Respiratory Therapists in Critical Care

Since the first intensive care units (ICUs) were staffed, training, education, and practice have changed significantly for physicians, nurses, advanced practice providers (APPs), respiratory therapists (RTs), pharmacists, and other healthcare professionals. They have had to adapt to new challenges, integrate new professional roles, learn about emerging technologies, and cultivate a growing awareness of the vital role of each team member in contributing to high-quality patient care outcomes. Retaining professionals requires a workplace culture emphasizing teamwork, autonomy, respect, and evidenced-based care.

Today, RTs are indispensable members of critical care teams. As healthcare delivery becomes more complex, retaining skilled RTs in these high-stress environments has become a pressing issue. Like other professions, the respiratory care workforce is aging. From 2018 to 2024, the median age of RTs has increased from 46 to 49 years.¹ This makes retention of RTs and other members of our aging workforce critical.

The Evolving Role of Respiratory Therapists
In the ICU, RTs work alongside physicians, APPs, nurses, pharmacists, and other specialists, often in high-pressure situations where quick decision-making can be the difference between life and death. As ICU clinicians, we recognize this is not hyperbole but rather a fact of our everyday practice.

The complexity of modern respiratory care has increased with the advent of advanced ventilatory technologies, noninvasive ventilation strategies, and improved monitoring systems. As a result, RTs have become more integral to multiprofessional teams. Their expertise is not limited to operating equipment but extends to clinical decision-making, patient assessment, and providing education to families and other healthcare staff.

Despite these advancements, the role of RTs may be underappreciated, particularly in critical care environments where burnout, high turnover, and the growing demand for healthcare workers remain significant challenges. Therefore, retaining RTs in the ICU requires a comprehensive approach to workplace culture and organizational support, including integrating evidence-based practices to optimize therapy.

Collaboration and Teamwork
The most successful ICU teams are those functioning as cohesive and collaborative units, with each team member contributing their expertise and respecting the unique skills others bring in a psychologically safe environment. Having RTs participate in rounds, contribute to care plans, and make clinical decisions creates a strong sense of collaboration and teamwork within the ICU. This collaborative environment fosters mutual respect among healthcare professionals, making RTs feel like an integral part of the healthcare team rather than isolated professionals with limited scope. RTs feel valued and integrated into patient care decision-making processes.

Autonomy and Respect
Autonomy in the ICU is crucial for retaining skilled professionals. For RTs, the ability to make clinical decisions within the scope of their training or through the use of protocols has been linked to increased job satisfaction and reduced turnover intention.² Allowing RTs to use their clinical judgment, assess patients independently, and implement care plans without the need for constant oversight also contributes to reduced job stress and burnout, which are crucial for retention in such demanding environments. ^2,3

Respect in the workplace is an essential element for job satisfaction and retention in any profession, and healthcare is no exception. For RTs working in the ICU, respect translates into recognition of their unique skill set and contributions to patient care. When RTs feel respected by their colleagues, particularly physicians and nurses, they are more likely to remain in their positions and continue to provide high-quality care.

Respect extends to work-life balance, an often overlooked aspect of retention. Many RTs in the ICU face high stress levels, long shifts, and the emotional toll of working with critically ill patients and families. Ensuring that RTs have time to decompress, opportunities for career development, and a supportive work environment is crucial to maintaining respect and preventing burnout.

Burnout and Retention Challenges
The stress of working in an ICU, combined with the emotional demands of caring for critically ill patients, can lead to burnout, a common cause of turnover for all clinicians in critical care. Burnout, characterized by emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment, is especially prevalent in high-pressure settings such as the ICU.

RTs, like other healthcare professionals, report a high rate of burnout; in some cases, burnout rates are as high as 79%.⁴ Leading causes of burnout among RTs include poor leadership, high workloads (often associated with inadequate staffing or high vacancy rates), an unwelcoming work environment, and lack of recognition and respect.³

Strategies Moving Forward
Several strategies can be employed to advance ICU care aimed at improving outcomes not only for our patients but also for our professionals.

• Education and training: To achieve a collaborative environment, leaders can employ simulation as a strategy shown to improve multiprofessional teamwork.⁵
• RT-driven protocols: Implementation of RT-driven protocols can reduce unnecessary therapies and liberate RTs to have a more active role in the care of other critically ill patients in need of RT expertise.
• Autonomous practice: With greater autonomy, RTs are more likely to stay in their roles longer, as they feel their expertise is recognized and trusted. This sense of ownership can lead to a greater emotional investment in patient outcomes.
• Respect: By valuing input from RTs, healthcare organizations can create a culture in which RTs feel their work is meaningful and essential to the success of the ICU team.
• Burnout mitigation: A multipronged approach to burnout mitigation is needed and may include peer counseling and professional development opportunities with clear advancement paths.

The American Association of Critical-Care Nurses’ six healthy work environments standards are skilled communication, meaningful recognition, authentic leadership, effective decision-making, true collaboration, and appropriate staffing.⁶ These standards have been shown to improve job satisfaction, decrease moral distress, and improve retention.⁶ If we apply these standards, we will not only improve RT-related outcomes but also outcomes for the entire critical care team and patients.

Maintaining each professional role is paramount to the provision of high-quality care in the ICU. Engaging in the strategies listed here may be a start to improving the role of the RT within the ICU. There is no doubt that RTs are necessary and pertinent members of the ICU team, who strive to deliver the Right Care, Right Now to improve patient and family outcomes.

References

1. American Association for Respiratory Care. AARC Respiratory Therapist Human Resource Study. November 18, 2024. Accessed December 13, 2024. https://www.aarc.org/resource/aarc-respiratory-therapist-human-resource-study/
2. Metcalf AY, Stoller JK, Habermann M, Fry TD. Respiratory therapist job perceptions: the impact of protocol use. Respir Care. 2015 Nov;60(11):1556-1559.
3. Miller AG, Burr KL, Juby J, et al. Enhancing respiratory therapists’ well-being: battling burnout in respiratory care. Respir Care. 2023 May;68(5)692-705.
4. Miller AG, Roberts KJ, Smith BJ, et al. Prevalence of burnout among respiratory therapists amidst the COVID-19 pandemic. Respir Care. 2021 Jul 16;66(11):1639-1648.
5. O’Brien B, Bevan K, Brockington C, Murphy J, Gilbert R. Effects of simulation-based cardiopulmonary and respiratory case training experiences on interprofessional teamwork: a systematic review. Can J Respir Ther. 2023 Mar 28;59:85-94.
6. American Association of Critical-Care Nurses. Healthy work environments. Accessed December 2, 2024. https://www.aacn.org/nursing-excellence/healthy-work-environments