The Retrospective Qualitative Analysis of Burnout and Self-Esteem among CT Technologist By Whitney Horn BSMI RT (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 April 2021 2 THE WEBER STATE UNIVERSITY GRADUATE SCHOOL SUPERVISORY COMMITTEE APPROVAL of a thesis submitted by Whitney Horn BSMI RT (R)(CT)(ARRT) This thesis has been read by each member of the following supervisory committee and by majority vote found to be satisfactory. ______________________________ Dr. Robert Walker, PhD Chair, School of Radiologic Sciences ______________________________ Dr. Laurie Coburn, EdD Director of MSRS RA ______________________________ Dr. Tanya Nolan, EdD Director of MSRS ______________________________________________________________________ Christopher Steelman, MS Director of MSRS Cardiac Specialist 3 THE WEBER STATE UNIVERSITY GRADUATE SCHOOL RESEARCH AGENDA STUDENT APPROVAL of a thesis submitted by Whitney Horn BSMI RT(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. 4/29/2021__________ Whitney Horn_______________ Date Student Name 4 Abstract Healthcare professionals have chosen a hard and tactful career, though each does it with so much care and heart that they do not know what else they would do. The COVID-19 pandemic presents unprecedented challenges for all imaging technologists. In studying both factors of burnout and self-esteem among healthcare professionals, researchers observe increased levels of burnout and decreased levels of self-esteem developed throughout this pandemic. Factors attributed to this relationship include: increased stress, decreased staffing, lack of safety, job satisfaction, and quality of patient care.This qualitative study was conducted through zoom interviews as a means to understand the experiences and perspectives of CT technologists throughout the COVID-19 pandemic. Five frontline CT technologists from the western states of the United States were solicited to participate in the study. Responses from participants indicate that factors relating to burnout they experienced during the pandemic included: increased work responsibilities, long hours of wearing PPE, changing of policies and procedures, decreased staffing, and increased workload. Reported factors related to self-esteem included feeling a lack of connection with patients, the risk of contracting or spreading COVID-19, and decreased response from the organization. This study may provide information to organizations where in support may be focused upon proper equipment (PPE), support from the organization, and overall effects of burnout is key in the overall well-being of their employees to be able to provide the best quality of patient care. Keywords: COVID-19, burnout, self-esteem, healthcare professions, imaging professional, PPE, organizational support. 5 Acknowledgements I would like to express my sincere gratitude and appreciation to Dr. Tanya Nolan and the rest of the Master of Science in Radiologic Sciences cohort for their continued support, guidance, and encouragement throughout this project. I would also like to thank my classes throughout my journey in this Master’s program at Weber State University. Also a huge thank you to the participants that contributed to the study and enable this research to be possible. And lastly, a thank you that is not big enough to give to my family, friends, co-workers for their unending support, patiences, and encouragement throughout my education career. Without them, it would not have been possible. And one last thank you to my late best friend Jared Hathaway, who has pushed me to become the best version of myself and made me apply to this Masters Program, without you, I would not be where I am today. I miss you so much. 6 Table of Contents Chapter 1: Introduction 1 Background 1 Statement of the Problem 2 Purpose of the Study 3 Research Questions 3 Hypotheses 4 Nature of the Study 4 Significance of the Study 5 Definition of Key Terms 5 Summary 6 Chapter 2: Literature Review 8 COVID-19 8 Testing, Tracing, Telehealth, and Vaccine Development 9 Factors Directly Affecting Healthcare Professionals During theCOVID-19pandemic 11 Government and Corporation Policy 11 PPE 13 Job Security and Healthcare Roles 14 The Evolution of Date and Human Response 16 Burnout in Healthcare Professionals 19 Burnout and COVID-19 21 Emotional Exhaustion 22 Depersonalization 24 Cynicism 25 Self-Efficacy 27 Personal Self-Esteem 28 Community Self-Esteem 28 Organization Self-Esteem 30 Resilience 31 Coping Mechanism 32 Summary 33 Chapter 3: Research Method 35 Research Methods and Design(s) 35 Population 36 Sample 36 Materials/Instruments 37 Data Collection, Processing, and Analysis 38 Assumptions 39 7 Limitations 39 Delimitations 40 Ethical Assurances 40 Summary 41 Chapter 4: Findings 43 Results 43 Discussion 48 Summary 51 Chapter 5: Implications, Recommendations, and Conclusions 52 Implications 52 Recommendations 53 Conclusions 54 References 55 Appendices 62 Appendix A: IRB Approval 62 Appendix B: Interview Questions 63 AppendixC: Informed Consent 68 Appendix D: Weber State Photo/Video Release Form 71 8 List of Tables Table 1. Burnout Variables Reported Over the Duration of the COVID-19 Pandemic..…44 Table 2. Burnout Research Question and Common Themes Results………………………..45 Table 3. Self-Esteem Levels Reported over the Duration of the COVID-19 Pandemic…..46 Table 4. Self-Esteem Research Question and Common Themes Results……………… .….47 9 List of Figures Figure 1. Total year of Medical Imaging Experience…………...………………………….43 1 Running Header Chapter 1: Introduction The COVID-19 pandemic has altered the human way of life on a global scale. This disease, with so many unknowns, has placed an increasing number of burdens on many healthcare systems. Frontline imaging professionals who are routinely exposed to COVID-19 positive patients are experiencing an unprecedented amount of stress and fatigue. The increase of positive COVID-19 cases are filling hospitals to maximum capacity, therefore increasing the need for diagnostic imaging. New PPE and sanitation protocols are increasing the amount of time to perform these examinations. We seek to understand how community and organizational factors affect the imaging professional and make it difficult to detach from their work environment. The focus of this research is to identify if the variables responsible for increasing levels of burnout among frontline CT professionals and to discover if there are effects on self-esteem, compassion and self-efficacy. Background COVID-19 was originally identified in December of 2019 in Wuhan, China by Chinese authorities who notified the World Health Organization. This notification was from an unknown case of pneumonia that could not be explained by physicians. The virus is spread from birds and mammals to people who are at risk from infection. Dissemination of human-to-human is then from the airborne droplets, close contact with an infected person, and from contaminated surfaces. When a person is infected and needs to receive treatment from the issues related to COVID-19, it comes from frontline healthcare professionals that are then also exposed to the virus. The overwhelming number of infected patients that have flooded the healthcare system has been larger than the average from these providers. This ongoing increase in patient care has led to burnout among healthcare professionals. It is not only the patient increased that is causing the 2 burnout but other factors like anxiety, stress, emotional exhaustion, depersonalization, a lack of person accomplishment, issues related to self-esteem and over all increased workload (Alqunmeeyn, Altakhineh, Azab, Babar, & El-Dahiyat, 2020). Statement of the Problem Burnout in healthcare professionals is not something new, but we have seen an increase in this during the COVID-19 pandemic. To provide the best care for patients it is important that healthcare professionals are able to perform their jobs in the way they care. To optimize care of patients it is important for healthcare organizations to understand this serious problem and be able to provide help to maintain/support their employees mental and physical wellbeing. In a study on the effects of COVID-19 on healthcare professionals, Fernandez (2021) stated that stress, depression, anxiety, and exhaustion are common among health professionals working with COVID-19 patients. There is a need for researching the cause and effect of COVID-19 on healthcare professionals. Among these healthcare professionals, this study takes a close look at imaging technologists who work in Computed Tomography (CT). Burnout has been reported within imaging departments around the world. It was reported in the Canadian Association of Medical Radiation Technologist, before the COVID-19 pandemic, that at least 57% of medical radiation technologists suffered from emotional exhaustion. With the influence of COVID-19, incidences of mental health illness among medical professionals in America have been elevated (Fernandez, 2021). Burnout can lead to adverse events, poor patient safety, reduced job performance, negative patient experience, and poor quality of care (Dall’Ora, Ball, Reinius, & Griffiths, 2020). Increased workload, due to COVID-19, is one of the major risk factors for burnout, (Garcia & Calvo, 2020). 3 This research seeks to understand how the COVID-19 pandemic has affected the mental and physical health of imaging professionals in relation to burnout and self-esteem. Purpose of the Study The purpose of this qualitative study is to evaluate the level of burnout and self-esteem experienced among imaging professionals who have worked as a CT technologist during the COVID-19 pandemic. Researchers will use semi-structured Zoom interviews to gather relevant data. Subjects will participate in one-on-one interviews and provide opinions about their perceived levels of burnout related exhaustion, depersonalization, and personal accomplishment as well as personal and organizational self-esteem. Participants will be allowed to expand upon and describe their rationale for changing or constant levels of burnout and self-esteem experienced during the COVID-19 pandemic. Interviews will be recorded and used for coding and study data mining. Subject time commitment to participate and complete the interview is approximately 30 minutes. Categorial themes will be described and compared in a constructivist framework among and between the responses from these CT technologists. Steps taken to develop appropriate interview questions included alignment with the research questions, constructs of the theoretical frameworks, and review of the current literature review. Research Questions The research questions for this qualitative study include: Q1. How has the perception of burnout and its related factors, among CT technologists, changed during the COVID-19 pandemic? 4 Q2. How has a sense of personal and organization self-esteem changed over time among CT technologists during the COVID-19 pandemic? Hypotheses H1. It is our hypothesis that CT technologists will have experienced an increased level of burnout. This is suspected that the respondents will cite poor communication, lack of resources (PPE), and stress-full working conditions leading to this conclusion over the duration of the COVID-19 pandemic. H2. It is our hypothesis that CT technologists will have experienced a decreased level of self-esteem. It is suspected that respondents will cite poor communication, unsupportive policy, fear of the disease, lack of resources (PPE), and stressful working conditions as factors leading to this conclusion. Nature of the Study This qualitative study is being used to analyze the effects of burnout and self-esteem among CT technologists over the duration of the COVID-19 pandemic. The data will be collected via Zoom interviews of a minimum of five CT technologists with direct patient care of COVID-19 patients. During the interview, participants will be asked basic demographic questions, including their age, gender, and current role in healthcare. There will be a total of 27 questions that will focus on the participants personal opinion and experience as an imaging professional on the frontlines during the COVID-19 pandemic. The data will then be analyzed to see if the hypothesis that CT technologists have experienced an increased level of burnout and decreased levels of self-esteem over the duration of the COVID-19 pandemic. 