The Power of Leadership in Respiratory Care
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* Lynda T Goodfellow

Leadership is a needed and valued asset. COVID-19 has affected all respiratory therapists (RTs), especially those with less-than-optimal working conditions during the pandemic. In this issue of Respiratory Care, Burr et al1 have provided a view from an open window into the important topic of respiratory care leadership. A previous study by many of these same authors regarding the prevalence of burnout amid the COVID-19 pandemic indicated about 79% of those surveyed expressed burnout, which can include exhaustion, stress, tension, fatigue, and poor health.2 In this article, a key component of burnout with approximately one third of the RTs reporting indicated that poor leadership was the reason for their feelings of burnout. Upon further review, the strongest predictors of a negative view of leadership were not having enough frontline staff and being a staff therapist. Strategies to alleviate or negate the effects of burnout are offered, but more attention to wellness and self-care is greatly needed.

As a profession, we have some previous insights into burnout and job dissatisfaction in which RT leadership was a key component. Factors of burnout included moral distress, lack of autonomy, lack of medical director engagement, and lack of RT leadership from administrative directors. Moral distress is the psychological disequilibrium experienced when one perceives the right moral action to take but is constrained from taking that action. Left unaddressed, moral distress may result in adverse emotional and physical symptoms, increased risk of burnout, and loss of staffing from the workforce.3-4 A lack of autonomy, or not having the ability to use one’s knowledge and skills in clinical practice, led to job dissatisfaction and was cited as a cause of burnout and intent to leave the profession.5-6 An unpublished dissertation exploring the relationship between burnout and supervisory support among 235 RTs reported that 34% of the respondents met the criteria for severe burnout, and more than 60% were emotionally exhausted. Furthermore, a lack of supervisory support was reported by 50% of the respondents.7 Lastly, lack of medical engagement and leadership from respiratory care leaders has been cited as a reason for less-than-optimal development of critical thinking skills from graduates of respiratory care educational programs and for continuing development of expert clinical skills in respiratory care practice.8-9

No one doubts that RT leadership has been under great pressure in the past 2 years. One notable achievement from the pandemic was the recognition given to front-line caregivers. But we have to question if respiratory care practice in a post–COVID-19 pandemic setting will change. Are staffing levels going back to pre-pandemic numbers, which were calculated based on relative value units (RVUs) in the majority of hospital settings? Or, will staffing calculations be based on appropriate care via value efficiency?10 RT leadership that will replace the use of RVUs with a more accurate accounting of patient care outcomes that is based on the actions of an RT, not just the quantification of the number of treatments given, is essential in a post–COVID-19 setting. To do this will require leadership by those who are willing to change the culture of their departments and units by utilizing or increasing the use of protocols and evidence-based care. The projected result is that more RTs will be needed in clinical practice, not less. This is in contrast to the current continuing shrinking of RT educational programs and hospital departments. In the future, RT leaders must avoid inadequate staffing levels as this worsens burnout of the frontline staff and will not be appealing to future RT students. Therefore, burnout and attrition, and also pay equity, are not just a challenge for RT leaders in clinical settings but are professional challenges that must be addressed. Innovative solutions are required to reverse attrition and job dissatisfaction or the respiratory care profession will not survive as there will not be enough RTs to take care of patients who need the services that frontline staff provide. RT leadership that implements value-efficiency care in their departments is one strategy, and once improved results are known, RT leadership can expect to see more positive views in the future.

## Footnotes

*   Correspondence: Lynda T Goodfellow EdD RRT FAARC. E-mail: lynda.goodfellow{at}aarc.org
*   See the Original Study on Page [1236](http://rc.rcjournal.com/lookup/doi/10.4187/respcare.10081)

*   Dr Goodfellow has disclosed no conflicts of interest.

*   Copyright © 2022 by Daedalus Enterprises

## REFERENCES

1.  1.Burr KL, Hinkson CR, Smith BJ, Roberts KJ, Strickland SL, Hoerr CA, et al. Factors associated with a positive view of respiratory care leadership. Respir Care 2022;67(10):1236-1245.
    
    [Abstract/FREE Full Text](http://rc.rcjournal.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoicmVzcGNhcmUiO3M6NToicmVzaWQiO3M6MTA6IjY3LzEwLzEyMzYiO3M6NDoiYXRvbSI7czoyNToiL3Jlc3BjYXJlLzY3LzEwLzEzNjYuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

2.  2.Miller AG, Roberts KJ, Smith BJ, Burr KL, Hinkson CR, Hoerr CA, et al. Prevalence of burnout among respiratory therapists amidst the COVID-19 pandemic. Respir Care 2021;66(11):1639-1648.
    
    [Abstract/FREE Full Text](http://rc.rcjournal.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoicmVzcGNhcmUiO3M6NToicmVzaWQiO3M6MTA6IjY2LzExLzE2MzkiO3M6NDoiYXRvbSI7czoyNToiL3Jlc3BjYXJlLzY3LzEwLzEzNjYuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

3.  3.Timmer MD. Assessment of moral distress in respiratory therapists. Emory University. May 2014. Available at [https://etd.library.emory.edu/concern/etds/b5644r77q?locale=zh](https://etd.library.emory.edu/concern/etds/b5644r77q?locale=zh). Accessed July 18, 2022.
    
    

4.  4.Timmer MD. Assessment of moral distress in respiratory therapists. Respir Care 2014;59(10)OF-33.
    
    

5.  5.Shelledy DC, Mikles SP, May DF, Youtsey JW. Analysis of job satisfaction, burnout, and intent of respiratory care practitioners to leave the field or the job. Respir Care 1992;37(1):46-60.
    
    [PubMed](http://rc.rcjournal.com/lookup/external-ref?access_num=10145581&link_type=MED&atom=%2Frespcare%2F67%2F10%2F1366.atom) 

6.  6.Shelledy DC, Goodfellow LT. Predictors of attrition among respiratory care practitioners. American Association for Respiratory Care. AARC Education Section Bulletin; April 1992.
    
    

7.  7.Alhaykan Ahmad Eissa. Exploring the relationship between burnout and supervisory support among respiratory therapists. Seton Hall University Dissertations and Theses 2021. Available at: [https://scholarship.shu.edu/dissertations/2929](https://scholarship.shu.edu/dissertations/2929). Accessed July 18, 2022.
    
    

8.  8.Mishoe SC. Critical thinking in respiratory care practice: a qualitative research study. Respir Care 2003;48(5):500-516.
    
    [Abstract/FREE Full Text](http://rc.rcjournal.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoicmVzcGNhcmUiO3M6NToicmVzaWQiO3M6ODoiNDgvNS81MDAiO3M6NDoiYXRvbSI7czoyNToiL3Jlc3BjYXJlLzY3LzEwLzEzNjYuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

9.  9.Goodfellow LT. A self-assessment by respiratory therapists of their own critical thinking behaviors. J Allied Health 2001;30(1):20-25.
    
    [PubMed](http://rc.rcjournal.com/lookup/external-ref?access_num=11265268&link_type=MED&atom=%2Frespcare%2F67%2F10%2F1366.atom) 

10. 10.Chatburn RL, Ford RM, Kauffman GW. Determining the value-efficiency of respiratory care. Respir Care 2021;66(12):1892-1897.
    
    [Abstract/FREE Full Text](http://rc.rcjournal.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoicmVzcGNhcmUiO3M6NToicmVzaWQiO3M6MTA6IjY2LzEyLzE4OTIiO3M6NDoiYXRvbSI7czoyNToiL3Jlc3BjYXJlLzY3LzEwLzEzNjYuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9)