Barriers to Respiratory Care Research in the United States

Abstract

BACKGROUND:

Respiratory therapists (RTs) are in a unique position to positively impact patient outcomes through respiratory care research. Research plays a key role in evidence-based medicine; however, few RTs perform and publish research. Identification of barriers experienced by RTs may help increase RT-driven research. Thus, we aimed to identify barriers and research interests for RTs.

METHODS:

American Association for Respiratory Care (AARC) members were invited to anonymously complete a survey via an electronic link posted on AARC Connect. Survey domains included research training, experience, reasons for doing research, important respiratory topics, and barriers to conduct research.

RESULTS:

Responses from 82 surveys were analyzed. The majority were female (56%), and most had a graduate degree (61%), with a mean working experience of 25.3 ± 13.6 y. Fifty-seven percent of respondents reported at least one publication in a peer-reviewed journal. The desire to improve patient outcomes was the top-ranked reason for doing research. Most received research training through a graduate-level program (56%), but few had a formal research mentor (26%). Clinical research (67%) and quality improvement (63%) were the most common types of research. Data collection was the most common research role (51%). Invasive ventilation, advanced monitoring, and airway clearance were identified as the most important research topics. The primary barriers for RTs to conduct research were lack of protected time for research, opportunities to participate, training, departmental support, and mentorship.

CONCLUSIONS:

Lack of time, resources, and opportunities were identified as the primary barriers to RT research, and many RTs have not received formal research training. Resources such as formal mentorship, funding, and protected time may help increase RT participation in research.

Introduction

Evidence-based practice is the integration of clinical expertise, scientific evidence, and patient preferences, allowing clinicians to make informed, evidence-based decisions and provide high-quality care.^1,2 A major component of evidence-based practice is the availability of high-quality scientific evidence. Respiratory care research plays a vital role in improving outcomes for critically ill patients, especially those requiring invasive mechanical ventilation, extracorporeal life support, noninvasive ventilation, and patients with chronic respiratory diseases such as asthma, COPD, and cystic fibrosis.¹ Unfortunately, in the respiratory care field, many procedures, treatments, and therapies are delivered with a low level of evidence or, in many cases, a lack of evidence entirely.^1,3,4

Many respiratory therapists (RTs) lack knowledge about research methodologies and the skills to conduct research independently, resulting in an inability to contribute new scientific evidence to the respiratory care field.^5,6 A survey of Canadian respiratory health care professionals explored the research priorities and barriers among a multidisciplinary group of health care professionals that included RTs.⁵ The top barriers identified were the lack of funding, infrastructure support, and skills and knowledge to engage in research.⁵ Similarly, a cross-sectional survey from Ontario identified that although > 70% of respondents would like to conduct research, most reported a lack of time, skill, and knowledge to perform research.⁷

These results were derived from RTs in Canada and may not be generalizable to other settings due to differences in educational offerings such as the type of degree program and the number of practitioners. For example, the number of practicing RTs and respiratory care programs in the United States is significantly larger than that in Canada^8,9 (Canadian Institute for Health Information. Health Workforce in Canada: Overview, November 24, 2022; https://www.cihi.ca/en/health-workforce-in-canada-overview. Accessed December 9, 2022). Additionally, some respiratory care programs in the United States offer graduate-level training as well as advanced practice programs.^10,11 Despite the availability of graduate-level training for RTs, most are trained in associate’s- or bachelor’s-level programs where there is inadequate time in the curricula to include detailed training on research methodology.⁶ As a result, many RTs miss the opportunity to acquire the necessary knowledge and skills to competently conduct research and are left to learn research methodologies on an ad hoc basis (eg, informal mentoring, short courses, etc), potentially limiting the ability to adequately contribute to respiratory care research. Thus, we aimed to investigate current barriers for American RTs to perform research and the important topics for respiratory care research using a cross-sectional survey.

QUICK LOOK.

Current knowledge

Respiratory therapists (RTs) are in a unique position to positively impact patient outcomes through respiratory care research. However, relatively few RTs perform and publish research. Many RTs lack knowledge about research methodologies and the skills to conduct research independently.

What this paper contributes to our knowledge

The desire to improve patient outcomes was the most important reason RTs conduct research. Lack of secured time, opportunity, and training were identified as the main barriers for RTs to conduct research. The primary research interests were invasive mechanical ventilation, advanced monitoring, and airway clearance. Although progress has been made to advance the respiratory care profession, results from this study indicate many RTs lack access to formal research training.

Methods

Following a literature review, a suitable measure to specifically assess RT research was not found. Therefore, an original survey instrument was developed for this study and administered using REDCap. Twenty experts in respiratory care and critical care medicine, including RTs, physicians, pharmacists, and advanced practice providers, who had worked in their fields for over 10 years and conducted research as principal investigators were invited as consultants for content and convergent validity assessments. The study was approved by the University of Arkansas for Medical Sciences Institutional Review Board (protocol 274136).

