New Graduate Respiratory Therapists' Perceptions of Their Transition to Practice

Abstract

BACKGROUND:

The emerging challenges in the healthcare system require a vision for the future of respiratory care to ensure a successful transition to practice for new graduate respiratory therapists (RT). The nursing profession has recognized the need to acknowledge the successes and failures of graduates' transition to practice so that these programs can be continuously improved. The challenge is in identifying aspects of the transition to practice that may improve job satisfaction, retention, professional development, and patient care for RTs. This research aimed to explore the perceptions of new graduate RTs' experiences during their first year of practice and identify barriers and facilitators to a successful transition to practice.

METHODS:

This qualitative descriptive study surveyed new graduate RTs who transitioned to practice from May 2019 to December 2021 at a New England academic medical center respiratory care department.

RESULTS:

Twenty-eight new graduate RTs responses were included in the study. The majority of the respondents experienced a successful transition to practice; however, they faced many barriers. New graduate RTs reported that their orientation did not provide enough experience and exposure to gain confidence in critical skills and procedures. They also experienced stress due to COVID-19 and interpersonal relationships, felt overwhelmed by their workload, and were subject to negative workplace behavior.

CONCLUSIONS:

New graduate RTs experienced many barriers to their transition to practice. Respiratory care leadership should identify barriers faced by new graduate RTs during their transition to practice. A nurse residency model may provide a framework for RT transition-to-practice programs. Improving transition-to-practice programs for new graduate RTs and surveying their experiences may lead to an increase in job satisfaction, retention, and improved patient care.

Introduction

The respiratory therapy profession has dramatically evolved since its establishment in 1947. Today's respiratory therapists (RT) provide direct patient care and education to patients of all ages. RTs practice in multiple locations, including acute and long-term care hospitals, physician offices, and home care.¹ The United States Bureau of Labor Statistics (https://www.bls.gov/ooh/healthcare/respiratory-therapists.htm#tab-6. Accessed March 19, 2022) reports a total of 135,100 RTs in the United States in 2020. RT employment is expected to grow 23% from 2020 to 2030, much faster than the average for all occupations. Over the decade, RT job openings are expected to increase by ∼10,100 each year. According to the 2020 human resource study from the American Association for Respiratory Care (https://www.aarc.org. Accessed March 24, 2022), an estimated 92,474 RTs will have left the workforce by 2030. In addition, the COVID-19 pandemic has increased the demand for RTs around the country. Many departments have experienced staffing challenges due to the increased workload, staff burnout, and staff leaving the profession for retirement or for temporary travel positions.²

Enrollment in RT entry-to-practice programs has decreased while vacant positions in hospitals have increased. According to the Commission on Accreditation for Respiratory Care (https://coarc.com/wp-content/uploads/2021/04/2020-CoARC-Report-on-Accreditation-4.29.21.pdf. Accessed March 20, 2022), there were 6,589 new graduates in 2019, a 5.9% increase compared with 2018 but a 19.0% decrease compared with its peak in 2012. It seems that the current number of new graduate RTs will not meet the profession's needs reported by the United States Bureau of Labor and Statistics, which makes it crucial for employers to recruit and retain their current RTs.

These emerging challenges in healthcare require a vision for the future of respiratory care. Emphasis on recruiting and retaining new graduate RTs could be one way to meet future staffing challenges. The nursing profession has recognized the need for supporting new graduates beyond a typical orientation period. The National Council of State Boards of Nursing (https://www.ncsbn.org. Accessed March 23, 2022) defines transition to practice as a formal program of active learning implemented for newly licensed nurses and licensed practical/vocational nurses designed to support their progression from education to practice. Transition-to-practice programs provide sustainable support for new graduate nurses by improving retention, patient care, and patient safety; strengthening communication skills; and creating a supportive work culture.³ Leaders in the respiratory profession could use this model to build an RT transition-to-practice program.

Challenges that face the respiratory care profession emphasize the importance of staff satisfaction and retention, professional development, and a successful transition of new graduate RTs into practice. There is little published research that describes the experiences of new graduate RTs or a framework for a successful transition. The aim of this research was to explore the experiences of new graduate RTs during their first year of practice.

QUICK LOOK.

