Characteristics, Identification, Training, and Perception of Leaders in Respiratory Care

Discussion

We found high levels of agreement that the most important skills for future leaders are critical thinking and people skills, with limited consensus on other skills. Important accomplishments to identify future leaders included self-initiated projects, precepting, providing intradepartmental education, and projects initiated by leadership. Disqualifying attributes had a high level of consensus, with poor work ethic, dishonesty, difficulty getting along with others, unreliability, and not being a team player all being identified by >85% of respondents. Surprisingly, most respondents felt AARC membership should be required for leaders, but only 31% actually required membership for leaders in their departments. This result may be influenced by our sampling methods as we surveyed individuals who were likely to value professional association membership. There was limited consensus on characteristics and behaviors of successful and unsuccessful leaders and what defines leadership success. Most respondents agreed leadership influenced well-being; however, a majority felt that peers had a greater influence on well-being than leaders and that it is an individual's responsibility to maintain their own well-being. Further research is needed to delineate how peers and leadership influence well-being.

Promotion to formal leadership positions in RT departments may be based on a high level of clinical acumen or technical skills; however, these skills may not translate into success as a leader.⁹ Only 33% of respondents indicated clinical and 15% that technical skills were important for potential leaders. Respondents indicated critical thinking, people skills, and verbal communication to be the most important skills. Surprisingly, very few respondents reported writing and presentation skills as being important despite both being critical to effective communication of departmental goals, developing policies and protocols, and hospital initiatives. We believe written communication to be an important skill for leaders, as there is a great need for leaders to communicate clearly, succinctly, and effectively.

Respondents reported self-initiated projects to be the most important accomplishment for potential leaders, followed by educating new staff and providing intradepartmental education. A small number (<15%) felt research publications were important. Most non-academic and many academic centers lack the resources and infrastructure to support RT research, and successful RT research programs are relatively rare, even in large academic centers. It is possible that some centers may not value publications but do value the effort and skills required to lead a project. Thus, most centers likely do not consider research experience to be important as few RTs would be able to meet this requirement. Despite these limitations, further advancement of the respiratory care profession will require high-level evidence, and centers should be encouraged to publish the findings of their quality improvement projects.¹¹ The rigor required to get a project published in a peer-reviewed journal should be celebrated as a great accomplishment by department leadership, especially when demonstrating improvement in patient outcomes, validating existing practice, or demonstrating RTs use of new technology.^12–15

The low number reporting local and national committee leadership was another surprising finding as leading a committee requires several key leadership skills including organization, communication, meeting management, presentation skills, people management, and accountability for the committee's mission. Many centers may have limited internal opportunities for committee involvement, and it is often challenging for less experienced but enthusiastic RTs to get involved without mentorship or guidance. At the national level, getting involved can be very difficult as the processes for committee membership are unclear, opaque, or dependent on being sponsored by someone who is already involved. This greatly limits opportunities for RTs to participate at the national level, which may explain why few leaders felt it was important to be involved.

Few respondents felt presenting at local or national meetings was an important accomplishment, which is an interesting finding given that those presenting at conferences are generally regarded by others in the respiratory care community to be leaders with significant expertise on the topic. It is possible some respondents felt those presenting at conferences were already in formal leadership positions or felt presenting is not important for departmental leadership as staff RTs give relatively few presentations at national and local meetings. A speaker with the expertise to speak at a regional or national conference would likely be an influential informal leader and a strong candidate for various formal leadership roles.

Selecting the wrong leader can have a negative effect on the entire department and organization. Respondents reported consensus that poor work ethic, dishonesty, difficulty getting along with others, and not being a team player would exclude someone from a leadership position. Surprisingly, being disliked by management, playing politics, and challenging leadership were rarely reported as reasons to exclude someone from leadership role. The minimum degree requirement varied, with a baccalaureate degree the most commonly reported requirement. The minimum degree required to effectively perform each job is unknown; however, we believe a master's degree or higher should be expected for director, manager, and educator positions. There are many successful leaders with a baccalaureate degree; however, health care is becoming increasingly complex, and institutional-specific training or on-the-job training may not be sufficient. Graduate school has been shown to increase leadership and management skills in nurses¹⁶ but has not been studied in RT leaders.

Only integrity reached consensus as a characteristic of successful leaders, whereas technical skills were reported by more than half of respondents as an unimportant characteristic. There was no consensus for behaviors of successful leaders, with advocating for staff, communicating clearly, and engagement with staff mentioned by over half of respondents. Consistent rounding was only reported by 12% as an important behavior of successful leaders, despite data suggesting leadership rounding is associated with higher staff engagement, better teamwork, and reduced burnout.¹⁷ Poor communication, dishonesty, and playing favorites were cited as behaviors of unsuccessful leaders, with limited consensus on other behaviors. There was no agreement on what defines leadership success. Creating opportunities for others and employee engagement were chosen by > 50% of respondents, and few respondents reported that employee well-being was indicative of leadership success.

There is a well-established link between leadership and burnout, with half of respondents reporting they felt burned out by their work.^7,8,18 There was consensus from respondents that department culture affects burnout, leaders with burnout increase staff burnout, individual well-being is influenced by leadership, and dissatisfaction with leadership drives burnout. A large prevalence study of RTs also noted that work environment was the strongest predictor of burnout.⁸ Leadership will affect the work environment, department culture, and help get those suffering from burnout the support they need. Unfortunately, a small number of respondents agreed their center provided good support for those suffering from burnout, which is consistent with prior reports of RTs.⁷ Few respondents reported they felt burnout resulted from low individual resilience; however, 60% thought it was an individual's responsibility to maintain their well-being. It is important for leaders to acknowledge and understand that most drivers of burnout are external, with the work environment being the strongest predictor of burnout among RTs.⁸ Thus, focusing on increasing personal resilience will have limited impact without also working to improve the work environment.⁵ Additionally, creating an environment with abundant professional growth opportunities, control over work schedule, peer support, and efforts to cultivate well-being may improve wellness.²

Whereas this is a novel study capturing perceptions of RT leadership, our study has several limitations. We did not clearly define individual leadership characteristics and behaviors. We surveyed RT leaders a priori identified by the authors, and respondents may not be representative of all leaders within respiratory care, thus limiting the generalizability of our results. This is compounded by a response rate < 50%. Despites these limitations, the 124 respondents represent a wide range of settings and departments. We did not survey staff RTs, and their perceptions may be different than those of established leaders. Non-RT leaders, who RT leaders often report to, were also not surveyed. In lieu of a validated survey to capture the data sought after, questions were created for this survey, and some questions may have been ambiguous or allowed for variable interpretation.