The survey domains included were research training and experience, reasons for doing research, important respiratory care topics, barriers for RTs to conduct research, and research engagement. Demographic data included sex, role, education level, and experience. Reasons for doing research were ranked in order of importance using a scale where a rank of one was most important. Participants were asked to select the top 5 research interests and barriers and to rank the importance of each using a 1–5 ranking scale with 1 being the most important and 5 being the least important. The survey was piloted with 22 experts in respiratory care prior to the study for wording accuracy, comprehension, and clarity of the items.

Members of the American Association for Respiratory Care (AARC) were invited to anonymously complete the survey via an electronic link posted on AARC Connect, an online community for AARC member networking. This forum has been previously utilized to recruit RT participation for surveys.^12-15 The invitation to complete the survey was posted in the Help Line section of AARC Connect. The survey was available for a 2-week period in May 2022. Participation was voluntary, and consent was obtained through completion of the survey.

Only complete responses were included in the analyses. Respondents who indicated employment outside the United States were excluded since practices and research opportunities may vary by country. For continuous variables, the Kolmogorov-Smirnov test was used to evaluate the normality of distribution. Based on the normality of distribution, continuous variables were expressed as mean ± SD or median (interquartile range). For categorical variables, frequency counts and percentages were used to describe the data. Data analysis was conducted with SPSS statistical software (SPSS 26.0, IBM, Armonk, New York).

Results

Of the 142 individuals who accessed the survey link, 83 completed the questionnaire. One survey was excluded due to practice outside of the United States. Responses from 82 surveys were included in the analysis. The majority of respondents were female (46, 56%), worked in an academic medical center (64, 78%), and had a graduate degree (50, 61%). The mean working experience was 25.3 ± 13.6 y (Table 1).

Table 1.

Respondent Demographics

Most respondents received research training through a graduate school or a graduate-level program (45, 55%). Few RTs had a formal research mentor (21, 26%). Clinical research (55, 67%) and quality improvement (52, 63%) were the most common types of research, and data collection was the most common research role (42, 51%). Not many reported having received research funding (18, 22%). Forty-seven (57%) respondents reported at least one publication in a peer-reviewed journal, and 29 (35%) were the lead author (Table 2).

Table 2.

Research Experience

Respondents ranked the desire to improve patient outcomes, personal interest, and professional prestige as the most important reasons for conducting research (Fig. 1). The 5 most important research topics were invasive mechanical ventilation, advanced monitoring (eg, electric impedance tomography, volumetric capnography), airway clearance, lung ultrasound, and high-flow nasal cannula (Fig. 2). Most participants (78, 95%) deemed that RTs could add valuable skill sets to the research team with technical expertise and experience with mechanical ventilation, hemodynamic monitoring, extracorporeal membrane oxygenation (ECMO), and intubation. Other skill sets that RTs added to the research team were working closely with a multidisciplinary team (70, 85%), close bedside involvement in patient care (69, 84%), and a unique education curriculum (44, 54%).

Fig. 1.

Participants ranked 7 reasons for doing research in the order of importance. Rank 1 was the most important.

Fig. 2.

Participants were asked to select and rank the 5 most important respiratory topics that should be investigated. Rank 1 was the most important.

The primary barriers for RTs to conduct research were lack of secured time for research, opportunities to participate, training, departmental support, and mentorship (Fig. 3). Seventy-seven (94%) participants felt that providing research training would engage more RTs in research, and one-on-one mentorship was the most common type of training desired to improve research skills and knowledge (37, 45%) (Table 3).

Fig. 3.

Participants were asked to select and rank the 5 most important barriers respiratory therapists face to conduct research. PI = principal investigator.

Table 3.

Research Engagement and Training

Discussion

The study aimed to identify barriers and research interests for RTs. The most common barriers identified for RTs to conduct research were lack of secured time, opportunity to participate in research, and formal research training. Most respondents reported that improving patient outcomes was the primary reason for doing research. The top research interests were invasive mechanical ventilation, advanced monitoring, and airway clearance, although there was significant variability among respondents.

A survey of respiratory research among RTs, nurses, physical therapists, occupational therapists, and other allied health professionals in Canada identified lack of infrastructure support and funding as the top barriers to conducting respiratory research.⁵ The same study included chronic disease management and aging as the top respiratory research priorities. These results differ from our study and are likely due to different respondent characteristics. Our study only included RTs, and the majority had graduate degrees, whereas their respondents were multidisciplinary health care professionals and most had bachelor’s degrees.