Current Knowledge

The future of the respiratory therapy profession is facing many challenges, most importantly the training and retention of new graduate respiratory therapists (RT). Methods to identify aspects of new graduate RTs' transition to practice that may improve job satisfaction, retention, professional development, and patient care are lacking. Transition-to-practice programs described in the nursing literature may be an effective framework for new graduate RT orientation programs.

What This Paper Contributes to Our Knowledge

New graduate RTs experienced many barriers to their transition to practice, including an inadequate orientation period, lack of leadership support, stress, overwhelming workload, and negative workplace behavior. Improving transition-to-practice programs for new graduate RTs and surveying their experiences may lead to an increase in job satisfaction, retention, and improved patient care.

Methods

This qualitative descriptive study surveyed new graduate RTs who transitioned to practice from May 2019 to December 2021 at an academic medical center. Qualitative descriptive research offers honest descriptions of experiences and perceptions of the study participants to allow for a better understanding of the human experience.⁴ It enables clinical researchers to explore important healthcare questions that directly impact their healthcare setting and discipline.⁵ This method can identify ways to contribute to change and quality improvement in the practice setting by identifying participants' perceptions of why an intervention worked or did not work and how the intervention might be improved.⁶

The detailed research protocol was approved by the Massachusetts General Hospital Institutional Review Board (protocol 2022P001413). The study consisted of a purposive sample of all new graduate RTs hired between May 2019 and December 2021 who had fully completed their RT orientation program. The target population included 31 academic medical centers in New England. The director, manager, or educator for each RT department was contacted by e-mail to invite eligible subjects to participate in the research study. Leaders were asked to identify staff members who met inclusion criteria and forward those individuals' e-mail addresses to the researchers or to forward the introductory letter to qualifying subjects. An introductory letter was sent via e-mail to the potential subjects, or their leaders, which described the purpose and benefits of the study, informed consent, and a link to the survey instrument. Responses were collected electronically in SurveyMonkey. Completion of the survey implied consent to participate.

A standardized survey instrument designed to obtain the perceptions of new graduate RTs does not exist. The instrument used in this study was a modified version of the Casey-Fink Graduate Nurse Experience Survey (e-Fig. 1 [see the supplementary materials at http://www.rcjournal.com]).⁷ Permission was obtained from Casey and Fink to modify and use the survey for this research. Questions in all sections were modified to match the clinical aspects of respiratory therapy more closely. The modified survey instrument consisted of 37 questions in 5 sections: demographic information, new graduate comfort and confidence (23 items with Likert scale response, with 1 = strongly disagree and 4 = strongly agree), new graduate job satisfaction dimensions (1 question, 8 items with Likert scale response, with 1 = very dissatisfied and 5 = very satisfied), new graduate perceptions of experiences during transition to practice (5 choice questions with open-ended answer option), and skills and/or procedure performance (2 open-ended questions).

Fig. 1.

Flow chart.

The Casey-Fink Graduate Nurse Experience Survey⁷ was developed, piloted, and revised to measure the new graduate nurse's experience from entering the workforce through the transition to practice. The content of the tool was created from a comprehensive literature review. The tool was piloted and tested for content validity and bias by using an expert panel of nurse directors and educators. Internal consistency reliability was established on the original survey instrument and subsequent modifications. Internal consistency describes the extent to which all the items in a test measure the same concept or construct; thus, it is connected to the inter-relatedness of the items within the test.⁸ The modified survey instrument (e-Fig. 2 [see the supplementary materials at http://www.rcjournal.com]) used in this study is expected to be similar in internal consistency and reliability because the foundation of each question was not appreciably changed. Subject matter experts piloted the modified survey within the respiratory care department at Massachusetts General Hospital, to ensure content validity, clarity, and the absence of bias.

Fig. 2.

Chart that shows the responses to the question, “What difficulties, if any, did you experience with the transition from the role of “student” to the “respiratory therapist” role?”

Raw data were downloaded into Microsoft Excel 2018 (Microsoft, Redmond, Washington) and all identifiers were removed. Descriptive statistics were used to present the demographic, job satisfaction, comfort and confidence data, and the skills/procedure performance questions. The open-ended responses were analyzed thematically by using a general inductive approach and open coding. This involved familiarization with the responses, identifying text most relevant to the study's purpose, and searching for similarities and patterns. The data were independently coded by the primary investigator. The content of the responses directed how categories and themes were constructed.

