Factors Associated With a Positive View of Respiratory Care Leadership

Discussion

The majority of respondents had a positive view of their local respiratory care leadership. We found no differences for employee characteristics such as highest degree earned, years as a RT, hours per week, commute time, or race. Furthermore, those with a positive view of leadership were less likely to be a staff RT, working fewer hours in the ICU, and more likely to be affiliated with a medical school. The only factor independently associated with a positive view of leadership was COVID-19 exposure, whereas inadequate RT staffing, being a staff therapist, working night shift, work environment, those who missed work for any reason, and burnout score were associated with a negative view of leadership. The strongest predictors of a negative view of leadership were being a staff therapist and not having enough first-line staff.

Our prior survey indicated that poor leadership was perceived as a major driver of burnout among RTs.¹⁰ Our current study indicated a positive view of leadership was protective against burnout. Leadership rounding with feedback has been associated with reductions in burnout, increases in engagement, and improved safety culture.¹¹ Personal burnout and burnout climate were lowest in settings with the highest rate of rounding with feedback.¹¹ RT leaders may consider consistent rounding within their department as a strategy to provide consistent, useful, and positive feedback for first-line staff while showing support for bedside providers by listening to their concerns, implementing suggestions, and increasing staff engagement in departmental decision-making. The association between providing direct care to patients with COVID-19 was an unexpected finding could be driven by increased leadership presence in patient care areas, including leadership providing direct patient care alongside staff RTs.^15,16 Twice daily huddles may be an effective strategy to provide a consistent forum for RT staff to express concerns about safety and clinical practice.¹⁷

Leaders also need to ensure staff feel psychologically safe to increase the willingness of staff to contribute their honest feedback without fear of retaliation.¹⁸ The COVID-19 pandemic has made psychological safety even more important as teams have been required to learn rapidly about a new disease, deal with sudden changes in workflow, learn from mistakes, and integrate new knowledge very rapidly from around the world.¹⁹ Through strategies to support a psychologically safe environment, leaders will be able to identify drivers of burnout, allow staff to feel supported, and also receive feedback about their own performance to allow their teams to work together effectively, which will in turn reduce burnout, turnover, and improve patient safety.²⁰

In respiratory care departments, as in other health care fields, individuals often rise to formal leadership positions based upon clinical acumen, scholarly work, or high level of technical skill.²¹ Clinical acumen and technical skills may often be considered a prerequisite for leader credibility among RTs; however, other characteristics may be more important for successful leaders. Hargett et al reported that the top competencies for health care leaders are to be acting with personal integrity, effective communication, acting ethically, pursuing excellence, building and maintaining relationships, and critical thinking.²² They did not mention technical skills as an important competency in their model. Many RTs who are promoted to leadership positions receive little to no formal training and are reliant on informal mentorship or role modeling by their immediate superior, who may also never have received formal leadership training. It is essential that new leaders quickly build new skills that focus on communication training, integrity, and relationship building. Organizations can build processes to help new leaders be successful, but it takes time, commitment, and resources.²¹ RT leaders should consider identifying internal staff with leadership potential and providing them with mentoring, feedback, and training prior to promotion to a formal management position.²¹ This strategy, along with clear succession planning, may help reduce costs and effort required to replace leaders moving on from the organization.²¹ Effective leaders will elicit feedback from a diverse group, both within and outside their department, to ensure they are performing their job effectively.²¹

In a systematic review of nursing leadership behaviors by Wei et al, authentic and transformational leadership styles created a healthy working environment necessary for building resilience, reduced burnout, and increased staff engagement.²³ In a large survey of registered nurses, 31.5% reported recently leaving a job due to burnout.²⁴ Among the reported contributed reasons to leaving were poor leadership, inadequate staffing, and stressful work environment.²³ Similar surveys of physicians found an association between leadership and burnout.¹ Whereas we lack hard data of RT turnover, it is likely that leadership has played a role in RTs choosing to leave their facilities, retire early, travel, or pursue nonclinical RT positions. Multiple studies of nurses have found that poor leadership support is associated with an intention to leave their current position.^25,26

There is a paucity of research on leadership in the field of respiratory care and how different leadership styles and practices can impact well-being. However, the findings of our survey are consistent with research in other health care fields, such as physician and nursing.^2,27 Both bodies of literature describe high workload as a contributing factor for burnout.^27,28 Respondents with a negative view of leadership reported working without resources more often than those with a positive view of leadership. This raises the possibility that these poor perceptions are a result of RT leaders providing inadequate resources or inability to provide adequate staffing resources, equitably distributing workload, or providing clinical support. Developing leadership skills may help change the perception of support and adequate resources, but it would be a fallacy to not also consider the actual workload of the staff and how it impacts well-being. The relationship between RT workload, staff well-being, and patient outcomes needs to be investigated in large, multi-center studies.

Excessive workload has been identified as a contributing factor for burnout in physicians, nurses, and RTs.^10,26,29,30 Respiratory therapy budgets and the number of full-time employees are typically set by hospital executives based on department productivity standards, which are developed using a variety of metrics such as ambulatory procedure weight, billed time units, or relative value units. The American Association for Respiratory Care (AARC) published the Uniform Reporting Manual to assist with established standard time units to clinical activities to determine expected workload efficiency, and some bench-marking agencies accept these.³¹ However, there is no mandate to accept the AARC time standards; there is no industry standard for setting respiratory therapy workload, and many administrators will only include billable services in their calculations. Importantly, these systems do not incorporate the value of respiratory care services in their calculations, only the number of clinical tasks that are performed.³² Hospital administrators, respiratory care leaders, and physicians should work to incorporate value-based respiratory care in order to decrease the amount of unnecessary or low-value respiratory care delivered. The use of respiratory care protocols is a useful tool to assist and mitigate workload management and enhance staff satisfaction.^19,33 All of our respondents reported that they used RT-driven protocols; however, our survey did not evaluate what individual departments used to manage their workload. Importantly, in a department that is largely protocol driven, short staffing has the potential to worsen patient outcomes as RTs may not have adequate time to follow the protocol, potentially delaying a spontaneous breathing trial or identifying patient-ventilator asynchrony. This is an important area of future study to guide respiratory care leaders in optimal use of resources.

Leadership styles that promoted professional standards and quality in patient care versus economic management have been associated with better evaluation of social climate, innovation climate, and engagement.³⁴ This raises an interesting parallel for the field of respiratory therapy as organizations that are more focused on productivity over value may not provide sufficient staffing to complete work assignments or have little incentive to reduce unnecessary treatments. Importantly, low-value, non-evidence–based therapy has been noted as a driver of burnout in a qualitative analysis of responses from this survey.³⁵ Thus, a focus on the value provided by respiratory care services may be a better model than focus on productivity and may allow individual RTs adequate time to complete all their work, an important factor we have identified as associated with burnout.⁹ More research is needed to establish the dynamic between workload and burnout in respiratory therapy.