID-19 policy regarding communication between healthcare teams to ensure all personnel were protected. Without this knowledge, imaging professionals were not always properly prepared and/or protected with PPE. All the participants related frustration with the Effect of COVID-19 Imaging Professional 46 accessibility, training, and use of PPE. For some participants, PPE was locked up and inaccessible without permission. Most participants had to reuse PPE, such as masks, and/or share potentially contaminated gowns. Similar to the findings of Morgantini et al. (2020), participants had anxiety due to a lack of adequate PPE, the fear of unknowingly bringing the infection home to friends and family, and the absence of updated information about the virus. Conversely, the data also showed participants having empathy or sympathy toward co-workers and patients whereby they felt a firm obligation to serve and protect them. These feelings may have also rendered them to be in a position of guilt or remorse. However, it is understood that most healthcare professionals are driven to the career based on their innate levels of compassion, empathy, and sympathy toward all humankind. For example, Participant 3 reported how sorry she was for her co-workers. While Participant 6 worried more about her coworkers and patients than she did about herself. Participant 11 expressed that she was “appreciative of the people I work with”. In conjunction, the participants reported having feelings of empathy toward their patients experiencing COVID-19 symptoms, most participants felt these feelings were intensified not only for the patient, but also for humankind, as the pandemic has raged on without a definitive timeline. Participant 11 reported how her empathy had grown deeper for people while seeing patients with the virus, stating,” It hits you right in the heart!” Some participants reported that they “just wanted to sit and hold the patients hands”, and they were heart-broken to witness isolated patients dying without their families present due to the restriction on visitors within the hospital. Participant 1 stated that they were “trying to make it a point to try to... get to know them [patients] a little bit.” Indeed, as reported by Lazaro-Perez et al. (2020), healthcare workers are vulnerable to events related to their patients, and they are affected by these personal and life-Effect of COVID-19 Imaging Professional 47 changing moments as it touches their very innate core. The ideas of empathy and sympathy have been extrapolated among relationships between patients, co-workers, and humankind because the COVID-19 pandemic is felt on all levels of human interaction. As related to burnout, these feelings exacerbated and unchecked over time may lead to both mental and physical exhaustion. In fact, feelings of increased empathy were not universal among participants. Some participants reported distancing themselves from the suffering. Emotional distancing is considered a defense mechanism. In the words of one participant, “I feel like it's kind of made me a little bit more apathetic, just because, you know, we're all going through, we're all fatigued. We're all tired and ready for this to be over” and “…it just makes tension a little bit more prevalent, and so it's a little bit harder to be empathetic”. These feelings, experienced by the exhausted health care professional, relate to symptoms of both depression and burnout because this defensive mechanism is a form of passive or avoidant coping focused on levels of helplessness. Shin et al. (2014) shared the concept that passive coping focuses on “emotional regulation and disengagement”. Hence, if chronic or long term, may indeed lead to burnout syndrome or post-traumatic stress disorders (Vagni, 2020). Morgantini et al. (2020) reported that not all healthcare professionals will experience burnout in the same manner. Burnout is dependent on occupation, the patient population, and how the pandemic is affecting the workplace. The participants in this study also experienced heightened worry regarding their job security and concerns about co-workers being furloughed or ‘flexed’ from their normal work hours because of decreased patient volumes. Participant 10 reported being temporarily furloughed from a second job as a per diem technologist for two months. Because facilities were asking full time staff to ‘flex’ during the week, bringing in per diem staff was unfeasible. Being Effect of COVID-19 Imaging Professional 48 concerned over job security by either being furloughed or flexed, was a common concern among multiple participants. Participant 2 reported that they all took a day off a week to make sure no other coworker had to be cut from their position. Participant 7 stated “I realized that even in healthcare your job isn’t as secure as you thought it would be.” No change in day to day responsibilities was a theme that was reported by some participants who experienced the same job responsibilities regarding patient care, work hours, and/or job security. For example, Participant 12 reported that “there was never really concern over job