5 Significance of the Study The researchers for this study seek to understand and define the areas of increased burnout and decreased self-esteem experienced by working CT technologists during the COVID-19 pandemic. Our goals are to help determine how we improve the lives of the CT technologist and imaging professionals in preparation for continuing changes associated with COVID-19 and future pandemics. The study is significant in educating organizations on best practice in preparation, response, and support to employees and patients. This study provides needed insight and recommendations from the front line. Definition of Key Terms COVID-19 Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus (World Health Organization , 2020). CT Technologist CT technologist is an imaging professional who performs scans on all parts of the body using a computed tomography machine (Computed tomography, 2021). Healthcare Professional Any licensed physician, licensed medical practitioner, registered nurse, licensed nurse practitioner, licensed physician’s assistant, licensed nurse’s assistant, and other similar licensed professionals who work directly with patients (Law Insider, 2021). PPE Personal Protective Equipment (PPE) is equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses. These injuries and illnesses may result from contact with biological, chemical, radiological, physical, electrical, mechanical, or other workplace hazards (OSHA, 2021). Healthcare Technology Healthcare technology also known as healthcare tech refers to any IT tools or software designed to improve hospital and administrative productivity, give new insights into medicines and treatments, or improve the overall quality of care provided (Healthcare Technology Trends, 2020). Burnout 6 Burnout is a state of emotional, physical, and mental exhaustion caused by excessive and prolonged stress. It occurs when one feels overwhelmed, emotionally drained, and unable to meet constant demands (Smith et al., 2020). Self-Esteem The term self-esteem is used to describe a person's overall sense of self-worth or personal value. In other words, how much you appreciate and like yourself. It involves a variety of beliefs about yourself, such as the appraisal of your own appearance, beliefs, emotions, and behaviors (Cherry, 2019). Self -Efficacy Self-efficacy refers to an individual's belief in his or her capacity to execute behaviors necessary to produce specific performance attainments. Self-efficacy reflects confidence in the ability to exert control over one's own motivation, behavior, and social environment (Bandura, 1997). Compassion Compassion is defined as the emotional response when perceiving suffering and involves an authentic desire to help (Seppala, 2013). Compassion Fatigue Compassion fatigue is a condition characterized by emotional and physical exhaustion leading to a diminished ability to empathize or feel compassion for others, often described as the negative cost of caring. It is sometimes referred to as secondary traumatic stress (STS), (Figley, 2002). Cynicism Cynicism is an emotion of jaded negativity, or a general distrust of the integrity or professed motives of other people. Cynicism can manifest itself by frustration, disillusionment and distrust in regard to organizations, authorities and other aspects of society, often due to previous bad experience (Your Dictionary, 2021). Resilience Resilience is the process of adapting well in the face of adversity, trauma, tragedy, threats, or significant sources of stress (American Psychological Association, 2012). Summary To summarize, the purpose of this study is to review the experience of CT technologists during the COVID-19 pandemic and document the self-reported factors they perceived as affecting their levels of burnout and self-esteem over the duration of this pandemic. Key perceptions will include the evolution of burnout and self-esteem 7 factors and how they have changed since the onset of the COVID-19 spread. The significance of this study is to assist in highlighting appropriate changes needed to better assist imaging technologists and patients in the case of another pervasive and global incident. 8 Chapter 2: Literature Review COVID-19 A timeline published by the American Journal of Managed Care (AJMC,2020) reports that on January 9, 2020, the World Health Organization (WHO) announced a new coronavirus related pneumonia in Wuhan, China. Within two weeks, cases had been reported around Asia and screening began at international airports in the United States. by the end of the month Wuhan, along with neighboring cities, were under strict quarantine. On January 31, 2020 less than four weeks after the announcement of a new virus, the World Health Organization declared a global health emergency, followed three days later by the United States own declaration of emergency. By this time, nearly 10,000 confirmed cases had been diagnosed worldwide, with more than two hundred deaths. Due to the alarming level of spread and severity of the outbreak, the World Health Organization declared the outbreak a pandemic on March 11, 2020, a mere two months after the first report of the virus. At the onset of the pandemic, the United States emphasized travel warnings and put international travel restrictions in place. The United States federal government put most decision making for pandemic related control in the hands of each individual state, rather than creating nationwide regulation. Each state responded in a different way, depending on region and population. Responding to the quickly spreading outbreaks in the country, many states and larger cities began to enforce lockdown measures and limited travel for non-essential workers. The term ‘essential worker’ is an umbrella term given to those whose work was determined to be essential in keeping the infrastructure of the country working. Healthcare professionals, emergency personnel, those working in food service, janitorial, 9 shipping, repair, energy, and providing public transportation were among those categorized as essential (NCSL.org, 2020). Healthcare professionals make up 30% (mass.gov) of all essential workers; working in hospitals, emergency clinicals, and long-term care facilities. Wang (2020) reports that in an early case study series from Wuhan, China, 29% of patients with COVID-19 were healthcare professionals and were assumed to have acquired the virus in the hospital. As of January 2021, the United States alone has reported more than 25 million confirmed cases and 420,000 deaths related to the COVID-19 virus, 3,000 of whom worked in healthcare. Testing, Tracing, Telehealth, and Vaccine Development As the pandemic escalated, the federal government and states activated emergency funds and personnel. Berquist, Otten, and Sarich (2020); reported that by July 2020, new testing technology was in place which enhanced COVID-19 testing. Intending to accelerate the vaccine development process, the federal government introduced the “Operation Warp Speed” to provide financing for vaccine production. Numerous measures were taken to combat the spread of the virus, including business closures, increased development and adoption of telemedicine, to reduce personal contact with those who may be infected, and research funding for treatment, testing, and the development of a vaccine. Some states developed new technological programs to track the spread of the virus, including smartphone-based contact tracing (Berquist, Otten, & Sarich, 2020). Advanced technological systems, while helpful, became stress for several reasons. For example, although artificial intelligence (AI) was developed to learn and quantify COVID-19 symptoms in some countries, its efficacy was not guaranteed 10 (Kumar, Gupta, & Srivastava, 2020). For smartphone based contract tracing, the use of Bluetooth technology was questioned due to issues related to consent and privacy (Mclachan et al., 2020). Although telehealth is essential in providing healthcare to those under quarantine regulations or those not allowed to visit the provider’s office due to COVID-19 symptoms, insurance coverage and other policy gaps made it difficult for healthcare providers to use throughout the pandemic (Goldschmidt 2020). Withstanding these obstacles, Goldschmidt (2020) stated that advanced technologies such as tele-monitoring and the use of video conferencing calls helps primary care providers effectively attend to local communities during the COVID-19 pandemic. In addition, other technologies such as drive-thru testing enabled patients to be evaluated without leaving their cars (Hill, Campbell, Mutch, Koch, & Mackintosh, 2020). The Internet of Things (IoT) helped in reducing the spread of COVID-19 and enhancing patient monitoring and treatment. The Internet of Things supplied and integrated networks for healthcare systems to fight the COVID-19 pandemic by linking personal medical devices to software on the internet. This has proven to be an excellent way to screen patients who may be infected, by relaying vital signs such as; temperatures, heart rate, and oxygen levels. Patients who are COVID-19 positive can be monitored from a remote location with the use of a well-connected device. During any healthcare emergency, the device will automatically send an alert message to healthcare personnel. By using a statistical-based method, the Internet of Things may be able to predict healthcare emergencies related to this virus before they happen. The advantage of this technology is its ability to provide quality distance supervision by accessing real-time information. Based on the evidence presented above, creative measures can be 11 taken to address the stressful times during the COVID-19 pandemic, but also effective in maintaining the health of the population. In December of 2020, two vaccines, Moderna COVID-19 vaccine and Pfizer-BioNTech COVID-19 vaccine, became available and approved by the Center of Disease Control and Prevention (CDC). In the same month, other vaccines (Novavax, Jansses, and AstraZeneca) were being tested (CDC, 2021). Although each state has power to decide who would receive the first vaccines, the Center of Disease Control and Prevention (2021) recommended healthcare personnel and residents of long-term care facilities be the first to receive the vaccine. Factors Directly Affecting Healthcare Professionals During the COVID-19 Response Government and Corporate Policy A significant source of stress to frontline healthcare professionals during the COVID-19 pandemic was perceived lack of response and constantly changing COVID-19 guidelines issued by the United States government. As reported by NELP.org (2020) on April 18, 2020 the Center of Disease Control and Prevention issued guidelines stating that an employer may require an exposed healthcare worker to continue working, providing they remain asymptomatic and additional precautions were implemented. This statement reversed the previous policy issued by the Center of Disease Control and Prevention one month earlier, which stated that people who had been exposed to COVID-19, should remain in quarantine for 14 days due to significant risk of transmission from asymptomatic and presymptomatic individuals. On November 19th 2020, the guidelines were then updated again, reversing the non-quarantine time from 12 exposed employees and now stated that an exposed healthcare worker must have a negative test and be asymptomatic before returning to work only as a last resort, until the 14-day quarantine period is over. Doubt in the governing bodies included feelings of mistrust amongst healthcare workers in the federal Occupational Safety and Health Administration (OSHA). According to Berlowiz (2020), the Occupational Safety and Health Administration had not issued any enforceable COVID-19 specific practices or policies that employers were focused to implement in protection of healthcare workers. All guidelines were voluntary recommendations that employers might choose whether or not follow. OSHA has not conducted any on-site inspections nor enforces, by mean of consequences, any guidelines during the pandemic. Furthermore, the CDC does not have strict guidelines regarding separating COVID-19 positive patients from non COVID-19 patients. Jewett (2020) states that in hospitals around the country, healthcare workers report having been exposed to COVID-19 when infected patients have been placed in non-dedicated areas. In a survey of 21,000 nurses, 32% reported that there were no dedicated COVID-19 units in their facility. Many healthcare workers in these non COVID-19 units were not provided with proper PPE by their employers and felt they were in danger of becoming infected with the virus. Without regulation, patients receiving care in hospitals or nursing care facilities, including those who had tested positive for COVID-19, were allowed to walk the hallways and mingle with other non infected patients and staff in states including California, Florida, New Jersey, Iowa, Ohio, Maryland, and New York. Berkowitz 13 (2020) reports that some states are adapting federal recommended guidelines into their own state-enforced policies, and are putting extensive protocols into place. The University of Nebraska Medical Center has implemented strict containment protocol, including isolation units with negative pressure capabilities and restricted access to these units by healthcare professionals trained in proper use of the PPE and respirators, by using standard infection control techniques and proper protective equipment; staff at the university who care for COVID-19 patient have not, thus far, been infected. PPE Healthcare professionals were deeply affected by the reduced availability of personal protective equipment (PPE), and the changing guidelines regarding the use of PPE. Early shortages and inaccessibility to PPE was a major source of anxiety and fear for healthcare professionals. Cohen (2020) conducted a study to discover the factors related to PPE shortage at the beginning of the COVID-19 pandemic. The first factor cited by the study was the budget model of many healthcare systems, which are incentivised to minimize cost. The purchase and storage of excessive supplies are feasible within the financial model. Second, the massive, acute need for PPE drained already depleted inventories. Third, the federal government failed to maintain a sufficient PPE stockpile and to distribute supplies to facilities in need. Last, is the disruption to the global supply chain created significant reductions in PPE being exported to the United States, which is highly dependent on imported medical supplies. PPE became scarce and competition between businesses, governments, and individuals to procure necessary PPE became increasingly competitive, which further reduced availability. 