1 THE WEBER STATE UNIVERSITY GRADUATE SCHOOL SUPERVISORY COMMITTEE APPROVAL of a thesis submitted by Kelsey Larsen, BS, R.T.(R)(ARRT) Taylor Bench, BS, R.T.(R)(ARRT) Tamara Harp, BAS, R.T.(R)(ARRT) Cory Huff, BSBM, R.T.(R)(CT)(ARRT) This thesis has been read by each member of the following supervisory committee and by majority vote found to be satisfactory. ______________________________ Dr. Robert Walker, PhD Chair, School of Radiologic Sciences ______________________________ Dr. Laurie Coburn, EdD Director of MSRS RA ______________________________ Dr. Tanya Nolan, EdD Director of MSRS ______________________________________________________________________ Christopher Steelman, MS Director of MSRS Cardiac Specialist 2 THE WEBER STATE UNIVERSITY GRADUATE SCHOOL RESEARCH AGENDA STUDENT APPROVAL of a thesis submitted by Kelsey Larsen, BS, R.T.(R)(ARRT) Taylor Bench, BS, R.T. (R)(ARRT) Tamara Harp, BAS, R.T.(R)(ARRT) Cory Huff, BSBM, R.T.(R)(CT)(ARRT) This thesis has been read by each member of the student research agenda committee and by majority vote found to be satisfactory. Date August 11, 2022 ____________________________________ Kelsey Larsen August 11, 2022 ____________________________________ Taylor Bench August 11, 2022 ____________________________________ Cory Huff August 11, 2022 ____________________________________ Tamara Harp 3 Coping Through COVID-19: Resiliency in Radiologic Science Students By Kelsey Larsen, BS, R.T.(R)(ARRT) Taylor Bench, BS, R.T.(R)(ARRT) Tamara Harp, BAS, R.T.(R)(ARRT) Cory Huff, BSBM, R.T.(R)(CT)(ARRT) A thesis submitted to the School of Radiologic Sciences in collaboration with a research agenda team In partial fulfillment of the requirements for the degree of MASTER OF SCIENCE IN RADIOLOGIC SCIENCES (MSRS) WEBER STATE UNIVERSITY Ogden, Utah August 11, 2022 4 Acknowledgements I want to thank my family and friends for their constant support and encouragement. I want to thank my amazing professors at Weber State University. Every single one of them has helped me get to where I am today. I want to personally thank Dr. Tanya Nolan for her outstanding help and advice throughout my entire college experience. I also want to thank my fellow students and their help during this process. I will always be thankful for my Weber State family. -Kelsey Larsen, BS, RT(R)(ARRT) I would like to thank the professors of Weber State University. All the professors at Weber have been really great to work with and I can not think of a group of professors that are better. Dr. Tanya Nolan has been a great leader, and has been there the whole time encouraging us students and keeping us on track. I would also like to thank my fellow students, they have all been great to work with and will miss them after we graduate. I would like to thank my family for the love and support they have given to me during this year of school. -Cory Huff, BSBM, RT(R)(CT)(ARRT) I will always be thankful to my wife and family for supporting me through this educational process. They have sacrificed a lot of time to allow me to pursue my goals. It has been an amazing journey and I have learned so much about myself and what I am able to accomplish when I commit to a challenge. Thank you also to all the Weber State University faculty for all of their hard work and support. -Taylor Bench, BS, RT(R)(ARRT) I am grateful for the support of my husband and the hard work of my classmates throughout this project. -Tamara Harp, BAS, RT(R)(ARRT)5 Table of Contents Chapter 1: Introduction 8 Background 8 Statement of the Problem 9 Purpose of the Study 10 Research Questions 11 Nature of the Study 12 Significance of the Study 13 Definition of Key Terms 14 Summary 15 Chapter 2: Literature Review 15 Literary Search Strategy 16 COVID-19: A Historical Account17 Summary 39 Chapter 3: Research Method 41 Research Methods and Design(s) 42 Population 44 Sample 44 Materials/Instruments 45 Operational Definition of Variables (Quantitative/Mixed Studies Only) 46 Data Collection, Processing, and Analysis 47 Assumptions 48 Limitations 49 Delimitations 49 Ethical Assurances 50 Summary 50 Chapter 4: Findings 51 Results 51 Evaluation of Findings 54 Summary 59 Chapter 5: Implications, Recommendations, and Conclusions 60 Implications 61 Recommendations 63 Conclusions 64 References 66 Appendices 72 Appendix A: Figures and Graphs 72 6 Appendix B: Informed Consent 75 Appendix C: IRB Permission Letter 82 7 List of Figures and Tables Figure 1. Distribution of Scores………………………………………………………….……..….54 Figure 2. Correlations of Coping Strategies and Resilience scores…….………………..……….56 Figure 3. Correlations Between Resilience Scores and the Students Clinical, School, and Home Environments……………………………………………………………………...…...…………….…….56 Figure 4. Correlations of coping strategies and resilience score……………………………..……………………………………………….……………….………....58 Figure 5. Correlations between resilience scores and the students clinical, school, and home environments…………………………………………………………………………………………….....59 Table 1. Keywords…………………………………………………………………………………………168 Chapter 1: Introduction There are numerous studies and literature focused on nurses and Radiologists (Perry, 2021), but little research has been conducted for imaging students in healthcare. This study seeks to better understand the resiliency of imaging students and their coping mechanisms. In part, researchers seek to define the students’ current emotional and physical well-being following the onset of the COVID-19 pandemic. The hope is that with a better understanding of the students’ current state of resiliency, imaging professionals and educators can work together to make the imaging students’ experience and career as beneficial, productive, and long-lasting, as possible. Background Health care professionals have been under immense stress and many hospitals have been overrun by the COVID-19 virus. Many of the stresses and challenges experienced by health professionals have influenced the intern and student experience. Within clinical rotations, most imaging students are learning in a burnt out and hostile environment due to the excessive workloads and staffing shortages. Student clinical hours may be rapidly altered based on changing protocols and Coronavirus variants. Outside of clinical education, students have endured University closures that have forced students to cope with their mental and emotional challenges alone and without social support (Kazerooni et al, 2020). Furthermore, the delivery of education changed in a dramatic way in 2020. Instruction that once was interactive, hands-on, and face to face was delivered through a computer screen. Students were forced to learn new material in a very limited and sometimes, negative environment. Personal lockdowns, virtual classes, restricted guidelines for patient exams, run down hospitals and overworked staff are only a few of the obstacles, past and current, that students face. Burnout among medical students has 9 been noted across the globe with excessive stress, anxiety and depression (Morgan 2021). In response, this study seeks to identify emotional well-being through the lens of resiliency and coping skills to ensure imaging students of tomorrow have the support and assistance they need for success. Statement of the Problem Medical imaging students are an integral part of an imaging department. They help replenish the imaging workforce and assist imaging technologists with patient care. The COVID-19 pandemic has altered the medical landscape for all medical professionals, including imaging students. Many of these students have had substantial educational delays with the onset of the COVID-19 pandemic along with growing uncertainty of what the medical landscape will be (Weber State University, 2022). The problem is that these imaging students are experiencing increased stressors and challenges that can jeopardize their educational experience. Their resiliency is being tested and they are needing to learn new strategies to cope with these new challenges to keep themselves from suffering the effects of burnout. As the world enters year three of the COVID-19 pandemic, along with the third new variant of the disease, Omicron, (CDC, 2022) it is apparent that the stresses and uncertainty will continue with these students’ education. These students are needed. The imaging workforce is overworked and many of them are suffering from burnout. A recent study surveyed imaging professionals employed during the COVID-19 pandemic about their levels of burnout. Of those surveyed, 85% reported moderate to severe levels of burnout while working during this pandemic (Milanes, et al., 2021). It is important to keep these medical imaging students engaged and help them from entering the workforce already burnt out. 10 Purpose of the Study The purpose of this quantitative study is to measure the current resiliency of imaging students enrolled at one institution and correlate levels of resilience with common coping practices. The first research question seeks to determine whether resilience is higher in current students when compared to the rate of student burnout measured in 2021. The dependent variable is students’ burnout or resilience as influenced by a changing environment. Burnout is a mediating factor on the overall resilience of each individual. Students are constantly faced with obstacles that could lead to burnout throughout their education. Depending on their individual coping skills, their resilience may play a factor in how much burnout they experienced during the pandemic. The second research question seeks to define the type and frequency of coping mechanisms utilized by students since the beginning of COVID-19. The dependent variable is the type and frequency of coping mechanisms utilized as influenced by the independent variable of stress or burnout experienced by the student in a changing pandemic environment. The quantitative data received will help decipher which coping strategies are most effective for current students and how frequently these strategies have been utilized since the beginning of the pandemic. The third research question correlates levels of resilience with various coping mechanisms. The independent variable will be the measured resiliency score. The dependent variable will be the coping mechanisms used by imaging students. Scores will be correlated to identify relationships between variables and further analyzed by regression to ascertain outcomes did not occur by chance. An effective size will be ascertained to assure the strength of the 11 relationship. Resiliency requires an ability to cope with stress and burnout. Thus, it is essential to correlate best practice in using stress and burnout coping mechanisms. The final research question seeks to determine whether specific environments cause more or less stress and additional coping skills. The amount of stress experienced is the dependent variable, and the environment is the independent variable. An understanding of which environment causes greatest stress in students informs supporting figures on how and where students may need the greatest resources. Research Questions To best understand the impact of the pandemic on resilience amongst imaging students, and the coping mechanisms they employ to deal with associated stress; the creation of a student survey, including a resiliency scale and coping instrument utilized and based on the following research questions. Q1. Has COVID-19 impacted the resiliency of imaging students? H10. There is no impact on the imaging students’ resiliency. Students from 2021 will demonstrate no burnout, and students from 2022 will demonstrate average resilience. H1a. Current medical imaging students will demonstrate high levels of resiliency, and students from 2021 will demonstrate high levels of burnout. Q2. What coping mechanisms are students using to deal with the global pandemic? H20. Current students will not use anyone coping mechanism more or less. H2a. Use of active coping mechanisms will be greater when compared with passive coping. Q3. How do students' level of resilience correlate with their coping mechanisms? H30. There is no correlation between resilience scores and coping mechanisms. H3a. Students who utilize more active coping strategies will demonstrate higher resilience. 12 H3b. Students who use more mental coping mechanisms will demonstrate higher resilience. Q4. Do students experience higher levels of stress in different environments? H40. There is no difference in stress related to clinical, school, or personal environments. H4a. Students will demonstrate higher stress in clinical environments than in school or home environments. Nature of the Study Our group chose a case study design of research. This type of research approach is taught by a man named Robert Yin who is widely known for his teachings in case studies. He believes that a research approach can contain both quantitative and qualitative methods. Yin’s case study design connects the empirical data to a study's initial research questions and eventually to its conclusions. Yin encourages researchers to research their questions and to consider the strengths and limitations of each one. He claims that each case study has a question or questions, propositions, analysis, and criteria for interpreting the results. He emphasizes having a solid foundation to work off of before gathering data, which can be done by doing research on the topic of choice first to see what information is already out there (Yazan, 2015). The goal of this study is to gather personal experiences from imaging students throughout their schooling during the COVID-19 pandemic. Everyone has a different experience and may have different stories to tell. We chose an approach that resembles the Clark Moustakas methodology which uses five different methodologies: ethnography, grounded theory, hermeneutics, empirical phenomenological research and heuristic research (Moustakas, 1994). Moustakas research design emphasizes interviews and using qualitative data to interpret meaning from what is said. We related our research to his design by gathering personal experiences from imaging students. 