status”. There was no concern over the use of the PPE and how they should be worn for protection”. Participant 6 stated, “I feel prepared and felt confident that we were well trained”. Initially, several participants reported that they were conserving the PPE, but as time passed, their concern for the shortage has transformed into confidence and a lack of concern. Hence, the perception and experience of every healthcare worker does vary widely based on geographic location and hospital/clinic resources. Another compelling supporting factor related to mental exhaustion was the ongoing anxiety and worry participants experienced over the affect COVID-19 would have on their families and loved ones. First, there was a fear of bringing COVID-19 home to their families, and second, there was concern about how their families would function if they contracted the virus and could not fulfill their roles as a supporter and provider. Participant 11 stated, “I just worry about passing that on to family [and] friends”. Participant 2 shared how she would tell her family “Don’t come near me, don’t touch me”. Consistently, participants would detail the ways they would decontaminate themselves before returning home to see their families. Participant 3 described the process of “not wearing the clothes and shoes and stripping in your garage”. Participant 12 spoke of wiping down his badge, wallet, and the steering wheel of the car before Effect of COVID-19 Imaging Professional 49 contact with his family. In support, Taylor, et al. (2020) reported the constant fear of the COVID-19 as one of the five factors of COVID stress syndrome exacted on healthcare workers. As a compounding factor, Participant 11 reported feeling mental exhaustion, worry, and isolation because of their efforts to physically remove themselves and stay away from friends and family. Cai et al. (2020) reported that the lack of contact with families and long hours of intensive work might be why frontline medical workers are experiencing mental health problems and are not seeking help or receiving treatment for mental health related issues. Adding to health professional’s mental and physical exhaustion, COVID-19 policies and procedures have been difficult to maintain and sustain over time. For example, imaging professionals reported having to adjust schedules to assure PPE was used properly and decontamination processes were complete after each and every patient leading to longer schedules, complex procedures, and longer patient exam times. Participant 3 stated, “I don’t know if I really want to do this anymore.” Participant 9 reflected on how the increased hours, the severity of the pandemic, and the emotional aspects resulted in her needing time off but that her “body wasn’t drained”. Barello (2020) reported physical symptoms, related to levels of professional burnout, were directly associated with the quality of patient care experienced during a COVID-19 era. Early on, Participants 1 and 4 felt increased levels of physical exhaustion that they attributed to the increased number of portable exams being ordered. In fact, all exams were being done portably during the initial stages of the pandemic. Participant 1 stated,” we’re seeing tenfold the amount of patients this time." To complicate matters, Participant 4 also reported physical exhaustion due to the use of heavy lead shielding worn at all times under gowns with masks and gloves. In summary, levels of burnout were most affected by levels of distress. Distress, during Effect of COVID-19 Imaging Professional 50 the COVID pandemic, was felt by imaging professionals as indicated by increased levels of stress, anxiety, concern, apathy, and frustration. Although Taylor et al. (2020) attributed the fear or anxiety felt during a pandemic as normal, they made clear a differentiation between that and traumatic stress or chronic burnout. In these latter cases, anxiety goes far beyond normal levels of worry because it is a constant anxiety that demands the mind’s attention all of the time. As this pandemic continues, and mental and physical exhaustion escalate, these variables will have influence on both the healthcare professional and the patient’s care. In agreement, Salyer’s (2016) reported that less burnout was associated with an improved quality of care for their patients. A plan to mitigate how imaging professionals could reduce anxiety during and after the COVID-19 pandemic may be an effective means of reducing levels of burnout and support both the healthcare professional and the quality of patient care. For example, Otto (2019), stated that healthcare professionals learned resilience by engaging in a variety of behaviors to reduce the effects of burnout such as leisure activities, relaxation, refusing additional work responsibilities, and reflective mediation. These are active coping mechanisms that would reduce psychological and physical demands in all aspects of the healthcare professional’s life. RQ2. Self-Esteem In relation to self-esteem, variables including increased or decreased performance satisfaction (confidence and competency in an individual’s ability) and