Abstract
BACKGROUND: Recent studies have revealed high rates of burnout among respiratory therapists (RTs), which has implications for patient care and outcomes as well as for the health care workforce. We sought to better understand RT well-being during the COVID-19 pandemic. The purpose of this study was to determine rates and identify determinants of well-being, including burnout and professional fulfillment, among RTs in ICUs.
METHODS: We conducted a mixed-methods study comprised of a survey administered quarterly from July 2020–May 2021 to critical-care health care professionals and semi-structured interviews from April–May 2021 with 10 ICU RTs within a single health center. We performed multivariable analyses to compare RT well-being to other professional groups and to evaluate changes in well-being over time. We analyzed qualitative interview data using thematic analysis, followed by mapping themes to the Maslow needs hierarchy.
RESULTS: One hundred eight RTs responded to at least one quarterly survey. Eighty-two (75%) experienced burnout; 39 (36%) experienced professional fulfillment, and 62 (58%) reported symptoms of depression. Compared to clinicians of other professions in multivariable analyses, RTs were significantly more likely to experience burnout (odds ratio 2.32 [95% CI 1.41–3.81]) and depression (odds ratio 2.73 [95% CI 1.65–4.51]) and less likely to experience fulfillment (odds ratio 0.51 [95% CI 0.31–0.85]). We found that staffing challenges, safety concerns, workplace conflict, and lack of work-life balance led to burnout. Patient care, use of specialized skills, appreciation and a sense of community at work, and purpose fostered professional fulfillment. Themes identified were mapped to Maslow’s hierarchy of needs; met needs led to professional fulfillment, and unmet needs led to burnout.
CONCLUSIONS: ICU RTs experienced burnout during the pandemic at rates higher than other professions. To address RT needs, institutions should design and implement strategies to reduce burnout across all levels.
Introduction
Emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment, collectively described as burnout or burn-out syndrome, have been described in health care professionals for decades and in critical-care health care professionals in particular.1,2 Burnout is associated with medical errors and adverse patient outcomes, including increased mortality and longer lengths of stay.3 At the level of the health care professional, burnout has been associated with a lack of professionalism, substance abuse, depression, and suicide.2,4 In addition to its negative impact on the individual and quality of care, burnout is also associated with high rates of turnover.2,4
Recently, studies have revealed high rates of burnout among respiratory therapists (RTs).5,6 RT skills are in high demand. Throughout the COVID-19 pandemic, with high patient volumes and an increased need for mechanical ventilation, respiratory care expertise has been more valuable than ever. Inadequate staffing, an excessive workload, poor work climate, and ineffective leadership appear to contribute to burnout among RT staff.6
In a previous study by Kerlin et al, critical-care health care professionals’ well-being declined during the COVID-19 pandemic, with RTs’ well-being declining more than other groups.5 Therefore, we sought to identify determinants of well-being, including burnout and professional fulfillment, among RTs. To inform organizational strategies to reduce burnout and increase professional fulfillment among RTs, we interviewed RTs working in critical care during the COVID-19 pandemic. We paired these qualitative data with longitudinal wellness surveys that assessed for burnout and professional fulfillment among critical-care health care professionals at an academic medical center.
QUICK LOOK
Current Knowledge
Burnout is associated with adverse outcomes and a negative impact on health care workers’ physiologic and psychologic well-being. High rates of burnout have been reported among respiratory therapists (RTs), yet little is known about the determinants of well-being among RTs.
What This Paper Contributes to Our Knowledge
RTs’ well-being was negatively impacted amid the COVID-19 pandemic. Through interviews with RTs, we found that staffing challenges and their consequences, safety concerns, workplace conflict, and lack of work-life balance led to burnout; whereas patient care, use of specialized skills, appreciation, and a sense of community fostered professional fulfillment. Our findings mapped to Maslow’s hierarchy of needs, highlighting the need for institutional leadership to implement strategies to address RT burnout across the following domains: physiological needs, safety, belongingness and love, esteem, and self-actualization.