14 As stated by the CDC (2020), the lack of sufficient N-95 respirators during the pandemic creased the need to conserve supplies, resulting in CDC recommendations of reusing and extending the life of respirators meant for one-time use. In the early days of the pandemic, when PPE supplies were very low, CDC guidance extended so far as to recommend bandana type face coverings for healthcare professionals. These compromises to best practice crested doubt and feelings of expendability amongst healthcare professionals. Cohen (2020) summarizes that the system wide shortage of PPE led to an increase in healthcare professional illness that was transmitted widely among staff, ending in staffing shortages. Healthcare professionals were now faced with increased patient loads, including large numbers of severely ill patients, taxing both the quantity and quality of patient care. In contrast, many hospitals within the United States reported providing sufficient PEE to employees and training them in its use Stewart et, al. (2020), argued that most hospital employees had proper access to PPE kits, especially gloves, eyewear, mask, and gowns. The report states that sufficient access to PPE kits relieved safety concerns of employees and resulted in better care for their patients, specifically those who were COVID-19 positive. According to Brat et al. (2020), the United States ensured an effective supply of PPE kits, especially amongst those working in emergency and surgical units. The researchers state that proper PPE provided with the United States ensured better outcomes. Job Security and Healthcare Roles Job insecurity is an additional stress experienced by healthcare professionals during the COVID-19 pandemic. As Paavola (2020) reported at the beginning of the 15 pandemic, many hospitals and healthcare systems suspended elective procedures to save bad capacity, supplies, and staff to treat COVID-19 patients. They also spent massive amounts of money to prepare for the perceived oncoming waves of critically ill patients including the purchase of ventilators and PPE. Paavola (2020) cited that Baylor Scott & White Health spent $85 million to prepare. As a result, many systems lost large amounts of annual revenue focusing them to reduce costs in terms of resources and manpower. Nationwide, hospitals and healthcare systems furlough and laid off healthcare personnel. As of June 4, 2020, 266 hospitals across the country had reduced staff in the effect to remain financially stable. Seattle based UW Medicine announced 5,500 furloughs as of May 25, 2020. Southcoast Health, based in Massachusetts, furloughed ten percent of their healthcare staff. Along with massive furloughs came permanent lay-offs. Mount Sinai Medical Center in Miami Beach Florida permanently eliminated 208 employees and in doing so saved their system $11.1 million in payroll expenses for the year. Baylor Scott & White Health, who spent $85 million to prepare for the pandemic, eliminated 1,200 positions and furloughed an unspecified amount of its workforce. Paavola reports that many furloughed employees were able to retain healthcare benefits and were also called back to work when patient volumes rose. In contrast, several other healthcare systems maintained all employees, but with reduced hours or by repurposing or re-assigning employees to different positions or locations. In a letter to its trustees, Intermountain Healthcare (2020) in Utah explained that the organization did not lay off any medical personnel, but in facing extreme financial loss of over $435 million in revenue due to reduced surgeries, inpatient admissions, ER and clinical visits, reduced wages for some physicians, physician 16 assistants, and nurse practitioners by fifteen percent (Gabbler, 2020), and paused matching contributions to employee 401k accounts. Many non-clinical employees were pushed toward or offered early retirement. Many employees who have been reassigned to work in different resportments have felt ill-prepared for the roles to which they have been re-assigned, and many of which require skills in which they have not been trained or have not regularly used. Healthcare professionals across the departments felt a loss of control over their schedules and fears for their future role in the workplace due to the uncertainty of what changed the ongoing epidemic continues to create (Elsevier, 2020). The Evolution of Date and Human Response The newness of the virus mant there was no solid evidence about the way it was spread and as the pandemic spread, misinformation was rampant. Reports of the virus lasting on surfaces for weeks were circulating and there was much discussion on whether the virus was spread by droplet or was airborne. Information was updated as the world learned more about the virus and in April of 2020 the CDC (2020) updated their website to reflect the newest information about how the virus spreads. The CDC reports that the virus most commonly spreads: ● Between people who are in close contract with one another (within six feet) ● The virus spreads through respiratory droplets or small particles, such as those in aerosols, produced when an infected person coughs, sneezes, sings, talks, or breaths. 17 ● The respiratory particles can be inhaled into the nose, mouth, airways, and ling and cause infections. This is thought to be the main way the virus spreads. ● Droplets can land on surfaces and objects and be transferred by touch. A person may get COVID-19 by touching the surface or the object that has the virus on it, and then touching their own mouth, nose, or eyes. ● Droplets and airborne particles may remain suspended in the air and be breathed in by others, and travel distances beyond six feet. Indoor environments without good ventilation increase this risk of transmission. The most recent CDC update reports that COVID-19 symptoms begin to appear two to fourteen days after exposure, and described ,ild symptoms of the disease which include fever, chills, cough, dyspnea, muscle or body aches, headache, loss of smell or taste, congestions, sore throat, nausea vomiting, and diarrhea. The CDC went on to describe severe, life threatening signs which require immediate medical care such as dyspnea, low oxygen saturation, persistent chest pressure, bluish lips or face, confusion, and inability to wake or stay awake. Respiratory failure, septic shock and multiple organ dysfunction are symptoms of critical illness. The NIH (2020) reports that certain comorbidities increase the risk of severe infection. The comorbidities include being over 65 years old, having cardiovascular disease, chronic lung disease, sickle cell disease, diabetes, obesity, cancer, kidney disease, or being recipient of a transplant. With evolving data, The Word Health Organization (WHO) stated that healthcare systems were not only battling the pandemic, but they are also in the midst of battling an “infodemic”. Siebenhaar, Kother, and Alpers (2020) examining the impact of COVID-10 18 infromationon societal compliance with preventive measures for containing and spreading the disease. From the onset of the pandemic in February of 2020, there have been non-stop new cycles on national television, social media sites, government agencies, and various websites regarding the pandemic. Seibenhaar (2020) reports that information regarding this virus which is viewed by the public elicits an emotional response. If the information is perceived as threatening, it can produce aversive emotions, like stress. WIth so many different media outlets, vast quantities of information are often contradictory and cause uncertainty that elevates a person’s level of distress. Seibenhaar (2020), goes on to state that “distress may generally induce adaptive behavior in support of crisis management, unless individuals respond to it by avoiding information.” (p.1). Information avoidance occurs when a person completely avoids listening to , reading about or gathering any further information. The act of compliance and/or avoidance are both coping mechanisms used to manage an emotional response. SIebenhaar (2020) categorized two behavior groups: one, those who actively cope with distress by surveilling threatening information and who take appropriate measures to survive it, and two, those who have avoidance anxiety and use passive coping mechanism wherein they miss out on important updates and may even underestimate the seriousness of the situation. The passive process involved information avoidance often leads to non-compliance, either intentionally or unintentionally. Lack of compliance with preventative measures has been shown to interfere with pandemic crisis management, whereby the goal is successful viral containment. Conclusively, the 19 researchers found “information avoidance a maladaptive response to exacerbated distress.” One method to learn how information should be presented to the public to encourage compliance is by using a predictive tool. According to Kowalski and Black (2021), the Protection Motivation Theory of Health (PMT) is a model that can help predict an individual’s compliance with health promoting behavior. Kowalski and Black explain that PMT uses a person’s cognitive evaluation of the consequences to determine one’s response to their health-related choices. All individuals have an anticipatory regret response whereby they might sometimes in the future regret not having done something that could have prevented or thwart a health threat. People are more likely to regret inactions as opposed to actions, because of the anticipatory regret, when public health information focuses on the community’s vulnerability to the virus, it may have little impact. The authors suggest that the message is best focused on understanding the severity of the virus and the efficacy of the health behaviors in decreasing the spread of the disease to achieve better compliance. By focusing public information on one controlled and effective aspect of the pandemic, greater compliance and less avoidance result and support behaviors preventing the spread of COVID-19. Burnout in Healthcare Professionals Burnout is a state of emotional, physical and mental exhaustion caused by excessive and prolonged stress. Excessive stress, related to COVID-19, has been recognized globally as a concern for the physical and mental wellbeing of healthcare professions. Freudenberger and Maslach, in the mid-1970s, defined burnout as “a state of physical, emotional, and mental exhaustion that results from long-term involvement in 20 work situations that are emotionally demanding” (p. 644). Burnout syndrome consists of emotional exhaustion, depersonalization, and reduced sense of personal accomplishment (Khasne, August, 2020). High levels of burnout have been associated with suboptimal judgment in patient care. Healthcare professional burnout is detrimental to the professional and to the patient (Khasne et al., 2020). Restauri and Sheridan (2020) warned that increasing burnout levels may lead to medical mistakes affecting the patients’ safety. As a result, burnout has contributed to decreased patient satisfaction with the HCP and increased litigation. There are several research studies that help provide a baseline understanding of burnout among healthcare professionals before the start of COVID-19 pandemic. In 2010, Singh, et al. (2016) evaluated burnout levels among radiographers, sonographers, and radiologists. The survey was administered to radiographers belonging to the Australian Institute of Radiology, sonographers belonging to the Australian Sonographer Association, and radiologist belonging to the Royal Australian and New Zealand College of Radiologist. The survey was administered to 5196 raidolographer, 3974 sonographers, and 1618 radiologists. However, only 613 radiographers, 121 sonographers, and 35 radiologists completed the survey. They utilized the Maslach Burnout Inventory (MBI) to evaluate burnout in areas of emotional exhaustion, depersonalization, and personal accomplishment. Their findings revealed higher than average burnout levels among this group. They also measured other factors such as work experience, education experience, marital status, gender, and hours of overtime worked, and amount of time educating students. The factors that had statistical significance