changes in role responsibility were identified and coded as common themes. Many participants experienced an increased satisfaction in their performance because they felt as though they held a vital role and a responsibility in the patients’ proper diagnosis. Participant 3 stated, “I’m just proud of being able to do what I do. I’m glad, I feel like I’m able to help take care of them [patients]". Participant 11 Effect of COVID-19 Imaging Professional 51 stated, “Our images decide what treatment will be given to the patient. So, I feel like our work is very valuable". Additionally, during COVID-19, many radiologic technologists received recognition for their role and its significance in helping diagnose and treat patients. At long last, it was not just the nurses and doctors who received full recognition as essential in the healthcare team. Participant 3 stated, “People were actually pointing it out, like hey, the x-ray techs, they’re right up there close and personal. And people didn’t realize that and it kind of brought our profession up there a bit". Even among patients, technologists felt a new sense of respect and gratitude. For example, Participant 7 stated “[It] feels like...the patients are very appreciative.". Because of these interactions, these radiologic technologists felt a sense of pride and justification for who they were and what they could accomplish as a valued team member among their peers. They also shared, with their interprofessional colleagues, a risk for infection offset by their innate sense of altruism. For example, Participant 7 stated, “I think people saw what we are doing more [and] kind of realized that we’re at risk of catching it.” Organization-based self-esteem is an individual’s perception of their own worth and meaning as part of an organization. Individuals with high organization-based self-esteem feel important to the organization, make a difference, and are better prepared to overcome obstacles (Gardner, 1998). Prior studies have correlated self-esteem as a low-level mediator (Sarpkaya, 2019) to job satisfaction which positively influences job performance (Pérez-Fuentes, 2019b) and patient care. According to participants, changes in responsibility also positively influenced their perception of personal and organizational self-esteem. Many perceived and felt their changes in roles and responsibilities were necessary, supportive, and cooperative to their health care team. As imaging professionals, these participants were well-equipped and prepared to change their Effect of COVID-19 Imaging Professional 52 roles because their career path demands consistent training and the ability to work in different environments, within various patient care experiences, and often, using multiple imaging credentials. However, much respect and appreciation was gained by these participants for their peers in healthcare because they were required to “walk in their shoes” and see healthcare from their coworkers perspective. During a situation like the COVID-19 pandemic, teams perform better when coworkers are able to rely on one another and are willing to lend a helping hand to those who need support, whether that be another radiologic technologist or another healthcare professional. Sociometer theory, for instance, asserts that people are motivated to act in their own self-preservation, as well as to expand their social position through thought and action (Leary, 1999). Meaning people have to work in groups and communities to help support their self-esteem. Interprofessional teamwork has proven to be an effective model in healthcare for providing high quality patient care and improving personal job satisfaction (Corbridge & Melander, 2019; Petersen, 2017; Verhovsek, 2009). RQ3. Outside Factors The participants’ increased performance satisfaction, supported by their ability to help patients and have positive interactions with co-workers, was considered an outside factor that affected the participants’ use of active coping mechanisms which moderated both burnout and self-esteem. This relationship occurs because factors of social trust and job satisfaction are correlated to individual and group resiliency (Bibi, 2017; Perez-Fuentes, 2019a). Bandura (1997) defined resiliency as the ability to change, adapt, and endure setbacks, problems, and high stress levels. Thus, those participants responding with these feelings and perceptions demonstrate their ability to cope and to cope well. Effect of COVID-19 Imaging Professional 53 Examples of social trust and job satisfaction included statements from Participant 4 who said, “I was satisfied that we did a good job and we kept everyone safe and healthy”. In many cases, participants found themselves more concerned about their coworkers than themselves. Thus, participants worked within their professional communities to actively help and alleviate their peers’ burnout resulting in feelings of self-esteem that diminished their own personal stress and anxiety. Participant 11 reported, “I love my coworkers, we work hard together, and they’re just great people to work with". Hence, the sociometer theory