Burnout Among Respiratory Therapists Amid the COVID-19 Pandemic

Staffing

Of the themes identified in our current study, staffing highlighted an issue that has been of growing concern for the profession.²⁰ The increased in-patient volumes experienced by acute care hospitals during the pandemic put a significant strain on staff, starkly illuminating the inability of respiratory departments to flex up staffing enough to meet the increased demand for respiratory care services.

The RTs who worked during the pandemic were also at risk of contracting the virus as they worked closely with infected patients and were frequently at the bedside during high-risk aerosol-generating procedures such as intubation, extubation, aerosol therapy, noninvasive ventilation, and airway suctioning. It was inevitable that some RTs would become infected and be forced to quarantine, rendering them unavailable to work for a period of time, thus exacerbating staffing shortages.^19,21 Those who returned to work may not have been able to perform their duties at 100% capacity due to resultant weakness along with mental and physical fatigue.

One temporary solution many facilities have employed to address the staffing shortage is contracting with agency or registry staff to supplement existing staffing levels. Agency RTs are hired to fill a short-term staffing need, and health care organizations pay a premium for the flexibility offered by this staffing solution. However, as the need for additional RT staffing spread, an increasing number of departments turned to agency therapists to supplement staffing. Inevitably, the agency rates for temporary RT staffing increased commensurate with demand; in many cases the wage paid to contract an agency RT was reportedly double, and in some cases even triple, the normal hourly wage.¹³

Another temporary solution involved the use of RT students and non-RT care extenders. Some state respiratory care licensing acts, such as Missouri, Indiana, Kansas, Kentucky, and Connecticut, allow RT students to gain employment under a temporary, limited practice license. In early months of the pandemic, displaced medical students offered to perform patient assessment and other routine care activities.²² Other facilities reassigned licensed health care providers, such as physical therapists, occupational therapists, certified registered nurse anesthetists, and other skilled providers whose primary work environment was halted to reduce the spread of COVID-19. These providers, commonly termed respiratory therapy extenders, performed patient assessments and other respiratory care that was within the purview of their professional state license.²³ Though these staffing solutions helped in the short term, they are not sustainable over a longer care period.

Some facilities offered monetary bonuses related to overtime shifts, caring for patients diagnosed with COVID-19, and other staffing shortage situations. In addition, recruitment of RTs in many cases has expanded to recruiting across the United States rather than regionally. Hospitals in rural states are competing for RTs with larger, urban facilities that may be able to offer a higher hourly wage. An organizational solution for long-term resolution of staffing shortages may include hospital administration evaluating and adjusting, as necessary, pay scales for first-line care providers.

Workload

A second theme identified by respondents was contingent on the high workload per RT as well as the unscheduled or emergent work required each shift. The comments paint a picture of RTs exhausted by the amount of work they were expected to accomplish, as well as their dismay at not being able to spend the time necessary with each patient to provide quality care, and concerns about delivering non-indicated therapies. Anecdotally, some RTs who routinely worked in areas other than the critical-care units were reassigned to help with the significant patient surge early in the pandemic. The challenge of working in an unfamiliar environment and doing unaccustomed work contributed to increased levels of discomfort and anxiety. Additionally, the pandemic brought a steep learning curve resulting from quickly developing evidence concerning the most effective COVID-19 patient care. Respondents’ feelings of ineffectiveness and their inability to provide valuable, quality care to their satisfaction, also known as reduced professional efficacy, are one of 3 dimensions used to define burnout.⁵

Similar to overcoming suboptimal staffing, overcoming excessive workload, especially during a respiratory pandemic, is a challenge. However, one organizational solution may be reducing the delivery of interventions that are not supported by the evidence. Lambden et al²⁴ found that the provision of futile or potentially inappropriate care was a factor for burnout. By reducing the amount of unnecessary therapies provided, the RT workload burden may be alleviated. Similar to the strategies to combat burnout caused by excessive workload as suggested by Gomez et al,²⁵ we also found that aspects of well-being include RT input into scheduling, work hours, and the implementation of care plans.