Methods
We conducted a mixed-methods study comprised of a survey administered quarterly from July 2020–May 2021 to critical-care health care professionals and semi-structured in-depth interviews from April–May 2021 with RTs staffing ICUs. Both the questionnaires and interview guides were focused on understanding the job-related factors that contributed to wellness, burnout, and professional fulfillment among critical-care health care professionals within the University of Pennsylvania Health System. The study was reviewed and approved by the institutional review board at the University of Pennsylvania.
Surveys
Questionnaires were distributed quarterly to critical-care attending physicians, advanced-practice providers (including nurse practitioners and physician assistants), RTs, and clinical pharmacists who staffed ICUs of 7 hospitals within the University of Pennsylvania Health System. Due to leadership concerns about survey fatigue with concurrent research, nurses did not participate. See Supplement A for the quantitative survey instrument (see related supplementary materials at http://www.rcjournal.com).
During each quarter, July–August 2020, October–November 2020, January–February 2021, and April–May 2021, we invited participants to complete a survey via e-mail via REDCap (Reasearch Electronic Data Capture, Vanderbilt University, Nashville, Tennessee), secured through the University of Pennsylvania.7 The questionnaire collected quantitative and qualitative data, including the 7-item Well-Being Index (WBI),8 the 16-item Stanford Professional Fulfillment Index (SPFI),9 and 3 open-ended questions inquiring about job-related factors influencing wellness, burnout, and fulfillment. We previously reported the results of the quantitative portion of the survey for first 3 quarters of this survey.5 Members of the research team (MPK and MM) shared results of the surveys with leadership throughout Penn Medicine and discussed possible interventions to address burnout.
Analysis of Quantitative Survey Data
We defined burnout as SPFI average burnout score ≥ 1.33 or WBI score ≥ 4 and professional fulfillment as SPFI fulfillment score > 3.8,9 We defined depression as response of yes to the single WBI question about whether the participant had experienced symptoms consistent with depression in the past month. Related to mental health, prior work demonstrated that WBI score ≥ 4 was associated with low mental quality of life, fatigue, or suicidal ideation.5
We first summarized responses using standard descriptive statistics, including conducting unadjusted comparisons of RT responses with responses from all other clinician groups in aggregate, using chi-square tests. We then conducted multivariable analyses by building 3 separate generalized estimating equations with logit link, binomial family, and exchangeable correlation structure, with dependent binary variables of burnout, professional fulfillment, and depression. Each model included clustering by participant to account for multiple responses by individuals over time. We a priori included female sex and years of experience as potential confounders based on previous literature.10,11 We used P = .05 as the threshold for statistical significance and used Stata 16.1 (StataCorp, College Station, Texas) for all statistical analyses.
Qualitative Comments
To learn why respondents felt burnout and fulfilled professionally and to elicit factors that could potentially improve wellness, we asked 3 questions and invited free-text comments in our quarterly surveys:
Are there specific things that strongly contributed to you feeling burned out over the past 3 months?
Are there specific things that contributed to your fulfillment over the past 3 months?
Are there specific things that would improve your well-being in the next 3 months?
We analyzed responses to open-ended survey questions using standard qualitative methods.12 Two of the authors (TK and JS) reviewed all of the data and performed a thematic analysis utilizing inductive reasoning. Qualitative data were initially organized by quarter to identify any changes over time, but themes remained consistent throughout the year. Next, we compared themes by provider type to identify areas with similarities, defined as consensus themes and appearing in ≥ 3 provider groups, and areas with differences, defined as role-specific and appearing in < 3 provider groups.
Interviews
Due to the highest levels of burnout among RTs, and at the request of leaders within the Respiratory Care Department, we conducted semi-structured interviews to more fully understand RTs’ experiences of wellness, burnout, and job fulfillment. We adapted a previously tested interview guide focused on the same subject matter to inquire about the factors influencing the above components of well-being, utilizing data from qualitative sections of the questionnaire to develop new probes. See Supplement B for the interview guide (see related supplementary materials at http://www.rcjournal.com).
Recruitment and scheduled interviews took place from April–May 2021 at one hospital within the University of Pennsylvania Health System. We recruited staff RTs by including study information in a biweekly e-mail and on flyers posted throughout workspaces. A single research coordinator conducted all interviews via telephone. Interviews ranged from approximately 20–40 min. Participants received a $50 gift card in compensation for their time. All interviews were recorded and transcribed for analysis.