is supported whereby people are motivated to expand their social position through thought and action (Leary, 1999). Participant 12 reflected, “It's definitely given me a sense of value within the workplace that [is] perhaps significantly more than there was before the pandemic". Participants exercised resilience and selected plans and behaviors that would effectively increase their self-esteem as a means to handle their burnout and its side effects which is related to active coping skills. Another outside factor affecting both burnout and self-esteem among participants was the rapidly changing institutional processes enacted in response to quickly evolving knowledge on the COVID-19 virus. Many healthcare facilities reduced elective procedures, changed cleaning policies, reduced/furloughed employees, and in some cases, increased work hours. Many participants discussed whether or not they had experienced a change in their time commitments, responsibilities, and/or rules and regulations, especially in situations involving cleaning/sanitation or PPE. The latter was likely an emphasis because, as Vagni et al. (2020) noted, adequate supplies and hospital training tended to reduce stress in health care professionals, but when these resources were limited, so were feelings of assurance, confidence, and self-efficacy. Participant number 8 stated, “It’s affected my daily life, and things I do there…”, Participant 7 noted, “It’s Effect of COVID-19 Imaging Professional 54 made things slower [using] PPE, … masking and gowning up for every patient or all the patients that were positive. It’s made work harder, more tiring at times because of all the work for that. It gets harder to keep up". Conversely, participants who experienced or perceived few to no changes in their daily work routines and responsibilities felt little impact regarding variables of burnout and self-esteem. Participant 10 stated, “I don’t think it really affected it at all...I feel pretty much the same". And, Participant 8 stated, “I just feel happy to help". Most participants reported having more positive feelings toward management than negative. These imaging professionals recognized their managers and leaders as having worked hard to incorporate good communication, demonstrate integrity, and to provide necessary resources, including PPE. As reported by Chi (2014), these managerial factors increased feelings of trust and value which both served to reduce burnout. Therefore, real leadership incorporates solidarity between managers and employees wherein they understand the needs of their team and are committed and competent in delivering them. As examples, Participant 6 reported having felt a low self-esteem among coworkers until their management gave them proper PPE to protect themselves. Participant 4 stated, “that they thanked management for getting us googles, and letting us wear scrubs”. Participant 11 stated, “...we were kept well informed”. Participant 6 said of their employer, “...they did a good job providing us N95 (respirators)”. And, Participant 1 reported, “I actually have a lot of respect for them. Because I think they did a great job putting together the communication system”. Supportive management and positive engagement assists employees in achieving workplace goals, maintaining positive work attitudes, increasing job-fulfillment, and reducing personal burnout (Schaufeli and Bakker, 2004). In support, Nowakowska (2016) and Baird (2019) reiterated that a healthy, safe, and friendly work Effect of COVID-19 Imaging Professional 55 environment with well-organized, supportive hierarchy can increase self-efficacy, foster well-being and eliminate the factors causing the occurrence of burnout. In opposition to this condition, researchers have indicated that negative team members, negative conditions, and lack of organizational support discourage and hinder a sense of hope (Duggleby, 2009). Participant 4 experienced negative feelings towards management stating, “...we had emails that went out in the morning that gave us what we should be doing. And then, we had an afternoon email that would tell us what we should be doing. So, things would change from the time I walked in one day - till the time I came in the next day.” With no real direction and overwhelming feelings of chaos and disorder, this participant could not fully prepare for the day nor react to the changes appropriately. It is important to have strong leadership with good communication and team building skills to create a healthy work environment where staff feels safe, supported, and valued. Leadership and management is a real modifier to the burnout and self-esteem experienced by the imaging professional because it allows the professional to feel support and anticipate his/her control, coping mechanisms, and reactions. Feelings one has about themselves and their control and their ability to respond appropriately and competently in different situations is considered a low-level mediator (Sarpkaya, 2019) to job satisfaction which positively influences job performance (Pérez-Fuentes, 2019b) and patient care. Therefore, taking care