13 Ethnography is direct observation of a certain group and how they communicate and interact with other members. This relates to how students interact with their teachers, peers and educational environments, like clinical sites and campus. Grounded theory approach is when the hypotheses are based on data analysis and will be tested throughout the duration of the study. Our group has come up with multiple hypotheses and these will be finalized at the conclusion of the study (Moustakas, 1994). This type of approach on research helps understand the experience as a whole and not just on an individual level. This methodology looks at meanings and first-person accounts. It helps researchers understand human behavior and collects evidence for future research. This type of methodology asks a question, looks at different perspectives and meanings, selects themes, defines terms, investigates other studies, selects participants, conducts questioning, summarizes findings, relates the study to other studies, and directs future research (Moustakas, 1994). Significance of the Study This study will contribute to the field of Radiology by addressing the impact and recovery of students during the COVID-19 pandemic and highlight coping mechanisms used as best practice to increase or decrease resilience. This study is different from other studies because it focuses solely on the imaging student, not nurses, physicians, or other medical staff. This study will further the research of the previous MSRS students at Weber State University who focused their work on burnout among imaging professionals and students during COVID-19. The benefits from this study include an understanding of which coping mechanisms are most effective for students in developing resiliency Results inform and support educators, preceptors, and staff in providing the best resources to enhance imaging students’ well-being, productivity, and career satisfaction. Without this study, students may not be supplied with skills necessary for 14 a consistent and accelerated pandemic recovery. Furthermore, a lack of knowledge limits the next generation of students from coping with future pandemics and stresses better than did their predecessors. Definition of Key Terms Resiliency: The inherent ability within an individual to continue working in the face of challenging or difficult situations and circumstances (APA, 2012). Coping: Tactics or mechanisms employed by an individual to manage difficult or challenging situations. In this specific study, these mechanisms will be identified in several sub-categories (APA, 2022). Active Coping: A stress-management strategy in which the individual directly works to control a stressor or problem through targeted and specific behavior. Generally considered to be adaptive or proactive (Brown, 2020). Passive Coping: A stress-management strategy where the individual absolves themselves of responsibility for managing the stressor or problem. They instead relinquish control over the resolution to external sources (Brown, 2020). Mental Coping: Any coping strategy that takes place in the individual’s self-consciousness and requires cognitive effort (APA, 2020). Physical Coping: Any coping strategy that requires physical exertion or application or alters one’s physical status. Emotional/Spiritual Coping: Any coping strategy that includes theology, religion, or other spiritual faith (APA, 2020). Also includes coping strategies that relate to emotional responses and health. 15 Burnout: A state of emotional, physical, and mental exhaustion caused by excessive and prolonged stress. It occurs when one feels overwhelmed, emotionally drained, and unable to meet constant demands (Smith et al, 2020). Summary In summary, the Covid-19 pandemic has caused immense stress and burnout among medical imaging students (Milanes, et al., 2021). This study aims to evaluate resilience and coping mechanisms being used by students enrolled in a medical imaging program during the pandemic; and identify any correlation between the two. A survey of imaging students including a demographic survey, the Connor-Davidson Resilience Scale, and coping skills instrument will be assessed to students enrolled in a Radiologic Sciences program located in the Intermountain West. Results from this survey will be used to demonstrate students’ resilience and hardiness; as well as the coping mechanisms they utilized during the global pandemic. Survey results will be used to discern accuracy in the hypothesis related to the research questions posed. Chapter 2: Literature Review The purpose of this study is to measure the resiliency of imaging students during the COVID-19 pandemic and correlate levels of resilience with common coping practices. This literature review describes the literary search strategies and common themes that relate to the research questions. A brief history of the pandemic will be explained, and resiliency will be defined and described with its associated characteristics followed by coping definitions and tactics. 16 Literary Search Strategy Researchers assessed academic search premier through the Weber State Stewart Library. Hundreds of scholarly articles dated within the last five years were compiled based on keywords. Table 1 demonstrates related terms used to narrow the search for literature. The main focus was resilience and how the term was defined in relation to imaging students. Articles were judiciously selected based on whether the study was peer reviewed, when it was published and if the research design was thorough from start to finish. The articles maintained for the literature review focused on resilience measured in a variety of student populations and how Covid-19 had affected the resiliency of college students. Additionally, the Connor Davidson Resilience Scale helped pinpoint areas of interest that would represent variables and sub-variables of resilience in this study. Each subtopic was researched individually along with types of coping mechanisms. Table 1. Keywords 17 COVID-19: A Historical Account In January 2020, the first case of Covid-19 hit the United States and since then 47.5 million cases have been reported and 767, 000 deaths have occurred according to the New York Times (nytimes.com, 2021). In the beginning and during waves of new variants, hospitals were overthrown by the disease. Every ICU was found full, and healthcare staff experienced varied levels of burnout due to harsh conditions and loss of personnel. Health care workers were, and continue to be, on the front lines everyday taking care of patients with the disease, exposing themselves and putting their own health and the health of those closest to them at risk. At its onset, little was known about Covid since it was a brand-new disease. Rules and regulations were constantly being changed. Administrators and advisors weren't sure how the disease was transmitted, how it would affect the human body, and what PPE would be required. The whole country shut down, and communities experienced lockdowns, curfews, and isolation. It was a very lonely time for everyone. Students who started their programs and experience on campus were required to learn virtually via zoom classes. The entire educational system had to be rewired to follow the protocols put into place by the CDC aimed to keep students and staff safe. The way students learned dramatically changed, and still to this day, online and virtual classes have replaced several in person face-to-face courses. For a period of time, clinical education and work was halted until programs and clinical affiliates had policy on how to return students back to professional practice safely. This halt in clinical experience was most devastating because it is vital in the acquisition of clinical skill and competency. Within radiologic sciences, students often acquire up to 1500 hours within one to two years. This time and effort ensure graduates are fully capable of performing as an employee and eligible for 18 certification through national credentialing bodies, such as the American Registry of Radiologic Technologists (ARRT). Students enrolled in radiologic science programs during the pandemic lost an immense and crucial amount of time. As evidence to the deficit, students lacked the same level of skill expected of previous students. They also had to relearn a great deal of information because they lacked constant and consistent practice. Even after students were cleared to return, they were not allowed to examine patients with the Covid-19 disease, which in some cases, included nearly every patient seen. Over time most students did gain permission to see Covid patients, but a new problem manifested itself. Many staff and clinical instructors were completely and utterly burnt out. The environment wasn't, and in some cases, still isn’t friendly toward teaching and assisting students. Additionally, most of the personnel have demonstrated negative attitudes towards their profession, their coworkers, and their patients. Furthermore, a large number of healthcare workers quit or retired from the workforce compounding the problem. Most hospitals have been severely under-staffed, and hospital employees have been and will be doing double to triple the work and hours with zero to little incentive with no immediate relief. Elmer et al. (2020) conducted a study on a group of students during the initial Covid 19 outbreak after the lockdown was effective for two weeks. Their results showed that students, on average, were more depressed, anxious, stressed, and lonely. Students reported feeling worried about family, future career, and less support from their personal network. Most students lacked social support during lockdowns due to their isolation. However, newly enrolled students were 19 most vulnerable to the negative effects of isolation since they hadn’t the chance to make any social ties with peers, instructors, or clinical personnel. As pandemic restrictions have eased, many students face mental health effects related to social distancing and online learning (Dumitrache et al, 2021). Busetta et al. (2021) showed that female students were more prone to having higher anxiety levels during the pandemic than male students. Additionally, they found that in their combined sample, 50% of the students suffered from anxiety during the Covid-19 lockdown, and more than 60% of students who had already had anxiety before the pandemic, had increased anxiety during the lockdown. Arsandaux et al, (2021) compared the mental health of students with non-students, and their findings showed that college students were at a higher risk for mental health problems during a lockdown than were non-students. As stated earlier, the pandemic reconstructed the educational system. The most reasonable and common answer to maintaining learning in isolation was remote, virtual, and online learning. Online study has many challenges, beyond isolation, for college students, and the abrupt change in delivery highlighted the preparedness and readiness of programs in having to effectively transition their educational practices. Kapasia et al. (2020) recommended that universities initiate a plan for students and staff to follow for the remainder of the pandemic and for future lockdowns. Both planning and funding are necessary to ensure that resources are available for vulnerable populations of students and fore-learning software, hardware, and training. 20 Radiology Shortage When Covid-19 spread across the world, everything and everyone slowed down. Orders were given that only essential businesses should stay open. All routine Radiology examinations were halted, and only emergent exams were treated. Covid-19 was given precedence, and everything else was put on the back burner. Routine cancer screenings in lungs and mammography examinations declined to nearly 25% of normal. Many surgeries and cardiac imaging halted. It was reported that a 60% decline in all imaging studies were documented (Radiology Workload Changes During the COVID-19 Pandemic: Implications for Staff Redeployment, 2021). With the sudden decline in imaging, hospitals started letting what they deemed non-essential employees go. Radiology schedulers, health technicians and transporters were cut, leaving the technologist to do more and more work. Students were sent home and were instructed they would carry out their learning via online or virtual methods. Changes in staffing and student assistance created a heavy burden on the radiology technologists. They were now shorthanded, scared, and working extra shifts and long hours to make up for the staffing shortage. These physical and mental hardships shortly resulted in the burnout of many technologists. At the time students slowly returned to hospitals, many were instructed that they could not image any of the Covid patients. Unfortunately, this was the majority of the patients at that time. Hence, students could not contribute as was hoped and expected by radiology staff. Some staff responded to the situation by choosing not to take extra time to teach the students the proper techniques they needed to become competent. Students were stressed by the lack of education they were receiving in their clinical sites. With everything they were trying to deal with due to the pandemic, they now were stressing on how they would pass both their classes and their 21 clinical education. In China, Huang and Wang (2020) found that female students experienced the most stress. Alternately, unmarried students in high-grade hospitals experienced the least amount of stress. Overall, students have had to learn how to cope with stress in a pandemic world. They have had to learn new coping skills and/or use ones they have learned in the past more effectively. These coping strategies have made many students resilient. Resilient students can overcome mental and physical health concerns. Creating a daily routine, getting good sleep, and connecting with others help students bounce back (Coping with the COVID-19 Pandemic as a College Student, 2020). Psychosocial Challenges As discussed earlier, social distance and isolation have contributed to poor mental health and stress among college students. Diverse students and student experience result in a variety of perceived stressors that are subject to personalized circumstances, economic