We completed thematic analysis of the interviews in 2 stages. First, research staff (TK and JS) reviewed all of the interview data and used an inductive analysis approach to identify themes. This approach allowed us to sort factors affecting burnout, wellness, and fulfillment both into the themes that we had previously identified during analysis of qualitative survey data while leaving room to include additional emergent themes as they arose. We then conducted a secondary analysis by mapping themes onto Maslow’s 5 hierarchy of needs, a framework for understanding individual happiness and fulfillment that has previously been used as a guide for well-being among health care professionals.13-15 From base to apex, the needs are physiologic, safety, love and belonging, esteem, and self-actualization.
Results
Of 554 critical-care health care professionals surveyed, 314 (57%) participated in at least one survey, including 108/249 (43%) RTs. The median age of health care professionals who responded at the time of the first survey was 39 (interquartile range [IQR] 32–47) and 42 (IQR 31–49) among RTs specifically. Among all who responded, 177 (59%) were male and 63 (62%) among RTs. The median years of experience at the time of the first completed survey among all participants was 7 (IQR 3–15) and 12 (IQR 5–23) among RTs. Ten RTs additionally participated in semi-structured telephone interviews. The median years of experience of the RTs interviewed was 14 (IQR 11–26).
Quantitative Instruments
Among all participants, 215 (68%) experienced burnout; 139 (44%) experienced professional fulfillment, and 145 (46%) reported symptoms of depression in at least one response during the survey period. Among RT participants, 82 (75%) experienced burnout; 39 (36%) experienced professional fulfillment, and 62 (58%) reported symptoms of depression. Figure 1 illustrates unadjusted estimates of wellness measures by group over time.
Unadjusted comparison of wellness domains between respiratory therapists and other critical care clinician groups. A: Burnout; B: Fulfillment; C: Depression. RT = respiratory therapist.
In multivariable analyses accounting for quarter of response, years of experience, and female sex, and clustered by participant to account for repeated responses, RTs were significantly more likely to experience burnout (odds ratio 2.32 [95% CI 1.41–3.81]) and depression (OR 2.73 [95% CI 1.65–4.51]) and less likely to experience fulfillment (OR 0.51 [95% CI 0.31–0.85]) compared to other critical-care health care professionals. Furthermore, wellness measures significantly worsened in the second and third quarters compared to the first quarter (Fig. 2).
Estimated percentage of clinicians experiencing burnout, fulfillment, and depression based on multivariable analyses accounting for differences in sex and years of experience. A: Burnout; B: Fulfillment; C: Depression. RT = respiratory therapist.
Qualitative Data
From the qualitative survey comments and the 10 interviews, we identified that teamwork, balance of tasks at work, work-life balance, and meaningful work contributed to well-being. We identified that lack of work-life balance, staffing challenges, physical and emotional tolls of the job, and workplace conflict led to burnout; and patient care, use of specialized skills, appreciation, and feeling community at work fostered professional fulfillment. The Supplementary Table (see related supplementary materials at http://www.rcjournal.com) provides example quotes for identified themes. Contributing factors in each of these domains are discussed below in relation to the individual corresponding need in Maslow’s hierarchy of needs (Table 1).
Wellness Themes Mapped to Maslow’s Needs for Respiratory Therapists
Burnout
When mapped to Maslow’s needs hierarchy, factors exacerbating burnout grouped toward the bottom 3 tiers of the pyramid. At times, physiological needs were not met, which contributed to burnout. Respondents reported an inability to take scheduled breaks (or even have time to use the lavatory) due to excessive workload and staffing shortages. Respondents were called to come into work on days off; many felt overwhelmed by work, while also being unable to take care of themselves, which negatively impacted work-life balance. RTs felt pressured to continue to work as patient loads increased and staff numbers remained the same. RTs also reported challenges accessing necessary equipment as factors contributing to burnout, which mapped to safety needs. Concerns were expressed over difficult-to-find and/or shortages of personal protective equipment (PPE) and other equipment needed to perform their jobs. Moving forward, preparedness is a major concern for RTs, as they wanted to be assured that adequate testing, PPE, equipment, and protocols were in place. Additionally, the emotional toll of COVID impacted the safety needs of RTs. Many respondents were fearful of contracting and spreading COVID, and many found the frequent changes in policy and precautions stressful. Patient families’ inability to visit, particularly during patients’ end of life, was also stressful. Some respondents became close with patients who died from COVID, sometimes multiple patients in a short period of time. Some respondents were also frustrated that their family and friends were not taking COVID seriously while they were treating patients with COVID.