Results

Thirty-one academic medical centers in New England were included as potential sources for subjects (e-Fig. 3 [see the supplementary materials at http://www.rcjournal.com]). We were unable to obtain contact information for 6 hospitals. Eleven hospitals did not respond with potential subject contact information or offer to cooperate with the study. Three hospitals had zero potential subjects. The introductory letter with a link to the survey was sent to 109 potential subjects from 11 New England academic medical centers on June 21, 2022, and the survey link was closed on July 5, 2022. Thirty subjects responded to the survey. Two subjects did not complete the survey and were excluded from the results. A total of 28 RTs (26%) completed the survey (Fig. 1).

Fig. 3.

Chart that shows the responses to the question, “What could have been done to help you feel more supported or integrated into your role?”

The demographics of the 28 respondents are shown in Table 1. Twenty two of the respondents (79%) identified as women. Seventeen of the respondents (61%) were between the ages of 25 and 34 years. Most respondents (26 [93%]) graduated with an associate's degree in respiratory care, and 17 (61%) previously worked in healthcare. The respondents reported positive perceptions of support (Table 2). All the respondents agreed that other RTs were available for support during new situations and procedures. Similarly, most respondents felt comfortable asking for help from other RTs (26 [93%]). However, some respondents did not agree that leadership provided encouragement and feedback (10 [36%]), and some did not feel that they had enough opportunities to practice skills and procedures (6 [21%]).

Table 1.

Demographic Characteristics (N = 28)

Table 2.

Graduate Comfort and Confidence: Support (N = 28)

The respondents felt that they provided safe patient care (Table 3). Most respondents agreed that they were able to complete their patient care workload on time (22 [78%]). However, some respondents felt overwhelmed by their responsibilities and workload (12 [43%]) and had trouble organizing their workload (8 [29%]). Most respondents agreed with the items that assessed their perception of communication (Table 4). All agreed that they felt prepared to complete their job responsibilities. Fewer of the respondents felt comfortable making suggestions to physicians and other members of the multidisciplinary team (19 [68%]). Respondents were in overall agreement with the items concerning professional satisfaction (Table 5). Almost all respondents were supported by their family and friends (26 [92%]) and were satisfied with their choice to become an RT (25 [89%]).

Table 3.

Graduate Comfort and Confidence: Patient Safety (N = 28)

Table 4.

Graduate Comfort and Confidence: Communication (N = 28)

Table 5.

Graduate Comfort and Confidence (N = 28)

Nearly all the respondents agreed that they experienced stress during their transition to practice (24 [85%]) (Table 5). The respondents who agreed were asked to indicate the source of their stress by selecting all applicable answers from the available choices: finances, child care, student loans, living situation, personal relationships, job performance, and COVID-19 pandemic (Table 6). Many respondents chose COVID-19 (15 [54%]) as a source of stress, followed by relationships (11 [39%]) and finances (8 [29%]). A theme from the 3 open responses was that the respondents experienced stress about their overall mental health. One respondent answered:

“Overwhelming PTSD after experiencing hundreds of casualties in just a couple years.”

Table 6.

Reported Causes of Stress

The percentages of agreement with the items related to job satisfaction are display in Table 7. Most of the respondents were satisfied with the hours and shifts that they worked (19 [68%]) and their amount of responsibility (18 [64%]). Respondents were least satisfied with their salary (12 [43%]) and amount of vacation time (11 [39%]). New graduate RTs perceived several difficulties during their transition to practice (Fig. 2). Half of the respondents experienced a lack in confidence (14 [50%]) and some experienced fears of possibly hurting their patients (9 [32%]). Respondents identified the need for an improved work environment (10 [36%]) to increase support and integration into the workplace (Fig. 3). Of the open responses for this question, some new graduate RTs expressed a certain level of self-responsibility for their transition:

“You're never going to be fully prepared once you step foot in that ICU room for the first time alone. You're meant to be put in the fire and in my opinion that's the best possible way to learn, particularly from mistakes.”

“It was a personal hurdle I had to overcome on my own.”

Table 7.

Job Satisfaction (N = 28)

Other respondents identified the need to recognize and address any negative work cultures in the department. Two respondents wrote:

“Recognize senior therapist bullying and intimidation towards new therapists. I was told early on about the history of several therapists and experienced it firsthand. This is unacceptable and causes a hostile work environment. One or two therapists need to stop this behavior towards new staff to maintain new staff retention.”