Physical/Emotional Consequences

The third theme was focused on feelings of fear, anxiety, isolation, loss, and exhaustion. Every health care worker had a unique experience of the pandemic, but the emotions expressed in the comments were remarkably similar and speak powerfully of the tremendous pressure of being overextended and required to do much more work with significantly less resources and support. As experts in respiratory care, RTs spent long hours caring for critically ill patients diagnosed with COVID-19. Despite expert care and best efforts, many of these patients died,²⁶ leaving RTs with a sense of overwhelming loss and a feeling of ineffectiveness. Respondents to this survey reported that they experienced multiple patient deaths each day at the height of the pandemic and felt personally responsible when patient outcomes were not positive. Repetitive exposure to critical illness and patient deaths can compound stress already felt by the RT.

Solutions to combat these physical and emotional consequences are complex. Mahan, in a review of the impact of death and dying on RTs, identified several strategies including keeping an open dialogue with staff about handling stressful situations, making available a social worker and/or chaplain services, and incorporating an ongoing educational program focused on dealing with death and dying.²⁷ West noted several individual-focused burnout strategies have been reported in the literature, including stress management training, self-care training, communication skills training, and mindfulness training, though it is important to ensure that these activities are included during work hours.¹⁰ Research has demonstrated that systematic interventions to combat burnout are more effective than those interventions focused on the individual.²⁸ It has been recommended that organizational strategies to enhance wellness should be informed by ensuring meaningful work, professional fulfillment, and providing social support and community at work.²⁵

Lack of Leadership

In a post hoc analysis of the quantitative data from our current survey, we found that a positive view of leadership was protective against burnout.²⁹ Crisis leadership requires clear communication and caring relationships. Respondents to our survey specifically highlighted several practices throughout the pandemic that contributed to their disappointment and disillusionment with hospital leadership, one of which was a perception that leadership was uncaring of the difficulties RTs were experiencing. Caring is demonstrated through presence, specifically a leader’s visibility and presence in the hospital and on the units where care was being provided. Through this analysis, it was evident that RTs look to their leadership for empathy and guidance. However, those reporting burnout emphasized that these attributes of leadership were missing.

Frustration was expressed about outdated leadership practices. This could be attributed to confusing and ever-changing guidance on providing care for patients with COVID-19, despite the fact that much of the guidance was based on protecting health care workers from infection. Getting the correct information to first-line caregivers proved to be challenging. Lack of consistent information contributed to RTs feeling that leaders were uncaring of work-related risks to their health. In commenting about incentives, several respondents pointed out that incentives arrived too little and too late and it appeared to staff that the money was a poor substitute for really caring about the health and well-being of first-line workers.

In a separate post hoc analysis of the same data set used for this analysis, we focused on leadership perceptions and offered several solutions.²⁹ These included effective communication, relationship building between department leadership and staff, leadership presence, and focusing less on productivity and more on the value added by RTs. However, there is a paucity of research in this area related to respiratory care and is an area for future investigation.

Lack of Respect

Though not as prevalent in this analysis as the prior 4 themes, lack of respect was evident in comments directly speaking to respect and a perceived lack of appreciation for the skills and abilities of the RT as well as comments addressing recognition and compensation. In the health care environment, respect toward employees, especially first-line health care workers, can take a variety of forms. Respect encompasses adequate monetary compensation, providing appropriate equipment, ensuring appropriate staffing/workload management, and public recognition of the value of those employees and their contributions to the health care facility and community in general. During a pandemic and high patient surge, this demonstration of respect can falter as focus shifts to managing these new challenges.

Respondents to this survey felt slighted in a variety of ways. This lack of recognition for the efforts of the RT occurred at the hospital level, the local level, as well as nationally, and dealt a significant blow to RT morale that continues to be felt throughout the profession. Unfortunately, there is a lack of research in this area. However, integration into the health care team, continued efforts to inform communities of the contribution of the RT and their role in critical care, along with hospital administration recognition of the RTs’ contribution to positive patient outcomes may be a key component to closing this gap.

Limitations

There are limitations to this study. Our original study was limited by self-selection of respondents who were interested in the study topic and may not have been representative of all RT departments. Specific to the qualitative analysis, the study does have a potential for research bias. The researchers looked for patterns in the comments provided in the original survey submissions and assigned specific words and phrases to categories. The responses were analyzed by 3 researchers in an effort to establish validity and inter-rater reliability.