of the psychological well-being of the healthcare worker is, in turn, taking care of the well-being of the patient. Effect of COVID-19 Imaging Professional 56 Conclusion Results from this study indicate that the high demands and risks associated with COVID-19 affect imaging professionals throughout their workday. And while participants expressed feelings of burnout, this did not seem to directly affect their self-esteem. Exploring these topics is important because healthcare professions are particularly stressful occupations, rooted in an environment that often leads to burnout (Chi, 2014). The imaging professionals interviewed for this study during the COVID-19 pandemic described mental, psychological, and physical factors that have been correlated to burnout. This should not be particularly surprising as research has suggested that healthcare professionals who deal with large levels of adversity, increased workloads, and high levels of stress during the COVID-19 pandemic are more likely to experience burnout (Morgantini et al., 2020; Ramaci, 2020). The concern about being exposed to COVID-19, as well as bringing the virus home to family and friends, contributed toward mental exhaustion, which in turn resulted in increased levels of distress, thereby increasing the likelihood of imaging professionals to experience burnout. Our sample reported that they had increased distress with a variable of anxiety toward management over the COVID-19 pandemic due to the daily changing protocols, or the initial conservative efforts to preserve PPE, as well as the delay in communication over the use of the PPE. Morgantini et al. and Lazaro-Perez et al. (2020) reported that the healthcare workers are experiencing large amounts of distress due to access to adequate PPE, unknowingly bringing the infection home, and a lack of current information about the virus. This directly relates to the findings of this study. Still other participants expressed sympathy for their institution’s leadership. In the words of one participant, “No one really, really knew what they were dealing with.” and, “ ...There were new things coming every day, new guidance from the CDC, like it Effect of COVID-19 Imaging Professional 57 just felt like they were doing the best they could, and I feel like [the leadership] did a good job, given what they had. I feel like they did try very hard to protect us and do the right thing. So, I think I'm proud of us". Previous research has shown that a work environment that is healthy, safe, and friendly, as well as directed by a supportive hierarchy, one which is well-organized, can lead to increased feelings of self-efficacy and foster well-being and trust. These elements could reduce the factors causing the occurrence of burnout (Chi, 2014; Nowakowska, 2016; Baird 2019). The study data indicated that positive feelings towards management outweighed the negative. This is particularly interesting as individuals with higher organizational-based self-esteem feel like they are important to the organization and that they make a difference. They exhibit greater social trust, optimism, job satisfaction, and resiliency (Bibi, 2017; Gardner, 1998; Perez-Fuentes 2019a; Williams, 2017). Negative team members, conditions, and lack of organizational support have the effect of causing discouragement, hinder hope (Duggleby, 2009) and reduce both organizational self-esteem and personal self-esteem. The data indicated that imaging professionals had an increase in empathy or sympathy toward their patients and towards coworkers during this pandemic. In fact, they were often more worried about keeping their fellow co-workers safe from contracting the virus than they were about contracting the virus themselves. Participants felt a strong sense of team comradery and mission, and derived satisfaction from being part of a team working together to take care of patients. Institutional programs that encourage interprofessional, team-based practice help relieve burnout by sharing care-taking responsibilities. For instance, an interprofessional approach to patient care recognizes that each individual on the healthcare team has unique skill sets. A culture of sharing care-taking responsibilities can help mitigate burnout by reducing the burden on any one profession (Corbridge & Melander, 2019). Imaging professionals are a valuable part Effect of COVID-19 Imaging Professional 58 of that healthcare team with unique skill sets and contributions, and a culture of sharing care-taking responsibilities. Participants also felt very sympathetic towards patients who were hospitalized without any family to talk to or hold their hands, and in some cases, dying alone due to the restrictive nature of hospital policies in place for community protection. This study also found that imaging professionals perceived an indirect effect on their sense of self-esteem during the COVID-19 pandemic. Burnout is often linked with a decrease in self-esteem. What is particularly interesting is, while this study found strong elements that could contribute to burnout, there was an increase in participants’ sense of