conditions, and mental health (Rikhi & Johar, 2021). According to the article “College from home during COVID-19” researchers found when “students stopped leaving home for classes and college activities, they struggled with myriad interconnected challenges. These included academic disengagement, displacement from the supportive milieu of campus, family needs that interfered with studying, restrictions to newfound independence, and difficulty meeting new people and sustaining recently formed friendships. Psychosocial challenges were often interwoven with academic challenges” (Morris et al, 2021, p. 7). Medical imaging students could also add the unique challenges of the clinical environment, profession, and expected competency. Students benefit by creating their own active coping strategies tailored to their particular social, academic, 22 and technical contexts (Morris et al, 2021). The sooner students recognize stress and use appropriate remediation, the better. Pandemic stressors have been erratic and unpredictable. Therefore, students need resilience, individual hardiness including flexibility, self-efficacy, optimism, cognitive focus, and emotional regulation. Resilience Resilience is the process of adapting well to adversity, tragedy, trauma, stress, and threats (American Psychological Association, April 2022). There are many aspects of resilience, but it’s important to acknowledge that resilience is both circumstantial and situational. One person may be resilient in their workplace but not resilient in their personal life. Resilience is learned over time as an individual goes through traumatic life events (Southwick et al, 2014). Everyone experiences a different story, so each individual has different coping mechanisms that may or may not help them be more resilient. Covid-19 affected students everywhere across the globe. Students have always been a focus for mental health. Before the pandemic, sources show increased rates in burnout, depression, eating disorders, self-harm, and alcohol abuse (Copeland et al, 2021). Anxiety is prevalent among most students and the pandemic has only added to this crisis. Studies show that since the pandemic started, burnout, depression, alcohol dependence, fatigue and suicidality has increased. Unfortunately, most medical students would not seek out help due to the stigma of having a mental illness and seeming weak to their peers for lacking the ability to handle hard situations (Morgan, 2021). There are many mental health programs in place at several institutions aimed to help students cope with the stresses that come with being a collegiate student, but the problem with medical students is that they don't often utilize them because of their demanding and busy schedules. 23 In a sample of 1004 U.S. adults, resilience was higher with those who exercised, had social support from family and friends, slept more, and prayed (Killgore et al, 2020). Because relationships were strained during the pandemic lockdown and social distancing, getting out of the house, and exercising played a major role in resilient mental health (Killgore et al, 2020). When students apply appropriate coping mechanisms, such as exercise, they can demonstrate resilience in an otherwise difficult environment. Zhao et al. (2021) found that depression rates in their sample of medical students were lower during the pandemic because they incorporated coping mechanisms and adapted to the environment. If students are taught proper ways to handle stress, the mental health crisis among college students may be decreased or avoided altogether. There are many instances where trials make an individual stronger and more resilient. The ability and confidence that a person can overcome a challenge requires that the person go through it. Indeed, stress can be a good thing in certain situations. Stress can be a motivator and keep individuals on track. It can enhance academic performance when the stress is goal relevant and controllable (Travis et al, 2020). Imaging students are working hard every day to be successful in their schoolwork and clinical studies. Their schooling is important to them, and they want to graduate and pass with good grades. As a result, their stress is both created and controlled by their expectations and the personal effort they exert toward their intended outcomes. The pandemic, in contrast, is uncontrollable, but how an individual chooses to respond is still controllable. For higher control in unpredictably stressful situations, it is recommended to use persistence, effort, attentive focus, and planning to help get through the challenge with the highest resilience (Travis et al, 2020). Thus, resilience has several variables including hardiness, flexibility, sense of self-efficacy, ability to regulate emotion, cognitive focus, and optimism (citation - scale). 24 Hardiness The definition of hardiness is having the ability to undertake things that involve risk or danger. Hardiness can be divided into three different categories: commitment, control, and challenge. Commitment is dependability and being involved and interested in activities specific to an environment. Control is the ability and confidence to influence life events. Challenge is seeing life as an opportunity to grow or learn something new. “Hardy individuals tend to reframe stressful situations and job demands, resulting in a more optimistic and challenging appraisal, thus adopting more effective coping strategies, focused on the problem rather than on an avoidant approach.” (Mazzetti et al, 2019, pg. 3). Flexibility Flexibility can be defined as the ability to adapt to changing emotional circumstances (Waugh et al, 2011). Part of one's flexibility is defined by self-management. Self-management is the combination of self-control and self-regulation. This is a skill that allows an individual to regulate their emotions, behaviors, and thoughts in any given circumstance. Self- management influences motivation to set and reach goals. The higher the self-management the higher the attained success an individual can experience. Individuals with self-management skills take responsibility for their own actions and have a sense of independence and control. Other pertinent skills related to self-management include communication, problem-solving, and productive management of time (Transforming Education, 2014). A person that exhibits flexibility has a growth mindset. Alternately, a person who lacks flexibility and is predetermined and fastened has a fixed mindset. Growth mindset is a belief that intelligence is malleable and improvable. Students with this mindset learn by a mastery 25 approach, embrace challenges, and put in the necessary work to succeed in school. They have plenty of motivation to persist when they run into roadblocks along the way. This is because personal growth is important to flexible students, and they embrace the challenge of change and adaptation. For flexible students, intelligence is not a fixed quality, and they feel that any knowledge or skill may be acquired over time and with effort. As a result, an individual will work harder and harder to demonstrate improvement. One of the biggest factors of a growth mindset is having intrinsic, personal, or internal motivation. The student becomes the master of their own outcomes, and they can monitor their own learning experience and handle their own academic tasks. By “encouraging a growth mindset, [educators] can improve the academic performance of college students.” (Ng, 2018, pg 3). Having a fixed mindset means an individual believes that their characteristics are unchangeable. It is believed that the end result will always remain the same regardless of how much effort is put forth. Most individuals with a fixed mindset are prone to wanting and needing to prove themselves right. They maintain the same habits and behaviors that ultimately lead to their suspected conclusion. Thus, they are their own worst self-fulfilling prophecy, and they must constantly face perceived failure. This perception and action correlates directly with personal self-worth and competence (Khalkhali, 2018). As a student in healthcare, it is important to have a growth mindset because no two days are exactly the same in the field of medicine. Health professionals experience a lifetime of learning and growth that varies based on best practice, leadership, and technology. As they develop, students are constantly being evaluated and tested to prove competency. For success, students must be able to challenge and motivate themselves to serve competently in wildly changing circumstances with varied patients experiencing a wide range of emotions. Through the 26 process of practice and learning, no student is expected to be perfect. However, each student is expected to learn from their mistakes. Taking feedback and using it to be better is vital to having a growth mindset. Fixed mindset students choose to focus on feedback as personal, negative, and embarrassing. . Students have the choice to either take control of their growth or let the lack of growth control them. Sense of Self Efficacy Self-efficacy is believing in one's own ability to perform certain tasks in a specific situation. This, in turn, builds confidence over time when an individual experiences success. Academic achievement has been predicted according to the amount of self-efficacy a student has obtained. The American Psychological Association defines self-efficacy as having confidence in the ability to exert control over one's own motivation (Carey, Forsyth, 2009). This can induce internal self-evaluations, goal setting, effort to reach a goal, and likelihood of positive performance. “It is not enough for individuals to possess the requisite knowledge and skills to perform a task; they also must have the conviction that they can successfully perform the required behavior(s) under typical and, importantly, under challenging circumstances.” (Artino, 2012, pg 2). Personal competence is a component of self-efficacy. Personal competence is the life-long accumulation of personal characteristics necessary to achieve goals. Personal competencies include cognitive, metacognitive, motivational, social, and emotional variables. Personal competence allows for self-evaluation and creates a space for knowing and recognizing strengths and weaknesses that are both unique and personal. Learning to view oneself from multiple perspectives and through different lenses, promotes self-confidence, job satisfaction, and open healthy relationships. Personal competence within students promotes significant problem 27 solving, time management,, clear communication, self-motivation, improved recall, goal setting, emotional control, compliance to policy, and the ability to work independently. These characteristics and behaviors promote resilience and help the overall success of students in an imaging program and professional career. Ability to Regulate Emotion The ability to regulate emotions (ATRE) requires both self-awareness and self-management. Self-awareness is when an individual can see themselves clearly and obtain more confidence and creativity. This, in turn, creates stronger relationships with others, better decision making, and clarified communication skills. ATRE is simply being able to monitor the “inner world”. There are two types of self-awareness. The first one being internal self-awareness and the second being external self-awareness. Internal self-awareness is how we see ourselves, our values, passions, reactions, and overall impact on those around us. This is associated with healthy relationships, overall happiness, and higher job satisfaction. External self-awareness is being able to see how others perceive us. This allows us to show empathy and see others’ points of view. Being competent in internal awareness doesn't necessarily mean you will be competent in external awareness and vice versa. An individual should master both internal and external awareness. As important as it is to see oneself clearly, individuals must acquire and learn from the feedback from others to improve flaws not readily seen within their private character or hidden within an individual’s personal blind spot. Self-reflection is key in becoming internally self-aware. “Self-awareness isn’t one truth. It's a delicate balance of two distinct, even competing, viewpoints.” (Eurich, 2018, pg 1). Research has shown positive results in asking “what” questions instead of “why” during self-reflection. Answers to why questions are broad with several confounding variables that may or 28 may not be helpful in goal setting. Whereas what questions allow for critical evaluations of the origins of feelings and behaviors. For example, compare the two questions: “Why do I feel so stressed?” versus “What are the situations that make me feel stressed?” The first question breeds frustration as there are no simple answers and stress is an apparent flaw within the individual. However, if a person can pinpoint what situations heighten stress, that person can identify similarities among stressful situations that cause stress and avoid or cope with the overlying stressor. In a study conducted by Harvard, researchers found that only 10-15% of people in their sample were self-aware. Being fully self-aware is being able to identify who you are as an individual, set appropriate goals, and seek out valuable feedback from others (Eurich, 2018). Linde (2020) expressed that “self-awareness is seen as particularly critical in the development and ability of healthcare providers to maintain and sustain our own mental health and resilience in the stresses of the healthcare environment.” (Linde, 2020, pg 2). The ability to control one’s emotions also requires one to develop emotional intelligence. Emotional intelligence is having the ability to monitor your own emotions, as well as the emotions of other individuals. Emotional intelligence begins by being able to label and identify emotions correctly. Students who use emotional intelligence use their knowledge to guide appropriate behavior and control, to some extent, their social environment (Srivastava, 2013). Emotional intelligence is made up of four skills which are perceiving emotions correctly, integrating