“The animosity between night shift and day shift is very stressful and sometimes overwhelming.”

Peer support was identified as the most satisfying aspect of their work environment (21 [75%]) (Fig. 4), whereas interpersonal relationships were considered the least satisfying aspect (14 [50%]) (Fig. 5). There were several themes identified from the open responses (Table 8): respondents' comments and concerns were related to workload, lack of leadership support, orientation, peer support, negative work culture, and stress and anxiety.

Fig. 4.

Chart that shows the responses to the question, “What aspects of our work environment were most satisfying?”

Fig. 5.

Chart that shows the responses to the question, “What aspects of our work environment were least satisfying?”

Table 8.

Comments and Concerns: Thematic Analysis

Several respondents commented on the effects of the COVID-19 pandemic on their transition and COVID-19 affected their workload, length of orientation, level of support, and negative workplace culture. Statements from respondents that described the effects of COVID-19 included the following:

“Graduating at the start of the pandemic made it challenging when coming off orientation as there were many times that I would have 12 COVID-positive patients on ventilators with many of them proned and with Flolan running. Very stressful and overwhelming at times.”

“I was hired in 2019, and my orientation ended, and I was on my own for most of 2019 and part of 2020 before COVID-19. I feel as though those first 6–12 months prior to COVID, I had anxiety coming to work each shift. Mostly due to the feeling of being new and having other department staff (RNs, MDs). Being new, staff tends to be “iffy” about you, and it makes you feel even more anxious and nervous then you felt to begin with. Trying to prove yourself while still learning more and more every day.”

Respondents also commented on negative workplace behavior:

“The other RTs were exceptionally toxic or practicing outdated medicine. New grads were not listened to, despite having more up to date information.”

Another theme was related to the improvement of new graduate RT orientation:

“Orientation could have been longer than 6 weeks. Introduction to doctors/providers. Consistency in preceptors could have helped, and the transitional period between orientation to independent RT should have included more support (ie, being placed in a unit near a senior RT who would give support when needed to new RT).”

“The workload made me feel like I didn't have time to learn. Yes, now I can manage my time and workload. However, it's like I am just now getting the time to slow down and take in new skills. I had to learn on the fly.”

The skills and procedures that respondents did not feel comfortable performing independently at the end of their first 6 to 12 months are listed in Table 9. The most common skill or procedure selected was the setup and initiation of nitric oxide therapy for an adult patient (15 [54%]). The overall theme of the respondents' comments centered on the need for more hands-on experience (Table 10).

Table 9.

Skills and Procedure Performance

Table 10.

Activities to Improve Skill and Procedure Independence: Open Response

Discussion

This qualitative analysis of new graduate RTs' perceptions of their transition to practice is valuable because no similar research was found for the respiratory care profession. As the demand for RTs continues to grow and the supply remains diminished, leaders must seek out the perceptions of new graduate RTs and identify facilitators and barriers to a successful transition to practice. The information could also inform aspects of job satisfaction to increase staff retention. The survey revealed several barriers to a positive transition to practice.

The demographic data reveals that a majority of respondents completed a 7-to-13–week orientation. These results are similar to other academic medical centers. Hehman et al⁹ surveyed respiratory care directors, managers, and hospital educators, and found that orientation programs for new graduate RTs at academic medical centers averaged 224.3 ± 185.0 (mean ± SD) hours or a range of 2–11 weeks. However, the respondents in this survey indicate that this may not be enough time to become competent in the skills and procedures required in respiratory care departments at these academic institutions:

“More experience. Just not enough patient volume requiring these modalities to practice on. In the case of bronchoscopy, we have a separate department which handles these … thus I only performed them as a student.”

Academic medical centers care for high-acuity patients who often require advanced respiratory modalities. Hehman et al⁹ found that most respiratory care leaders expected their staff to be competent in bronchoscopy procedures, 71%, and initiation of medical gas therapy, such as nitric oxide, 95%. However, respondents in this survey were least comfortable with the setup, initiation, and maintenance of nitric oxide therapy for an adult patient. New graduate RTs repeatedly stated that they did not experience many of these skills and procedures during their transition to practice and needed more hands-on exposure to be competent.