self-esteem, self-efficacy, and personal satisfaction. The majority of participants in this study reported feeling fully prepared and capable to provide high quality patient care. This indicates that the participants experienced increased levels of self-efficacy and self-esteem as a result of working and mastering the skills necessary during adversity. Possessing self-efficacy, or the conviction that one can successfully execute a task, is linked to a self-perpetuating cycle of the personal sense of self-efficacy and self-esteem (Bandura, 1977; Gardner, 1998; Mruk, 2006a). As with prior studies, the participants of this study reported personal levels of higher self-efficacy after facing the adversity associated with the pandemic (Ramaci, 2020). Self-esteem has been linked to personal levels of hope (Duggleby, 2009; Ramaci, 2020) and is an essential personal resource to the emotional and psychological well-being of healthcare workers (Pérez-Fuentes et al., 2019a). As if to illustrate this point, one participant stated, “…I had the exhaustion, but I did have the fulfillment that I was doing good". Healthcare professionals with a build-up of personal resources are better able to navigate difficult situations and are more likely able to control their emotional responses during personal setbacks (Peterson, 2017). Thus, increased levels of self-efficacy and self-esteem contribute to resilient psychosocial outcomes. A result that was Effect of COVID-19 Imaging Professional 59 noteworthy was that increased personal satisfaction was the second strongest theme expressed by the participants in this study. As such, the results of this study mirror prior studies that noted healthcare workers expressed higher levels of fear and fatigue at the beginning of the COVID-19 pandemic due to long hours and lack of information. That fear and fatigue decreased over time while personal satisfaction increased (Ramaci, 2020). As the COVID-19 pandemic has evolved and a resurgence is being experienced worldwide, more information about burnout and healthcare workers has become available. Recent National Public Radio (NPR) reports point out that healthcare workers experienced increased levels of satisfaction and exhilaration from helping in areas like New York during the early phase of the pandemic. That same increase in performance satisfaction is reflected in the results of this study. However, the pandemic has progressed to all areas of the country and we are currently facing high infection rates and a healthcare crisis due to exhausted staff and understaffing because of COVID-19 infection or quarantining and no reinforcements available as there were in the early days. Perceived burnout is increasing among healthcare professionals. As we understand the effects of burnout on imaging professionals, we can then begin to address factors that affect employee satisfaction, retention and assure the stability of the imaging industry going forward. The long-term taxing ramifications of burnout on personal levels of self-esteem experienced by imaging professionals was an issue before the pandemic but has been amplified since the start of COVID-19. Effective workplace leaderships strive to provide a well-organized, safe, healthy and friendly work environment to instill in their employees feelings of support and trust thereby increasing optimism and job satisfaction. Wellbeing programs and support resources (i.e. child and family care, access to counseling, and peer support groups) provide Effect of COVID-19 Imaging Professional 60 employees opportunities for stress management by validating and normalizing experiences and helping them develop coping skills. These coping skills can reduce the impact of exposure to trauma and stress felt by imaging professionals. Limitations and Recommendations for Future Study The researchers acknowledge several limitations in this study. First, because the participants of the study were solicited through convenience rather than random sampling, the data is vulnerable to inherent bias. Second, the small sample size makes it difficult to generalize the results. That said, because the study participants differ sociodemographically, coming from different states and regions within the United States and working in different sized healthcare facilities, their responses may be at least somewhat representative of the larger population of imaging professionals. Third, the data was collected from responses of frontline imaging professionals after the uncertainty of the initial emergent period of the COVID-19 pandemic. It is possible that the original burnout and exhaustive emotions experienced have subsided in favor of apathy or, more positively, evolved to resilience. A longitudinal study utilizing a mixed method approach, in order to reduce bias and to more thoroughly investigate the correlation between burnout and self-esteem and resiliency, is recommended for future studies. 