emotions, understanding emotional cause/consequence, and managing emotions (Schneider et al, 2013). When an individual perceives and identifies emotion correctly, they are able to respond to and express their own emotions in an effective manner. Emotionally intelligent individuals use emotion to enhance cognitive thinking and process new perspectives 29 within their environment. Being open minded and seeing other viewpoints reinforces and expands emotional intelligence. Emotions shape individual reactions and help focus attention on external stimuli (Schneider et al, 2013). Being in control of your emotions and how you react to other emotions is important because it gives the individual power over their situation. Imaging students are having to manage multiple emotions throughout their day. They interact with many different personnel throughout their schooling and clinical experience. The emotions in the healthcare environment can be negative, and students are having to cope with that energy while trying to stay motivated to do well in their programs. It takes a lot of maturity and emotional intelligence to stay diligent and succeed in negative environments. Cognitive Focus Having cognitive focus means an individual can concentrate all their attention on one specific target for a period of time. This individual isn't distracted and is productive when working. Cognitive focus is a huge indicator for student success and academic achievement. In comparison, cognitive stress, including anxious thoughts, fearful anticipation, poor concentration, memory problems and distractions, increase stress and academic failure (Friedman, n.d.). Everyone experiences stress at some point in their life. Students in health professions are under immense stress between school and clinical work, as well as outside stressors related to relationships and family. Having a sense of control in life is vital to feeling focused and able to manage the stressors that could distract from their professional development. There are two aspects of control within everyone. Primary control, defined as having the ability to change a situation, and secondary control, meaning the ability to control how one reacts to a situation that may be unchangeable. Being in control means an individual can act on or accept change. Difficult circumstances arise often and how an individual is able to control their 30 feelings and actions towards it are important. Some things in life aren't under direct control, but how someone reacts to those situations can give a sense of control. Emotions can be controlling, and when left unchecked, may overpower the mind. External triggers occur readily and surround each person every single day. Ultimately, it is up to the individual going through those stressors to gain a sense of control for themselves. Whether they choose to act in response to the stressor or accept the outcomes of a stressor, they are choosing how to handle the emotions attached to the stressor. For students during a pandemic, their sense of control was immensely interrupted. Life changed rapidly and the future was unknown in every aspect. Family, school, friends, and jobs were all affected. Choosing adaptability through levels of control affected students’ overall success. Control is a basic need for any one person to survive. A sense of control leads to both power and trust. People who take control of their lives have more motivation and are more proactive when faced with challenges. Whereas those who believe external factors control their lives, respond to challenges by being reactive to stressors and display more passive behaviors. Although it seems counteractive, sometimes individuals need to give up control to gain control. In this case, one must accept what can’t be changed and take action when it can be changed. Control is a variable of resilience, and students who test more resilient have more control over their life. In a study conducted by Shamloo and Cox (2010), their findings showed a positive relationship between sense of control and intrinsic motivation. In contrast, they discovered people who were motivated extrinsically were more vulnerable to developing helplessness, problem solving issues, and poor sense of control. In support, Collie et al. (2015) concluded that control and achievement are closely related. 31 Optimism Optimism can be highly beneficial for the student psyche. Optimism improves mood, achievement, physical health, and perseverance. Actions of optimistic people are greatly affected by their beliefs about the possible positive outcomes of their actions (Atalay, 2012). An optimistic person pays close attention to the details of situations when compared to a person with pessimistic thought processes. Pessimistic people focus only on the bad or the negative aspects of a situation or challenge. On the other hand, the optimist focuses on both the positive and negative aspects of a situation or challenge and uses this information to improve outcomes. Optimism, combined with social support, has been found to be a pertinent factor in the protective measures used against distress in ill patients. A person with a high level of optimism has been found to be significantly less anxious, depressive, and has a better quality of life (Applebaum, 2013). This may offer some explanation as to why many studies support the negative effects of Covid-19 on medical students whereas other studies indicate students' resilience improved during the same pandemic. The power of positive thinking plays is fundamental to overall mental health. In a study conducted by Yang et al. (2020) several students reported the virus played no role in hindering their positive mindset or resilience. A positive mindset increases resilience and decreases burnout. Building Support Founded on Trust Thus far, the focus has been upon the individual responsibility and effort used to maintain emotional and cognitive control as means to reduce negative outcomes from a stressful external environment. However, resilience is multi-faceted and will require social support and constructs based on open compassion and trust. There are four variables of trust including credibility, 32 reliability, intimacy, and self-orientation. Credibility has to do with the experience, expertise, and words one uses to speak and communicate. For example, a person may be trusted giving a speech on neuroscience due to their credibility on a subject. Reliability is tied to the way a person acts. For example, if a person gets something done on time, they are dependable and can be trusted to be relied upon. Intimacy refers to when a person feels safe and secure. In this case, a person could feel entrusted to a peer, friend, or colleague because they are confident that they would not try to embarrass them. In conclusion, self-orientation refers to a person's focus. This focus may be solely upon themselves or on someone else. They can be trusted or not trusted depending on where they spend their focus. A person is found trustworthy when they help others achieve their goals even when obstacles are in their way (Trusted advisor, 2021). Humor can relieve stress and build rapport among colleagues, but it can also be misinterpreted, sarcastic, and offensive. A person that uses appropriate humor when they run into obstacles and does not take themselves too seriously often attracts individuals who benefit from their positive attitude. Individuals with a positive outlook toward life are often thought as trustworthy and collegial Therefore, humor can be considered a meaningful way to cope with stress. Coping Skills Often a variety of behavioral activities, whether done consciously or unconsciously, are deployed in response to stressful situations. Coping has been defined as “the thoughts and behaviors mobilized to manage internal and external stressful situations. It is a term used distinctively for conscious and voluntary mobilization of acts, different from 'defense mechanisms' that are subconscious or unconscious adaptive responses, both of which aim to reduce or tolerate stress.” (Algorani, 2021, pg. 1). 33 Coping is used to describe the use of behavioral or cognitive strategies to manage a particular stressful situation (APA, 2022). The type and extent of coping skills, strategies, or abilities can also be described as a “coping reservoir” (Dunn, 2008). Certain behaviors can either add to, or take from this reservoir, or reserve, of coping. The COVID-19 environment was full of new stresses and challenges; therefore, it was essential that individuals find ways and strategies to help them overcome, or cope, with new obstacles. While no individual or challenge is exactly the same, the common theme is that every individual will face adversity and require a way to cope. Coping is individualized. The ability to which an individual is able to cope varies widely among all demographics. Some individuals can actively face challenges head-on without reservation, while there are others that prefer a more passive approach. As varied as the people needing to cope are the number of strategies that can be utilized. While some may have different outcomes, all are viable. The following sections aim to provide specific examples of coping mechanisms and outline the pros and cons of each method. Active and Passive Coping In many studies, passive coping and avoidant coping are terms that seem to be interchangeable. Some behaviors that may fall into this category are procrastination, avoidance, or active ignorance, meaning that the individual chooses not to be fully informed so they can’t worry about the full consequences. This can be a combination of denial and withdrawal. Other actions include worrying, retreating, or the dependency on others to function in their scope of work. An interesting term is catastrophizing, meaning that one assumes the worst-case scenario, which would likely have a negative effect on the individual. But at the same time, it is important 34 to be aware of what can happen and not just ignore it. Typically, these passive or negative strategies take away from the “coping reservoir” (Dunn, 2008). Passive versus active strategies have negative and positive connotations, respectively. Active coping tends to be a more optimistic and confident approach. A common theme within active coping strategies is awareness, implying that the individual has knowledge and can then prepare themselves for the best outcome. Behaviors associated with active coping strategies are planning, communication, proper time management, and for a lack of a better term, the ability to triage issues that need to be addressed first. In most cases these active strategies add to the “coping reservoir” (Dunn, 2008). These behaviors can be difficult to learn, but that is the “active” part about it. They take a conscious effort to employ. It takes time and experience to acquire and hone these active coping skills. It is difficult to be an active participant when one is in a new or foreign environment. While it is not a perfect comparison, there are several “fight or flight” parallels. With flight being the passive and fight being the active. Passive versus active coping is a dynamic situation in most cases. It is not common for an individual to remain static for a prolonged period when presented with a stressful situation. The Assimilation of Problematic Experiences Scale, developed by William Stiles (1999), helps explain the process of moving from a passive situation to a more productive, active role in coping. Additionally, Wilson et al. (2014) uses the scale to demonstrate a gradient of grief. The scale offers various stages (0-7) in which an individual may find themselves when presented with a problematic experience. The lower the value on the scale, the more passive/negative the trait. While the higher end of the scale demonstrates active/positive traits. This scale was customized to demonstrate stages of passive versus active coping behaviors. 35 Stage 0 - Warded off. The individual is unaware of the problem; numb or disassociated. May deny the need for coping or the existence of a problem. Stage 1 - Unwanted thoughts. Discomforting thoughts and emotions about the problem begin to emerge but are largely ignored or avoided. Stage 2 - Vague awareness. The individual is able to articulate and acknowledge the problem but may not be able to deal with the issue and may begin to panic. Stage 3 - Problem statement/clarification. The individual is beginning to accept and recognize the gravity of the situation and can recognize coping strategies to deal with the situation. They are no longer panicky. Stage 4 - Understanding/insight. The situation is now fully understood and accepted. The individual is now able to make a “bridge” between the problem and possible solutions/coping strategies. Stage 5 - Application/working through. These solutions are now put into practice to address the problem. There is more positivity and optimism. Stage 6 - Problem solution. The individual achieves a successful outcome for a specific problem/coping strategy. There is now more flexibility in the ability to face other situations. Stage 7 - Mastery. The individual no longer stresses about finding solutions/coping strategies. It becomes a natural, unconscious action and they are able to face the challenge without reservation. In the early stages of a problematic experience, the passive/negative coping strategies are demonstrated in full effect wherein a person uses ignorance, denial, procrastination, and avoidance. Some individuals may even get to the point of panicking from feeling so overwhelmed and unprepared. When able to take a step back and begin to make a full assessment of the situation, individuals can begin to make a plan and move toward the latter 36 stages of the scale which are more active and positive in nature. Active and positive coping strategies include planning, positive communication, task persistence, and personal accountability. Most people can relate to each of these stages at one point or another. When presented with a stressful or unwanted situation, it is human nature to avoid or deny that there is an issue that needs to be addressed. These are the passive/negative strategies. With