were the amount of overtime worked and time spent educating students. It was found that those who worked more 21 overtime and spent less time in education roles experienced more emotional exhaustion and higher levels of depersonalization respectively. In 2019, health technology company Philips performed a study to measure stress and burnout among imaging technologists. To do so, they used the Emotional Exhaustion Subscale of the Maslach Burnout Inventory. The results showed that an alarming 36% of radiological technologists in the United States were at a moderate or high level of burnout. The study goes on to ask technologists to identify their causes of stress that lead to burnout. Of the technologists surveyed, 40% reported workload and 35% reported lack of appreciation as their major causes of stress. These studies demonstrated that burnout was an issue among radiology staff even before the COVID-19 pandemic occurred. The studies link increased levels of burnout to increased workload, increase in overtime hours, and lack of appreciation. With the COVID-19 pandemic bringing a surge in patient volumes and higher workload for radiology staff, concerns of increased burnout are valid and pertinent. Burnout and COVID-19 Burnout, resulting from the pandemic, is significant to understand when trying to maintain quality healthcare in the future (Khasne et al., 2020). Although job security and a lack of available work hours were previously cited as a source of elevated stress for healthcare professionals during COVID-19, a contrasting source of stress occurred when healthcare professionals were faced with too much work. There are numerous doctors that can contribute to the burnout of healthcare professionals on the frontlines like the ones mentioned in this research including the workloads that these individuals encounter (Abern, et al., 2020). In another study conducted in sixty different countries, it was 22 reported that 51% of the 2,707 participating healthcare professionals questioned declared having experienced burnout. These professionals’ burnout was reported to be from the manner in which their home life was impacted due to their workload, feeling as if they were being pushed beyond their scope of practice to get the job done, being exposed to positive COVID-19 patients, having to make life prioritizing triage decisions, and lacking access to proper PPE (Abern, et al., 2020). Burnout can also be exacerbated by limited organization support (Abern, et al., 2020). Ideally, the factors leading to burnout may be diminished if the healthcare organization provides support to its staff. Best preventative practices include hiring more employees whenever possible, skill based training, maintaining adequate levels of PPE, providing supportive strategies for families, and offering resources for employees’ mental health. Reduced hospital resources, the threat of COVID-19 exposure to both the healthcare professional and their families, longer shift with larger workloads, lack of sleep, poor work-life balance, and lack of communication and information are all overwhelming healthcare professionals. Indeed, these conditions have contributed to increased fatigue, anxiety, stress, and burnout among current healthcare teams (Kaye et al., 2020). Methods of evaluating healthcare professionals who are experiencing burnout include assessing the exposure, understanding perceptions, noticing when the workload increases, and monitoring for emotional exhaustion (Abern, et al., 2020). Emotional Exhaustion Restauri and Sheridan (2020) describe the COVID-19 pandemic as the perfect storm that intersects chronic workplace stress and acute traumatic stress from the pandemic. As outlined by Esterwood and Saeed (2020), these psychological effects are 23 numerous and have both short and long-term effects. Immediate effects reported in relation to COVID-19, include post-traumatic stress disorder (PTSD), anxiety, fear, low self-esteem, and distrust (Esterwood & Saeed, 2020). As the pandemic continues beyond one year, there is also increased potential for long-term PTSD> Emotional exhaustion is not unique to the United States healthcare professional. Severe professional-related stress is a global problem (Khasne et al., 2020). As discussed in the previous section, lack of PPE, staffing shortages, and the fear of contracting and spreading the disease has added to healthcare professionals' level of burnout. Lai et al., (2019) studied healthcare professionals during COVID-19 in China and they discovered their participants were more likely to have signs of depression, anxiety, insomnia, and distress. This research supported another study completed in INdia by Khasce et al., (2020) in which researchers questioned healthcare professionals on the extent of burnout they experienced during the COVID-19 pandemic as compared to that of their pre- COVID-19 work environment. The results of the India study showed that “compared to normal circumstances, there was a significant increase in pandemic-related burnout.” The first report on burnout comparing job categories and associated risk factors among healthcare professionals in Japan during the pandemic was performed by Matsuo et al., (2020). Researchers used the Maslach Burnout Inventory-General Survey to show the overall prevalence in radiologic technologists was 36.4%. Statistically, stress levels in the pre-COVID-19 era were lower than current stress levels during the pandemic for healthcare professionals. In a literature review conducted by Lagasse in 2020, he shared a survey conducted by Berxi, a division of Berkshire Hathaway Specialty Insurance, which is a provider of professional liability insurance for medical professionals. Berix’s 24 urvery compared healthcare professionals’ current mental and physical well-being to that of the previous year. A total of 84% of respondents reported feeling at least mildly burnt out from work, while 18% stated they felt totally burnt out. Nearly half the respondents (48%) stated they had considered retiring, quitting their job, or changing careers. These healthcare professionals no longer had a rewarding connection to their career or the patients that they served. Depersonalization Compassion fatigue (CF) has been described as the convergence of secondary traumatic stress resulting from exposure to a traumatized individual and cumulative burnout (Cockerm, 2016). Alharbi (2020) reports that compassion fatigue is associated with those who have been affected by severe emotional distress. Individuals exposed daily to high pressure and high risk situations, such as in times of a pandemic, may become immersed in the suffering and the traumatic experiences of those they help. In time, these healthcare professionals begin to perceive and believe in their inabilities to alleviate the suffering of those entrusted to their care. Those at greatest risk for compassion fatigue are healthcare professionals because they often put the needs of their critical patient above their own. Compassion fatigue is especially high for those who work in environments where there are daily interactions with patients whose outcomes are bleak. On many ICU COVID-19 designed floors with high patient mortality rates, healthcare professionals feel frustrated and helpless because they believe their actions will make no difference to their patients’ outcomes (Alharbi, 2020). This detachment can impact the standards of care, impact co-worker relations, and lead to serious mental health conditions, such as 25 post traumatic stress disorder. Aron Steward, PhD, states the compassion fatigue is a biological response that occurs when a person is so exhausted-physically, emotionally, and psychologically that there is no longer any reserve to feel for another person. A healthcare professional feels they have nothing left to give and become emotionally depleted. (uvmhealth.org, 2020). Compassion fatigue carries a heavy personal toll, including isolation from others, anger, low morale, reduced ability to feel sympathy or empathy, a diminished sense of enjoyment, and an impaired ability to make decisions and care for patients (Cocker, 2020). Healthcare professionals with compassion fatigue are also likely to use detrimental coping measures such as increased absenteeism, excessive eating, drinking, and drug use. Current coping recommendations to frontline healthcare professionals are to maintain a work-life balance, practice mindfulness, mediation, and offer support to other healthcare professionals when possible. Managerial interventions that promote individual resilience and educate at-risk individuals about these coping strategies are considered beneficial. Cynicism Along with compassion fatigue, organizational cynicism is another aspect of depersonalization that healthcare professionals are experiencing in the workplace. According to Duurah et al., (2019), organization cynicism is a feeling of dissatisfaction towards an organization when employees believe the organization's management lacks honesty, justice, and transparency. These feelings of hopelessness result in employee dissatisfaction and lack of confidence within the organization. Cynicism exists in many forms; person cynicism can be seen as a personality trait within an individual. Work 26 cynicism is more associated with burnout in the workplace and defined as an indifferent attitude towards one’s work. When it comes to organizational cynicism, employee performance is negatively impacted when the organization is viewed as insincere and focused on the needs of the company with little regard to the individual. One way this was seen amid the COVID-19 pandemic, is in the communication that has taken place between the healthcare organization and its employees. Management has had a difficult time fostering camaraderie between employees throughout the pandemic. As stated earlier, with management making cuts to pay, employment status, and asking employees to perform more tasks with less resources, it is difficult for the healthcare professional to feel valued. Durrah et al., (2019), also describes how organizational pride is the opposite of organizational cynicism. Organizational pride is a positive feeling toward the institution for whom a person works. Professional communication and team collaboration are tools that can be used to help boost organizational pride. By fostering a work environment that consists of open communication and collaboration between employees and management, employees are more likely to develop organization pride rather than organizational cynicism in the workplace (Durrah et al., 2019). O’Daniel and Rosenstein (2008) define team collaboration as healthcare professionals and management assuming complementary roles and cooperatively working together, sharing responsibility for problem-solving and making decisions to formulate and carry out plans for patient care. Collaborating as a team and making decisions together in an environment where employees have an active role in decision making may lead to organizational pride rather than organizational cynicism. 27 Organization pride is achieved through the healthcare professionals personal accomplishments, coupled with a team based approach to task and problems. The feelings of “I can do it” is elevated when fellow healthcare professionals work together on the same problem. THe healthcare professionals self-efficacy is also elevated because they believe in their ability to achieve goals set before them. In their 2019 study, Phillips asked imaging professionals, “What motivated you to choose your current profession?” In the United States, 73% of respondents stated “helping people,” as a reason for choosing their profession (Phillips, p.10). As the pandemic continues past the one year mark, the public who once hailed healthcare professionals as heroes, now accuses them of lying and manipulating the public. As primary motivation to excel within the profession fades, so also fades the help healthcare professional sense of personal accomplishment and self-efficacy both tied to self-esteem. Self-Efficacy “Self-efficacy refers to an individual’s belief in his or her capacity to execute behaviors necessary to produce specific performance attainments. Self-efficacy reflects confidence in the ability to exert control over one’s own motivation, behavior, and social environment” (Bandura, p. 191-215, 1977). In an article by Molero, Perez-Fuentes and Gazquez (2018), the authors state “there is a positive relationship between self-efficacy and self-esteem in which positive beliefs about one’s efficacy increase one’s sense of self-worth as stressful situation of heavy workload are coped with successfully” (p.2). Burnout not only relates to high volume of work but also to feelings of frustration generated by not being able to attend adequately to the needs of the patient or offer them quality service (Molero et al., 2018). Feelings of inadequacy jeopardize 28 self-efficacy. The conclusion of the Molero study was that “workload has a significant positive with burnout [and]... the joint effect of self-efficacy and self-esteem can buffer the negative effects of workload on burnout.” Personal Self-Esteem Self-esteem is the ability to see one’s self worth, based on evaluation of social and communal worth, self-evaluation and self efficacy. The healthcare professional faced new challenges with the COVID-19 pandemic in determining their social place and communal worth. Routinely healthcare professionals ``...voluntarily act to help others in the face of recognized personal risk when they are routinely exposed to infectious disease” (Cox, p. 511). The new pandemic challenges the healthcare professional to re-evaluate their self worth and their place in society to see how they fit in. Many members of their community were no longer working and were isolated. The healthcare professional also has to face stigmatisation, ultimately in regards to self-evaluation, healthcare professionals ``..dedication and commitment outweigh the risk” of working during the pandemic (Pablo, pg.54). Healthcare professionals who learn to maintain healthy self-esteem and self-efficacy display greater resilience to burnout and high burdened workloads. Healthcare professionals during the COVID-19 pandemic have unfortunately been faced with both high job demands and lack of resources. To summarize, healthcare professionals need to perform their jobs with a moderate to high level of self-esteem and self-efficacy in order to protect themselves, their patients and their organization from the negative effects of burnout and high workloads. 