Respondents described many challenges that affected their personal, social, and job-related experiences. They reported levels of fear, anxiety, and stress as well as communication flaws, staffing issues, and limited exposure to specialty procedures. Magola et al¹⁰ found comparable results in their research, which aimed to identify the challenges to transition and their perceived impact on the nursing and medical fields. Novice practitioners and their peers perceived barriers to transition to practice as impeding learning, impairing performance, and negatively impacting patient care.

The respondents in this survey demonstrated similar transition experiences. The COVID-19 pandemic was identified as a barrier in multiple survey sections. New graduate RTs associated their perceived stress with COVID-19. Multiple open responses in the perception section of the survey commented on how the respondents' transition was affected by COVID-19:

“I feel as though those first 6–12 months prior to COVID, I had anxiety coming to work each shift. Mostly due to the feeling of being new and having other department staff (RNs, MDs). Being new, staff tends to be “"iffy"” about you, and it makes you feel even more anxious and nervous then you felt to begin with. Trying to prove yourself while still learning more and more every day.”

“Graduating at the start of the pandemic made it challenging when coming off orientation as there were many times that I would have 12 COVID-positive patient's on ventilators with many of them prone and with Flolan running. Very stressful and overwhelming at times.”

Batra et al¹¹ published a meta-analysis that provided evidence related to the psychological impact of COVID-19 among healthcare workers. They found a high prevalence of anxiety, depression, stress, and insomnia among workers during the pandemic. Batra et al¹¹ emphasized the need for organizational support to help with these effects, which suggests interventions such as buddy support systems, listening sessions, and mental health support through employee assistance programs. These interventions could be valuable for the new graduate RTs' transition to practice.

New graduates from many healthcare disciplines transitioned to practice during a pandemic, which may have amplified all other barriers. Kovancı and Özbaş¹² explored the experiences of new nursing during the COVID-19 pandemic. They found that COVID-19 negatively affected the length and quality of their orientation program. They also saw a decrease in teamwork and supportive behavior as well as an increase in workload. It is reasonable to believe that new graduate RTs' transition to practice was affected in a similar manner.

Respondents struggled with their workload and gaining experience with skills and procedures. They felt overwhelmed by their patient care assignment and identified workload as a cause of difficulty with their transition to practice. They also noted that an unrealistic workload contributed to a dissatisfying work environment:

“Workload could become too much for one person in an assignment post orientation. Many responsibilities that could be shared with other staff is not and often there would be a need to prioritize some patients over others.”

“Post orientation would get heavy work loads and have constant change during shift of assignment change, which I felt like I was not prepared for.”

Charette et al¹³ identified workload as a factor that influences the practice of new graduate nurses. The study reported that the workload given to new graduate nurses was not always adjusted to their level of competence. These elevated expectations could be perceived as work overload by new graduate RTs, which may negatively impact the quality of the care they provide and impede their growth.

Graf et al¹⁴ described this perception of being overwhelmed as transitional shock, initially seen throughout the “doing” stage of the transitional theory model, followed by transition crisis. New graduates often cope but felt anxious, uncertain, and stressed, particularly when caring for patients who are critically ill, and they feel overwhelmed by the workload and out of their depth. They concluded that new graduate nurses currently transition into the workforce with various challenges, such as limited clinical hours and decreasing face-to-face education, which contributed to an increased gap between theory and practice, raising the possibility of transition shock.¹⁴ The new graduate RTs in this survey describe similar experiences to their nursing counterparts. They perceived that their workload impaired their learning ability and affected their ability to communicate with the multidisciplinary team.

Results also show respondents experienced negative workplace behavior that affected their confidence, level of stress, and interpersonal relationships. Some felt uncomfortable making suggestions to the team for changes to the respiratory care plan. A lack of confidence was identified as a barrier to their transition to practice. New graduate RTs identified interpersonal relationships as the least satisfying aspect of their work environment. When asked to share additional comments, several respondents noted that they experienced bullying and a lack of acceptance from experienced RTs and other team members:

“The other RTs were exceptionally toxic or practicing outdated medicine. New grads were not listened to, despite having more up to date information.”

“Recognize senior therapist bullying and intimidation towards new therapists. I was told early on about the history of several therapists and experienced it firsthand. This is unacceptable and causes a hostile work environment. One or two therapists need to stop this behavior towards new staff to maintain new staff retention.”