time, most people begin to recognize and accept the problem and take a more active/positive posture in dealing with issues. These approaches may be further divided into mental, physical, spiritual, and/or emotional coping. Mental Coping When an individual is presented with a stressful event or situation, a first line of defense is in the mind. The mind is a powerful instrument that will likely determine how well an individual will cope with a stressful incident. Some stressful situations present themselves in such a way that a person or group of people can plan and prepare for its arrival, whereas many other situations arrive unexpectedly and catch individuals off guard. The COVID-19 pandemic experienced within the United States was a unique situation wherein its associated circumstances could fall into both categories. Because the COVID-19 disease ravaged through foreign countries first, there was an opportunity and time for preparation. However, when the disease was made manifest in the United States, the situation escalated quickly (CDC, 2021). First, the mental state of people within the United States was already in a precarious position. Johnson (2021) estimated that 1 in 5 adults already suffered from mental illness. “Despite the high prevalence of mental health concerns…including a shortage of professionals, 37 limited access, lack of adequate funding, and stigma meant that as many as 70% of people with these conditions never sought treatment” (p.35). Now, with the added uncertainty of a global pandemic, mental health and its associated coping strategies became an ever more important critical focus. One mental coping strategy is mental preparedness. A practice that constitutes mental preparedness is reviewing potential challenges that one might face (Gilbar, Ben-Zur, Lubin, 2010). This can be practiced on a personal level and can take little to no time to accomplish. It can be as simple as taking a deep breath before going into a patient’s room and taking that moment to mentally review what your plan is and how you plan to react to any surprises. This can also be done at the end of a stressful encounter. Take time to mentally review the situation and recognize what went well, and what can be improved upon. All of this experience helps make the individual more resilient and more capable of dealing with new challenges in the future. Mindful meditation is another mental coping strategy. Meditation can be performed in a variety of ways including, but not limited to, personal practice and professional intervention. It is a practice directed at bringing conscious awareness to one’s thoughts in a non-judgmental way, accepting both positive and negative thoughts, events, and emotions as normal experiences (Jones, Lehman, Noriega, Dinnel 2019). It helps individuals be present in the moment and allows them to quiet the outside stressors enabling them to accomplish tasks successfully. A powerful mind is an invaluable tool and preparing and exercising the mind is necessary for that tool to be used effectively. 38 Physical Coping Physical coping, as defined in this study, relates to any strategy that requires physical application, or alters one’s physical status. Physical activity has been shown to have considerable positive effects on performance and includes a variety of activities. Activities such as running, weightlifting, yoga, and swimming are popular choices for physical activity. In a study done by Mahmood et al. (2021), 459 medical students were studied based on their academic standing. A weak negative correlation was established between a sedentary/insufficiently active lifestyle and academic status. The study determined that the majority of the students that were in “good standing” academically, participated in some form of physical activity. While physical activity alone will not increase a student's academic success, it can certainly be implemented as a beneficial coping strategy for a stressful student life. Contrarily, substance use and abuse are common physical coping strategies for individuals to use when feeling stressed and overwhelmed. These substances can include caffeinated energy drinks, alcohol, prescription medication, smoking, and other harsh substances. While some of these substances, such as energy drinks and prescription medication, can be beneficial, they still alter physiological and physical functions. In a recent study performed by Panchal et al (2020), it was found that more than 50% of American adults reported worry and stress from coronavirus had affected their mental health and that 1 in 3 adults now report experiencing symptoms of anxiety and depression. Since the onset of the COVID-19 pandemic, more than 40 states in the US have experienced increases in opioid-related mortality and other drug overdoses (Johnson, 2021). Substance use and abuse can be a dangerous form of physical coping. 39 Emotional and Spiritual Coping Emotional responses are a large part of the human experience. Medical personnel can feel a wide range of these emotions ranging from elation to despair. Managing emotional responses in stressful situations can be a difficult endeavor. Many medical personnel have suffered increased levels of burnout throughout the COVID-19 pandemic (Milanes, 2021). This resulted in studies focused on the specific coping strategies used by medical professionals. In a study by Benjamin Doolittle (2021), internal medicine physicians were surveyed as to their emotional coping strategies and how they correlated with their overall burnout. Some of the measured emotional coping strategies included denial, disengagement, self-blame, and venting. Doolittle concluded that physicians who commonly used the above coping strategies had greater burnout and lower compassion satisfaction. Another measured aspect of emotional coping is spirituality. Religion and spirituality in this study includes any theology or faith, and it is not limited to a particular denomination or organization. Any belief was categorized and captured under this umbrella term. Spirituality has long been used as a coping strategy for stressful and difficult situations, and the COVID-19 pandemic was no different. However, Elliott and Reuter (2021) found that it may not always be a positive practice. Although some benefits of spiritual coping include a sense of belonging and purpose along with supportive relationships, some problematic aspects of spirituality may include risky refuges, religious struggles, and abuse in religious settings. Summary The COVID-19 global pandemic presented “drastic disruptions to social, economic, and healthcare structures globally.” Those working or learning in healthcare environments have 40 faced “increasing cases, insufficient amount of personal protection equipment (PPE), extremely demanding workloads, and lack of adequate therapies to save lives can contribute to a psychological burden directly related to working during disease outbreak.” (Rose et al, 2021, pp. 1-2). The increased level of pressure and distress experienced by health care providers demanded some level of coping for survival. “Disengagement forms of coping, often characterized as avoidance, distraction, and suppression, reduce negative emotions brought on by stressful events, but do not address the underlying causes of stress” (Morris et al, 2021, p. 3). While other studies suggest that “problem-focused strategies (i.e., active coping techniques such as seeking advice or cognitive reappraisal) may protect against the deleterious effects of COVID-related stress” (Morris et al, 2021, p. 3). The authors of this manuscript will use a survey instrument to explore the active and passive coping strategies utilized by medical imaging students with various levels of resilience as a means to inform best practice. 41 Chapter 3: Research Method The purpose of this quantitative study is to compare burnout reported by students Spring 2021 to current measures of resilience in imaging students enrolled in programs at Weber State University in 2022 in correlation with common coping practices during Covid-19. Current imaging students are experiencing challenges that may jeopardize their educational experience. Their resiliency is being tested, and they are needing to learn new strategies to cope with these new challenges to keep themselves from suffering the effects of burnout. Q1. Has Covid-19 impacted the resiliency of imaging students? H10. There is no impact on the imaging students’ resiliency. Students from 2021 will demonstrate no burnout, and students from 2022 will demonstrate average resilience. H1a. Current medical imaging students will demonstrate high levels of resiliency, and students from 2021 will demonstrate high levels of burnout. Q2. What coping mechanisms are students using to deal with the global pandemic? H20. Current students will not use anyone coping mechanism more or less. H2a. Use of active coping mechanisms will be greater when compared with passive coping. Q3. How do students' level of resilience correlate with their coping mechanisms? H30. There is no correlation between resilience scores and coping mechanisms. H3a. Students who utilize more active coping strategies will demonstrate higher resilience. H3b. Students who use more mental coping mechanisms will demonstrate higher resilience. Q4. Do students experience higher levels of stress in different environments? H40. There is no difference in stress related to clinical, school, or personal environments. H4a. Students will demonstrate higher stress in clinical environments than in school or home environments. 42 Research Methods and Design(s) This study uses a Phenomenological research design. We wish to investigate quantitative student responses to the Connor-Davidson resilience scale to determine their experiences during the pandemic, how the pandemic affected them, how they coped with the challenges they faced, and how their coping methods helped them become more or less resilient. The goals from this research are to explore the philosophy, methods, and applicability of resilience and coping strategies to Radiology students. In research, phenomenology is the study of the human experience from the student’s perspective (Manen & Manen, 2021). Phenomenology is the method in social sciences known as the process of “becoming” (Knaack, 1984). This means that it is visible and temporary and that it will change. Phenomenology has four design steps. First, is bracketing where the researchers have a preconceived belief and opinion concerning the research. Second is intuiting, this is when the researchers are focused on what caused the phenomenon to happen. A shared understanding of what caused the phenomenon is achieved. During this step the researchers are actively immersed in the study and what caused the phenomenon to happen. Next the researchers will analyze and try to make sense of what caused or created the phenomenon. It is important to attain a pure and thorough description of the phenomenon during this step. Last, is describing the phenomenon, coming up with a definition and comprehension of the phenomenon for the research. This will provide a distinction and critical descriptions in verbal and written form (Aomatani-higashi, 2019). Phenomenology research is an optimum choice because findings are distinguished between qualitative and statistical validity. Data helps indicate the presence of factors and the implications in definite contexts of cases. General theories will be made that will back the 43 phenomenon and provide the ability to work through the findings and investigate the methods that will develop critical interpretations. A cross-sectional quantitative study will be incorporated to acquire data used to satisfy correlational and descriptive design purposes. Correlational designs are used to understand relationships between two or more variables, and descriptive designs explain the attributes associated with the relationships that exist among variables. This quantitative r data will describe imaging students' resilience and coping mechanisms during the global pandemic. The survey includes demographic, resilience, and coping sections. The resilience instrument includes 10 questions developed by Kathryn M. Conner and Jonathan R.T. Davidson (2003). This scale, called the Connor-Davidson Resilience Scale, measures resilience factors in adults and is widely used in research literature. The scale focuses on hardiness subcategories including flexibility, self-efficacy, regulation of emotions, optimism, and cognitive focus. Radiology students will respond to written statements on a Likert scale based on how they have felt over the last 3 months. The goal is to sample at least 100 students enrolled in a large radiology program located in Utah, although many students live across the country. In order to participate, students must be over the age of 18 and younger than 65. Students will be invited to the survey via email from school staff who do not have a teaching or supervisory position over the students. The survey will be conducted through Qualtrics, which is password protected and accessible through a QR code or email link. Subjects will be allowed to take the survey once, and it should take roughly 10-15 minutes from start to finish. The results will only be shared with the research team and data will be destroyed following the conclusion of the study. 