29 Community Self-Esteem According to Ramaci et al., (2020) there is a stigma in the community setting around healthcare professionals who care for patients with COVID-19. The authors used a behavioral health definition calling stigma “a mark of disgrace that sets a person apart from others.” The nature of working with a highly contagious patient population increases the prejudice of the community. Social stigma makes it challenging for healthcare professionals to recover when emotions like shame and embarrassment play into the equation. Society stereotypes the healthcare professional linked to COVID-19 patients with a discriminatory label. Healthcare professionals may be conceived as carrying around a contagion and being a “plague spreader” (Ramaci et al., 2020). This stigmatization leads to higher stress and burnout rates, and these emotional stressors ultimately have an impact on the healthcare professionals' view of their professional life. Although some communities have tired to rid healthcare workers of any stigma by calling them, “Healthcare Heroes,” Cox (2020) says that use of the term “Healthcare Heroes” can actually have a negative connotation for healthcare professionals in the community setting. There are limitations in the extent to which these healthcare professionals owe the community. The article states that healthcare professionals, whie dedicated to their work, “are not duty bound to do absolutely everything in their power to benefit their patients at any level of personal risk.” Healthcare professionals undertake an inherent risk merely by going to work each day. With added exposure to COVID-19 patients, their risk for personal safety is appreciably higher. Social reciprocity is an important community accord and commitment that supports all human interests. Healthcare professionals risk their lives at work believing 30 that the general public will play a supporting role. Reciprocity comes when the public adheres to health safety precautions, such as wearing masks, hand hygiene, and social distancing to demonstrate their support. Cox (2020) states, “The hero narrative fails to remind the public and healthcare institution of their own moral duties and in its focus on individual healthcare professionals selfless sacrifice, it does not recognize that their duty to treat is irrevocably tied to reciprocal social obligations.” Organizational self-esteem Organizational based self-esteem is said to be when a well-established company establishes a certain set of job outcomes, job satisfaction, organizational commitment, and mood outcomes, These measures can be either positive or negative depending on the individual’s understanding of the organization. The acceptance is widely known that people who have a high organizational based self-esteem believe they are valued members of the organization and that self-esteem molds employee’s attitudes, motivation, and behaviors (Brougham & Harr, 2016). Billings et al., (2020) compiled a rapid review of 40 qualitative studies on the healthcare professionals’ experiences during pandemic. The authors shared that the healthcare professional colleagues and peers provided an important source of mutual support through shared training and camaraderie. By taking the time to sit together, discuss and decompress over the day’s event, the healthcare professionals were provided an opportunity for valuable group reflection, which normalized the situation and provided reassurance to one another. Conversely, this same type of community gathering in a different setting might be a source of stress to coworkers. When an organization allows unfair distribution of 31 work or allows healthcare professionals to refuse to work in certain situations, it may create division amongst the staff. Feelings of resentment and hostility may diminish the healthcare professionals self-esteem and reflect poorly on the organization. Healthcare professionals want their hard work and sacrifice to be recognized by the organization (Billings et al., 2020). Resilience Khalid (2016) studied the emotions of healthcare professionals in the Middle East during the MERS-CoV epidemic and found that 80% of the staff has an “innate professional and ethical obligation that drove staff to continue working during the epidemic.” As healthcare professionals continue to “fight the fight,” it is necessary to find strategies to help them deal with burnout. Healthcare professionals need support with coping and well-being strategies, along with hospital leadership providing system-based interventions (Restauri, 2019). Fleming and Legogar (2008) explain that resilience is a positive adaptation to adversity. Resilience involves positive outcomes while being subjected to situations with high amounts of risk and recovering from those situations. Resilience exists within the individual, in the family, and within the society or community. Development of resilience in the individual can be obtained through protective mechanisms such as high self-esteem, self-efficacy, and good communication skills. For some, resilience is thought to be more of a process rather than an innate trait. Meanding, that resilience can be taught, learned, and practiced. Resilience includes “building a positive self-image, reducing the effect of risk factors, and breaking a negative cycle to create more opportunities for the individual.” 32 Resilience also exists at cultural and community levels (Khasne et al., 2020). Resilience, in this sense, is defined as the capacity of a distinct community to encounter disturbance and reorganize while maintaining key cultural components. Reorganization includes support among peers and educators, and positive reinforcement and authoritative figures which builds rapport, trust, and friendship. By developing resilience early on, healthcare professionals will be able to increase their self-esteem and effectively reduce the toll that future pandemics have on individuals and communities. As resilience can be learned, we can also utilize the assistance of the employers to teach and create interventions to reduce burnout, decrease, stress, and enhance the opportunity for resilience to grow in healthcare professionals. Coping Mechanisms As COVID-19 difficulties have increased day by day, researchers have begun to see weakened resilience amongst healthcare professionals. Gilrain, et al., (2020) states that targeting self-resilience early may be the key factor to reducing the psychosocial effects of the COVID-19 pandemic. Coping mechanisms are beneficial tools that healthcare professionals can use to maintain resiliency. Each person deals with stress differently, so coping mechanisms for each individual may be different as well. Positive coping strategies for healthcare professionals to promote self-resiliency include: ● Social and family support. This support system can be a solid foundation for promoting self-resiliency ● Showing compassion for others. Compassion has a positive impact on self well-being and can be one of the remedies for burnout. Some may find ways of offering compassion by associating with religious or volunteer groups. 33 ● “The Pause” is a method of taking a moment to breathe and focus on oneself for a moment. The pause prepares the caregiver to offer compassion to the next patient. ● Education. Consider learning more about mindfulness, grounding techniques, mediation, biofeedback, yoga, and telehealth services from peer support and counselling. ● Debriefing: is a team based coping strategy to unload emotions after a stressful day or experience. Having a conversation with co-workers about the events during the shift can decrease anxiety and grief. ● “Battle Buddies” Healthcare professionals pairing up to talk about COVID-19 on a level the family and friends may not understand. ● “Hear Me, Protect Me, Prepare Me, Support Me, Care for Me, and Honor Me,” coping skill programs directed at healthcare leadership to help employees. ● The COVID-19 factor is having a big impact on the healthcare community. The simple act of realizing others vulnerabilities and focusing on the present will be a powerful coping mechanism. Summary One January 9th 2020 the World Health Organization announced a new coronavirus related pneumonia in Wuhan China (AJMC,2020). This virus within weeks shut down the country and changed the way the healthcare system operated. With this abrupt change in policies, procedures, and patient care there was an impact to healthcare professionals levels of burnout and self-esteem. Wang (2020) reports that in an early case study series from Wuhan, China 29% of the patients with COVID-19 were healthcare 34 professionals and were assumed to have acquired the virus in the hospital. As of January 2021, the United States alonge has reported more than 25 million confirmed cases and 420,000 deaths related to the COVID-19 virus, 3,000 of whom worked in healthcare (CDC, 2021). Factoring directly affecting healthcare professionals during the COVID19 pandemic include, government and corporate response, PPE, job security, healthcare roles, evaluation and human response, emotional exhaustion, depersonalization, cynicism, self-esteem (personal/organizational), and resilience. As information changed and development, there was consistent change in policy and procedures by the CDC (2020), with changes in how patient care should be done, PPE to be worn, and quarantine lengths. The lack of PPE and changing guidelines regarding the use became a major source of anxiety and fear among healthcare professions (Cohen, 2020). The risk of job security became a fear to healthcare professionals, Paavola (2020), reported at the beginning of the pandemic, many hospitals and healthcare systems suspended elective procedures to save bed capacity, supplies, and staff to treat COVID-19 patients. Restauri and Sheridan (2020) warned that increasing burnout levels may lead to medical mistakes affecting patient safety. These studies all stated above demonstrate the burnout and self-esteem issues the imaging professional across the world are experiencing during this COVID-19 pandemic. These studies have linked these factors of increased workload, increased hours, lack of appreciation, lack of PPE, changings of policy and procedure. All of these are concerns to be brought to the attention of healthcare organizations to better prepare for the next 35 pandemic, to better assist the healthcare professionals trying to provide the best quality care to the patients. 