Professional Fulfillment
Alternatively, RTs felt fulfilled professionally when esteem and self-actualization needs were attained. They found these higher-level needs were met primarily through applying their specialized skillset to provide patient care. Taking care of patients, especially patients with COVID, who improved after being very ill was fulfilling. Additionally, RTs felt fulfilled when they were able to learn, utilize their skills, and/or teach to arrive at good clinical outcomes.
Wellness
Wellness mapped to most of the Maslow’s needs. Physiological and safety needs were impacted by the level of work-life balance RTs felt they were able to achieve. In order to achieve work-life balance, RTs would like to have time off to take vacations and the ability to spend more quality time with their friends and families. They also recognized the importance of focusing on habits/activities that promote self-care such as meditation, sleep, and healthy eating, but they also wrestled with demanding schedules. RTs had their esteem needs met when they were able to participate in a variety of activities at work including bedside care and special projects that required non-clinical time. Both esteem and self-actualization needs were addressed and contributed to wellness when RTs were able to engage in meaningful work such as positively impacting patients.
Table 2 summarizes the intersections of Maslow’s needs with the well-being domains of burnout, fulfillment, and wellness. One of Maslow’s needs, belongingness and love needs, was present throughout all 3 domains: teamwork and positive relationships contributed to wellness; conflict with co-workers contributed to burnout; and community and appreciation at work were viewed as fulfilling. The remaining 4 needs—physiological, safety, esteem, and self-actualization—mapped to combinations of burnout, fulfillment, and/or wellness.
Relationship Between Wellness, Burnout, and Professional Fulfillment and Maslow’s Hierarchy of Needs
Discussion
Our mixed-methods study, which included surveys and semi-structured interviews with critical-care RTs, extends our understanding of the high level of burnout experienced by RTs working in critical care during the COVID-19 pandemic. We found that a large majority of RTs experience burnout, confirming a recent study by Miller and colleagues that reported 79% of 1,156 RTs surveyed across 26 United States hospitals experienced burnout.6 We confirmed that RTs experience high rates of symptoms of depression, and a minority experiences professional fulfillment. Furthermore, the impact of the pandemic on RT well-being persists, as burnout remains high and professional fulfillment low, as the pandemic continues.
We also found that drivers of burnout aligned with Maslow’s hierarchy of needs for RTs. As detailed in Tables 1–2, physiological needs, safety, and belongingness were identified as needs that, if unmet, contributed to burnout. For example, interviews revealed that the inability to eat, drink, or use the restroom given workload and poor staffing contributed to burnout. Physical safety and the threat to the well-being of family members, through occupational hazards in the pandemic, were also identified as contributors to burnout. Likewise, conflict among co-workers, which could lead to a lack of belongingness, was identified as a source of burnout by those interviewed.
Conversely, our interviews revealed a sense of community and purpose (mapping to the need of belongingness and love) contributed to professional fulfillment. As teamwork emerged as an important contributor to wellness, organizational strategies that promote team building, excellence in communication, and professionalism are warranted. Further, we found that RTs in an academic medical center achieved professional fulfillment through the role of teacher and learner. Collectively, these findings reveal that RTs fulfill their needs for esteem and self-actualization through their clinical and non-clinical professional roles (ie, teacher, participant in quality improvement) and reveal the importance of professional development and career growth as means to combat burnout.
Coupled with recommended organizational strategies to combat physician burnout and prior RT-focused research, our findings can be used to design and implement strategies to reduce burnout among RTs.2,4,6,14 First, as recommended by Shanafelt and colleagues,4 it is critical to “acknowledge and assess the problem.” Because evidence suggests that as few as 10% of RT departments currently measures burnout, an important initial step for institutions will be to initiate surveillance programs to assess RT workforce wellness.16 Recommended survey instruments, which would serve to “align values and strengthen culture” and demonstrate a commitment to clinician wellness, can be found at the National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience site (https://nam.edu/valid-reliable-survey-instruments-measure-burnout-well-work-related-dimensions. Accessed June 17, 2022). Related, being mindful of the role of supportive and engaged leadership who are aware of the RT experience and appreciate their important and valuable role in the interdisciplinary critical care team is a second important organizational strategy.