44 The survey mentioned above will provide information on how many of our subjects found themselves to be resilient when faced with the challenges of a pandemic and how they chose to cope with the stressful pandemic environment. The results will be collected and analyzed by a statistical software program (SPSS). Researchers will analyze the data by the end of August 2022. Population The population of interest for this study is the collegiate level imaging student that has clinical experience during the COVID-19 pandemic. These students can be enrolled in any imaging modality program and can be studying at a variety of clinical sites ranging from rural clinics to major trauma centers. The important factor is that the imaging students have had their educational experience affected by the COVID-19 pandemic. With an inherently demanding educational experience, imaging students are a great population to study to understand resiliency and associated coping strategies. While not every imaging student can be surveyed, this study aims to provide a sufficient sample size to provide quality information pertaining to the resiliency and coping strategies of imaging students. Sample A convenience sample of imaging students with clinical experience during the COVID-19 pandemic from spring of 2020 through spring of 2022 was used for statistical analysis. An online survey QR code was distributed to these students via their institutional email. As part of the Weber State University MSRS Research Agenda, the survey was made available to all imaging students enrolled in clinical education including general radiology and all of the related imaging modalities. The scope of the study was limited to imaging students attending Weber 45 State University with clinical experience. All surveys that did not meet this criteria were excluded from analysis. Materials/Instruments An online questionnaire was the primary instrument used to collect data. Demographic information collected included the student’s age, gender, race, state of residence. Additionally, the following student clinical experience details were gathered: type of medical facility where most of time as a student is spent, how many clinical facilities rotated through, which imaging program(s) students are enrolled in, what year the student started the imaging program they are currently enrolled in, how many semesters of clinical education completed, expected year for graduation, and what degree will be earned at the completion of current program. Students completing the survey then completed the Connor-Davidson Resilience Scale 10 (RD-RISC-10). This scale has students’ rate 10 statements on a 0 – 4 scale, 0 representing ‘not at all’ and 4 representing ‘true nearly all the time’. Scores from each statement are added to determine a respondent’s hardiness and resilience. Lower scores represent less resilience and higher scores suggest greater levels of resilience. Next, students identify their level of stress on a Likert scale from 1 (no stress) to 5 (extreme stress) in three separate environments: clinical education, school or classroom environment, home, or personal life. Coping mechanisms are then ranked on a Likert scale (1: not true at all – 5: true nearly all the time) for eight statements each relating to mental, physical, emotional/spiritual mechanisms used to cope. Finally, participants will rate (1) less than usual, (2) no change in frequency, or (3) more than usual, their use of coping skills before the pandemic, at the peak of the pandemic, and within the last month. 46 Operational Definition of Variables There are a few variables in this study that will be mentioned below. The main topic of this study is resilience. This research focuses on imaging students and if they are resilient when faced with the Covid-19 pandemic and the trials that accompany it. In this study, resilience is broken down into subcategories which consist of hardiness, flexibility, self-efficacy, ability to regulate emotion, optimism, and cognitive focus. Resilience (independent variable) can be defined as the process of adapting well in the face of adversity, trauma, tragedy, threats, or even significant sources of stress (Southwick et al, 2014). Hardiness can be defined as an ability to adapt easily to unexpected changes, have a sense of purpose in daily life, and obtain personal control over what occurs in life. Hardiness helps eliminate negative effects of stress and can even help an individual stay healthy (American Psychological Association, 2022). Flexibility can be defined as the ability to respond flexibly to changing emotional circumstances (Waugh et al, 2011). Self-efficacy refers to the belief or capacity to execute behaviors necessary to produce specific tasks (Carey, Forsyth, 2009). Being able to regulate emotions basically means being fully self-aware and being able to identify who you are as an individual, pinpoint what you want to accomplish and seeking out and valuing feedback from others (Eurich, 2018). Having cognitive focus means an individual can concentrate all attention onto a specific target for any period of time. The individual isn't distracted and is productive when working (Friedman, n.d.). Optimism can be defined as an inclination to put the most favorable construction upon actions and events or to hope for the best possible outcome (Merriam Webster, 2022). Combined, these variables make up the whole of resilience in imaging students as defined by our study. To measure these variables, resilience data is gathered by means of a survey called the Connor Davidson Resilience Scale. It is a 10-47 question survey with a Likert scale ranging from 0-4 giving the individual five options to choose from ranging from not true at all to true nearly all the time. The sum will show how much resilience a student has by asking questions about the topics mentioned above. Burnout (dependent variable) Burnout is dependent on the overall resilience of each individual. Students are constantly faced with obstacles that could possibly lead to burnout throughout their college education. Depending on their individual coping skills, their resilience may play a factor in how much burnout they experienced during the pandemic. This study will compare the results from the resilience scale in this study to the previous MSRS group who studied burnout on health care workers. This group measured burnout with OLBI which consists of 16 questions based on a 1 – 4 Likert scale ranging from strongly disagree to strongly agree (Milanes et al, 2021). Coping mechanisms (dependent variable) vary from student to student. Data is meant to define both popular t mechanisms used during the pandemic to either support or reduce resilience. Coping will be measured by the survey made by the MSRS group which will ask the participant to answer questions ranging from strongly disagree to strongly agree. The results will be coded, grouped, and summed. The Covid 19 Pandemic (independent) is phenomenological and unpredictable. Data Collection, Processing, and Analysis This quantitative study will be conducted through Qualtrics which is an online survey tool. The survey will be sent as a QR to imaging students at Weber state through an email. The students can access this QR code which will take them to the survey where they will have to consent before proceeding on with the research questions. If the student does not consent the 48 survey will be discontinued. The next question will ask if the student attends Weber State University. If the student selects no, they will be taken out of the survey. At the conclusion of the survey period, all information will be gathered from Qualtrics and uploaded to a statistical software called SPSS. Tests, coding, and grouping will be done through this software. The Likert scale surveys will be coded in a way that attaches numerical data to the quantitative data so that the software can make an overall score for each individual student. For example, a question will ask a student on a scale of 1-5 how they would rate their resilience, 1 being low and 5 being high. The more resilient the student answers the higher their overall score will be. If a student does not answer a question the research team will assign a zero value to the data. Assumptions Several assumptions were made about the study population. One is that the participants are or were imaging students with clinical experience from 2020 to 2022 during the COVID-19 pandemic. This assumption was made by the researchers by asking the participants about their clinical experience during this time. Another assumption that was made by the researchers is that all participants were students at Weber State University. This was also assumed by asking this question at the beginning of the survey. Those that answered “no” had their survey ended. It was expected that most of our participants would be located in Utah and female. The radiology program is based out of Ogden, Utah and the radiology field is predominately female. It was assumed that most students would be ages 18-30 since most people attending college fall into this age range. Since many of our students attending Weber State are from Utah and Utah’s population being mostly White/Caucasian, it was assumed that a majority of our sample would be White/Caucasian. 49 Limitations There are several limitations in our study. The individuals we surveyed all go to the same institution. Students in imaging outside of this institution were not able to take the survey. This limits the amount of responses from different clinical locations, states, other radiology programs, etc. The location of these students varies from Montana, Florida, Arizona, and California, but the majority of participants come from Utah. This study does not represent the entire country of the United States. The primary investigator of this research group is a professor for the imaging program. The sample was chosen out of convenience and accessibility. 84 students participated in the study which didn’t reach the previous goal of 100. This can lead to data not being represented properly due to lack of responses. Relationships are harder to identify in smaller sample sizes. As far as the sample goes involving race, the demographic varies very little and does not represent diversity in imaging students. Delimitations Our sample group are all Weber State University medical imaging students that have clinical education rotations, the authors chose this as a way to reduce error and research imaging students specifically attending clinical education through the COVID-19 pandemic. Imaging students from all modalities are being surveyed, with the largest number represented in radiography students. While the authors acknowledge that there are multiple factors at play that may not be addressed, however, we hope to identify coping strategies used by the sample, and any correlation to their resilience and hardiness. The Connor-Davidson Resilience Scale 10 (RD-RISC-10) being used is a reliable and valid tool. The use of passive versus active coping strategies is a subject that has been explored in numerous studies, however the specific methods being used by medical imaging students during the global pandemic has not been explored. 50 Ethical Assurances This study has received approval from both the Institutional Review Board and Weber State University. The IRB will be notified of any unanticipated effects during the course of this research. All participants in this study will be required to sign an electronic informed consent. Participants will be aware of the limited risks involved in participating in this study. All personal information will remain confidential, and results will be held in a secure location during the collection of information. Informed consent will be found in the Appendix of this study. Only the individuals mentioned in this study, along with their mentor, will have access to this information. Data will be destroyed at the conclusion of this research. Summary The goal of this study was to assess the overall resilience and coping skills utilized by imaging students during the COVID-19 pandemic. A quantitative approach was conducted by the use of two surveys; one being the Connor-Davidson Resilience scale and a coping skills survey developed by the research team. The goal from this research was to explore and relate the philosophy, methods, and applicability of resilience and coping strategies to medical imaging students during the global pandemic. The goal was to sample 100 students at one institution; with students reached via email with a survey link through Qualtrics. Students surveyed were enrolled in any type of imaging program at Weber State University that included clinical hours. The Connor-Davidson Resilience scale asked questions about resiliency within given situations. The second half of the survey was a coping mechanism questionnaire that assesses coping skills students used to handle clinical, social, and academic stressors. The authors recognize there are limitations to this study, including the sample being conducted through one institution, the majority of students were based in the state of Utah, and were predominantly female. Survey 51 responses were coded into SPSS statistical software and thoroughly evaluated to ensure accuracy and consistency. Several statistical tests were run to establish the mean scores of the Connor-Davidson Resilience scale and the Coping Mechanisms survey, as well as correlation between resilience and particular coping mechanisms. Environmental stressors (clinical, home, school) as well as use of coping mechanisms at different times of the pandemic were also evaluated. Chapter 4: Findings This study includes findings from the Connor-Davidson Resilience survey and also a coping survey developed by the research team. The coping survey uses a Likert scale to identify what type of coping mechanisms students use or do not use. This includes topics such as students' daily lives, clinical setting, and social environment during the COVID-19 global pandemic. These surveys provided information on the relationships between imaging students' resilience and coping mechanisms after going through the pandemic. Results Eighty-four students participated in this study. One chose not to consent to the survey so only 83 samples were taken. Out of the sample, 52 students fell into the 18-30 age range which makes up 63% of the population in this study. Following that, 26% of the students fell into the 31-40 age range, 8% in the 41-50 age range and 1% in the 51-60 age range. Females made up 80% of the population, 18% were male and 1% identified as non-binary/third gender. 89% of the sample identified as White/Caucasian, 6% identified as Hispanic/Latino, 1% identified as Native American/Native Alaskan and the final 1% identified as Asian. All but 2 students reported being a Weber State student with clinical education. As far as location, 68% of students live in Utah, 6% in Colorado, 6% in Arizona, 6% in Idaho, 5% in Wyoming, 2% in Florida, 2% in Oregon, 1% in Montana, and 1% in Washington. 