These negative workplace behaviors have been seen in the nursing profession. Hawkins et al¹⁵ identified various terms that describe negative workplace behavior, such as workplace incivility, bullying, eating their young, tough love behaviors, horizontal violence, and lateral violence. The effects of negative workplace behavior include emotional distress, low self-esteem, anxiety, depression, and disempowerment. It has also been shown to affect job satisfaction, cynicism, burnout, and their intention to leave. Patient care and safety are negatively affected because the new graduates are unwilling to seek assistance when needed and avoid some staff members. Leaders could address this barrier by developing a mentor program that would allow new graduate RTs to discuss challenges, such as negative workplace behavior, in a safe space.

A low percentage of respondents agreed that leadership provided encouragement and feedback about their work. Respondents identified the need for increased support to help with integration into their new role:

“Feeling like it's a good pace that would benefit from more check ins from our educator.”

These results magnify the importance of leadership support throughout the graduate RTs transition to practice. Wakefield¹⁶ reported that graduate nurses who were less supported were more likely to feel overwhelmed, scared, have self-doubt, and be fearful. Fear of being viewed as clinically inadequate and failing to provide appropriate care or failing to accept responsibility as a registered nurse increased during the first four months of the transition to practice. In this survey, a lack of leadership support may have contributed to the new graduate RTs' experiences of stress, self-doubt, and being overwhelmed.

A respiratory transition-to-practice program that provides prolonged support may help the new graduate RT by providing a reduced workload and allowing more time to develop time management, critical thinking, and communication skills, improving their confidence. Structured nurse residency programs vary in length up to 18 months. This extended time helps transition to practice by providing continued preceptor clinical support and mentorship to bridge the practice gap. New graduate nurses participating in a residency program were more prepared to face challenges they encountered as practicing nurses in an increasingly complex healthcare arena.¹⁷

A residency program can also improve leadership support. Turpin et al¹⁸ found that new graduates highly valued formal and informal support provided by leaders during the residency. An increase in support may help to create a culture in which negative workplace behavior is decreased. Hawkins et al¹⁵ reported that new graduate nurses who participated in a transition-to-practice program had better access to support when exposed to negative workplace behavior and had higher transition scores compared with nurses who were not part of a program. Authentic leadership, in which leaders build relationships with their employees and colleagues, and establish real connections with the people around them, can be essential in reducing new graduate nurses' exposure to workplace bullying and to establish respectful, positive workplace culture.¹⁵ RT leaders can use the framework of nurse residency programs to help overcome these identified barriers.

This study had several limitations. First, fewer than half of the academic medical centers included responded with potential subjects. Second, some of the respondents may have graduated > 2 years ago and their experiences might be biased or changed over time. Third, many of the respondents transitioned to practice during an unprecedented pandemic, which may have impacted their training in ways not previously seen. Fourth, the modified survey was not tested for reliability and validity. Future research is needed to develop and validate a survey instrument that measures the experiences of new graduate RTs. Another limitation was the use of an open-coding method for the thematic analysis. This method is subject to researcher bias and human error. Also, the response rate of 26% and the total number of survey respondents, 28, were low. The respondents were from one region of the country and a majority of them were in the same age group, which makes it difficult to generalize these results to the entire RT population.

This survey shows the importance of understanding the perceptions of new graduate RTs so that future transition programs, whether in a traditional orientation or a residency framework, can be developed to improve their experiences. Transition-to-practice programs have the potential to increase job satisfaction and retention, and to improve patient care. Similar to our survey tool, a modified version of the Casey-Fink Graduate Nurse Experience Survey⁷ may be one method for new graduate RTs to provide feedback and facilitate a positive transition to practice. Further research with larger sample sizes is needed to validate our survey and to assess new graduate RTs' perceptions of their transition to practice on a broader scale.

Conclusions

This survey described the perceptions and experiences of new graduate RTs who completed their transition to practice in New England. The respondents experienced barriers to their transition, including an inadequate orientation period, lack of leadership support, stress, overwhelming workload, and negative workplace behavior. The literature that describes nurse residency programs may provide a framework for an RT transition-to-practice program that improves on these barriers. Surveying new graduate RTs experiences may lead to an increase in job satisfaction, retention, and improved patient care.