36 Chapter 3: Research Method This qualitative research was designed to use a phenomenological approach to understand the perceived levels of burnout and self-esteem over the duration of the COVID-19 pandemic among CT technologists. The analysis was conducted by student researcher Whitney Horn, under the direction of Dr. Tanya Nolan, Associate Professor and Director of the Master of Science in Radiologic Sciences (MSRS) program at Weber State University in Ogden, Utah. Data was collected from participant responses of interview questions conducted via a Zoom video conference platform. A convenience sample was drawn from healthcare professionals currently working in computed tomography (CT) who are working directly on the front lines with COVID-19 patients. The sample size of this qualitative study included five participants. Research Methods and Design(s) The design of this qualitative research was to investigate and identify two key areas that the COVID-19 pandemic is affecting frontline radiology professionals across the United States. First, researchers sought to identify how CT technologists working, in a healthcare setting with patients infected with COVID-19, perceived their levels of burnout during the duration of the pandemic. Second, researchers identified how their levels of self-esteem may have changed over the duration of the pandemic. Sub-variables used to characterize the levels of burnout included exhaustion levels, depersonalized, and the professional’s level of personal accomplishment or competence. Self-esteem was characterized by personal or individualized self-esteem and organizational self-esteem and/or professional community support. Having experienced the COVID-19 pandemic over one year, researchers studied how perceptions of these variables evolved from the 37 beginning of the pandemic to now. Researchers are specifically searching for information and understanding on how the COVID-19 pandemic has affected the professional and personal lives of CT technologists as an example of many imaging technologists who work on the frontline. Q1. How has the perception of burnout and its related factors, among CT technologists, changed during the COVID-19 pandemic? Q2. How has a sense of personal and organization self-esteem changed over time among CT technologists during the COVID-19 pandemic? Population The population for this research included five CT technologists who were ARRT (American Registry of Radiologic Technologists) certified and working in a healthcare setting, on the front lines with COVID-19 patients. Sample A convenience sample of eligible participants included five ARRT certified radiographers who primarily worked in Computed Tomography (CT).These imaging professionals worked prior to and after March 13, 2020, the date the United State declared COVID-19 a national emergency. All participants lived and worked within the Western United States during the pandemic, and each was invited to the study by personal invite and/or email. In process, participants received and signed an informed consent and video release consent prior to engaging in a recorded ZOOM interview. The respondents’ identity was kept anonymous and no personal information was requested. All participants voluntarily participated in the interview, and each was given permission to leave the study at any time without a penalty or loss of benefits. Overall, the risk to 38 participants was considered to be low, and the research team received an exemption from the Weber State University IRB review (see Appendix A). Materials/Instruments The research team at Weber State University designed the interview questions for this study. The questions were developed to analyze the participants’ perceptions of burnout and self-esteem over the duration of the COVID-19 pandemic. The interview questions were intended to characterize variables affecting the mental and physical health of frontline healthcare professionals during the duration of the COVID-19 pandemic. These variables may, in turn,affect the healthcare professional’s ability to provide quality patient care. Questions highlighted sub-variables of both burnout and self-esteem published within The Rosenberg Self-Esteem Scale and Maslach Burnout Inventory. These sub-variables included: exhaustion , depersonalization, personal accomplishment, personal self-esteem , and organization self-esteem or professional community support (see Appendix B). ● Emotional Exhaustion: feelings of being emotionally overextended and exhausted by work. ● Depersonalization: unfeeling and impersonal responses toward recipients of one’s service, care, or treatment. ● Personal accomplishment: feeling of competence and successful achievement in one's work with patients. (Maslach Burnout inventory, 2019). 39 All interview questions were aligned with the study’s research questions. Acquired and reported data was supported by literature review, the repetition and echo of interviewee responses, and the feedback from previous research accomplished byWeber State University MSRS faculty and students. Through the process of coding, common themes among CT technologists' experiences and impressions during the duration of the COVID -19 pandemic were discovered and recorded.. Data Collection, Processing, and Analysis Participants took part in one-on-one interviews via ZOOM, answering demographic questions to establish age, professional title, role, employment status, location and position before and after the COVID-19 pandemic. Participants were then asked open-ended interview questions to allow expression of their personal opinions and experiences regarding their perception and levels of burnout and self-esteem over the duration of the COVID-19 pandemic. ZOOM interviews were recorded,transcribed by Otterbox, and stored in a password protected electronic Box allowing for continued research and analysis after the interviews were completed. The transcribed data collected from Zoom interviews was analyzed for common codes and themes.The categoricals were identified through research of previous survey methods and by thematic coding from the responses of the CT technologist regarding their experiences of burnout and self-esteem over the duration of the COVID-19 pandemic. 40 Codebook. Through data cleaning, a codebook was created whereby common themes, supported by literature, acted as an umbrella to secondary reporting factors reported by participants. All reported factors were perceived by participants as supportive, associated, or causative for the common themes. For example, the common theme, emotional exhaustion, has a high association with the reporting factor increased work responsibilities with less resources. Researchers reviewed interview transcripts on the sentence level, developed a matrix of common these and frequency, and organized these themes under the research questions (See Table 2 and 4). Reviews of the transcription were done for each participant's interview. Once codes were determined, these codes were checked for redundancy and clarity. Definitions of f inal were determined as guidelines for the reader. Assumptions The researcher acknowledges that bias will be evident in self-reported responses.. It was assumed that most healthcare professionals already experience some level of burnout or related self-esteem prior to the COVID-19 pandemic. A study performed in 2019 by Phillips health technology, to evaluate stress and burnout among imaging technologists, showed that technologists identify their causes of stress that lead to burnout was 40% workload and 35% reported lack of appreciation as their major causes of stress (Phillips, 2019). It was also assumed that the CT technologist would most likely have interactions with COVID-19 patients on a regular and acute basis. Hence, their experience would be most telling of worst-case scenarios. 41 Limitations The researchers acknowledge there are several limitations in this study. First, the participants of the study were solicited through convenience sampling rather than random sampling, the data is vulnerable to inherent bias. Second, the small sample size makes it difficult to generalize the results. The demographics included in this study are limited to a small region of the United States. It is recommended that for future studies to increase the participant count and broaden the demographic to reduce bias. Delimitations The delimitation of this study could be seen as we are researching what has caused the increased levels of burnout and decreased level of self-esteem over the duration of the COVID-19 pandemic. What is not looked at is the reasons why participants may have had increased levels of burnout and decreased levels of self-esteem prior to the COVID-19 pandemic. Also, the study does not address or decipher best practice for individual or group resilience. Ethical Assurances The study was approved by the Weber State University Institutional Review Board (IRB) (Appendix A). This study, including the collection and long-term storage of data, was the responsibility of principal researcher and team lead, Dr. Tanya Nolan, Associate Professor and Director of the Master Sciences in Radiologic Sciences (MSRS) program at Weber State University. The student researcher received no direct financial compensation or incentive for completing this study other than the reward of completing a Master’s Thesis and obtaining a Master’s Degree in Radiologic Sciences. 42 The interviews were strictly voluntary and participation held minimal risk to interviews. Subjects were informed of minimal risk and gave verbal consent prior to participating in the Zoom interview. To assure and maintain confidentiality, no subject personal data was recorded. Participants also signed a standard informed consent document which included a disclosure about any risk and benefits associated with the study, the purpose of the research, and details for requirements from participation. Examples of the consent forms given to each participant are located in Appendix C and Appendix D. Each participant was assigned a number to de-identify electronic data. Interviews were recorded via Zoom, then transcribed by Otter.ai before being secured within a password protected electronic Box accessible only to the research team. No data was shared outside of the research group. In addition, no identifying details are included in the publication of this study. Qualitative data was extracted and any quotations are attributed to the assigned subjects’s number, to ensure anonymity. At the conclusion of the study, the primary investigator will maintain the password-protected electronic Box for a minimum of two years. After which, all data will be destroyed according to institutional policy. Summary The purpose of these qualitative research methods was to investigate and identify two key areas of how the COVID-19 pandemic has affected frontline CT technologists. In the interview process of five CT technologists working in the frontlines, key factors were identified and coded to provide results and recommendations on why COVID-19 had such mental and physical effects on healthcare professionals. Interview questions were based upon variables introduced by the Rosenberg Self-Esteem Scale (Rosenberg, 43 1986) and Maslach Burnout Inventory. Categorical data was organized under exhaustion, depersonalization, personal accomplishment, personal self-esteem, and organizational and community self-esteem. Zoom interviews were transcribed via otter box transcription and a codebook was developed to identify the common themes and secondary reporting factors as evidence for support of the researchers’ hypothesis. Although limited by sample size and geographic region, this data may have significant impact on the education and preparations healthcare systems may consider for the next global pandemic. 44 Chapter 4: Findings Results All five participants were registered CT Technologists working in the Western States. The median age of the sample is 30 years old, ranging from 23 to 47 years old. The breakdown of years of total experiences in medical imaging includes 1 to 5 years (20%), 6 to 10 years (40%), 11-15 years (20%), and 15 plus years (20%), with the median years of experience being 7 years of experience (Figure 1 ). Figure 1. Total years of Medical Imaging Experience Four of the participants were full time employees working 36+ hours per week with one PRN employee, All participants have worked in their current role from the onset of the COVID-19 pandemic. 