31% of students reported spending their clinical time in 52 a trauma facility, 30% in a mid-sized hospital, 25% in a rural community hospital and 12% in a clinic. Most of the students rotated to one clinical site in their clinical experience, making up 60% of the sample. 16% rotated to 3 facilities, 15% rotated to 4 or more facilities and 7% rotated to 2 facilities. When it comes to which program the student was in a majority were enrolled in the Radiography (RT) program. 69% of students make up this population followed by 8% in sonography, 7% in Radiologist Assistant, 6% in Nuclear Medicine, 3% in Cardiac Cath Lab, 2% in Radiation Therapy, and 1% in Computed Tomography. 65% of the sample started their specific program in 2021, followed by 31% in 2020, 2% in 2019. 48% of students have completed 1 or less semesters of clinical education, followed by 25% completing 5 semesters, 16% completing 2 semesters, 7% completed 4 semesters, and finally 2% reported 3 semesters. A majority of students (68%) will be graduating in 2022, 31% will graduate in 2023, 2% will graduate in 2025 or further. 67% of the sample will be graduating with an Associate’s degree at the completion of their program, followed by 21% obtaining their Bachelors, and 11% receiving their master's degree. Students were asked to fill out the Connor-Davidson resilience scale. This included ten statements in a Likert scale format. Factors being measured in this survey are flexibility, self-efficacy, ability to regulate emotion, optimism, and cognitive focus/maintaining attention under stress. 5 being the most resilient and 1 being the least resilient. The mean score was the highest (4.42) in believing in oneself to achieve goals even if obstacles are in the way. The lowest mean score (3.35) was not feeling discouraged by failure. An overall mean score of 40.2 was reported. What's interesting about this survey is that optimism had the highest score and the lowest score. The coping survey was developed by the research team. This survey will show which coping mechanism students most likely will use to get through hard times. There are three separate 53 surveys that will demonstrate mental, physical, and emotional coping. Each survey contains eight statements. Half of the statements are active and positive while the others are passive and negative. The lowest mean score (2.44) in the mental active coping strategies was using meditation or imagery to relax. The highest active mental score (4.34) was showing confidence in competence. The lowest score in the mental passive coping strategies (2.59) was feeling like they don’t know what they are doing, meaning students used this coping mechanism the most. The highest score (1.95) was feeling like things will not eventually get better, meaning students disagreed with this statement. The highest mean score (3.84) in the physical active coping strategies was being able to openly communicate and collaborate with others. The lowest physical active score (2.85) was getting plenty of sleep and feeling refreshed. The lowest score (3.47) in the passive physical coping strategies was distracting oneself with social media, television and screen time, meaning students used this coping mechanism the most. The highest passive score (2.38) was eating or drinking unhealthy substances to help deal with life, meaning students used this coping mechanism the least. The highest mean active score (3.92) for emotional and spiritual coping mechanism strategies was seeking ways to serve and be compassionate towards others. The lowest active mean score (3.14) was using spirituality like prayer as a release from stress. The lowest passive mean score (2.89) was not liking others to acknowledge mistakes, meaning students agreed with this statement most. The highest passive mean score (1.92) was ignoring problems and hoping they resolve on their own, meaning students disagreed with this statement most and didn't use this way of coping. 54 Students reported using coping strategies mostly during the peak of the pandemic compared to before the pandemic or within the last month. Students also reported that stress was felt more in the clinical environment compared to the school/classroom or in their personal life. Evaluation of Findings The first research question sought to establish the resiliency of imaging students, comparing students in their first two semesters of learning versus those with three or more semesters of their imaging program complete. Resiliency measured through the Connor-Davidson resilience scale in this study showed students in their first two semesters of their imaging program with a mean resiliency score of 40.58 with a standard deviation of 6.13, while those with more than two semesters in their program scored 39.52 with a standard deviation of 6.12. Figure 1 55 These scores demonstrate that students with more time spent in their program, meaning more time spent in clinical setting during the COVID-19 pandemic, overall reported an entire point lower, with a mean resiliency score of 39.52, than those with less time spent in the same settings reporting a mean resiliency score of 40.58. The lower resiliency scores indicate these students may have trouble bouncing back from adversity, while their counterparts with less time spent in their programs reporting higher scores suggests they felt more resilient when faced with hardships at the time of the survey responses. The increased time spent in a healthcare setting during the height of a global pandemic and disruptions in their learning may be an explanation for the levels of resiliency being reported by students with more than 2 semesters of clinical education. Students with more than two semesters were in the midst of their clinical education throughout some of the most unpredictable times of the pandemic for education and healthcare as discussed in the literature review. The uncertainty and challenges facing medical imaging students has shown to have an effect on their resiliency the more time spent in their program. The second research question delves into the coping skills imaging students are using during the pandemic, specifically whether the use of passive or active mechanisms is more prevalent when faced with stress during their medical imaging program. Across questions dealing with mental, physical, and emotional/spiritual coping, the active mechanisms proved to be utilized more to manage stressors in those surveyed (see Figure 2 and Figure 3). 56 Figure 2 Figure 3 57 As the literature review showed, passive versus active coping strategies have negative and positive connotations, respectively, and the coping survey was structured to represent those two sides. Overall scores from the survey indicate that students are using active coping strategies at a higher rate than the more passive options (see Figure 3). When asked about physical coping mechanisms students' most highly reported mechanism utilized was actively working to collaborate and communicate with others; while they were least likely to eat or drink unhealthy as a way to cope. “I am competent” was highly selected across students when mentally dealing with stressors, indicating they feel prepared with strong self-confidence in their skillset; while “I don’t feel like anything will get better” garnered the most “not true at all” in the mental realm; indicating that students surveyed feel like they are actively coping rather than doing nothing on the assumption it will not change anyways. Finally, emotional, or spiritual aspects reveal that these imaging students are asking for help when they are feeling vulnerable, instead of ignoring their issues in hopes they will just go away. These results indicate that students are seeking out the resources they need to help them cope rather than sitting back hoping things will change on their own. As expected through literature review, passive coping mechanisms do not prove to be as often employed as active options when dealing with the stressors present for medical imaging students. The third research question is looking at whether a correlation exists between resiliency and any specific areas of coping. A strong, positive correlation was made between resilience and both mental and emotional/spiritual coping skills. A Pearson bivariate correlation was run resulting in an r value of 0.79 indicating a strong positive correlation between mental coping skills and resilience levels reported; an r value of 0.67 between emotional/spiritual coping skills and resiliency, again indicating a positive strong correlation; and finally, an r value of 0.55 for 58 physical coping and resiliency (see Figure 4). Each of these correlation coefficients are statistically significant with each having a p value of <.001, with a stronger focus on mental and emotional coping skills as opposed to physical management of stressors by those surveyed. Figure 4 Correlations Physical Emotional Resilience Mental r 0.56 0.68 0.79 p <.001 <.001 <.001 N 73 73 73 Physical r 0.58 0.55 p <.001 <.001 N 73 73 Emotional r 0.67 p <.001 N 73 As literature review indicated, many of the characteristics of a resilient individual can be paralleled to utilizing active mental coping mechanisms, demonstrating the significance of the author’s hypothesis that imaging students using more active mental coping skills will also demonstrate higher resiliency levels. The final research question seeks to identify an environment where medical imaging students may be feeling most overwhelmed comparing three different settings: home or personal life, school or classroom, or clinical education; and seeking any correlations between those environments. A Pearson bivariate correlation resulted in no significant correlation made between resilience and the stress the students are feeling at home or school with an r value of -0.07 for home and -0.04 for school; a weak negative correlation was found between resilience and the clinical environment with an r value of -0.28 (see Figure 5). The negative correlation 59 between resilience and clinical environments signifies that as a student’s stress in their clinical environment goes up their resilience is going down with a p value of 0.02. Results also demonstrate a significant p value of 0.05 between clinicals and school, indicating that as stress at clinicals goes up, so does stress at school and vice-versa. The link between home and school holds a p value of .06 so it is approaching significance (see Figure 5). Figure 5 Correlations School Home Resilience Clinical r 0.23 -0.10 -0.28 p 0.05 0.42 0.02 N 73 72 73 School r 0.22 -0.04 p 0.06 0.76 N 72 73 Home r -0.07 p 0.57 N 72 While no significant correlations were found, those surveyed did indicate a higher level of stress in the clinical environment as expected by the review of literature showing heightened stressors in healthcare environments, as well as major disruptions in educational programs since the onset of the global pandemic. Summary In summary, the majority of the population in this study is White/Caucasian females between the ages of 18 and 30, who are enrolled in a Radiography program. This was to be expected. The electronic survey scored students to evaluate their overall resiliency along with the specific coping mechanisms that are utilized to handle stressful situations. These coping 60 mechanisms were separated into three categories, mental, physical, and emotional/spiritual strategies. The population scored well on their overall resilience with a mean score of 40.21 out of a maximum score of 50. The coping strategy that scored the highest was mental coping with an overall mean of 29.47 out of a maximum score of 40. Next, was emotional/spiritual coping mechanisms with a mean of 28.25 out of a maximum of 40. And finally, physical coping mechanisms had a mean of 26.01 out of the maximum score of 40. Medical imaging student’s resiliency was surveyed with results demonstrating overall high resiliency, with those having spent less time in the clinical environment reporting slightly higher levels of resiliency. This result was expected as those with more time in the clinical environment having endured the pandemic and the stressors it holds for those training to become healthcare professionals. Among medical imaging students surveyed, strong correlations can be made between resilience and both mental and emotional coping skills as well as a moderate correlation between resilience and physical coping skills. Active coping mechanisms were identified as being utilized as the more proactive approach to dealing with stress as opposed to passive skills. Finally, while no correlations were made between different environments and resilience; more students did report feeling stressed in their clinical environment versus at home or school. Survey results show that medical imaging students are overall feeling resilient, however with time spent in clinical environments they are demonstrating more difficulty dealing with adversity; with active coping mechanisms proving across the board to be more effectively utilized by students surveyed. Chapter 5: Implications, Recommendations, and Conclusions The COVID-19 pandemic has affected all medical professionals, including imaging students. The problem is that imaging students are experiencing increased stressors and 61 challenges due to the pandemic that can jeopardize their educational experience. The purpose of this quantitative study is to measure the current resiliency of imaging students enrolled at one institution and correlate levels of resilience with common coping practices. The research team has investigated quantitative student responses to the Connor-Davidson resilience scale to determine their experiences during the pandemic, how the pandemic affected them, how they coped with the challenges they faced, and how their coping methods helped them become more or less resilient. Following this questionnaire students responded to coping mechanism questions to assess how each individual copes with different stressors in multiple settings. The location of these students varies from Montana, Florida, Arizona and California, but the majority of participants come from Utah. This study has received approval from both the