Resilience and Burnout Resources in Respiratory Care Departments

Discussion

The majority of RTs in our survey self-reported having experienced burnout, yet few departments measured burnout or utilized resilience tools. Most departments reported having access to free EAPs and wellness programs. Overall estimates of burnout were low, but increased since onset of the COVID-19 pandemic. Poor leadership, staffing, and high workloads were identified as the most common drivers of burnout among RTs. Responses were significantly different between management and staff RTs. Staff RTs provided higher estimates of burnout, did not agree that leadership provided adequate support for those suffering from burnout, and were more likely to identify poor leadership as a driver of burnout. Surprisingly, there were few differences between COVID-19 hotspots and non-hotspots, raising the question of whether self-perceived burnout is a generalized concern among RTs. The lack of differences may be related to individual COVID-19 exposure as we determined hotspots by case load in each state, which may not have reflected the true impact in individual RT departments.

Despite the high prevalence of self-reported RT burnout in our study, few RT departments measured burnout or utilized resilience tools. The most common intervention was nothing, although taking time off, exercise, mindfulness, counseling, and changing jobs were also mentioned. Given that management respondents reported lower estimated burnout rates than RT staff and low levels of burnout overall, management respondents may not be aware of burnout within their departments, may perceive burnout to be an individual problem, or may not be aware of resources for burnout. This is despite very high levels of agreement that RTs have similar risk of burnout as other health care providers and that burnout is a problem in health care. To help reduce the stigma associated with asking for help, leaders need to be willing to be open about their own use of resources and encourage staff to take advantage.

Poor leadership was the most common driver of burnout reported in our study. Though the relationship between RT leadership and burnout has not been specifically studied, studies of physicians and nurses have found leadership behaviors significantly impact burnout and well-being.^14–16 Nursing studies indicate that low support from leadership, inauthentic leadership, and negative team relationships are associated with burnout.¹⁶ The first step in combating burnout within RT departments is to accurately measure burnout rates and identify key drivers in individual centers. RT leaders could then use these data to focus on specific leadership behaviors as a strategy to combat burnout. RT leaders should also learn to recognize the signs of burnout, understand the causes of burnout, and help staff overcome burnout while creating a positive, supportive work environment.

Staff RTs were less aware of burnout and resilience resources than management, suggesting that improved communication and reduction of stigma related to asking for help may increase awareness of these resources among front-line staff. Managers are more likely to be aware of these resources as part of their regular job duties, while staff may have been informed during orientation but are no longer aware after being employed for a period of time. Other drivers, such as lack of recognition/appreciation, are areas in which leadership can have an impact. A recent study of an in-patient infusion team reported that peer recognition and daily huddles resulted in reductions in burnout and stress and increased job satisfaction.¹⁷ Leadership also influences staffing and high workloads, which may be related to poor staff retention, difficulty recruiting staff, or distribution of work load.

Staffing and high work load are highly interrelated. High work load in nurses was associated with burnout in 13 of 15 studies, although no studies have been performed in RTs to date.¹⁶ Interestingly, 15 studies reported that high patient to nurse ratios were associated with burnout, but there were no studies that found an association with more than sufficient staffing and burnout.¹⁶ Thus, for RTs, simply increasing staffing to reduce burnout is an effective strategy only when short-staffed, and it may not be impactful when staffing is already sufficient. There is no current national standard to establish RT staffing norms, and determining adequate staffing can be complex when considering patient acuity, staff skill levels, and physical layout of the hospital. The AARC Uniform Reporting Manual (https://www.aarc.org/resources/tools-software/benchmarking, Accessed November 12, 2020) provides time standards for most RT clinical tasks. However, hospital executive leadership and other benchmarking groups may be dismissive of the data because the time standards are published by an RT professional organization. What constitutes an acceptable work load or staffing likely varies between centers and between individual RT perceptions and hospital leadership. Finally, more experienced and skilled RTs may be asked to take on heavier assignments and non-clinical tasks, which may increase their susceptibility to burnout.

Strategies to reduce burnout are commonly focused on individual health care providers. A single-center quality improvement project that evaluated the role of brief mindfulness sessions during RT staff meetings reported reductions in physical and emotional stress levels.¹⁸ The relationship between these interventions and burnout was not evaluated, and the authors did not evaluate whether the intervention resulted in sustained differences over time. Mindfulness training in nurses reduced burnout, stress, anxiety, and depression and improved job satisfaction in a meta-analysis of 9 studies, although the effect of brief sessions (ie, < 4 h) on clinical outcomes has yet to be clearly demonstrated.^19,20 Mindfulness also aids physicians in emotional regulation and reducing burnout.²¹ Mindfulness was the most common resilience strategy noted by our respondents; however, it was only mentioned by 10% of total respondents, indicating mindfulness strategies are currently underutilized by RT departments. The second most common strategy was referring staff to EAPs, which used counseling and unspecified employee assistance. The effectiveness of counseling for burnout is unclear, as some studies have reported a modest benefit while others were not effective.²² There is significant overlap between depression, anxiety, and burnout, and symptoms may be similar, so referring staff to counseling or EAPs is a reasonable strategy to help staff obtain treatment for burnout or other mental health challenges.²³ In summary, burnout is multifactorial and complex, and focusing solely on the individual's resilience without addressing systemic issues will have minimal positive effects on staff well-being in the long term. Too much focus on individuals' resilience carries the implication that staff who are suffering from burnout are weak, flawed, or unable to cope with their job requirements.

Our respondents indicated they were unsure whether burnout was primarily caused by external forces, but most of the reported drivers were external. Individual responses to stress and emotional toll may be modifiable through resilience training, although the effectiveness of resilience training to reduce burnout is unclear.²⁴ A recent study by West et al²⁴ reported that physicians with the highest resilience scores still had a burnout rate of 29%. This is highly indicative that burnout is driven largely by organizational or departmental factors such as staffing, leadership, workloads, and perceived lack of appreciation, respect, or recognition. Studies of nurses have provided inconclusive results about which individual factors associated with burnout.¹⁶ Organizational strategies to reduce burnout need to be identified, and RT leaders need to evaluate staffing and workloads. Reducing unnecessary therapies or non-evidence-based care through development of RT-driven protocols has been shown to reduce work load, stress, and RT intentions to leave their current positions.^25,26 Burnout was not directly measured in these studies; however, turnover and intentions to leave their current position are highly associated with burnout in nurses.¹⁶ A simple organizational intervention that has been demonstrated to have a positive effect on burnout is “Three Good Things”; in this activity, staff write down 3 good things at the end of each shift or at the end of the day, and highlights can then be shared with the oncoming shift.²⁷ This was reported to increase overall happiness, decrease burnout, decrease depression, and improve work-life balance in a cohort of health care workers.²⁷