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IRB Approval Letter, Instrument, Supporting Docs September 21, 2020 Tanya Nolan Aubree Warner, Paige Lueck, Susan Schiffbauer, Tina Horbach Students, School of Radiologic Sciences Re: Exempt - Initial - IRB-AY20-21-49 The Affect of COVID-19 on Imaging Professionals Level of Burnout and Self- Esteem Dear Tanya Nolan: Weber State University Institutional Review Board has rendered the decision below for The Affect of COVID-19 on Imaging Professionals Level of Burnout and Self-Esteem. Decision: Exempt Approval: September 21, 2020 Expiration: -- Selected Category: Category 2.(i). Research that only includes interactions involving educational tests (cognitive, diagnostic, aptitude, achievement), survey procedures, interview procedures, or observation of public behavior (including visual or auditory recording). The information obtained is recorded by the investigator in such a manner that the identity of the human subjects cannot readily be ascertained, directly or through identifiers linked to the subjects. Category 2.(ii). Research that only includes interactions involving educational tests (cognitive, diagnostic, aptitude, achievement), survey procedures, interview procedures, or observation of public behavior (including visual or auditory recording). Any disclosure of the human subjects’ responses outside the research would not reasonably place the subjects at risk of criminal or civil liability or be damaging to the subjects’ financial standing, employability, educational advancement, or reputation. Subjects are considered adults and signatures are required. They may choose not to participate. You have one year to complete the study. Anonymity and confidentiality are addressed appropriately, and the type of information gathered could not "reasonably place the subjects at risk of criminal or civil liability or be damaging to the subjects' financial standing, employability, or reputation" (Code of Federal Regulations 45 CFR 46, Subpart D). You may proceed at this time. Please remember that any anticipated changes to the project and approved procedures must be submitted to the IRB prior to implementation. Any unanticipated problems that arise during any stage of the project require a written report to the IRB and possible suspension of the project. Findings: Research Notes: Sincerely, Matthew Nicholaou, DrPH, MT(ASCP) Chair, DCHP IRB Sub-Committee Weber State University Institutional Review Board Effect of COVID-19 Imaging Professional 73 Appendix B. Burnout and Self-esteem Questionnaire 1. What is your gender? 2. What is your age? 3. What state are you employed in? 4. What is your current medical imaging role and how long have you been in this position? 5. Do you work full-time or part-time? Has this changed since COVID-19 started? 6. Do you work with patients when they initially come to the hospital with potential COVID-19? 7. Did you ever experience concern for your job status or were temporarily redeployed during the COVID-19 pandemic and how did that make you feel? 8. How have your job expectations and performance changed since the COVID-19 pandemic, if at all? 9. Professional burnout is characterized by high levels of emotional exhaustion, cynical attitudes, and a diminished sense of personal accomplishment at work. Describe for me how or whether you experienced this sort of burnout during the pandemic. 10. How has your interest and empathy for your patients and co-workers changed during this pandemic? 11. How do you feel about yourself since working through the COVID-19 pandemic? Are you feeling more satisfied in yourself, or do you feel less so? 12. Describe how your attitude toward yourself and the work that you do has changed as a result of the pandemic. Effect of COVID-19 Imaging Professional 74 13. What are your feelings toward leadership, your co-workers, and patients since the COVID-19 pandemic? 14. In what ways has the COVID-19 pandemic affected your sense of value in the work that you do? 15. Describe how you feel about your value after working with a COVID-19 patient. 16. Knowing that you could be contaminated, describe how you feel about returning home after working with COVID-19 patients. 17. Were you infected with COVID-19 in the course of performing your job, and if so, how did that make you feel about your job? 18. How has your institution’s response to COVID-19 affected your sense of self-esteem? 19. How has the use or lack of PPE affected your work experience during COVID-19? 20. Describe how prepared you feel to provide care for your patients. Effect of COVID-19 Imaging Professional 75 Appendix C. STANDARD MEDIA RELEASE FORM Organization/Program: Weber State University – Master of Science in Radiologic Sciences Dates: September 2020 – December 2020 Location: Via Zoom meetings I hereby authorize the Master of Science in Radiologic Sciences students to record and edit my likeness, voice, and interview. I agree that the Master of Science in Radiologic Sciences students may use and authorize the use of any part of this documentation for, but not limited to, educational purposes, statistical data, and as part of a Master’s thesis paper. Additionally, I waive any right to royalties or other compensation arising or related to the use of my information or recording. I also understand t