Institutional Review Board and Weber State University. All participants in this study were required to sign an electronic informed consent. Participants are aware of the limited risks involved in participating in this study. All personal information will remain confidential, and results will be held in a secure location during the collection of information. Only the individuals mentioned in this study, along with their mentor, will have access to this information. Data will be destroyed at the conclusion of this research. Implications The first research question asked if the ongoing COVID-19 pandemic has impacted the resiliency of imaging students, achieved through comparing resiliency scores between students in the first two semesters of their program to those with more than two semesters in their program. Results revealed students with more than two semesters in their program had lower resiliency scores than their counterparts with less time spent in their program (see Figure 1). These results imply that medical imaging students that have spent more time learning during the pandemic 62 may be being impacted by the stressors in their lives and not coping as effectively as those just getting started in their educational journey. Next, the coping mechanisms students are using were surveyed, looking to find the more commonly used strategies to cope with stress in their lives and whether active or passive mechanisms were being used at a higher rate; results showed that overall students surveyed are using more active and positive ways to cope with their stress than the passive alternatives (see Figures 2 and 3). Students are taking an active approach to deal with the stresses that accompany being a healthcare student in the midst of a global pandemic, implying that they are finding more relief from those stressors by actively engaging in taking steps to improve their situation rather than passively waiting for change. The third research question identified a strong correlation between mental coping mechanisms and resiliency scores, implying that there is an emphasis on actively engaging mental coping strategies to maintain resilience. Additionally, correlations made between all coping mechanisms and resilience, as well as results revealing active strategies are being used, implies that students are actively working to keep their resilience strong with a priority in engaging in positive mental health strategies. Finally, the authors sought to identify any correlation between resilience and different environments (home, school, clinical), revealing a weak negative correlation only between resilience and the clinical environment, and nothing statistically significant with either home or school setting; implying that the clinical environment may be having the most impact on students’ resilience of the three settings surveyed. This result is not surprising as literature review revealed and the authors hypothesis suggested, the ongoing pandemic has had many impacts on healthcare and for those training in that environment, and it is starting to affect the resiliency of those learning in that challenging space. 63 The information and conclusions drawn from these research questions may be used to benefit healthcare educational programs, particularly medical imaging students in the clinical setting; encouraging students to engage in active coping strategies by creating time and space for those students to employ those tactics in their lives. Providing resources to plan ahead and manage their clinical expectation or even teaching time management may encourage students’ feelings of competence and bolster their resilience. Imaging departments training students will benefit from having an open means of communication that students are comfortable using when feeling vulnerable or needing help; having open means of communication proved to be important for students to actively participate in their overall well-being; they are not just hoping their problems will resolve themselves, they are engaging and working toward change as a means of coping. A focus on continually engaging in support, particularly in the clinical environment, may help reduce the gap in resilience seen in this study between students with more time spent in clinical education and the added stress being reported by students as a part of that setting. Clinical education courses could promote the use of active coping mechanisms by building time and support into the curriculum, for example, direct students as a part of their grade to take a 15-minute break during each clinical shift to go for a walk, take time to meditate and breath, or have a quick pressure-free study time. While this study may have been small in numbers, it identified valuable information that medical imaging programs may use to bolster the resilience of students supporting a balanced approach to coping with the stresses of being a student particularly during the ongoing global pandemic. Recommendations One of the goals of this study was to inspire others to research topics that influence imaging students. There is not much on the impact of COVID-19 on imaging personnel and 64 students. It is recommended that more studies are conducted on this topic to ensure that imaging students have the tools they need to succeed in a stressful environment like a pandemic. This study only touched on a small group of individuals whereas more research needs to be done on a much larger scale. There are imaging students across the world who have been impacted by the effects of the pandemic. A follow up study focused on these individuals in 2-3 years would be valuable to understand if their overall resilience has been affected and whether they have learned to utilize different coping strategies. It is recommended that researchers take these baseline results and investigate the importance of students' mental health during a crisis like a pandemic and understand why certain coping aspects are lacking and why others are higher. This could in turn help future students stay resilient and educate staff and students on how to promote a successful educational environment. Researchers could develop educational programs that could be implemented by the university or school to ensure students are remaining healthy while going through their courses. Another goal of this study was to evaluate how students are coping through the stress of being a student, particularly during a difficult time for learning and how those involved in their education might learn or benefit from the findings of this study. Educators in both the clinical and traditional school environment may promote a more positive and effective educational program by nurturing students’ vulnerabilities and promoting active coping possibilities. Conclusions Review of the survey results demonstrate overall high resiliency among medical imaging students, particularly for those in the start of their program journey; those with more time spent in their program in the midst of the COVID-19 pandemic may be starting to show the effects of burnout with lower resiliency levels indicating the adverse effects of stress may be impacting 65 their lives and experience in their imaging programs. Among coping mechanisms surveyed, active skills rose to the top as those being employed by students across mental, emotional, and physical coping. While there were no statistically significant results correlating stress in different environments, the students surveyed did report higher amounts of stress felt while in the clinical setting. Big picture that can be drawn from the results is that imaging students are feeling most resilient and feel they are effectively managing their stress when they are deploying active coping mechanisms in their lives and educational experiences. This research, while small in scale, hopes to inspire more efforts to study the topics impacting medical imaging students starting their careers as healthcare professionals; and identify resources which may benefit future students to help them effectively manage major adversity that may influence their experience and outcomes. 66 References Algorani, E., Gupta, V. (2021). Coping Mechanisms. 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Volume 23; No 6. doi: 10.2196/25259 72 Appendix A: Figures and Graphs Figure 1 Figure 1: Distribution of scores where 1 represents newer students with 1 to 2 semesters of experience and 2 represents the students with 3 or more semesters of experience 73 Figure 2: Figure 2: Mean scores of active vs. passive coping mechanisms Figure 3 Figure 3: Overall coping scores active vs. passive 74 Figure 4 Correlations Physical Emotional Resilience Mental r 0.56 0.68 0.79 p <.001 <.001 <.001 N 73 73 73 Physical r 0.58 0.55 p <.001 <.001 N 73 73 Emotional r 0.67 p <.001 N 73 Figure 4: Correlations of coping strategies and resilience scores Figure 5 Correlations School Home Resilience Clinical r 0.23 -0.10 -0.28 p 0.05 0.42 0.02 N 73 72 73 School r 0.22 -0.04 p 0.06 0.76 N 72 73 Home r -0.07 p 0.57 N 72 Figure 5: Correlations between resilience scores and the students clinical, school, and home environments75 Appendix B: Informed Consent IRB STUDY #XXXXXXXXXX WEBER STATE UNIVERSITY INFORMED CONSENT Resilience of Imaging Students During the Covid-19 Pandemic You are invited to participate in a research study of imaging students' resilience during the Covid-19 global pandemic. You were selected as a possible subject because you are enrolled in an imaging program at a single institution of interest during Covid-19. We ask that you read this form and ask any questions you may have before agreeing to be in the study. The study is being conducted by Tanya Nolan, Kelsey Larsen, Cory Huff, Tamara Harp, and Taylor Bench, students of Weber State University, Innovation and Improvement Master of Science. It is funded by Weber State University. STUDY PURPOSE The purpose of this study is to measure the burnout reported by students Spring 2021 to current measures of resilience Fall 2021 in correlation with common coping practices during Covid-19. No investigational drugs or devices are used in this study. NUMBER OF PEOPLE TAKING PART IN THE STUDY: If you agree to participate, you will be one of at most 200 subjects. PROCEDURES FOR THE STUDY: If you agree to be in the study, you will do the following things: You will partake in one online survey that will ask a series of questions regarding your experiences throughout the imaging program during the Covid-19 pandemic. Before you begin you will be asked to agree to the terms of the survey. One of the tools used in the survey is called the Connor-Davidson Resilience Scale which helps measure PTSD which will include 10 questions. These questions will then be followed by coping mechanisms measured by the research team. The survey may take up to 10-15 minutes of your time. All answers are anonymous. 76 RISKS OF TAKING PART IN THE STUDY: Risks The possible risks or discomforts of the study are minimal however some risks are unforeseeable. There is the risk that you may find some of the questions to be sensitive. Loss of time taking survey Request of personal information such as behaviors and experiences. All answers to this study will be anonymous and held as confidential as possible. BENEFITS OF TAKING PART IN THE STUDY Benefits To contribute towards the advancement of science. To exercise one's autonomy and take an active role in society. All your answers will remain anonymous. This survey is accessible remotely. This study will solely help the future of radiologic imaging students by acquiring a baseline of resilience during a global pandemic. It is completely your choice to participate in this study. You may back out at any time during the process. See confidentiality tab for further information on our policy. Gratification of being apart of research that will aide future students ALTERNATIVES TO TAKING PART IN THE STUDY: Instead of being in the study, you have these options: Not participating in this study. COSTS/ COMPENSATION FOR INJURY There is no cost to participate in this study. You will not be paid to participate in this study. In the event of physical injury resulting from your participation in this research, necessary medical treatment will be provided to you and billed as part of your medical expenses. Costs not covered by your health care insurer will be your responsibility. Also, it is your responsibility to determine the extent of your health care coverage. There is no program in place for other monetary compensation for such injuries. However, you are not giving up any legal rights or benefits to which you are otherwise entitled. If you are participating in research which is not conducted at a medical facility, you will be responsible for seeking medical care and for the expenses associated with any care received. 77 CONFIDENTIALITY Efforts will be made to keep your personal information confidential. We cannot guarantee absolute confidentiality. Your personal information may be disclosed if required by law. Your identity will be held in confidence in reports in which the study may be published. The research team will have access to the records and the information will be stored for two years and then deleted. Your answers will be anonymous. Organizations that may inspect and/or copy your research records for quality assurance and data analysis include groups such as the study investigator and his/her research associates, the Weber State University Institutional Review Board or its designees, the study sponsor, and (as allowed by law) state or federal agencies, specifically the Office for Human Research Protections (OHRP) and the Food and Drug Administration (FDA) [for FDA-regulated research and research involving positron-emission scanning], the National Cancer Institute (NCI) [for research funded or supported by NCI], the National Institutes of Health (NIH) [for research funded or supported by NIH], etc., who may need to access your medical and/or research records. CONTACTS FOR QUESTIONS OR PROBLEMS For questions about the study, contact the researchers: Kelsey Larsen at kelseylarsen5@mail.weber.edu; Cory Huff at coryhuff@mail.weber.edu; Tamara Harp at tamaraharp@mail.weber.edu; Taylor Bench