45 Burnout Each respondent was asked to rate on a scale from 1-10 their personal level of exhaustion, depersonalization, and self-accomplishment as related to burnout and experienced before, at the beginning, and currently within the pandemic (Table 1) Table 1 Burnout Variables Reported Over The Duration of the COVID-19 Pandemic Exhaustion Levels Pre COVID-19 Beginning COVID-19 Current Participant 1 6 6 9 Participant 2 4 6 7 Participant 3 4 6 7 Participant 4 6 6 10 Participant 5 4 4 6 Depersonalization Levels Pre COVID-19 Beginning COVID-19 Current Participant 1 10 8 7 Participant 2 9 7 9 Participant 3 7 5 4 Participant 4 3 3 7 Participant 5 2 7 4 Self-Accomplishment Levels Pre COVID-19 Beginning COVID-19 Current Participant 1 7 7 5 Participant 2 10 9 10 Participant 3 9 7 7 Participant 4 7 7 7 Participant 5 5 5 7 46 In review of these reported levels, all perceived levels of exhaustion have increased since the beginning of the pandemic. The majority of the respondents stated that they are still working with less staff with the same or greater patient volume from the start of the COVID--19 pandemic. Participant 4 stated that, “there is an added pressure to get more done with less resources.” With depersonalization, there was minimal and mixed change from before the COVID-19 pandemic to currently. A drop in depersonalization is seen at the beginning of the pandemic which led to a few respondents reporting a fear of getting the virus which resulted in less time spent with the patients. Respondent number one stated, “I feel very automated.”, The third factor, related to burnout, is self-accomplishment. Reported change was minimal dropping one or two numbers at the beginning of the COVID-19 pandemic. Participant 3 stated, “ This is a new thing, and I don't really know what I am doing, and practices and policies are changing.” However, numbers returned to the same level as reported pre COVID-19 as for the current time. Themes reported by respondents affecting self-accomplishment include a lack of communication and continuous policy and protocol changes. With the data collected on variables of burnout, it has become evident that the biggest change was found in exhaustion levels of CT technologists with an overall increased level of burnout throughout the duration of the COVID-19 pandemic. The researcher’s overall hypothesis was not fully supported because little to no change was determined within two of three variables related to burnout. An overview of the related research questions, variables of burnout, and common reported themes are listed in Table 2. Table 2 Burnout Research Question and Common Themes Results 47 Research Question Variables of Burnout Reported Common Themes How has the perception of burnout and its related factors, among CT technologists, changed during the COVID-19 Pandemic? ● Exhaustion ● Depersonalization ● Self-Accomplishme nt ● Increased patient load ● Decreased staffing ● Increased responsibilities ● Less resources ○ PPE ● Feeling automated ● Lack of connect with patient s ● PPE barrier ● Increased workload ● Communication ● Policy changes ● DIfferent roles Self-Esteem Each respondent was asked to rate on a scale from 1-10 their level of personal self-esteem and organizational/community support experienced before, at the beginning, and currently within the pandemic (Table 3) Table 3 Self-Esteem Levels Reported over the Duration of the COVID-19 Pandemic Personal Self-Esteem Levels Pre COVID-19 Beginning COVID-19 Current Participant 1 7 7 4 Participant 2 10 7 10 Participant 3 10 8 9 Participant 4 8 8 9 Participant 5 4 2 6 Organizational/ Community support Pre COVID-19 Beginning COVID-19 Current 48 Levels Participant 1 7 7 5 Participant 2 10 7 10 Participant 3 6 4 4 Participant 4 5 4 3 Participant 5 3 5 7 Levels of self-esteem over the duration of the COVID-19 pandemic were minimally affected. When it comes to personal self-esteem, there was a noticeable drop reported during the beginning of COVID-19 with a common theme expressed about a lack of communication with policy and protocol changes. In relation to organizational support, four of the respondents were affected by decreased staffing directly related to budget. An overview of the related research question, variables of self-esteem, and common reported themes are listed in Table 4. Table 4 Self-Esteem Research Question and Common Themes Results Research Question Variables of Self-Esteem Reported Common Themes How has a sense of personal and organization self-esteem changed over time among CT technologists during the COVID-19 pandemic? ● Self-worth ● Organization support ● Community Support ● Negative change ○ Feeling automated ○ Lack of Communica tion ○ Policy Changes ○ Lack of funds ○ Cutbacks ● Positive change ○ “Healthcare Hero” ○ Working 49 together as a team Discussion Burnout is a state of emotional, physical, and mental exhaustion caused by excessive and prolonged stress (Smith, et al., 2020). Over the duration of the COVID-19 pandemic the participants all experienced increased levels of exhaustion. There were many common factors listed by each participant which included increased patient load, with less staffing, new role responsibility with cleaning protocols after taking care of COVID-19 patients, the use of PPE. Participant number 4 stated, “just the added stress of everything, the added pressure of getting more done with less resources.” Several healthcare professionals have reported that stress and exhaustion are physical and mental phenomena experienced on a global level(Khasne et al., 2020). Lai et al. (2019) reported that healthcare professionals have demonstrated signs of depression, anxiety, insomnia, and distress during COVID-19.. Factors attributing to these findings included a lack of PPE, staffing shortages, and the fear of contracting the virus themselves (Lai et al., 2019). The two oldest respondents reported their exhaustion levels were 9 and 10 at their current states. Their reasoning was a lack of staffing, increased patient volumes, cleaning protocols, and PPE wear. In comparison, the youngest respondent, age 23, stated a current level of exhaustion was a 6, saying “ I think a lot of it has to do with no vacation and not being able to do anything. There is no release to do fun things, and with my personality that is something I need.” This could be an ideal topic to continue to research on the generational reasoning on burnout and exhaustion, not only caused by this pandemic, but overall working in the healthcare field. 50 Depersonalization is the unfeeling or impersonal feelings toward recipients of one’s care or treatment, directly related to compassion fatigue. There was a decrease in the level of depersonalization among all 5 participants at the beginning of COVID. Participant 3 stated, “ I feel there is a barrier between us and the patient with the use of PPE.” Participant 1 stated, “ I think imaging is set up where we are a very automated process, and I am not able to put forth 100%, to connect and comfort the patient.” Molero et al. (2018) supported that burnout was not only related to high volumes of work, but it was also affected by the feelings of frustration generated by not being able to attend adequately to the needs of the patient or offer them quality service. Although little change was reported in personal accomplishment, participant 1 provided insights in the frustrations had between personal competency and organizational acknowledgement and communication. Participant 1 stated, “ I do not want to say my level of competency has dropped, but the acknowledgment for everything that we have done for the organization has dropped, the lack of its poor communication during the things, such as the increase in COVID changes.” NELP.org (2020) found a significant source of stress to frontline healthcare professionals during the COVID-19 pandemic including a perceived lack of response and constantly changing COVID-19 guidelines issued by the United State government. The CDC (2020) also reported that compromises to best practices committed by organizations crested doubt and feelings of expendability amongst healthcare professionals. Personal self-esteem dropped at the start of the pandemic, but has since risen back up. However organizational self-esteem started low and dropped even lower throughout the pandemic. The fear of the unknown seems to be a common factor listed by the 51 participants. Participant number 4, stated “I felt like at the beginning, I felt a drop because we are unsure of what was going on, canceling outpatient, feeling cutbacks and feeling a lot of uncertainty in job security.” The Baylor Scott & White Health system spent $85 mullion to prepare, resulting in many systems losing large amounts of annual revenue that led to reduced cost in terms of resources and manpower (Paavola, 2020). Nationwide, healthcare systems were furloughing and laying off healthcare professionals. By June 4th 2020, 266 hospitals across the country had reduced staff to be able to remain financially stable (Pavvola, 2020). Intermountain Healthcare (2020), in Utah, explained their organization did not make cuts, but it is facing extreme financial loss of over $435 million in reverence resulting in reduced wages and reduced 401K contributions. Organizationalsupport is perceived lower among technologists who have worked in the field for 5+ years. Participant 1 stated, ``I am going to assume that financially the organization has begun to get into the level of reading hours, being more numbers focused, and less focused on the staff who have to take the hit from lost hours.” Participant 2 stated `` I felt like at the beginning we were getting so much different feedback back, and policies and roles were being changed so frequently.” Participant #3 stated, “The organizational support changed, because the unknown of how they can help and what to do, and having the funds to help us as far as PPE and our basic needs are not being met.” Cohen (2020) documented that the purchase and storage of excessive PPE was incentivised to minimize costs, but supply and demand was unrealistic and varied. Unfortunately, healthcare professionals during the COVID-19 pandemic have been faced with both high job demands and lack of resources which have both been fully out of their control (Cohen, 2020). 52 Summary From the results collected by the researchers, we can conclude that our hypothesis has been proven partially correct in that there is an increased level of burnout and decreased self-esteem factors among CT technologists throughout the duration of the COVID-19 pandemic. Most unique, the researchers have reported a significant difference in levels of burnout and self-esteem between technologists who have been in the field for several years and those who have not. There is an interesting and unexplored comparison between generational ideals and values. Both technologists, older than 30 years of age and r with over 10 years experience reported high levels of burnout pre-COVID-19 which only continued to increase based on work-related factors. Whereas the youngest technologist, in their early 20s with less than 2 years experience, perceived burnout not from work but from a lack of social life outside of work. This concept is not seen within the literature review and is something that could be further researched. Younger generations require a different work life balance outside of the workplace to support and maintain motivation and commitment to the profession.. As noted within these interviews, many researchers have concluded that much of the burnout reported comes from the effects of poor organization and administration. Often, organizational support appears chaotic,and employees fail to see administrators as desiring or fighting to meet their basic needs. Participant 4 state, “ I feel they do not have the funding to meet our basic needs.” Participant 1 echoed “ I feel we are meant to be automated machines, get the patients in and out, my joy and enjoyment of my career has dramatically chipped away and feel less of a person and more of a machine.” 53 Chapter 5: Implications, Recommendations, and Conclusions Implications Burnout and self-esteem levels have varied to different degrees throughout healthcare professionals for years. When the pandemic hit the United States, it altered the way healthcare was provided on many levels. There was an unknown of what was going to happen with this virus, leaving healthcare professionals questioning their careers. This study was done to help show recognition of healthcare professionals' thoughts and opinions of how their related burnout and self-esteem was affected through the pandemic. With the data collected, it was perceived by participants that alack of trust within their organizations and managements was a strong factor relating to increased burnout and decreased self-esteem. Thus, it can be concluded that healthcare professionals need support from their management and organizations to be able to keep providing the best patient care possible to themselves and their patients. As means to enable this support, management teams may focus upon PPE and resources necessary for a future pandemic and current needs. Many budgets and planning models were created to minimize costs for purchase and storage of resources. However, under current circumstances the acute need for PPE has drained already depleted inventory and organizations may not be able to rely on the Federal Government to control cost and supply overage. (Cohen, 2020). The implications of this research is to identify and bring to attention a current trend in burnout and self-esteem, in presence of COVID-19, that is affecting the emotional and physical well-being of imaging professionals and subsequently, their patients. It is a call for action whereby leadership and management may retrospectively 54 research and act upon better communication models and practice to support the imaging professional who is experiencing moral injury while subsequently preparing for cases of future crisis.s. Recommendations With the conclusion of this research that the hypotheses were proven to be correct at different variable degrees, over the duration of the COVID-19 pandemic there has been increased levels of burnout and decreased levels of self-esteem seen with frontline CT Technologists. Though the population is small and limited there are common key factors given by all participants that provide clear indication of recommendations that can be given to healthcare systems to better prepare for the next pandemic. Healthcare systems need to be able to provide for their staff. Healthcare is expensive but giving quality care to patients is why healthcare professionals work in this field. Making sure the systems are within budget is important, but making budget cuts to staffing numbers will not increase that patient satisfaction score. When healthcare systems like Southcoast Health are furloughing 5,500 along with permanent lay-offs to meet budget needs to be cautious of staffing shortages (Paavola, 2020). Not only does staffing shorts run the healthcare profession dry, increasing their exhaustion and enjoyment of their profession, it is also a liability issue with quality patient care, recommended research may include best practice in crisis financial stability. Future study on the effects of the COVID-19 pandemic on the mental and physical well-being of healthcare professionals across the United States is important for the professional and the patient. Systems should protect their employees and provide for their basic needs.. Burnout is not something new seen in healthcare, but organizations 55 continue to be more worried about their budgets and less worried about staffing and employees. With this goal, healthcare will see an increase in turnover rates and lower satisfaction of patient quality care. Healthcare systems should consider a source for employees to reach out when they are overwhelmed and be prepared to help them, as much as possible, through this extreme COVID-19 crisis. Conclusions This retrospective qualitative study has been completed with the collected data from five CT technologists with COVID-19 patient experience.e. Both hypotheses have been proven at different degree variables, with the data collected through interviews and evaluated for common factors from each participant on why their levels of burnout has increased and self-esteem has decreased over the duration of the COVID-19 pandmeic. Researchers have given recommendations on how to help prepare for the next pandemic and thoughts on what should be continued to be research on burnout and self-esteem in healthcare professionals. Healthcare is an incredibly taxing field, and outnumber one priority is to provide the best patient care to patients, and to do that organizations need to make sure their employees' basic needs are met to do so. 