Many respondents in our survey indicated that research training was either self-taught or received on the job, which may have contributed to the perceived lack of training as a barrier to RT research. Most RT programs in the United States are associate’s degree programs that generally do not incorporate research training in their entry-to-practice curriculum, as their primary focus is preparing students for clinical practice. A study of RT degree programs in China found that graduates with a bachelor’s degree were more likely to perform tasks with advanced skills, such as lung ultrasound, ECMO, and clinical research.¹⁶ In the United States, however, a bachelor’s degree is not usually required to perform advanced skills such as intubation.^17,18

The AARC Issue Paper regarding Entry to Respiratory Therapy Practice 2030 described the need to advance the minimum education for RT from an associate’s to a baccalaureate degree for several reasons.¹⁹ For example, RTs are increasingly called to make complex decisions and provide advanced care for patients. A baccalaureate degree provides a more in-depth education that can better prepare graduates for these demands. Additionally, RTs with baccalaureate degrees may be better equipped to identify and mitigate risks for patients, improve patient outcomes, and reduce health care costs. This is consistent with research in other health care professions where advanced education has shown to be beneficial.^20,21 As a result, the AARC Strategic Direction 2022–2025 included an operational goal to create a task force to advance credentialing, academic degrees, and advanced practice RT.²²

Raising the minimum standards for entry to practice and increasing the availability of advanced degree programs might produce graduates with the necessary competencies to critically appraise, conduct, and analyze research. This might aid in the advancement of respiratory care research. However, enrollment in RT education programs has declined 27% since 2010, and only 10% of programs are at capacity.⁸ Additionally, there is an ongoing nationwide shortage of RTs that existed even prior to the COVID-19 pandemic.^23,24 The pandemic has further intensified the shortage of all health care workers.^25,26

The majority of respondents reported data collection as their primary type of research role, whereas few were investigators or coordinators. This suggests that few RTs are driving the intellectual work of research or formulating research questions. Additionally, RTs are underrepresented in Delphi studies focused on consensus for respiratory care practices, despite having a primary role in respiratory therapies and relevant experience.²⁷ A review of RT involvement found that RTs were rarely included as panel experts for respiratory research topics of mechanical ventilation, high-flow nasal cannula, respiratory management of COVID-19, home oxygen, cardiopulmonary monitoring, or disease-specific guidelines.^27,28 Likewise, over half of the respondents in this survey reported publication in a peer-reviewed journal, whereas only 35% were lead authors.

Notably, Ring²⁹ investigated RT scholarly activity published in respiratory care over a 10-y period. The study found that publications with at least one RT author increased from 47.5% in 2011 to 60.2% in 2021, and co-authorship for original research publications increased to 84.6%.²⁹ Whereas these results are promising, the data are representative of a single journal specifically geared toward RTs. An analysis of publication diversity from the Canadian Critical Care Trials Group identified only 0.3% of publications from 1994–2020 included RT authors in any authorship capacity.³⁰ Importantly, RTs often contribute to clinical trials but may not be included as co-authors due to limitations on the number of authors allowed from each center in large, multi-center studies. For example, in a clinical trial published by the ARDS Network, RTs contributed to the study and were not included as co-authors but acknowledged in the appendix as a network participant.³¹

The role of the RT has evolved from oxygen orderlies who would clean cylinders and administer therapy without critical thinking to being involved in complex clinical decision making and providing valuable contributions to multidisciplinary care teams.³² Training requirements have advanced from on-the-job training in hospitals to successful completion of an accredited educational training program to practice as an RT. Despite this progress in advancing the profession, room for improvement remains in the area of RT-driven respiratory care research to further support the legitimacy of the RT profession.³² Most RT researchers have learned research methodologies in an apprenticeship-type model after graduation.³³ The best time (pre- or post-program graduation) to provide research training is unclear, and the feasibility of incorporating research training into entry-to-practice programs should be explored.

The development of formal mentorship programs and multi-center collaborations provide additional opportunities for RT participation. Even when RTs have the requisite skills, they still need the opportunity to participate, and it is essential that non-RT researchers consider the technical and clinical expertise RTs can offer for respiratory research. Additionally, RT departments could invest in research by protecting time, funding additional training, and providing necessary resources to support research programs in the department.³⁴

There were several limitations to this study. The topic may have primarily attracted the attention of RTs with research experience, as most participants had over a decade of working experience. This may have resulted in a lack of perspective from RTs new to the field or those who had never participated in the research process. Likewise, most participants had a bachelor’s degree or higher, whereas only a few had an associate’s degree. Thus, the viewpoints from those RTs might differ from our findings. Further investigations including practitioners with and without research experience are warranted. By inviting RTs to complete the survey through AARC Connect, participation was limited to AARC members who utilize the online forum. RTs not engaged in AARC Connect or who are not members of the AARC likely missed the opportunity to complete the survey. This recruitment method resulted in a small sample size that is not representative of all practicing RTs.

Conclusions

The desire to improve patient outcomes was the most important reason for RTs to conduct research. Lack of secured time, opportunity, and training were identified as the main barriers for RTs to conduct research. The primary research interests were invasive mechanical ventilation, advanced monitoring, and airway clearance. Many RTs have not received formal research training. Formal mentorship programs, funding, opportunities for research, and protected time may help increase RT participation in research.