Third, institutions need to develop and implement interventions targeted to RT professionals. Consistent with recent work by Hale et al17 that focused on resident physicians, interventions designed to address the physical and mental health needs of RTs are warranted. Three scheduling-focused interventions, drawn from recommendations from the Critical Care Societies Collaborative and informed by our findings, may include ensuring that breaks during the workday are provided, limiting the number of days worked consecutively, and supporting staff to take time off (ie, vacation).2 We recognize the challenge to achieve these latter aims given RT staffing shortages occurring across the United States. A separate, but related, organizational strategy that is recommended is to cultivate community at work.4 Team-building exercises, in particular, have the potential to fulfill the expressed needs of RTs in this regard. Organizations can also use rewards and incentives to honor and appreciate the contributions of RTs over the course of the pandemic, including overtime given staffing shortages, as well as to recruit and retain RTs to stabilize the RT workforce. For the reasons noted above, administrative leaders should also encourage and support interested RT staff to incorporate teaching and/or quality improvement into their work duties as a compensated, non-clinical component of their duties.
An organizational strategy, germane to all critical-care health care professionals, is to adopt policies and procedures that “promote flexibility and work-life integration.”4 Whereas organizations may consider this to be a longer-term strategy, we would caution against such thought given the imminent threat of the situation worsening if more of those experiencing burnout leave health care. Related, we support the recommendation to “provide resources to promote resilience and self-care.”4 For reasons that warrant investigation, it is notable that a recent study of RTs revealed that only 36% utilized tools to combat burnout, despite 73% of respondents having access to those resources.16
The study has several notable strengths. First, our longitudinal wellness surveys began prior to, and have continued through, the pandemic. As a result, we were able to assess burnout among RTs over time. Second, we conducted interviews to understand the RT experience. We mapped our qualitative results to Maslow’s hierarchy of needs. Through the process, we identified threats to RT wellness across multiple domains. Given the duration of the pandemic and the relationship between Maslow’s hierarchy of needs and motivation, our results provide insight to the exodus of RTs from the critical-care health care professional workforce currently being experienced across the United States.
Our study has several limitations. First, although survey respondents came from different institutions within our health system, interview data were limited to a single hospital. Second, validity of qualitative analyses depends on data collected and triangulated from multiple sources. Although our study collected data from 2 sources, we acknowledge that alternative explanations may exist, and further investigations into drivers of burnout and professional fulfillment among the RT workforce are necessary. Third, our study took place during the pandemic and, therefore, may not apply to other times. Future studies, designed to examine the RT experience post-pandemic, will be necessary to understand the nature of RT wellness more comprehensively. Fourth, we could not make comparisons to the experiences of bedside nurses, since they did not participate. Finally, our response rate among RTs was modest; however, it is consistent with prior studies of critical-care health care professionals and RTs in particular.5,6
Conclusions
We found that the COVID-19 pandemic has had a significant impact on RTs’ well-being, with many RTs experiencing burnout and symptoms of depression. Interviews with RTs revealed that physiological and personal safety needs, when unmet, contributed to burnout. Further, RTs often felt undervalued despite an excessive and unprecedented workload. To avert an RT workforce crisis, it is imperative that institutions design and implement organizational strategies to reduce RT burnout and energize and motivate the RT workforce by addressing their needs across all levels, beginning with basic physiologic needs and working to self-actualization.
Footnotes
- Correspondence: Karsten J Roberts MSc RRT FAARC, Respiratory Care Services, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104. E-mail: karsten.j.roberts{at}gmail.com
The authors have disclosed no conflicts of interest.
The study was supported in part by the Clifton Grant, University of Pennsylvania Health System.
Supplementary material related to this paper is available at http://www.rcjournal.com.
Drs Kerlin and Mikkelsen are co-senior authors.
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