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Personal protective equipment and COVID-19: a review for surgeons. Annals of surgery, 272(2), e132. Obtained https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7268841/pdf/ansu-272-e132.pdf UVMHealth.org.(May1,2020)https://www.uvmhealth.org/coronavirus/staying-healthy/co mpassion-fatigue. Had Enough? You Might Be Suffering From Compassion Fatigue. University of Vermont health Network. Accessed February 4, 2021 Wahed, W. Y., Hefzy, E. M., Ahmed, M. I., & Hamed, N. S. (2020). Assessment of knowledge, attitudes, and perception of health care workers regarding COVID-19, a cross-sectional study from Egypt. Journal of Community Health, 45(6), 1242-1251. Doi: 10.1007/s10900-020-00882-0 Wang Y., Wang, Y., Chen, Y., Qin, Q. (2020)Unique epidemiological and clinical features of the emerging 2019 novel coronavirus pneumonia (COVID-19) implicate special control measures. World Health Organization. (2020, January 10). Coronavirus. Retrieved February 14, 2021 from Https://Www.Who.Int/Health-Topics/Coronavirus#tab=tab_1. Your Dictionary. (n.d.). Cynicism Meaning | Best 11 Definitions of Cynicism. Yourdictionary.Com. Retrieved February 14, 2021, from https://www.yourdictionary.com/cynicism 63 Appendix A: IRB Approval February 8, 2021 Tanya Nolan School of Radiologic Sciences Re: Exempt - Initial - IRB-AY20-21-257 A RETROSPECTIVE QUALITATIVE ANALYSIS OF BURNOUT AND SELF-ESTEEM AMONG CT TECHNOLOGISTS Dear Tanya Nolan: The Weber State University Institutional Review Board has rendered the decision below for A RETROSPECTIVE QUALITATIVE ANALYSIS OF BURNOUT AND SELF-ESTEEM AMONG CT TECHNOLOGISTS. Decision: Exempt Approval: February 8, 2021 Selected Category: Category 3.(i)(B). Research involving benign behavioral interventions in conjunction with the collection of information from an adult subject through verbal or written responses (including data entry) or audiovisual recording if the subject prospectively agrees to the intervention and information collection. Any disclosure of the human subjects’ responses outside the research would not reasonably place the subjects at risk of criminal or civil liability or be damaging to the subjects’ financial standing, employability, educational advancement, or reputation. Findings: Research Notes: 64 Subjects are considered adults, signatures/consent are required, and they may choose not to participate. Anonymity and confidentiality are addressed appropriately, and the type of information gathered could not "reasonably place the subjects at risk of criminal or civil liability or be damaging to the subjects' financial standing, employability, or reputation" (Code of Federal Regulations 45 CFR 46, Subpart D). You may proceed at this time; you have one year to complete the study. Please remember that any anticipated changes to the project and approved procedures must be submitted to the IRB prior to implementation. Any unanticipated problems that arise during any stage of the project require a written report to the IRB and possible suspension of the project. If you have any questions please contact your review committee chair or irb@weber.edu. Sincerely, Miland Palmer, PhD, MPH, RHIA Co-Chair, DCHP IRB Sub-committee Weber State Institutional Review Board 65 Appendix B: Interview Questions Primary Investigator: Dr. Tanya Nolan MSRS Researcher : Whitney Horn Email Invitation Hello, I am completing an MSRS research project on the effects of COVID-19 on burnout and self-esteem in CT technologists. You have been identified as a possible volunteer. I will be conducting 30 minute interviews for the project. If interested in helping me with this research, will you please respond to this email and complete the attached informed consent and media release form. I appreciate your consideration. Interview Thank you for providing me with a signed copy of the media release form and consent. For the record, do you voluntarily consent to this research interview based on the information I provided you? Please answer the following: 1. How old are you? 2. In which state are you currently practicing? 3. What is your professional title? 4. How many years have you worked in this position? 5. Do you work full time, part time, or PRN? 6. How many total years of experience do you have in imaging? 7. Did you work in the same location and position from the onset of Covid-19 pandemic until the present? Burnout is defined as a state of emotional physical and mental exhaustion caused by excessive and prolonged stress.Self-esteem describes a persons’ overall sense of 66 self-worth or personal value. Please answer the following questions regarding your perception and level of burnout and self-esteem. Burnout-Ex haustion Burnout-Cynicism Burnout-Efficacy Self-Esteem/Pers onal Self-Esteem/Organizati onal How has the perception of burnout and its related factors, among CT Technologists, changed during the Covid-19 pandemic? How has a sense of personal and organization self-esteem changed over time among CT technologists during the Covid-19 pandemic? 67 Q1. On a scale from 1-10 (1 being the least and 10 being the greatest), how would you rate your level of exhaustion before the COVID-19 pandemic? Q2. On a scale from 1-10, how would you rate your level of exhaustion at the beginning of the COVID-19 pandemic? Q3. On a scale from 1-10, how would you rate your current level of exhaustion? Q4. Why do you feel your level of exhaustion Q5. On a scale from 1-10 (1 being the least and 10 being the greatest), how would you rate your level of depersonalization, described as unfeeling or impersonal toward recipients of one’s care or treatment, before the COVID-19 pandemic? Q6. On a scale from 1-10, how would you rate your level of depersonalization at the beginning of the COVID-19 pandemic? Q7. On a scale from 1-10, how would you rate your current level of depersonalization? Q8. Why do you feel your level of depersonalization has changed or remained the same? Q9. On a scale from 1-10 (one being the least and 10 being the greatest), how would you rate your level of personal accomplishment or competence before the COVID-19 pandemic? Q10. On a scale from 1-10, how would you rate your level of personal accomplishment or competence at the beginning of the COVID-19 pandemic? Q11. On a scale from 1-10, how would you rate your current level of personal accomplishment or competence? Q12. Why do you feel your level of personal accomplishment or competence has changed or Q13. On a scale from 1-10 (one being the least and 10 being the greatest), how would you rate your level of self-esteem (how you feel about yourself) before the COVID-19 pandemic? Q13. On a scale from 1-10, how would you rate your level of self-esteem at the beginning of the COVID-19 pandemic? Q14. On a scale from 1-10, how would you rate your current level of self-esteem? Q15. Why do you feel your level of self-esteem has changed or remained the same? Q16. On a scale from 1-10 (one being the least and 10 being the greatest), how would you rate your level of organizational and/or professional community support before the COVID-19 pandemic? Q17. On a scale from 1-10, how would you rate your level of organizational and/or professional community support at the beginning of the COVID-19 pandemic? Q18. On a scale from 1-10, how would you rate your current level of organizational and/or professional community support? Q19. Why do you feel your level of organizational and/or professional community support changed or remained the same? 68 has changed or remained the same? remained the same? 69 Appendix C: Informed Consent IRB STUDY #XXXXXXXXXX WEBER STATE UNIVERSITY INFORMED CONSENT A RETROSPECTIVE QUALITATIVE ANALYSIS OF BURNOUT AND SELF-ESTEEM AMONG CT TECHNOLOGISTS You are invited to participate in a research study on how COVID-19 has affected the level burnout and self-esteem experienced by imaging professionals working on the front lines. You were selected as a possible subject because you work in a healthcare setting as a CT Technologist. We request 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 and Whitney Horn STUDY PURPOSE The purpose of this study is to evaluate the level of burnout and self-esteem experienced among imaging professionals who have worked as CT technologists during the COVID-19 pandemic. NUMBER OF PEOPLE TAKING PART IN THE STUDY: We anticipate that a minimum of 4 Computed Tomography (CT) Technologists will participate in the study. PROCEDURES FOR THE STUDY: If you agree to be in the study, you will be asked to complete a media release form because all interviews will be recorded. Interviews will be conducted through ZOOM, and we will request that you turn on your video and microphone. Your name will not be included as part of the verbal or visual documentation; however, participants will be asked basic demographic questions including their age, gender, and current role in healthcare. You may refuse to answer any question. Most questions focus on your personal opinion and experience as an imaging professional on the front lines during the COVID-19 pandemic. There are a total of 26 questions included in the survey, and it is anticipated the interview will last 30 minutes. RISKS OF TAKING PART IN THE STUDY: 70 The risks for this study are considered low; however, some participants may be uncomfortable answering questions of a personal nature. Also, the loss of confidentiality is a possible risk regardless of our safeguards. BENEFITS OF TAKING PART IN THE STUDY You will not receive payment for taking part in this study. ALTERNATIVES TO TAKING PART IN THE STUDY: There are no other alternatives to taking part in the study. COSTS/ COMPENSATION FOR INJURY There is no cost in participating in the research study. CONFIDENTIALITY Efforts will be made to keep your personal information confidential. We cannot guarantee absolute confidentiality. Your personal information may be disclosed if required by law. Your identity will be held in confidence in reports in which the study may be published and databases in which results may be stored. Only the researchers assigned to the study will have access to the ZOOM recordings. All data will be used for education purposes and will be destroyed after the completion of the study. 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 primary investigator, Tanya Nolan, 801-626-8172 For questions about your rights as a research participant or to discuss problems, complaints or concerns about a research study, or to obtain information, or offer input, contact the Chair of the IRB Committee IRB@weber.edu. VOLUNTARY NATURE OF STUDY 71 Taking part in this study is voluntary. You may choose not to take part or may leave the study at any time. Leaving the study will not result in any penalty or loss of benefits to which you are entitled. Your decision whether or not to participate in this study will not affect your current or future relations with Weber State University. SUBJECT’S CONSENT In consideration of all of the above, I give my consent to participate in this research study. I will be given a copy of this informed consent document to keep for my records. I agree to take part in this study. Subject’s Printed Name: Subject’s Signature: Date: (must be dated by the subject) Printed Name of Person Obtaining Consent: Signature of Person Obtaining Consent: Date: 72 Appendix C: Weber State Photo/Video Release Form